Medical Fee Schedule Eff. January 1, 2024

North Carolina Industrial Commission
Workers' Compensation Fee Schedule
Fees Effective January 1, 2024

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Please go to the bottom of the table for a link to download the fee schedule.

CODE_MOD	NCIC Category Assignment	Description	NC Non-Facility Rate	NC Facility Rate
0001U	Clinical Laboratory	RBC DNA HEA 35 AG 11 BLD GRP	1080.00	1080.00
0002U	Clinical Laboratory	ONC CLRCT 3 UR METAB ALG PLP	37.50	37.50
0003U	Clinical Laboratory	ONC OVAR 5 PRTN SER ALG SCOR	1425.00	1425.00
0005U	Clinical Laboratory	ONCO PRST8 3 GENE UR ALG	1140.00	1140.00
0007U	Clinical Laboratory	RX TEST PRSMV UR W/DEF CONF	171.65	171.65
0008U	Clinical Laboratory	HPYLORI DETCJ ABX RSTNC DNA	896.87	896.87
0009U	Clinical Laboratory	ONC BRST CA ERBB2 AMP/NONAMP	160.50	160.50
0010U	Clinical Laboratory	NFCT DS STRN TYP WHL GEN SEQ	640.89	640.89
0011U	Clinical Laboratory	RX MNTR LC-MS/MS ORAL FLUID	171.65	171.65
0016U	Clinical Laboratory	ONC HMTLMF NEO RNA BCR/ABL1	245.94	245.94
0017U	Clinical Laboratory	ONC HMTLMF NEO JAK2 MUT DNA	137.49	137.49
0018U	Clinical Laboratory	ONC THYR 10 MICRORNA SEQ ALG	4503.14	4503.14
0019U	Clinical Laboratory	ONC RNA TISS PREDICT ALG	5512.50	5512.50
0021U	Clinical Laboratory	ONC PRST8 DETCJ 8 AUTOANTB	1140.00	1140.00
0022U	Clinical Laboratory	TGSAP NSM LUNG NEO DNA&RNA23	2925.00	2925.00
0023U	Clinical Laboratory	ONC AML DNA DETCJ/NONDETCJ	372.77	372.77
0024U	Clinical Laboratory	GLYCA NUC MR SPECTRSC QUAN	51.29	51.29
0025U	Clinical Laboratory	TENOFOVIR LIQ CHROM UR QUAN	128.66	128.66
0026U	Clinical Laboratory	ONC THYR DNA&MRNA 112 GENES	5400.00	5400.00
0027U	Clinical Laboratory	JAK2 GENE TRGT SEQ ALYS	182.87	182.87
0029U	Clinical Laboratory	RX METAB ADVRS TRGT SEQ ALYS	1113.41	1113.41
0030U	Clinical Laboratory	RX METAB WARF TRGT SEQ ALYS	201.20	201.20
0031U	Clinical Laboratory	CYP1A2 GENE	262.22	262.22
0032U	Clinical Laboratory	COMT GENE	262.22	262.22
0033U	Clinical Laboratory	HTR2A HTR2C GENES	524.43	524.43
0034U	Clinical Laboratory	TPMT NUDT15 GENES	699.26	699.26
0035U	Clinical Laboratory	NEURO CSF PRION PRTN QUAL	811.49	811.49
0036U	Clinical Laboratory	XOME TUM & NML SPEC SEQ ALYS	7170.00	7170.00
0037U	Clinical Laboratory	TRGT GEN SEQ DNA 324 GENES	5250.00	5250.00
0038U	Clinical Laboratory	VITAMIN D SRM MICROSAMP QUAN	44.40	44.40
0039U	Clinical Laboratory	DNA ANTB 2STRAND HI AVIDITY	20.61	20.61
0040U	Clinical Laboratory	BCR/ABL1 GENE MAJOR BP QUAN	614.85	614.85
0041U	Clinical Laboratory	B BRGDRFERI ANTB 5 PRTN IGM	25.82	25.82
0042T	Other professional services	CT PERFUSION W/CONTRAST CBF	310.94	310.94
0042U	Clinical Laboratory	B BRGDRFERI ANTB 12 PRTN IGG	25.82	25.82
0043U	Clinical Laboratory	TBRF B GRP ANTB 4 PRTN IGM	22.29	22.29
0044U	Clinical Laboratory	TBRF B GRP ANTB 4 PRTN IGG	22.29	22.29
0045U	Clinical Laboratory	ONC BRST DUX CARC IS 12 GENE	5809.50	5809.50
0046U	Clinical Laboratory	FLT3 GENE ITD VARIANTS QUAN	611.15	611.15
0047U	Clinical Laboratory	ONC PRST8 MRNA 17 GENE ALG	5809.50	5809.50
0048U	Clinical Laboratory	ONC SLD ORG NEO DNA 468 GENE	4379.40	4379.40
0049U	Clinical Laboratory	NPM1 GENE ANALYSIS QUAN	611.15	611.15
0050U	Clinical Laboratory	TRGT GEN SEQ DNA 194 GENES	4374.90	4374.90
0051U	Clinical Laboratory	RX MNTR LC-MS/MS UR/BLD 31	290.57	290.57
0052U	Clinical Laboratory	LPOPRTN BLD W/5 MAJ CLASSES	50.79	50.79
0054T	Other professional services	BONE SRGRY CMPTR FLUOR IMAGE	194.54	194.54
0054U	Clinical Laboratory	RX MNTR 14+ DRUGS & SBSTS	223.44	223.44
0055T	Other professional services	BONE SRGRY CMPTR CT/MRI IMAG	194.54	194.54
0055U	Clinical Laboratory	CARD HRT TRNSPL 96 DNA SEQ	4860.00	4860.00
0058U	Clinical Laboratory	ONC MERKEL CLL CARC SRM QUAN	484.44	484.44
0059U	Clinical Laboratory	ONC MERKEL CLL CARC SRM +/-	484.44	484.44
0060U	Clinical Laboratory	TWN ZYG GEN SEQ ALYS CHRMS2	1138.58	1138.58
0061U	Clinical Laboratory	TC MEAS 5 BMRK SFDI M-S ALYS	37.65	37.65
0062U	Clinical Laboratory	AI SLE IGG&IGM ALYS 80 BMRK	571.08	571.08
0063U	Clinical Laboratory	NEURO AUTISM 32 AMINES ALG	1125.00	1125.00
0064U	Clinical Laboratory	ANTB TP TOTAL&RPR IA QUAL	47.00	47.00
0065U	Clinical Laboratory	SYFLS TST NONTREPONEMAL ANTB	27.14	27.14
0067U	Clinical Laboratory	ONC BRST IMHCHEM PRFL 4 BMRK	2845.50	2845.50
0068U	Clinical Laboratory	CANDIDA SPECIES PNL AMP PRB	213.95	213.95
0069U	Clinical Laboratory	ONC CLRCT MICRORNA MIR-31-3P	570.00	570.00
0070U	Clinical Laboratory	CYP2D6 GEN COM&SLCT RAR VRNT	1014.56	1014.56
0071T	Other professional services	US LEIOMYOMATA ABLATE <200	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0071U	Clinical Laboratory	CYP2D6 FULL GENE SEQUENCE	900.00	900.00
0072T	Other professional services	FCSD US ABLTJ LEIOMYOM>=200	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0072U	Clinical Laboratory	CYP2D6 GEN CYP2D6-2D7 HYBRID	676.37	676.37
0073U	Clinical Laboratory	CYP2D6 GEN CYP2D7-2D6 HYBRID	676.37	676.37
0074U	Clinical Laboratory	CYP2D6 NONDUPLICATED GENE	676.37	676.37
0075T	Other professional services	PERQ STENT/CHEST VERT ART	873.12	873.12
0075T-26	Other professional services	PERQ STENT/CHEST VERT ART	1395.75	1395.75
0075T-TC	Other professional services	PERQ STENT/CHEST VERT ART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0075U	Clinical Laboratory	CYP2D6 5' GENE DUP/MLT	676.37	676.37
0076T	Other professional services	S&I STENT/CHEST VERT ART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0076T-26	Other professional services	S&I STENT/CHEST VERT ART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0076T-TC	Other professional services	S&I STENT/CHEST VERT ART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0076U	Clinical Laboratory	CYP2D6 3' GENE DUP/MLT	676.37	676.37
0077U	Clinical Laboratory	IG PARAPROTEIN QUAL BLD/UR	65.15	65.15
0078U	Clinical Laboratory	PAIN MGT OPI USE GNOTYP PNL	676.37	676.37
0080U	Clinical Laboratory	ONC LNG 5 CLIN RSK FACTR ALG	5280.00	5280.00
0082U	Clinical Laboratory	RX TEST DEF 90+ RX/SBSTS UR	370.38	370.38
0083U	Clinical Laboratory	ONC RSPSE CHEMO CNTRST TOMOG	251.03	251.03
0084U	Clinical Laboratory	RBC DNA GNOTYP 10 BLD GROUPS	1080.00	1080.00
0086U	Clinical Laboratory	NFCT DS BACT&FNG ORG ID 6+	300.00	300.00
0087U	Clinical Laboratory	CRD HRT TRNSPL MRNA 1283 GEN	4739.13	4739.13
0088U	Clinical Laboratory	TRNSPLJ KDN ALGRFT REJ 1494	4739.13	4739.13
0089U	Clinical Laboratory	ONC MLNMA PRAME & LINC00518	1140.00	1140.00
0090U	Clinical Laboratory	ONC CUTAN MLNMA MRNA 23 GENE	2925.00	2925.00
0092U	Clinical Laboratory	ONC LNG 3 PRTN BMRK PLSM ALG	3732.00	3732.00
0093U	Clinical Laboratory	RX MNTR 65 COM DRUGS URINE	93.21	93.21
0094U	Clinical Laboratory	GENOME RAPID SEQUENCE ALYS	11373.30	11373.30
0095T	Other professional services	RMVL ARTIFIC DISC ADDL CRVCL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0095U	Clinical Laboratory	EE&MJ BSC PRTN ELISA EST DEV	1157.97	1157.97
0096U	Clinical Laboratory	HPV HI RISK TYPES MALE URINE	52.64	52.64
0098T	Other professional services	REV ARTIFIC DISC ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0100T	Other professional services	PROSTH RETINA RECEIVE&GEN	1764.33	1764.33
0101T	Other professional services	ESW MUSCSKEL SYS NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0101U	Clinical Laboratory	HERED COLON CA DO 15 GENES	2615.93	2615.93
0102T	Other professional services	ESW PHY ANES LAT HMRL EPCNDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0102U	Clinical Laboratory	HERED BRST CA RLTD DO 17 GEN	1955.93	1955.93
0103U	Clinical Laboratory	HERED OVA CA PNL 24 GENES	2615.93	2615.93
0105U	Clinical Laboratory	NEPH CKD MULT ECLIA TUM NEC	1425.00	1425.00
0106T	Other professional services	TOUCH QUANT SENSORY TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0106U	Clinical Laboratory	GSTR EMPTG 7 TIMED BRTH SPEC	1311.74	1311.74
0107T	Other professional services	VIBRATE QUANT SENSORY TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0107U	Clinical Laboratory	C DIFF TOX AG DETCJ IA STOOL	24.00	24.00
0108T	Other professional services	COOL QUANT SENSORY TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0108U	Clinical Laboratory	GI BARRETT ESOPH 9 PRTN BMRK	7425.00	7425.00
0109T	Other professional services	HEAT QUANT SENSORY TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0109U	Clinical Laboratory	ID ASPERGILLUS DNA 4 SPECIES	213.95	213.95
0110T	Other professional services	NOS QUANT SENSORY TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0110U	Clinical Laboratory	RX MNTR 1+ORAL ONC RX&SBSTS	40.67	40.67
0111U	Clinical Laboratory	ONC COLON CA KRAS&NRAS ALYS	1023.44	1023.44
0112U	Clinical Laboratory	IADI 16S&18S RRNA GENES	534.20	534.20
0113U	Clinical Laboratory	ONC PRST8 PCA3&TMPRSS2-ERG	1140.00	1140.00
0114U	Clinical Laboratory	GI BARRETTS ESOPH VIM&CCNA1	2907.02	2907.02
0115U	Clinical Laboratory	RESPIR IADNA 18 VIRAL&2 BACT	413.03	413.03
0116U	Clinical Laboratory	RX MNTR NZM IA 35+ORAL FLU	370.38	370.38
0117U	Clinical Laboratory	PAIN MGMT 11 ENDOGENOUS ANAL	1260.98	1260.98
0118U	Clinical Laboratory	TRNSPLJ DON-DRV CLL-FR DNA	4129.88	4129.88
0119U	Clinical Laboratory	CRD CERAMIDES LIQ CHROM PLSM	125.64	125.64
0120U	Clinical Laboratory	ONC B CLL LYMPHM MRNA 58 GEN	3765.32	3765.32
0121U	Clinical Laboratory	SC DIS VCAM-1 WHOLE BLOOD	763.80	763.80
0122U	Clinical Laboratory	SC DIS P-SELECTIN WHL BLOOD	789.35	789.35
0123U	Clinical Laboratory	MCHNL FRAGILITY RBC PRFLG	536.45	536.45
0129U	Clinical Laboratory	HERED BRST CA RLTD DO PANEL	1955.93	1955.93
0130U	Clinical Laboratory	HERED COLON CA DO MRNA PNL	877.35	877.35
0131U	Clinical Laboratory	HERED BRST CA RLTD DO PNL 13	1065.00	1065.00
0132U	Clinical Laboratory	HERED OVA CA RLTD DO PNL 17	1112.46	1112.46
0133U	Clinical Laboratory	HERED PRST8 CA RLTD DO 11	1035.44	1035.44
0134U	Clinical Laboratory	HERED PAN CA MRNA PNL 18 GEN	1122.59	1122.59
0135U	Clinical Laboratory	HERED GYN CA MRNA PNL 12 GEN	1050.84	1050.84
0136U	Clinical Laboratory	ATM MRNA SEQ ALYS	611.15	611.15
0137U	Clinical Laboratory	PALB2 MRNA SEQ ALYS	424.32	424.32
0138U	Clinical Laboratory	BRCA1 BRCA2 MRNA SEQ ALYS	702.50	702.50
0140U	Clinical Laboratory	NFCT DS FUNGI DNA 15 TRGT	235.13	235.13
0141U	Clinical Laboratory	NFCT DS BACT&FNG GRAM POS	235.13	235.13
0142U	Clinical Laboratory	NFCT DS BACT&FNG GRAM NEG	235.13	235.13
0152U	Clinical Laboratory	NFCT DS DNA UNTRGT NGNRJ SEQ	3189.30	3189.30
0153U	Clinical Laboratory	ONC BREAST MRNA 101 GENES	4739.13	4739.13
0154U	Clinical Laboratory	ONC URTHL CA RNA FGFR3 GENE	723.21	723.21
0155U	Clinical Laboratory	ONC BRST CA DNA PIK3CA GENE	412.25	412.25
0156U	Clinical Laboratory	COPY NUMBER SEQUENCE ALYS	2610.00	2610.00
0157U	Clinical Laboratory	APC MRNA SEQ ALYS	424.32	424.32
0158U	Clinical Laboratory	MLH1 MRNA SEQ ALYS	424.32	424.32
0159U	Clinical Laboratory	MSH2 MRNA SEQ ALYS	424.32	424.32
0160U	Clinical Laboratory	MSH6 MRNA SEQ ALYS	424.32	424.32
0161U	Clinical Laboratory	PMS2 MRNA SEQ ALYS	424.32	424.32
0162U	Clinical Laboratory	HERED COLON CA TRGT MRNA PNL	729.81	729.81
0163U	Clinical Laboratory	ONC CLRCT SCR 3 PRTN ALG	586.13	586.13
0164T	Major surgery	REMOVE LUMB ARTIF DISC ADDL	2365.41	2365.41
0164U	Clinical Laboratory	GI IBS IA ANTI-CDTB&VINCULIN	168.03	168.03
0165T	Major surgery	REVISE LUMB ARTIF DISC ADDL	2303.11	2303.11
0165U	Clinical Laboratory	PEANUT ALLG ASMT EPI PRB ALL	695.64	695.64
0166U	Clinical Laboratory	LIVER DS 10 BIOCHEM ASY SRM	755.10	755.10
0167U	Clinical Laboratory	CHORNC GONADOTROPIN HCG IA	11.28	11.28
0169U	Clinical Laboratory	NUDT15&TPMT GENE COM VRNT	699.26	699.26
0170U	Clinical Laboratory	NEURO ASD RNA NEXT GEN SEQ	2925.00	2925.00
0171U	Clinical Laboratory	TRGT GEN SEQ ALYS PNL DNA 23	2278.59	2278.59
0172U	Clinical Laboratory	ONC SLD TUM ALYS BRCA1 BRCA2	4545.00	4545.00
0173U	Clinical Laboratory	PSYC GEN ALYS PANEL 14 GENES	699.26	699.26
0174T	Other professional services	CAD CXR WITH INTERP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0174U	Clinical Laboratory	ONC SOLID TUMOR 30 PRTN TRGT	1958.06	1958.06
0175T	Other professional services	CAD CXR REMOTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0175U	Clinical Laboratory	PSYC GEN ALYS PANEL 15 GENES	2004.14	2004.14
0176U	Clinical Laboratory	CDTB&VINCULIN IGG ANTB IA	96.29	96.29
0177U	Clinical Laboratory	ONC BRST CA DNA PIK3CA 11	412.25	412.25
0178U	Clinical Laboratory	PEANUT ALLG ASMT EPI CLIN RX	689.79	689.79
0179U	Clinical Laboratory	ONC NONSM CLL LNG CA ALYS 23	2914.82	2914.82
0180U	Clinical Laboratory	ABO GNOTYP ABO 7 EXONS	412.25	412.25
0181U	Clinical Laboratory	CO GNOTYP AQP1 EXON 1	277.80	277.80
0182U	Clinical Laboratory	CROM GNOTYP CD55 EXONS 1-10	452.03	452.03
0183U	Clinical Laboratory	DI GNOTYP SLC4A1 EXON 19	277.80	277.80
0184T	Other professional services	EXC RECTAL TUMOR ENDOSCOPIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0184U	Clinical Laboratory	DO GNOTYP ART4 EXON 2	277.80	277.80
0185U	Clinical Laboratory	FUT1 GNOTYP FUT1 EXON 4	277.80	277.80
0186U	Clinical Laboratory	FUT2 GNOTYP FUT2 EXON 2	277.80	277.80
0187U	Clinical Laboratory	FY GNOTYP ACKR1 EXONS 1-2	412.25	412.25
0188U	Clinical Laboratory	GE GNOTYP GYPC EXONS 1-4	412.25	412.25
0189U	Clinical Laboratory	GYPA GNOTYP NTRNS 1 5 EXON 2	412.25	412.25
0190U	Clinical Laboratory	GYPB GNOTYP NTRNS 1 5 SEUX 3	412.25	412.25
0191U	Clinical Laboratory	IN GNOTYP CD44 EXONS 2 3 6	412.25	412.25
0192U	Clinical Laboratory	JK GNOTYP SLC14A1 EXON 9	412.25	412.25
0193U	Clinical Laboratory	JR GNOTYP ABCG2 EXONS 2-26	424.32	424.32
0194U	Clinical Laboratory	KEL GNOTYP KEL EXON 8	277.80	277.80
0195U	Clinical Laboratory	KLF1 TARGETED SEQUENCING	562.88	562.88
0196U	Clinical Laboratory	LU GNOTYP BCAM EXON 3	277.80	277.80
0197U	Clinical Laboratory	LW GNOTYP ICAM4 EXON 1	277.80	277.80
0198T	Other professional services	OCULAR BLOOD FLOW MEASURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0198U	Clinical Laboratory	RHD&RHCE GNTYP RHD1-10&RHCE5	424.32	424.32
0199U	Clinical Laboratory	SC GNOTYP ERMAP EXONS 4 12	412.25	412.25
0200T	Other professional services	PERQ SACRAL AUGMT UNILAT INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0200U	Clinical Laboratory	XK GNOTYP XK EXONS 1-3	412.25	412.25
0201T	Other professional services	PERQ SACRAL AUGMT BILAT INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0201U	Clinical Laboratory	YT GNOTYP ACHE EXON 2	277.80	277.80
0202T	Other professional services	POST VERT ARTHRPLST 1 LUMBAR	3535.14	2160.56
0202U	Clinical Laboratory	NFCT DS 22 TRGT SARS-COV-2	625.17	625.17
0203U	Clinical Laboratory	AI IBD MRNA XPRSN PRFL 17	1140.00	1140.00
0204U	Clinical Laboratory	ONC THYR MRNA XPRSN ALYS 593	4379.40	4379.40
0205U	Clinical Laboratory	OPH AMD ALYS 3 GENE VARIANTS	70.50	70.50
0206U	Clinical Laboratory	NEURO ALZHEIMER CELL AGGREGJ	3323.10	3323.10
0207T	Other professional services	CLEAR EYELID GLAND W/HEAT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0207U	Clinical Laboratory	NEURO ALZHEIMER QUAN IMAGING	766.80	766.80
0208T	Other professional services	AUDIOMETRY AIR ONLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0209T	Other professional services	AUDIOMETRY AIR & BONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0209U	Clinical Laboratory	CYTOG CONST ALYS INTERROG	1180.73	1180.73
0210T	Other professional services	SPEECH AUDIOMETRY THRESHOLD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0210U	Clinical Laboratory	SYPHILIS TST ANTB IA QUAN	27.95	27.95
0211T	Other professional services	SPEECH AUDIOM THRESH & RECOG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0211U	Clinical Laboratory	ONC PAN-TUM DNA&RNA GNRJ SEQ	12682.50	12682.50
0212T	Other professional services	COMPRE AUDIOMETRY EVALUATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0212U	Clinical Laboratory	RARE DS GEN DNA ALYS PROBAND	8212.80	8212.80
0213T	Other professional services	NJX PARAVERT W/US CER/THOR	301.97	171.72
0213U	Clinical Laboratory	RARE DS GEN DNA ALYS EA COMP	4064.93	4064.93
0214T	Major surgery	NJX PARAVERT W/US CER/THOR	194.77	126.34
0214U	Clinical Laboratory	RARE DS XOM DNA ALYS PROBAND	7836.90	7836.90
0215T	Major surgery	NJX PARAVERT W/US CER/THOR	196.77	128.35
0215U	Clinical Laboratory	RARE DS XOM DNA ALYS EA COMP	3861.98	3861.98
0216T	Other professional services	NJX PARAVERT W/US LUMB/SAC	269.48	144.90
0216U	Clinical Laboratory	NEURO INH ATAXIA DNA 12 COM	2305.53	2305.53
0217T	Major surgery	NJX PARAVERT W/US LUMB/SAC	175.99	107.48
0217U	Clinical Laboratory	NEURO INH ATAXIA DNA 51 GENE	3297.53	3297.53
0218T	Major surgery	NJX PARAVERT W/US LUMB/SAC	178.68	108.87
0218U	Clinical Laboratory	NEURO MUSC DYS DMD SEQ ALYS	3418.50	3418.50
0219T	Other professional services	PLMT POST FACET IMPLT CERV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0219U	Clinical Laboratory	NFCT AGT HIV GNRJ SEQ ALYS	1087.50	1087.50
0220T	Other professional services	PLMT POST FACET IMPLT THOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0220U	Clinical Laboratory	ONC BRST CA AI ASSMT 12 FEAT	1059.38	1059.38
0221T	Other professional services	PLMT POST FACET IMPLT LUMB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0221U	Clinical Laboratory	ABO GNOTYP NEXT GNRJ SEQ ABO	412.25	412.25
0222T	Major surgery	PLMT POST FACET IMPLT ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0222U	Clinical Laboratory	RHD&RHCE GNTYP NEXT GNRJ SEQ	424.32	424.32
0223U	Clinical Laboratory	NFCT DS 22 TRGT SARS-COV-2	625.17	625.17
0224U	Clinical Laboratory	ANTIBODY SARS-COV-2 TITER(S)	77.15	77.15
0225U	Clinical Laboratory	NFCT DS DNA&RNA 21 SARSCOV2	625.17	625.17
0226U	Clinical Laboratory	SVNT SARSCOV2 ELISA PLSM SRM	63.42	63.42
0227U	Clinical Laboratory	RX ASY PRSMV 30+RX/METABLT	93.21	93.21
0228U	Clinical Laboratory	ONC PRST8 MA MOLEC PRFL ALG	259.55	259.55
0229U	Clinical Laboratory	BCAT1&IKZF1 PRMTR MTHLN ALYS	576.00	576.00
0230U	Clinical Laboratory	AR FULL SEQUENCE ANALYSIS	452.03	452.03
0231U	Clinical Laboratory	CACNA1A FULL GENE ANALYSIS	1269.41	1269.41
0232T	Other professional services	NJX PLATELET PLASMA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0232U	Clinical Laboratory	CSTB FULL GENE ANALYSIS	412.25	412.25
0233U	Clinical Laboratory	FXN GENE ANALYSIS	412.25	412.25
0234T	Major surgery	TRLUML PERIP ATHRC RENAL ART	2673.43	2673.43
0234U	Clinical Laboratory	MECP2 FULL GENE ANALYSIS	791.81	791.81
0235T	Major surgery	TRLUML PERIP ATHRC VISCERAL	15545.58	1022.13
0235U	Clinical Laboratory	PTEN FULL GENE ANALYSIS	900.00	900.00
0236T	Major surgery	TRLUML PERIP ATHRC ABD AORTA	2276.24	2276.24
0236U	Clinical Laboratory	SMN1&SMN2 FULL GENE ANALYSIS	904.05	904.05
0237T	Major surgery	TRLUML PERIP ATHRC BRCHIOCPH	2516.24	2516.24
0237U	Clinical Laboratory	CAR ION CHNLPTHY GEN SEQ PNL	877.35	877.35
0238T	Major surgery	TRLUML PERIP ATHRC ILIAC ART	2089.11	2089.11
0238U	Clinical Laboratory	ONC LNCH SYN GEN DNA SEQ ALY	877.35	877.35
0239U	Clinical Laboratory	TRGT GEN SEQ ALYS PNL 311+	5250.00	5250.00
0240U	Clinical Laboratory	NFCT DS VIR RESP RNA 3 TRGT	213.95	213.95
0241U	Clinical Laboratory	NFCT DS VIR RESP RNA 4 TRGT	213.95	213.95
0242U	Clinical Laboratory	TRGT GEN SEQ ALYS PNL 55-74	7500.00	7500.00
0243U	Clinical Laboratory	OB PE BIOCHEM ASSAY PGF ALG	96.62	96.62
0244U	Clinical Laboratory	ONC SOLID ORGN DNA 257 GENES	5250.00	5250.00
0245U	Clinical Laboratory	ONC THYR MUT ALYS 10 GEN&37	1899.11	1899.11
0246U	Clinical Laboratory	RBC DNA GNOTYP 16 BLD GROUPS	1080.00	1080.00
0247U	Clinical Laboratory	OB PRTRM BRTH IBP4 SHBG MEAS	1125.00	1125.00
0248U	Clinical Laboratory	ONC BRN SPHRD CLL 12 RX PNL	4550.79	4550.79
0249U	Clinical Laboratory	ONC BRST ALYS 32 PHSPRTN ALG	3328.70	3328.70
0250U	Clinical Laboratory	ONC SLD ORG NEO DNA 505 GENE	4379.40	4379.40
0251U	Clinical Laboratory	HEPCIDIN-25 ELISA SERUM/PLSM	25.91	25.91
0252U	Clinical Laboratory	FTL ANEUPLOIDY STR ALYS DNA	1138.58	1138.58
0253T	Major surgery	INSERT AQUEOUS DRAIN DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0253U	Clinical Laboratory	RPRDTVE MED RNA GEN PRFL 238	4739.13	4739.13
0254U	Clinical Laboratory	REPRDTVE MED ALYS 24 CHRMSM	1138.58	1138.58
0255U	Clinical Laboratory	ANDROLOGY INFERTILITY ASSMT	47.40	47.40
0256U	Clinical Laboratory	TMA/TMAO PRFL MS/MS UR ALG	239.93	239.93
0257U	Clinical Laboratory	VLCAD LEUK NZM ACTV WHL BLD	1068.71	1068.71
0258U	Clinical Laboratory	AI PSOR MRNA 50-100 GEN ALG	5512.50	5512.50
0259U	Clinical Laboratory	NEPH CKD NUC MRS MEAS GFR	79.07	79.07
0260U	Clinical Laboratory	RARE DS ID OPT GENOME MAPG	1895.30	1895.30
0261U	Clinical Laboratory	ONC CLRCT CA IMG ALYS W/AI	7425.00	7425.00
0262U	Clinical Laboratory	ONC SLD TUM RT-PCR 7 GEN	4800.00	4800.00
0263T	Other professional services	IM B1 MRW CEL THER CMPL	504.72	504.72
0263U	Clinical Laboratory	NEURO ASD MEAS 16 C METBLT	1125.00	1125.00
0264T	Other professional services	IM B1 MRW CEL THER XCL HRVST	226.50	226.50
0264U	Clinical Laboratory	RARE DS ID OPT GENOME MAPG	1895.30	1895.30
0265T	Other professional services	IM B1 MRW CEL THER HRVST ONL	19.01	19.01
0265U	Clinical Laboratory	RAR DO WHL GN&MTCDRL DNA ALS	8213.70	8213.70
0266T	Major surgery	IMPLT/RPL CRTD SNS DEV TOTAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0266U	Clinical Laboratory	UNXPL CNST HRTBL DO GN XPRSN	4800.00	4800.00
0267T	Major surgery	IMPLT/RPL CRTD SNS DEV LEAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0267U	Clinical Laboratory	RARE DO ID OPT GEN MAPG&SEQ	10109.00	10109.00
0268T	Major surgery	IMPLT/RPL CRTD SNS DEV GEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0268U	Clinical Laboratory	HEM AHUS GEN SEQ ALYS 15 GEN	912.26	912.26
0269T	Other professional services	REV/REMVL CRTD SNS DEV TOTAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0269U	Clinical Laboratory	HEM AUT DM CGEN TRMBCTPNA 22	912.26	912.26
0270T	Other professional services	REV/REMVL CRTD SNS DEV LEAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0270U	Clinical Laboratory	HEM CGEN COAGJ DO 20 GENES	912.26	912.26
0271T	Other professional services	REV/REMVL CRTD SNS DEV GEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0271U	Clinical Laboratory	HEM CGEN NEUTROPENIA 24 GEN	912.26	912.26
0272T	Other professional services	INTERROGATE CRTD SNS DEV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0272U	Clinical Laboratory	HEM GENETIC BLD DO 60 GENES	912.26	912.26
0273T	Other professional services	INTERROGATE CRTD SNS W/PGRMG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0273U	Clinical Laboratory	HEM GEN HYPRFIBRNLYSIS 9 GEN	912.26	912.26
0274T	Major surgery	PERQ LAMOT/LAM CRV/THRC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0274U	Clinical Laboratory	HEM GEN PLTLT DO 62 GENES	912.26	912.26
0275T	Other professional services	PERQ LAMOT/LAM LUMBAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0275U	Clinical Laboratory	HEM HEPRN NDUC TRMBCTPNA SRM	27.56	27.56
0276U	Clinical Laboratory	HEM INH THROMBOCYTOPENIA 42	3672.84	3672.84
0277U	Clinical Laboratory	HEM GEN PLTLT FUNCJ DO 40	912.26	912.26
0278T	Other professional services	TEMPR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0278U	Clinical Laboratory	HEM GEN THROMBOSIS 14 GENES	912.26	912.26
0279U	Clinical Laboratory	HEM VW FACTOR&CLGN III BNDG	17.30	17.30
0280U	Clinical Laboratory	HEM VW FACTOR&CLGN IV BNDG	25.91	25.91
0281U	Clinical Laboratory	HEM VWD PROPEPTIDE AG LVL	25.91	25.91
0282U	Clinical Laboratory	RBC DNA GNTYP 12 BLD GRP GEN	1080.00	1080.00
0283U	Clinical Laboratory	VW FACTOR TYPE 2B EVAL PLSM	27.60	27.60
0284U	Clinical Laboratory	VW FACTOR TYPE 2N EVAL PLSM	25.91	25.91
0285U	Clinical Laboratory	ONC RSPS RADJ CLL FR DNA TOX	664.97	664.97
0286U	Clinical Laboratory	CEP72 NUDT15&TPMT GENE ALYS	201.20	201.20
0287U	Clinical Laboratory	ONC THYR DNA&MRNA 112 GENES	5400.00	5400.00
0288U	Clinical Laboratory	ONC LUNG MRNA QUAN PCR 11&3	5809.50	5809.50
0289U	Clinical Laboratory	NEURO ALZHEIMER MRNA 24 GEN	1140.00	1140.00
0290U	Clinical Laboratory	PAIN MGMT MRNA GEN XPRSN 36	1140.00	1140.00
0291U	Clinical Laboratory	PSYC MOOD DO MRNA 144 GENES	2632.50	2632.50
0292U	Clinical Laboratory	PSYC STRS DO MRNA 72 GENES	2632.50	2632.50
0293U	Clinical Laboratory	PSYC SUICIDAL IDEA MRNA 54	1140.00	1140.00
0294U	Clinical Laboratory	LNGVTY&MRTLTY RSK MRNA 18GEN	1140.00	1140.00
0295U	Clinical Laboratory	ONC BRST DUX CARC 7 PROTEINS	8152.50	8152.50
0296U	Clinical Laboratory	ONC ORL&/OROP CA 20 MLC FEAT	2925.00	2925.00
0297U	Clinical Laboratory	ONC PAN TUM WHL GEN SEQ DNA	4379.40	4379.40
0298U	Clinical Laboratory	ONC PAN TUM WHL TRNS SEQ RNA	4379.40	4379.40
0299U	Clinical Laboratory	ONC PAN TUM WHL GEN OPT MAPG	2794.83	2794.83
0300U	Clinical Laboratory	ONC PAN TUM WHL GEN SEQ&OPT	6274.70	6274.70
0301U	Clinical Laboratory	IADNA BARTONELLA DDPCR	394.08	394.08
0302U	Clinical Laboratory	IADNA BRTNLA DDPCR FLWG LIQ	542.06	542.06
0303U	Clinical Laboratory	HEM RBC ADS WHL BLD HYPOXIC	3302.43	3302.43
0304U	Clinical Laboratory	HEM RBC ADS WHL BLD NORMOXIC	3113.70	3113.70
0305U	Clinical Laboratory	HEM RBC FNCLTY&DFRM SHR STRS	993.87	993.87
0306U	Clinical Laboratory	ONC MRD NXT-GNRJ ALYS 1ST	5817.68	5817.68
0307U	Clinical Laboratory	ONC MRD NXT-GNRJ ALYS SBSQ	1191.74	1191.74
0308T	Major surgery	INSJ OCULAR TELESCOPE PROSTH	935.10	935.10
0308U	Clinical Laboratory	CRD CAD ALYS 3 PRTN 3 PARAM	586.13	586.13
0309U	Clinical Laboratory	CRD CV DS ALY 4 PRTN PLM ALG	586.13	586.13
0310U	Clinical Laboratory	PED VSCLTS KD ALYS 3 BMRKS	586.13	586.13
0311U	Clinical Laboratory	NFCT DS BCT QUAN ANTMCRB SC	12.12	12.12
0312U	Clinical Laboratory	AI DS SLE ALYS 8 IGG AUTOANT	1260.98	1260.98
0313U	Clinical Laboratory	ONC PNCRS DNA&MRNA SEQ 74	5400.00	5400.00
0314U	Clinical Laboratory	ONC CUTAN MLNMA MRNA 35 GENE	2925.00	2925.00
0315U	Clinical Laboratory	ONC CUTAN SQ CLL CA MRNA 40	12750.00	12750.00
0316U	Clinical Laboratory	B BRGDRFERI LYME DS OSPA EVL	27.99	27.99
0317U	Clinical Laboratory	ONC LUNG CA 4-PRB FISH ASSAY	3045.00	3045.00
0318U	Clinical Laboratory	PED WHL GEN MTHYLTN ALYS 50+	2655.72	2655.72
0319U	Clinical Laboratory	NEPH RNA PRETRNSPL PERPH BLD	3975.00	3975.00
0320U	Clinical Laboratory	NEPH RNA PSTTRNSPL PERPH BLD	3975.00	3975.00
0321U	Clinical Laboratory	IADNA GU PTHGN 20BCT&FNG ORG	952.26	952.26
0322U	Clinical Laboratory	NEURO ASD MEAS 14 ACYL CARN	1125.00	1125.00
0323U	Clinical Laboratory	IADNA CNS PTHGN NEXT GEN SEQ	3189.30	3189.30
0326U	Clinical Laboratory	TRGT GEN SEQ ALYS PNL 83+	7500.00	7500.00
0327U	Clinical Laboratory	FTL ANEUPLOIDY TRSMY DNA SEQ	1192.50	1192.50
0328U	Clinical Laboratory	DRUG ASSAY 120+ RX&METABLT	171.65	171.65
0329T	Major surgery	MNTR IO PRESS 24HRS/> UNI/BI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0329U	Clinical Laboratory	ONC NEO XOME&TRNS SEQ ALYS	5156.97	5156.97
0330T	Major surgery	TEAR FILM IMG UNI/BI W/I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0330U	Clinical Laboratory	IADNA VAG PTHGN PANEL 27 ORG	625.17	625.17
0331T	Major surgery	HEART SYMP IMAGE PLNR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0331U	Clinical Laboratory	ONC HL NEO OPT GEN MAPPING	2794.83	2794.83
0332T	Major surgery	HEART SYMP IMAGE PLNR SPECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0332U	Clinical Laboratory	ONC PAN TUM GEN PRFLG 8 DNA	1713.09	1713.09
0333T	Major surgery	VISUAL EP SCR ACUITY AUTO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0333U	Clinical Laboratory	ONC LVR SURVEILANC HCC CFDNA	993.48	993.48
0334U	Clinical Laboratory	ONC SLD ORGN TGSA DNA 84/+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0335T	Major surgery	INSJ SINUS TARSI IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0335U	Clinical Laboratory	RARE DS WHL GEN SEQ FETAL	7836.90	7836.90
0336U	Clinical Laboratory	RARE DS WHL GEN SEQ BLD/SLV	3861.98	3861.98
0337U	Clinical Laboratory	ONC PLSM CELL DO&MYELOMA ID	3652.50	3652.50
0338T	Major surgery	TRNSCTH RENAL SYMP DENRV UNL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0338U	Clinical Laboratory	ONC SLD TUM CRCG TUM CL SLCT	3652.50	3652.50
0339T	Major surgery	TRNSCTH RENAL SYMP DENRV BIL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0339U	Clinical Laboratory	ONC PRST8 MRNA HOXC6 & DLX1	1140.00	1140.00
0340U	Clinical Laboratory	ONC PAN CA ALYS MRD PLASMA	5385.00	5385.00
0341U	Clinical Laboratory	FTL ANEUP DNA SEQ CMPR ALYS	2850.30	2850.30
0342T	Major surgery	THXP APHERESIS W/HDL DELIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0342U	Clinical Laboratory	ONC PNCRTC CA MULT IA ECLIA	1345.50	1345.50
0343U	Clinical Laboratory	ONC PRST8 XOM ALY 442 SNCRNA	1140.00	1140.00
0344U	Clinical Laboratory	HEP NAFLD SEMIQ EVL 28 LIPID	1188.26	1188.26
0345T	Major surgery	TRANSCATH MTRAL VLVE REPAIR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0345U	Clinical Laboratory	PSYC GENOM ALYS PNL 15 GEN	2004.14	2004.14
0346U	Clinical Laboratory	BETA AMYL A40&A42 LC-MS/MS	139.89	139.89
0347T	Major surgery	INS BONE DEVICE FOR RSA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0347U	Clinical Laboratory	RX METAB/PCX DNA 16 GEN ALYS	2004.14	2004.14
0348T	Major surgery	RSA SPINE EXAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0348U	Clinical Laboratory	RX METAB/PCX DNA 25 GEN ALYS	1113.41	1113.41
0349T	Major surgery	RSA UPPER EXTR EXAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0349U	Clinical Laboratory	RX METAB/PCX DNA 27GEN RX IA	1113.41	1113.41
0350T	Major surgery	RSA LOWER EXTR EXAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0350U	Clinical Laboratory	RX METAB/PCX DNA 27 GEN ALYS	2004.14	2004.14
0351T	Major surgery	INTRAOP OCT BRST/NODE SPEC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0351U	Clinical Laboratory	NFCT DS BCT/VIRAL TRAIL IP10	390.75	390.75
0352T	Major surgery	OCT BRST/NODE I&R PER SPEC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0352U	Clinical Laboratory	NFCT DS BV&VAGINITIS AMP PRB	213.95	213.95
0353T	Major surgery	INTRAOP OCT BREAST CAVITY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0353U	Clinical Laboratory	IADNA CHLMYD&GONORR AMP PRB	105.27	105.27
0354T	Major surgery	OCT BREAST SURG CAVITY I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0354U	Clinical Laboratory	HPV HI RSK QUAL MRNA E6/E7	52.64	52.64
0355U	Clinical Laboratory	APOL1 RISK VARIANTS	205.50	205.50
0356U	Clinical Laboratory	ONC OROP/ANAL 17 DNA DDPCR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0358T	Major surgery	BIA WHOLE BODY	9.75	9.75
0358U	Clinical Laboratory	NEURO ALYS -AMYL 1-42&1-40	390.75	390.75
0359U	Clinical Laboratory	ONC PRST8 CA ALYS ALL PSA	1140.00	1140.00
0360U	Clinical Laboratory	ONC LUNG ELISA 7 AUTOANT ALG	1260.98	1260.98
0361U	Clinical Laboratory	NEURFLMNT LT CHN DIG IA QUAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0362T	Major surgery	BHV ID SUPRT ASSMT EA 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0362U	Clinical Laboratory	ONC PAP THYR CA RNA 82&10	5400.00	5400.00
0363U	Clinical Laboratory	ONC URTHL MRNA 5 GEN ALG	1140.00	1140.00
0364U	Clinical Laboratory	ONC HL NEO GEN SEQ ALYS ALG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0365U	Clinical Laboratory	ONC BLDR 10 PRB BLDR CA	1345.50	1345.50
0366U	Clinical Laboratory	ONC BLDR 10 PRB RECR BLDR CA	1345.50	1345.50
0367U	Clinical Laboratory	ONC BLDR 10 FLWG TRURL RESCJ	1353.27	1353.27
0368U	Clinical Laboratory	ONC CLRCT CA MUT&MTHYLTN MRK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0369U	Clinical Laboratory	IADNA GI PTHGN 31 ORG&21 ARG	625.17	625.17
0370U	Clinical Laboratory	IADNA SURG WND PTHGN 34&21	625.17	625.17
0371U	Clinical Laboratory	IADNA GU PTHGN SEMIQ DNA16&1	625.17	625.17
0372U	Clinical Laboratory	NFCT DS GU PTHGN ARG DETCJ	625.17	625.17
0373T	Major surgery	ADAPT BHV TX EA 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0373U	Clinical Laboratory	IADNA RSP TR NFCT 17 8 13&16	625.17	625.17
0374U	Clinical Laboratory	IADNA GU PTHGN 21 ORG&21ARG	625.17	625.17
0375U	Clinical Laboratory	ONC OVRN BCHM ASY 7 PRTN ALG	1345.50	1345.50
0376U	Clinical Laboratory	ONC PRST8 CA IMG ALYS 128	1059.38	1059.38
0377U	Clinical Laboratory	CV DS QUAN ADVSRM/PLSM LPRTN	71.37	71.37
0378T	Other professional services	VISUAL FIELD ASSMNT REV/RPRT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0378U	Clinical Laboratory	RFC1 REPEAT XPNSJ VRNT ALYS	205.50	205.50
0379T	Other professional services	VIS FIELD ASSMNT TECH SUPPT	116.85	116.85
0379U	Clinical Laboratory	TGSAP SL OR NEO DNA523&RNA55	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0380U	Clinical Laboratory	RX METB ADVRS TRGT SQ ALY 20	625.17	625.17
0381U	Clinical Laboratory	MAPLE SYRUP UR DS MNTR QUAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0382U	Clinical Laboratory	HYPRPHENYLALNINMIA MNTR QUAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0383U	Clinical Laboratory	TYROSINEMIA TYP I MNTR QUAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0384U	Clinical Laboratory	NEPH CKD RSK HI STG KDN DS	1125.00	1125.00
0385U	Clinical Laboratory	NEPH CKD ALG RSK DBTC KDN DS	586.13	586.13
0387U	Clinical Laboratory	ONC MLNMA AMBRA1&AMLO	1422.75	1422.75
0388U	Clinical Laboratory	ONC NONSM CLL LNG CA 37 GEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0389U	Clinical Laboratory	PED FBRL KD IFI27&MCEMP1 RNA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0390U	Clinical Laboratory	OB PE KDR ENG&RBP4 IA ALG	96.62	96.62
0391U	Clinical Laboratory	ONC SLD TUM DNA&RNA 437 GEN	5400.00	5400.00
0392U	Clinical Laboratory	RX METAB GEN-RX IA 16 GENES	2004.14	2004.14
0393U	Clinical Laboratory	NEU PRKSN MSFL -SYNCLN PRTN	811.49	811.49
0394T	Other professional services	HDR ELCTRNC SKN SURF BRCHYTX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0394U	Clinical Laboratory	PFAS 16 PFAS COMPND LC MS/MS	298.11	298.11
0395T	Other professional services	HDR ELCTR NTRST/NTRCV BRCHTX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0395U	Clinical Laboratory	ONC LNG MULTIOMICS PLSM ALG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0396U	Clinical Laboratory	OB PREIMPLTJ TST 300000 DNA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0397T	Other professional services	ERCP W/OPTICAL ENDOMICROSCPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0398T	Other professional services	MRGFUS STRTCTC LES ABLTJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0398T-26	Other professional services	MRGFUS STRTCTC LES ABLTJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0398T-TC	Other professional services	MRGFUS STRTCTC LES ABLTJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0398U	Clinical Laboratory	GI BARET ESPH DNA MTHYLN ALY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0399U	Clinical Laboratory	NEURO CERE FOLATE DEFNCY SRM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0400U	Clinical Laboratory	OB XPND CAR SCR 145 GENES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0401U	Clinical Laboratory	CRD C HRT DS 9 GEN 12 VRNTS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0402T	Other professional services	COLGN CRS-LINK CRN&PACHYMTRY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0402U	Clinical Laboratory	NFCT AGT STI MULT AMP PRB TQ	213.95	213.95
0403T	Other professional services	DIABETES PREV STANDARD CURR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0403U	Clinical Laboratory	ONC PRST8 MRNA 18 GEN DRE UR	1140.00	1140.00
0404U	Clinical Laboratory	ONC BRST SEMIQ MEAS THYM KN	484.44	484.44
0405U	Clinical Laboratory	ONC PNCRTC 59 MTHLTN BLK MRK	2655.72	2655.72
0406U	Clinical Laboratory	ONC LUNG FLOW CYTMTRY 5 MRK	1140.00	1140.00
0407U	Clinical Laboratory	NEPH DBTC CKD MULT ECLIA ALG	1425.00	1425.00
0408T	Other professional services	INSJ/RPLC CARDIAC MODULJ SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0408U	Clinical Laboratory	IAAD BLK AC WV BSNSR SARSCV2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0409T	Other professional services	INSJ/RPLC CAR MODULJ PLS GN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0409U	Clinical Laboratory	ONC SLD TUM DNA 80 & RNA 36	4379.40	4379.40
0410T	Other professional services	INSJ/RPLC CAR MODULJ ATR ELT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0410U	Clinical Laboratory	ONC PNCRTC DNA WHL GN SEQ 5-	1740.00	1740.00
0411T	Other professional services	INSJ/RPLC CAR MODULJ VNT ELT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0411U	Clinical Laboratory	PSYC GENOM ALYS PNL 15 GEN	2004.14	2004.14
0412T	Other professional services	RMVL CARDIAC MODULJ PLS GEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0412U	Clinical Laboratory	BETA AMYLOID A42/40 IMPRCIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0413T	Other professional services	RMVL CAR MODULJ TRANVNS ELT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0413U	Clinical Laboratory	ONC HL NEO OPT GEN MAPG DNA	1895.30	1895.30
0414T	Other professional services	RMVL & RPL CAR MODULJ PLS GN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0414U	Clinical Laboratory	ONC LNG AUG ALG ALY WHL SLD8	1059.38	1059.38
0415T	Other professional services	REPOS CAR MODULJ TRANVNS ELT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0415U	Clinical Laboratory	CV DS ACS BLD ALG 5 YR SCORE	586.13	586.13
0416T	Other professional services	RELOC SKIN POCKET PLS GEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0416U	Clinical Laboratory	IADNA GU PTHGN 20BCT&FNG ORG	625.17	625.17
0417T	Other professional services	PRGRMG EVAL CARDIAC MODULJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0417U	Clinical Laboratory	RARE DS ALYS 335 NUC GENES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0418T	Other professional services	INTERRO EVAL CARDIAC MODULJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0418U	Clinical Laboratory	ONC BRST AUG ALG ALY WHL SL8	1059.38	1059.38
0419T	Other professional services	DSTRJ NEUROFIBROMA XTNSV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0419U	Clinical Laboratory	NRPSYC GEN SEQ VRNT ALY 13	2004.14	2004.14
0420T	Other professional services	DSTRJ NEUROFIBROMA XTNSV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0420U	Clinical Laboratory	ONC URTHL MRNA XPRSN 6 SNP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0421T	Other professional services	WATERJET PROSTATE ABLTJ CMPL	970.85	970.85
0421U	Clinical Laboratory	ONC CLRCT SCR SGL AMP 8 RNA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0422T	Other professional services	TACTILE BREAST IMG UNI/BI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0422U	Clinical Laboratory	ONC PAN SOLID TUM ALYS DNA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0423U	Clinical Laboratory	PSYC GENOMIC ALYS PNL 26 GEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0424U	Clinical Laboratory	ONC PRST8 XOM ALYS 53 SNCRNA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0425U	Clinical Laboratory	GENOM RPD SEQ ALYS EA CMPRTR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0426U	Clinical Laboratory	GENOME ULTRA-RAPID SEQ ALYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0427U	Clinical Laboratory	MONOCYTE DSTRBJ WDTH WHL BLD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0428U	Clinical Laboratory	ONC BRST CTDNA ALYS 56/> GEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0429U	Clinical Laboratory	HPV OROP SWAB 14 HI-RISK TYP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0430U	Clinical Laboratory	GI MALABS AAT CALPRO PNCRTC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0431U	Clinical Laboratory	GLY RCPTR ALPHA1 IGG SRM/CSF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0432U	Clinical Laboratory	KLHL11 ANTB SR/CSF ASY QUAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0433U	Clinical Laboratory	ONC PRST8 5 DNA REG MRK PCR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0434U	Clinical Laboratory	RX METAB ADVRS VRNT ALYS 25	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0435U	Clinical Laboratory	ONC CHEMO RX CYTOX CSC 14 RX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0436U	Clinical Laboratory	ONC LNG PLSM ALYS 388 PRTN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0437T	Other professional services	IMPLTJ SYNTH RNFCMT ABDL WAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0437U	Clinical Laboratory	PSYC ANXIETY DO MRNA 15 BMRK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0438U	Clinical Laboratory	RX METAB ADVRS VRNT ALYS 33	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0439T	Other professional services	MYOCRD CONTRAST PRFUJ ECHO	374.63	374.63
0440T	Other professional services	ABLTJ PERC UXTR/PERPH NRV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0441T	Other professional services	ABLTJ PERC LXTR/PERPH NRV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0442T	Other professional services	ABLTJ PERC PLEX/TRNCL NRV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0443T	Other professional services	R-T SPCTRL ALYS PRST8 TISS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0444T	Other professional services	1ST PLMT DRUG ELUT OC INS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0445T	Other professional services	SBSQT PLMT DRUG ELUT OC INS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0446T	Other professional services	INSJ IMPLTBL GLUCOSE SENSOR	4229.40	79.65
0447T	Other professional services	RMVL IMPLTBL GLUCOSE SENSOR	139.83	93.45
0448T	Other professional services	REMVL INSJ IMPLTBL GLUC SENS	4212.59	132.89
0449T	Other professional services	INSJ AQUEOUS DRAIN DEV 1ST	1018.79	1018.79
0450T	Other professional services	INSJ AQUEOUS DRAIN DEV EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0464T	Other professional services	VISUAL EP TEST FOR GLAUCOMA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0469T	Other professional services	RTA POLARIZE SCAN OC SCR BI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0472T	Other professional services	PRGRMG IO RTA ELTRD RA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0473T	Other professional services	REPRGRMG IO RTA ELTRD RA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0474T	Other professional services	INSJ AQUEOUS DRG DEV IO RSVR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0479T	Other professional services	FXJL ABL LSR 1ST 100 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0480T	Other professional services	FXJL ABL LSR EA ADDL 100SQCM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0481T	Other professional services	NJX AUTOL WBC CONCENTRATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0483T	Other professional services	TMVI PERCUTANEOUS APPROACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0484T	Other professional services	TMVI TRANSTHORACIC EXPOSURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0485T	Other professional services	OCT MID EAR I&R UNILATERAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0485T-26	Other professional services	OCT MID EAR I&R UNILATERAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0485T-TC	Other professional services	OCT MID EAR I&R UNILATERAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0486T	Other professional services	OCT MID EAR I&R BILATERAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0486T-26	Other professional services	OCT MID EAR I&R BILATERAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0486T-TC	Other professional services	OCT MID EAR I&R BILATERAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0488T	Other professional services	DIABETES PREV ONLINE/ELEC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0489T	Other professional services	REGN CELL TX SCLDR HANDS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0490T	Other professional services	REGN CELL TX SCLDR H MLT INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0494T	Other professional services	PREP & CANNULJ CDVR DON LUNG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0495T	Other professional services	MNTR CDVR DON LNG 1ST 2 HRS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0496T	Other professional services	MNTR CDVR DON LNG EA ADDL HR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0500T	Other professional services	HPV 5+ HI RISK HPV TYPES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0505T	Other professional services	EV FEMPOP ARTL REVSC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0506T	Other professional services	MAC PGMT OPT DNS MEAS HFP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0506T-26	Other professional services	MAC PGMT OPT DNS MEAS HFP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0506T-TC	Other professional services	MAC PGMT OPT DNS MEAS HFP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0507T	Other professional services	NEAR IFR 2IMG MIBMN GLND I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0507T-26	Other professional services	NEAR IFR 2IMG MIBMN GLND I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0507T-TC	Other professional services	NEAR IFR 2IMG MIBMN GLND I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0509T	Other professional services	PATTERN ERG W/I&R	104.90	104.90
0509T-26	Other professional services	PATTERN ERG W/I&R	29.52	29.52
0509T-TC	Other professional services	PATTERN ERG W/I&R	75.38	75.38
0510T	Other professional services	RMVL SINUS TARSI IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0511T	Other professional services	RMVL&RINSJ SINUS TARSI IMPLT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0512T	Other professional services	ESW INTEG WND HLG 1ST WND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0513T	Other professional services	ESW INTEG WND HLG EA ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0515T	Other professional services	INSJ WCS LV COMPL SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0516T	Other professional services	INSJ WCS LV ELTRD ONLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0517T	Other professional services	INSJ WCS LV BOTH COMPNT PG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0518T	Other professional services	RMVL PG WCS LV BATTERY ONLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0519T	Other professional services	RMV&RPLCMT PG WCS LV BOTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0520T	Other professional services	RMV&RPLCMT PG WCS LV BATTERY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0521T	Other professional services	INTERROG DEV EVAL WCS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0521T-26	Other professional services	INTERROG DEV EVAL WCS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0521T-TC	Other professional services	INTERROG DEV EVAL WCS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0522T	Other professional services	PRGRMG DEV EVAL WCS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0522T-26	Other professional services	PRGRMG DEV EVAL WCS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0522T-TC	Other professional services	PRGRMG DEV EVAL WCS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0523T	Other professional services	NTRAPX C FFR W/3D FUNCJL MAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0524T	Other professional services	EV CATH DIR CHEM ABLTJ W/IMG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0525T	Other professional services	INSJ/RPLCMT COMPL IIMS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0526T	Other professional services	INSJ/RPLCMT IIMS ELTRD ONLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0527T	Other professional services	INSJ/RPLCMT IIMS IMPLT MNTR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0528T	Other professional services	PRGRMG DEV EVAL IIMS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0528T-26	Other professional services	PRGRMG DEV EVAL IIMS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0528T-TC	Other professional services	PRGRMG DEV EVAL IIMS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0529T	Other professional services	INTERROG DEV EVAL IIMS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0529T-26	Other professional services	INTERROG DEV EVAL IIMS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0529T-TC	Other professional services	INTERROG DEV EVAL IIMS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0530T	Other professional services	REMOVAL COMPLETE IIMS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0531T	Other professional services	REMOVAL IIMS ELECTRODE ONLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0532T	Other professional services	REMOVAL IIMS IMPLT MNTR ONLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0537T	Other professional services	BLD DRV T LYMPHCYT CAR-T CLL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0538T	Other professional services	BLD DRV T LYMPHCYT PREP TRNS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0539T	Other professional services	RECEIPT&PREP CAR-T CLL ADMN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0540T	Other professional services	CAR-T CLL ADMN AUTOLOGOUS	236.15	236.15
0541T	Other professional services	MYOCARDIAL IMAGING MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0542T	Other professional services	MYOCARDIAL IMAGING MCG I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0543T	Other professional services	TA MV RPR W/ARTIF CHORD TEND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0544T	Other professional services	TCAT MV ANNULUS RCNSTJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0545T	Other professional services	TCAT TV ANNULUS RCNSTJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0546T	Other professional services	RF SPECTRSC NTRAOP MRGN ASMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0547T	Other professional services	B1 MATRL QUAL TST MCRIND TIB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0552T	Other professional services	LOW-LEVEL LASER THERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0553T	Other professional services	PERQ TCAT ILIAC ANAST IMPLT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0554T	Other professional services	B1 STR & FX RSK ANALYSIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0555T	Other professional services	B1 STR&FX RSK TRANSMIS DATA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0556T	Other professional services	B1 STR & FX RSK ASSESSMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0557T	Other professional services	B1 STR & FX RSK I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0558T	Other professional services	CT SCAN F/BIOMCHN CT ALYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0559T	Other professional services	ANTMC MDL 3D PRINT 1ST CMPNT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0560T	Other professional services	ANTMC MDL 3D PRINT EA ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0561T	Other professional services	ANTMC GUIDE 3D PRINT 1ST GD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0562T	Other professional services	ANTMC GUIDE 3D PRINT EA ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0563T	Other professional services	EVAC MEIBOMIAN GLND HEAT BI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0564T	Other professional services	ONC CHEMO RX CYTOTOX CSC 14	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0565T	Other professional services	AUTOL CELL IMPLT ADPS HRVG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0566T	Other professional services	AUTOL CELL IMPLT ADPS NJX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0567T	Other professional services	PERM FLP TUBE OCCLS W/IMPLT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0568T	Other professional services	INTRO MIX SALINE&AIR F/SSG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0569T	Other professional services	TTVR PERQ APPR 1ST PROSTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0570T	Other professional services	TTVR PERQ EA ADDL PROSTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0571T	Other professional services	INSJ/RPLCMT ICDS SS ELTRD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0572T	Other professional services	INSERTION SS DFB ELECTRODE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0573T	Other professional services	REMOVAL SS DFB ELECTRODE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0574T	Other professional services	REPOS PREV SS IMPL DFB ELTRD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0575T	Other professional services	PRGRMG DEV EVAL ICDS SS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0576T	Other professional services	INTERROG DEV EVAL ICDS SS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0577T	Other professional services	EPHYS EVAL ICDS SS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0578T	Other professional services	REM INTERROG DEV ICDS PHYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0579T	Other professional services	REM INTERROG DEV ICDS TECH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0580T	Other professional services	RMVL SS IMPL DFB PG ONLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0581T	Other professional services	ABLTJ MAL BRST TUM PERQ CRTX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0582T	Other professional services	TRURL ABLTJ MAL PRST8 TISS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0583T	Other professional services	TMPST AUTO TUBE DLVR SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0584T	Other professional services	PERQ ISLET CELL TRANSPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0585T	Other professional services	LAPS ISLET CELL TRANSPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0586T	Other professional services	OPEN ISLET CELL TRANSPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0587T	Other professional services	PERQ IMPLTJ/RPLCMT ISDNS PTN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0588T	Other professional services	REVISION/REMOVAL ISDNS PTN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0589T	Other professional services	ELEC ALYS SMPL PRGRMG IINS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0590T	Other professional services	ELEC ALYS CPLX PRGRMG IINS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0591T	Other professional services	HLTH&WB COACHING INDIV 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0592T	Other professional services	HLTH&WB COACHING INDIV F-UP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0593T	Other professional services	HLTH&WB COACHING GROUP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0594T	Major surgery	OSTEOT HUM XTRNL LNGTH DEV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0596T	Other professional services	TEMP FML IU VLV-PMP 1ST INSJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0597T	Other professional services	TEMP FML IU VALVE-PMP RPLCMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0598T	Other professional services	NCNTC R-T FLUOR WND IMG 1ST	224.78	224.78
0599T	Other professional services	NCNTC R-T FLUOR WND IMG EA	112.40	112.40
0600T	Other professional services	IRE ABLTJ 1+TUM ORGAN PERQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0601T	Major surgery	IRE ABLTJ 1+TUMORS OPEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0602T	Other professional services	TRANSDERMAL GFR MEASUREMENTS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0603T	Other professional services	TRANSDERMAL GFR MONITORING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0604T	Other professional services	REM OCT RTA DEV SETUP&EDUCAJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0605T	Other professional services	REM OCT RTA TECHL SPRT MIN 8	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0606T	Other professional services	REM OCT RTA PHYS/QHP EA 30D	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0607T	Other professional services	REM MNTR PULM FLU MNTR SETUP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0608T	Other professional services	REM MNTR PULM FLU MNTR ALYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0609T	Other professional services	MRS DISC PAIN ACQUISJ DATA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0610T	Other professional services	MRS DISC PAIN TRANSMIS DATA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0611T	Other professional services	MRS DISC PAIN ALG ALYS DATA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0612T	Other professional services	MRS DISCOGENIC PAIN I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0613T	Major surgery	PERQ TCAT INTRATRL SEPTL SHT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0614T	Other professional services	RMVL&RPLCMT SS IMPL DFB PG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0615T	Other professional services	EYE MVMT ALYS W/O CALBRJ I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0616T	Major surgery	INSERTION OF IRIS PROSTHESIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0617T	Major surgery	INSJ IRIS PROSTH W/RMVL&INSJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0618T	Major surgery	INSJ IRIS PROSTH SEC IO LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0619T	Major surgery	CYSTO W/PRST8 COMMISSUROTOMY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0620T	Other professional services	EVASC VEN ARTLZ TIBL/PRNL VN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0621T	Other professional services	TRABECULOSTOMY INTERNO LASER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0622T	Other professional services	TRABECULOSTOMY INT LSR W/SCP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0623T	Other professional services	AUTO QUANTIFICATION C PLAQUE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0624T	Other professional services	AUTO QUAN C PLAQ DATA PREP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0625T	Other professional services	AUTO QUAN C PLAQ CPTR ALYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0626T	Other professional services	AUTO QUAN C PLAQ I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0627T	Other professional services	PERQ NJX ALGC FLUOR LMBR 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0628T	Other professional services	PERQ NJX ALGC FLUOR LMBR EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0629T	Other professional services	PERQ NJX ALGC CT LMBR 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0630T	Other professional services	PERQ NJX ALGC CT LMBR EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0631T	Other professional services	TC VIS LIT HYPERSPECTRAL IMG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0632T	Other professional services	PERQ TCAT US ABLTJ NRV P-ART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0633T	Other professional services	CT BREAST W/3D UNI C-	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0633T-26	Other professional services	CT BREAST W/3D UNI C-	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0633T-TC	Other professional services	CT BREAST W/3D UNI C-	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0634T	Other professional services	CT BREAST W/3D UNI C+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0634T-26	Other professional services	CT BREAST W/3D UNI C+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0634T-TC	Other professional services	CT BREAST W/3D UNI C+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0635T	Other professional services	CT BREAST W/3D UNI C-/C+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0635T-26	Other professional services	CT BREAST W/3D UNI C-/C+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0635T-TC	Other professional services	CT BREAST W/3D UNI C-/C+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0636T	Other professional services	CT BREAST W/3D BI C-	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0636T-26	Other professional services	CT BREAST W/3D BI C-	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0636T-TC	Other professional services	CT BREAST W/3D BI C-	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0637T	Other professional services	CT BREAST W/3D BI C+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0637T-26	Other professional services	CT BREAST W/3D BI C+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0637T-TC	Other professional services	CT BREAST W/3D BI C+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0638T	Other professional services	CT BREAST W/3D BI C-/C+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0638T-26	Other professional services	CT BREAST W/3D BI C-/C+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0638T-TC	Other professional services	CT BREAST W/3D BI C-/C+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0639T	Other professional services	WRLS SKN SNR ANISOTROPY MEAS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0640T	Radiology	NCNTC IFR SPCTRSC O/T PAD 1	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0643T	Major surgery	TCAT L VENTR RSTRJ DEV IMPLT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0644T	Major surgery	TCAT RMVL/DBLK ICAR MAS PERQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0645T	Major surgery	TCAT IMPLTJ C SINS RDCTJ DEV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0646T	Major surgery	TTVI/RPLCMT W/PRSTC VLV PERQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0647T	Other professional services	INSJ GTUBE PERQ MAG GASTRPXY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0648T	Radiology	QUAN MR TIS WO MRI 1ORGN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0648T-26	Radiology	QUAN MR TIS WO MRI 1ORGN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0648T-TC	Radiology	QUAN MR TIS WO MRI 1ORGN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0649T	Radiology	QUAN MR TISS W/MRI 1ORGN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0649T-26	Radiology	QUAN MR TISS W/MRI 1ORGN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0649T-TC	Radiology	QUAN MR TISS W/MRI 1ORGN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0650T	Other professional services	PRGRMG DEV EVAL SCRMS REMOTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0650T-26	Other professional services	PRGRMG DEV EVAL SCRMS REMOTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0650T-TC	Other professional services	PRGRMG DEV EVAL SCRMS REMOTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0651T	Other professional services	MAG CTRLD CAPSULE ENDOSCOPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0652T	Other professional services	EGD FLX TRANSNASAL DX BR/WA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0653T	Other professional services	EGD FLX TRANSNASAL BX 1/MLT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0654T	Other professional services	EGD FLX TRANSNASAL TUBE/CATH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0655T	Other professional services	TPRNL FOCAL ABLTJ MAL PRST8	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0656T	Major surgery	VRT BDY TETHERING ANT <7 SEG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0657T	Major surgery	VRT BDY TETHERING ANT 8+ SEG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0658T	Other professional services	ELEC IMPD SPECTRSC 1+SKN LES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0659T	Major surgery	TCAT INTRA-C NFS SUPERSAT O2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0660T	Major surgery	IMPLT ANT SGM IO NBIO RX SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0661T	Major surgery	RMVL&RIMPLTJ ANT SGM IMPLT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0662T	Other professional services	SCALP COOL 1ST MEAS&CALBRJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0663T	Other professional services	SCALP COOL PLMT MNTR RMVL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0664T	Major surgery	DON HYSTERECTOMY OPEN CDVR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0665T	Major surgery	DON HYSTERECTOMY OPEN LIV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0666T	Major surgery	DON HYSTERECTOMY LAPS LIV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0667T	Major surgery	DON HYSTERECTOMY RCP UTER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0668T	Major surgery	BKBENCH PREP DON UTER ALGRFT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0669T	Major surgery	BKBENCH RCNSTJ DON UTER VEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0670T	Major surgery	BKBENCH RCNSTJ DON UTER ARTL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0671T	Major surgery	INSJ ANT SGM AQ DRG DEV 1+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0672T	Major surgery	NDOVAG CRYG RF REMDL TISS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0673T	Major surgery	ABLTJ B9 THYR NDUL PERQ LASR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0674T	Major surgery	LAPS INSJ NW/RPCMT PRM ISDSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0675T	Major surgery	LAPS INSJ NW/RPCMT ISDSS 1LD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0676T	Major surgery	LAPS INSJ NW/RPCMT ISDSS EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0677T	Major surgery	LAPS REPOS LEAD ISDSS 1ST LD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0678T	Major surgery	LAPS REPOS LEAD ISDSS EA ADD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0679T	Major surgery	LAPS RMVL LEAD ISDSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0680T	Major surgery	INSJ/RPLCMT PG ONLY ISDSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0681T	Major surgery	RLCJ PULSE GEN ONLY ISDSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0682T	Major surgery	REMOVAL PULSE GEN ONLY ISDSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0683T	Other professional services	PRGRMG DEV EVAL ISDSS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0683T-26	Other professional services	PRGRMG DEV EVAL ISDSS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0683T-TC	Other professional services	PRGRMG DEV EVAL ISDSS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0684T	Other professional services	PERI-PX DEV EVAL ISDSS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0684T-26	Other professional services	PERI-PX DEV EVAL ISDSS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0684T-TC	Other professional services	PERI-PX DEV EVAL ISDSS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0685T	Other professional services	INTERROG DEV EVAL ISDSS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0685T-26	Other professional services	INTERROG DEV EVAL ISDSS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0685T-TC	Other professional services	INTERROG DEV EVAL ISDSS IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0686T	Other professional services	HISTOTRIPSY MAL HEPATCEL TIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0687T	Other professional services	TX AMBLYOPIA DEV SETUP 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0688T	Other professional services	TX AMBLYOPIA ASSMT W/REPORT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0689T	Radiology	QUAN US TIS CHARAC W/O DX US	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0689T-26	Radiology	QUAN US TIS CHARAC W/O DX US	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0689T-TC	Radiology	QUAN US TIS CHARAC W/O DX US	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0690T	Radiology	QUAN US TIS CHARAC W/DX US	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0690T-26	Radiology	QUAN US TIS CHARAC W/DX US	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0690T-TC	Radiology	QUAN US TIS CHARAC W/DX US	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0691T	Radiology	AUTO ALYS XST CT STD VRT FX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0691T-26	Radiology	AUTO ALYS XST CT STD VRT FX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0691T-TC	Radiology	AUTO ALYS XST CT STD VRT FX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0692T	Other professional services	THERAPEUTIC ULTRAFILTRATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0693T	Radiology	COMPRE FUL BDY 3D MTN ALYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0694T	Radiology	3D VOL IMG&RCNSTJ BRST/AX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0694T-26	Radiology	3D VOL IMG&RCNSTJ BRST/AX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0694T-TC	Radiology	3D VOL IMG&RCNSTJ BRST/AX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0695T	Radiology	BDY SRF MPG PM/CVDFB TM IMPL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0696T	Radiology	BDY SURF MAPG PM/CVDFB F/UP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0697T	Radiology	QUAN MR TIS WO MRI MLT ORGN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0697T-26	Radiology	QUAN MR TIS WO MRI MLT ORGN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0697T-TC	Radiology	QUAN MR TIS WO MRI MLT ORGN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0698T	Radiology	QUAN MR TISS W/MRI MLT ORGN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0698T-26	Radiology	QUAN MR TISS W/MRI MLT ORGN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0698T-TC	Radiology	QUAN MR TISS W/MRI MLT ORGN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0699T	Other professional services	NJX PST CHMBR EYE MEDICATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0700T	Radiology	MOLEC FLUOR IMG SUS NEV 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0700T-26	Radiology	MOLEC FLUOR IMG SUS NEV 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0700T-TC	Radiology	MOLEC FLUOR IMG SUS NEV 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0701T	Radiology	MOLEC FLUOR IMG SUS NEV EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0701T-26	Radiology	MOLEC FLUOR IMG SUS NEV EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0701T-TC	Radiology	MOLEC FLUOR IMG SUS NEV EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0704T	Other professional services	REM TX AMBLYOPIA SETUP&EDU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0705T	Other professional services	REM TX AMBLYOPIA TECH SPRT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0706T	Other professional services	REM TX AMBLYOPIA I&R PHY/QHP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0707T	Other professional services	NJX B1 SUB MTRL SBCHDRL DFCT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0708T	Other professional services	ID CA IMMNTX PREP & 1ST NJX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0709T	Other professional services	ID CA IMMNTX EACH ADDL NJX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0710T	Radiology	N-INVAS ARTL PLAQ ALYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0711T	Radiology	N-NVS ARTL PLAQ ALYS DAT PRP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0712T	Radiology	N-NVS ARTL PLAQ ALYS QUAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0713T	Radiology	N-NVS ARTL PLAQ ALYS RVW I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0714T	Other professional services	TPLA B9 PRST8 HYPRPLSA<50ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0716T	Other professional services	CAR ACOUS WAVFRM REC CAD RSK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0717T	Other professional services	ADRC THER PRTL RC TEAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0718T	Other professional services	ADRC THER PRTL RC TEAR NJX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0719T	Major surgery	PST VRT JT RPLCMT LMBR 1 SGM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0720T	Other professional services	PRQ ELC NRV STIM CN WO IMPLT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0721T	Radiology	QUAN CT TISS CHARAC W/O CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0721T-26	Radiology	QUAN CT TISS CHARAC W/O CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0721T-TC	Radiology	QUAN CT TISS CHARAC W/O CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0722T	Radiology	QUAN CT TISS CHARAC W/CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0722T-26	Radiology	QUAN CT TISS CHARAC W/CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0722T-TC	Radiology	QUAN CT TISS CHARAC W/CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0723T	Radiology	QMRCP W/O DX MRI SM ANAT SES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0723T-26	Radiology	QMRCP W/O DX MRI SM ANAT SES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0723T-TC	Radiology	QMRCP W/O DX MRI SM ANAT SES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0724T	Radiology	QMRCP W/DX MRI SAME ANATOMY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0724T-26	Radiology	QMRCP W/DX MRI SAME ANATOMY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0724T-TC	Radiology	QMRCP W/DX MRI SAME ANATOMY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0725T	Major surgery	VESTIBULAR DEV IMPLTJ UNI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0726T	Major surgery	RMVL IMPLT VSTIBULAR DEV UNI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0727T	Major surgery	RMVL&RPLCMT IMPLT VSTBLR DEV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0728T	Other professional services	DX ALYS VSTBLR IMPLT UNI 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0729T	Other professional services	DX ALYS VSTBLR IMPLT UNI SBQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0730T	Other professional services	TRABECULOTOMY LSR W/OCT GDN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0731T	Other professional services	AUGMNT AI-BASED FCL PHNT A/R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0732T	Other professional services	IMMNTX ADMN ELECTROPORATN IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0733T	Other professional services	REM R-T MTN NREHAB THER SPLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0734T	Other professional services	REM R-T MTN NREHAB TX MGMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0735T	Major surgery	PREP TUM CAV IORT PRIM CRNOT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0736T	Other professional services	COLONIC LAVAGE 35+L WATER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0737T	Other professional services	XENOGRAFT IMPLTJ ARTCLR SURF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0738T	Radiology	TX PLN MAG FLD ABLTJ PRST8	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0739T	Other professional services	ABLTJ MAL PRST8 MAG FLD NDCT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0740T	Other professional services	REM AUTON ALG NSLN CAL SETUP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0741T	Other professional services	REM AUTON ALG NSLN DATA COLL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0742T	Other professional services	AQMBF SPECT XERS/STRS & REST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0742T-26	Other professional services	AQMBF SPECT XERS/STRS & REST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0742T-TC	Other professional services	AQMBF SPECT XERS/STRS & REST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0743T	Radiology	B1 STR & FX RSK VRT FX ASSMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0743T-26	Radiology	B1 STR & FX RSK VRT FX ASSMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0743T-TC	Radiology	B1 STR & FX RSK VRT FX ASSMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0744T	Other professional services	INSJ BIOPROSTC VLV FEM VN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0745T	Other professional services	CAR ABLT RAD ARR N-INVAS LOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0746T	Other professional services	CAR ABLT RAD ARR CNV LOC MAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0747T	Other professional services	CAR ABLT RAD ARRHYT DLVR RAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0748T	Other professional services	NJX STM CL PRDCT ANL SFT TIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0749T	Radiology	B1 STR&FX RSK ASSMT DXR-BMD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0750T	Radiology	B1 STR&FX RSK ASMT DXRBMD1VW	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0751T	Clinical Laboratory	DGTZ GLS MCRSCP SLD LEVEL II	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0752T	Clinical Laboratory	DGTZ GLS MCRSCP SLD LVL III	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0753T	Clinical Laboratory	DGTZ GLS MCRSCP SLD LEVEL IV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0754T	Clinical Laboratory	DGTZ GLS MCRSCP SLD LEVEL V	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0755T	Clinical Laboratory	DGTZ GLS MCRSCP SLD LEVEL VI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0756T	Clinical Laboratory	DGTZ GLS MCRSCP SLD SPC GRPI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0757T	Clinical Laboratory	DGTZ GLS MCRSCP SL SPC GRPII	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0758T	Clinical Laboratory	DGTZ GLS MCRSCP SL SPC HCHEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0759T	Clinical Laboratory	DGTZ GLS MCRSCP SL SP GRPIII	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0760T	Clinical Laboratory	DGTZ GLS MCRSCP SL IMM 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0761T	Clinical Laboratory	DGTZ GLS MCRSCP SL IMM EA 1	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0762T	Clinical Laboratory	DGTZ GLS MCRSCP SL IMM EA M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0763T	Clinical Laboratory	DGTZ GLS MCRSCP MPHMTRC ALYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0764T	Other professional services	ASSTV ALG ECG RSK ASMT CNCRT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0765T	Other professional services	ASSTV ALG ECG RSK ASMT PREV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0766T	Other professional services	TC MAG STIMJ PN 1ST NERVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0767T	Other professional services	TC MAG STIMJ PN EA ADDL NRV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0770T	Other professional services	VR TECHNOLOGY ASSIST THERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0771T	Other professional services	VR PX DISSOC SVC SM PHY 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0772T	Other professional services	VR PX DISSOC SVC SM PHY EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0773T	Other professional services	VR PX DISSOC SVC OTH PHY 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0774T	Other professional services	VR PX DISSOC SVC OTH PHY EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0776T	Other professional services	THER INDCTJ NTRABRN HYPTHRM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0777T	Other professional services	R-T PRS SENSING EDRL GDN SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0777T-26	Other professional services	R-T PRS SENSING EDRL GDN SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0777T-TC	Other professional services	R-T PRS SENSING EDRL GDN SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0778T	Other professional services	SMMG CNCRNT APPL IMU SNR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0779T	Other professional services	GI MYOELECTRICAL ACTV STUDY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0779T-26	Other professional services	GI MYOELECTRICAL ACTV STUDY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0779T-TC	Other professional services	GI MYOELECTRICAL ACTV STUDY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0780T	Other professional services	INSTLJ FECAL MICROBIOTA SSP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0781T	Other professional services	BRNCHSC RF DSTRJ PULM NRV BI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0782T	Other professional services	BRNCHSC RF DSTRJ PLM NRV UNI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0783T	Other professional services	TC AURICULR NEUROSTIMULATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0784T	Other professional services	INS/RPLMT ELTRD RA SPI NSTIM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0785T	Other professional services	REVJ/RMVL NEA SPI W/NSTIM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0786T	Other professional services	INSJ/RPLCMT PRQ RA SAC NSTIM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0787T	Other professional services	REVJ/RMVL NEA SAC W/NSTIM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0788T	Other professional services	ELEC ALY SMP IINS SP/SAC NRV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0789T	Other professional services	ELEC ALY CPX IINS SP/SAC NRV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0790T	Other professional services	REVJ RPLCMT/RMVL VRT TETHRG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0791T	Other professional services	MOTR COG VR GAIT TRAIN EA 15	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0792T	Other professional services	APPL SLVR DIAMN FLUORIDE 38%	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0793T	Other professional services	PRQ TCAT THRM ABLT NRV P-ART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0794T	Other professional services	PT SPEC ALG RX-ONC TX OPTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0795T	Major surgery	TCAT INS 2CHMBR LDLS PM CMPL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0796T	Major surgery	TCAT INS 2CHMBR LDLS PM RA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0797T	Major surgery	TCAT INS 2CHMBR LDLS PM RV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0798T	Major surgery	TCAT RMV 2CHMBR LDLS PM CMPL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0799T	Major surgery	TCAT RMVL 2CHMBR LDLS PM RA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0800T	Major surgery	TCAT RMVL 2CHMBR LDLS PM RV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0801T	Major surgery	TCAT RMV&RPL 2CHMBR LDLS PM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0802T	Major surgery	TCAT RMV&RPL2CHMB LDLS PM RA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0803T	Major surgery	TCAT RMV&RPL2CHMB LDLS PM RV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0804T	Other professional services	PRGRMG EVL LDLS PM 2CHMBR IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0804T-26	Other professional services	PRGRMG EVL LDLS PM 2CHMBR IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0804T-TC	Other professional services	PRGRMG EVL LDLS PM 2CHMBR IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0805T	Other professional services	TCAT S&IVC PRSTC VL IMPL PRQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0806T	Other professional services	TCAT S&IVC PRSTC VL IMPL OPN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0807T	Other professional services	PULM TISS VNTJ ALYS PREV CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0807T-26	Other professional services	PULM TISS VNTJ ALYS PREV CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0807T-TC	Other professional services	PULM TISS VNTJ ALYS PREV CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0808T	Other professional services	PULM TISS VNTJ ALYS W/CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0808T-26	Other professional services	PULM TISS VNTJ ALYS W/CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0808T-TC	Other professional services	PULM TISS VNTJ ALYS W/CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0810T	Other professional services	SUBRTA NJX RX AGT W/VTRC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0811T	Other professional services	REM MLT DAY UROFLOW SETUP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0812T	Other professional services	REM MLT DAY UROFLOW DEV SPLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0813T	Other professional services	EGD VOL ADJMT BARIATRIC BALO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0814T	Other professional services	PRQ NJX BIOD OSTEO MATRL FEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0815T	Other professional services	US REMS B1 DNS HIPS PLVS/SPI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0815T-26	Other professional services	US REMS B1 DNS HIPS PLVS/SPI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0815T-TC	Other professional services	US REMS B1 DNS HIPS PLVS/SPI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0816T	Other professional services	OPN INSJ/RPLCMT INS PTN SUBQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0817T	Other professional services	OPN INSJ/RPLCMT INS PTN SUBF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0818T	Other professional services	REVJ/RMVL INS PTN SUBQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0819T	Other professional services	REVJ/RMVL INS PTN SUBF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0820T	Other professional services	MNTR PSYCHDLC MED 1STPHY/QHP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0821T	Other professional services	MNTR PSYCHDLC MED 2NDPHY/QHP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0822T	Other professional services	MNTR PSYCHDLC MED CLN STAFF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0823T	Other professional services	TCAT INS 1CHMBR LDLS PM RA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0824T	Other professional services	TCAT RMV 1CHMBR LDLS PM RA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0825T	Other professional services	TCAT RMV&RPL1CHMB LDLS PM RA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0826T	Other professional services	PRGRMG EVL LDLS PM 1CHMBR IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0826T-26	Other professional services	PRGRMG EVL LDLS PM 1CHMBR IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0826T-TC	Other professional services	PRGRMG EVL LDLS PM 1CHMBR IP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0827T	Clinical Laboratory	DGTZ GLS MCRSCP CYTP SMEARS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0828T	Clinical Laboratory	DGTZ GLS MCRSCP CYTP SMPL FL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0829T	Clinical Laboratory	DGTZ GLS MCRSCP CYTP CONCTRJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0830T	Clinical Laboratory	DGTZ GLS MCRSCP CYTP SLCTV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0831T	Clinical Laboratory	DGTZ GLS MCRSCP CYTP C/V	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0832T	Clinical Laboratory	DGTZ GLS MCRSCP CYTP OTH SCR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0833T	Clinical Laboratory	DGTZ GLS MCRSCP CYTP OTH PRP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0834T	Clinical Laboratory	DGTZ GLS MCRSCP CYTP OTH XTN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0835T	Clinical Laboratory	DGTZ GLS MCRSCP FNA 1ST EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0836T	Clinical Laboratory	DGTZ GLS MCRSCP FNA EA ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0837T	Clinical Laboratory	DGTZ GLS MCRSCP FNA I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0838T	Clinical Laboratory	DGTZ GLS MCRSCP CSLT SLD ELS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0839T	Clinical Laboratory	DGTZ GLS MCRSCP CSLT MAT PRP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0840T	Clinical Laboratory	DGTZ GLS MCRSCP CSLT COMPRE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0841T	Clinical Laboratory	DGTZ GLS MCRSCP PTH CSLT 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0842T	Clinical Laboratory	DGTZ GLS MCRSCP PTH CSLT EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0843T	Clinical Laboratory	DGTZ GLS MCRSCP CSLT CYT 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0844T	Clinical Laboratory	DGTZ GLS MCRSCP CSLT CYT EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0845T	Clinical Laboratory	DGTZ GLS MCRSCP IMFLUOR 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0846T	Clinical Laboratory	DGTZ GLS MCRSCP IMFLUOR EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0847T	Clinical Laboratory	DGTZ GLS MCRSCP XM ARCH TISS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0848T	Clinical Laboratory	DGTZ GLS MCRSCP ISH 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0849T	Clinical Laboratory	DGTZ GLS MCRSCP ISH EA ADL 1	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0850T	Clinical Laboratory	DGTZ GLS MCRSCP ISH EA MULT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0851T	Clinical Laboratory	DGTZ GLS MCRSCP MPHMTRC 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0852T	Clinical Laboratory	DGTZ GLS MCRSCP MPHMTRC EA 1	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0853T	Clinical Laboratory	DGTZ GLS MCRSCP MPHMTRC EA M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0854T	Clinical Laboratory	DGTZ GLS MCRSCP BLD SMR PRPH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0855T	Clinical Laboratory	DGTZ GLS MCRSCP B1 MAROW SMR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0856T	Clinical Laboratory	DGTZ GLS MCRSCP ELECTRON MIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0857T	Radiology	OPTO-ACOUSTIC IMG BREAST UNI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0857T-26	Radiology	OPTO-ACOUSTIC IMG BREAST UNI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0857T-TC	Radiology	OPTO-ACOUSTIC IMG BREAST UNI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0858T	Other professional services	EXT TRNSCRANL MAG STIMJ MEAS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0858T-26	Other professional services	EXT TRNSCRANL MAG STIMJ MEAS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0858T-TC	Other professional services	EXT TRNSCRANL MAG STIMJ MEAS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0859T	Other professional services	NCNTC IFR SPCTRSC O/T PAD EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0860T	Other professional services	NCNTC IFR SPCTRSC SCR PAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0861T	Other professional services	RMVL PG WCS LV BOTH COMPNT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0862T	Other professional services	RLCJ PG WCS LV BATTERY ONLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0863T	Other professional services	RLCJ PG WCS LV TRNSMTR ONLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0864T	Other professional services	LOW NTSTY ESWT CORPUS CVRNSM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0865T	Other professional services	QUAN MRI ALYS BRN W/O DX MRI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0865T-26	Other professional services	QUAN MRI ALYS BRN W/O DX MRI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0865T-TC	Other professional services	QUAN MRI ALYS BRN W/O DX MRI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0866T	Other professional services	QUAN MRI ALYS BRN W/DX MRI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0866T-26	Other professional services	QUAN MRI ALYS BRN W/DX MRI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
0866T-TC	Other professional services	QUAN MRI ALYS BRN W/DX MRI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
10004	Other professional services	FNA BX W/O IMG GDN EA ADDL	72.65	59.91
10005	Other professional services	FNA BX W/US GDN 1ST LES	186.54	101.49
10006	Other professional services	FNA BX W/US GDN EA ADDL	84.23	69.66
10007	Other professional services	FNA BX W/FLUOR GDN 1ST LES	418.10	124.29
10008	Other professional services	FNA BX W/FLUOR GDN EA ADDL	194.76	71.51
10009	Other professional services	FNA BX W/CT GDN 1ST LES	587.10	150.93
10010	Other professional services	FNA BX W/CT GDN EA ADDL	323.96	100.19
10011	Other professional services	FNA BX W/MR GDN 1ST LES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
10012	Other professional services	FNA BX W/MR GDN EA ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
10021	Other professional services	FNA BX W/O IMG GDN 1ST LES	140.22	76.08
10030	Other professional services	IMG GID FLU COLL DRG SFT TIS	869.72	186.59
10035	Other professional services	PLMT SFT TISS LOCLZJ DEV 1ST	495.66	116.34
10036	Other professional services	PLMT SFT TISS LOCLZJ DEV EA	404.33	58.67
10040	Other professional services	ACNE SURGERY	161.21	72.53
10060	Other professional services	I&D ABSCESS SIMPLE/SINGLE	176.97	149.22
10061	Other professional services	I&D ABSCESS COMP/MULTIPLE	299.07	257.69
10080	Other professional services	I&D PILONIDAL CYST SIMPLE	344.81	146.51
10081	Other professional services	I&D PILONIDAL CYST COMP	473.79	237.29
10120	Other professional services	INC&RMVL FB SUBQ TISS SMPL	211.28	147.60
10121	Other professional services	INC&RMVL FB SUBQ TISS COMP	367.32	255.89
10140	Other professional services	I&D HMTMA SEROMA/FLUID COLLJ	235.92	165.42
10160	Other professional services	PNXR ASPIR ABSC HMTMA BULLA	180.33	134.85
10180	Other professional services	I&D COMPLEX PO WOUND INFCTJ	362.04	246.98
11000	Other professional services	DBRDMT ECZ/INFECTED SKIN<10%	82.50	38.84
11001	Major surgery	DBRDMT ECZ/INFCT SKN EA ADDL	49.39	26.93
11004	Other professional services	DBRDMT SKIN XTRNL GENT&PER	778.50	778.50
11005	Other professional services	DBRDMT SKIN ABDOMINAL WALL	1051.73	1051.73
11006	Other professional services	DBRDMT SKIN XTRNL GENT PER	955.67	955.67
11008	Major surgery	RMV PRSTC MTRL/MESH ABD WALL	480.87	480.87
11010	Other professional services	DEBRIDE SKIN AT FX SITE	617.01	381.42
11011	Other professional services	DEBRIDE SKIN MUSC AT FX SITE	688.20	409.40
11012	Other professional services	DEB SKIN BONE AT FX SITE	896.51	571.77
11042	Other professional services	DBRDMT SUBQ TIS 1ST 20SQCM/<	179.39	84.33
11043	Other professional services	DBRDMT MUSC&/FSCA 1ST 20/<	322.61	212.99
11044	Other professional services	DBRDMT BONE 1ST 20 SQ CM/<	431.70	312.08
11045	Major surgery	DBRDMT SUBQ TISS EACH ADDL	71.97	45.38
11046	Major surgery	DBRDMT MUSC&/FSCA EA ADDL	131.20	98.09
11047	Major surgery	DBRDMT BONE EACH ADDL	216.70	172.97
11055	Other professional services	PARING/CUTG B9 HYPRKER LES 1	98.22	21.81
11056	Other professional services	PARNG/CUTG B9 HYPRKR LES 2-4	114.11	30.87
11057	Other professional services	PARNG/CUTG B9 HYPRKR LES >4	124.98	40.38
11102	Other professional services	TANGNTL BX SKIN SINGLE LES	138.86	52.44
11103	Other professional services	TANGNTL BX SKIN EA SEP/ADDL	69.54	30.44
11104	Other professional services	PUNCH BX SKIN SINGLE LESION	172.74	64.95
11105	Other professional services	PUNCH BX SKIN EA SEP/ADDL	82.28	35.43
11106	Other professional services	INCAL BX SKN SINGLE LES	214.41	78.42
11107	Other professional services	INCAL BX SKN EA SEP/ADDL	98.40	42.45
11200	Other professional services	RMVL SKIN TAGS UP TO&INC 15	128.72	106.89
11201	Major surgery	RMVL SKIN TAGS EA ADDL 10	33.38	29.25
11300	Other professional services	SHAVE SKIN LESION 0.5 CM/<	138.65	47.22
11301	Other professional services	SHAVE SKIN LESION 0.6-1.0 CM	168.00	71.12
11302	Other professional services	SHAVE SKIN LESION 1.1-2.0 CM	189.80	82.91
11303	Other professional services	SHAVE SKIN LESION >2.0 CM	210.15	98.72
11305	Other professional services	SHAVE SKIN LESION 0.5 CM/<	145.73	52.50
11306	Other professional services	SHAVE SKIN LESION 0.6-1.0 CM	169.71	68.28
11307	Other professional services	SHAVE SKIN LESION 1.1-2.0 CM	192.03	86.97
11308	Other professional services	SHAVE SKIN LESION >2.0 CM	202.85	97.79
11310	Other professional services	SHAVE SKIN LESION 0.5 CM/<	160.04	63.15
11311	Other professional services	SHAVE SKIN LESION 0.6-1.0 CM	189.39	87.06
11312	Other professional services	SHAVE SKIN LESION 1.1-2.0 CM	215.33	102.99
11313	Other professional services	SHAVE SKIN LESION >2.0 CM	251.09	133.29
11400	Other professional services	EXC TR-EXT B9+MARG 0.5 CM<	177.75	117.71
11401	Other professional services	EXC TR-EXT B9+MARG 0.6-1 CM	216.83	147.69
11402	Other professional services	EXC TR-EXT B9+MARG 1.1-2 CM	238.89	161.57
11403	Other professional services	EXC TR-EXT B9+MARG 2.1-3CM	275.21	208.80
11404	Other professional services	EXC TR-EXT B9+MARG 3.1-4 CM	311.10	229.23
11406	Other professional services	EXC TR-EXT B9+MARG >4.0 CM	442.32	344.99
11420	Other professional services	EXC H-F-NK-SP B9+MARG 0.5/<	176.21	115.26
11421	Other professional services	EXC H-F-NK-SP B9+MARG 0.6-1	222.39	152.81
11422	Other professional services	EXC H-F-NK-SP B9+MARG 1.1-2	249.47	189.89
11423	Other professional services	EXC H-F-NK-SP B9+MARG 2.1-3	286.02	219.62
11424	Other professional services	EXC H-F-NK-SP B9+MARG 3.1-4	330.83	252.60
11426	Other professional services	EXC H-F-NK-SP B9+MARG >4 CM	456.60	373.37
11440	Other professional services	EXC FACE-MM B9+MARG 0.5 CM/<	199.34	149.76
11441	Other professional services	EXC FACE-MM B9+MARG 0.6-1 CM	242.24	186.29
11442	Other professional services	EXC FACE-MM B9+MARG 1.1-2 CM	268.97	205.29
11443	Other professional services	EXC FACE-MM B9+MARG 2.1-3 CM	317.31	250.01
11444	Other professional services	EXC FACE-MM B9+MARG 3.1-4 CM	394.37	314.78
11446	Other professional services	EXC FACE-MM B9+MARG >4 CM	534.95	442.17
11450	Major surgery	EXC SKN HDRDNT AX SMPL/NTRM	770.35	472.35
11451	Major surgery	EXC SKN HDRDNT AX COMPLEX	939.88	597.54
11462	Major surgery	EXC SKN HDRDNT ING SMPL/NTRM	749.01	449.85
11463	Major surgery	EXC SKN HDRDNT ING COMPLEX	952.38	601.17
11470	Major surgery	EXC SKN H/P/P/U SMPL/NTRM	815.88	517.88
11471	Major surgery	EXC SKN H/P/P/U COMPLEX	980.56	635.86
11600	Other professional services	EXC TR-EXT MAL+MARG 0.5 CM/<	273.72	170.48
11601	Other professional services	EXC TR-EXT MAL+MARG 0.6-1 CM	317.69	206.72
11602	Other professional services	EXC TR-EXT MAL+MARG 1.1-2 CM	340.25	224.72
11603	Other professional services	EXC TR-EXT MAL+MARG 2.1-3 CM	387.48	268.32
11604	Other professional services	EXC TR-EXT MAL+MARG 3.1-4 CM	431.39	294.95
11606	Other professional services	EXC TR-EXT MAL+MARG >4 CM	620.64	437.36
11620	Other professional services	EXC H-F-NK-SP MAL+MARG 0.5/<	275.00	171.75
11621	Other professional services	EXC S/N/H/F/G MAL+MRG 0.6-1	318.51	207.53
11622	Other professional services	EXC S/N/H/F/G MAL+MRG 1.1-2	352.07	235.64
11623	Other professional services	EXC S/N/H/F/G MAL+MRG 2.1-3	411.42	290.43
11624	Other professional services	EXC S/N/H/F/G MAL+MRG 3.1-4	468.14	329.87
11626	Other professional services	EXC S/N/H/F/G MAL+MRG >4 CM	562.22	402.12
11640	Other professional services	EXC F/E/E/N/L MAL+MRG 0.5CM<	282.18	176.67
11641	Other professional services	EXC F/E/E/N/L MAL+MRG 0.6-1	329.16	216.38
11642	Other professional services	EXC F/E/E/N/L MAL+MRG 1.1-2	372.66	253.04
11643	Other professional services	EXC F/E/E/N/L MAL+MRG 2.1-3	437.70	315.36
11644	Other professional services	EXC F/E/E/N/L MAL+MRG 3.1-4	539.96	390.33
11646	Other professional services	EXC F/E/E/N/L MAL+MRG >4 CM	700.02	538.11
11719	Other professional services	TRIM NAIL(S) ANY NUMBER	20.04	10.50
11720	Other professional services	DEBRIDE NAIL 1-5	45.81	19.88
11721	Other professional services	DEBRIDE NAIL 6 OR MORE	62.40	33.29
11730	Other professional services	REMOVAL OF NAIL PLATE	160.04	75.44
11732	Major surgery	REMOVE NAIL PLATE ADD-ON	59.83	30.85
11740	Other professional services	DRAIN BLOOD FROM UNDER NAIL	80.10	45.08
11750	Other professional services	REMOVAL OF NAIL BED	224.21	143.25
11755	Other professional services	BIOPSY NAIL UNIT	170.18	85.13
11760	Other professional services	REPAIR OF NAIL BED	256.37	153.12
11762	Other professional services	RECONSTRUCTION OF NAIL BED	400.32	261.62
11765	Other professional services	EXCISION OF NAIL FOLD TOE	230.57	130.50
11770	Other professional services	REMOVE PILONIDAL CYST SIMPLE	487.26	256.68
11771	Major surgery	REMOVE PILONIDAL CYST EXTEN	1128.84	810.75
11772	Major surgery	REMOVE PILONIDAL CYST COMPL	1382.94	1042.37
11900	Other professional services	INJECT SKIN LESIONS	79.80	41.60
11901	Other professional services	INJECT SKIN LESIONS >7	97.85	63.29
11920	Other professional services	CORRECT SKIN COLOR 6.0 CM/<	276.72	157.10
11921	Other professional services	CORRECT SKN COLOR 6.1-20.0CM	305.90	180.36
11922	Major surgery	CORRECT SKIN COLOR EA 20.0CM	109.61	51.66
11950	Other professional services	TX CONTOUR DEFECTS 1 CC/<	112.89	71.51
11951	Other professional services	TX CONTOUR DEFECTS 1.1-5.0CC	150.23	100.20
11952	Other professional services	TX CONTOUR DEFECTS 5.1-10CC	200.93	140.90
11954	Other professional services	TX CONTOUR DEFECTS >10.0 CC	221.13	153.83
11960	Major surgery	INSERT TISSUE EXPANDER(S)	1829.30	1829.30
11970	Major surgery	RPLCMT TISS XPNDR PERM IMPLT	1014.41	1014.41
11971	Major surgery	RMVL TIS XPNDR WO INSJ IMPLT	998.32	998.32
11976	Other professional services	REMOVE CONTRACEPTIVE CAPSULE	201.38	128.61
11980	Other professional services	IMPLANT HORMONE PELLET(S)	130.79	77.12
11981	Other professional services	INSERTION DRUG DLVR IMPLANT	139.26	86.51
11982	Other professional services	REMOVE DRUG IMPLANT DEVICE	153.71	100.95
11983	Other professional services	REMOVE/INSERT DRUG IMPLANT	196.79	142.67
12001	Other professional services	RPR S/N/AX/GEN/TRNK 2.5CM/<	130.17	61.95
12002	Other professional services	RPR S/N/AX/GEN/TRNK2.6-7.5CM	157.79	81.38
12004	Other professional services	RPR S/N/AX/GEN/TRK7.6-12.5CM	183.90	101.58
12005	Other professional services	RPR S/N/A/GEN/TRK12.6-20.0CM	244.91	130.74
12006	Other professional services	RPR S/N/A/GEN/TRK20.1-30.0CM	282.83	160.04
12007	Other professional services	RPR S/N/AX/GEN/TRNK >30.0 CM	321.02	198.68
12011	Other professional services	RPR F/E/E/N/L/M 2.5 CM/<	154.92	76.70
12013	Other professional services	RPR F/E/E/N/L/M 2.6-5.0 CM	161.46	80.04
12014	Other professional services	RPR F/E/E/N/L/M 5.1-7.5 CM	197.18	103.49
12015	Other professional services	RPR F/E/E/N/L/M 7.6-12.5 CM	238.13	129.87
12016	Other professional services	RPR FE/E/EN/L/M 12.6-20.0 CM	302.09	176.10
12017	Other professional services	RPR FE/E/EN/L/M 20.1-30.0 CM	211.94	211.94
12018	Other professional services	RPR F/E/E/N/L/M >30.0 CM	238.85	238.85
12020	Other professional services	TX SUPFC WND DEHSN SMPL CLSR	415.02	261.75
12021	Other professional services	TX SUPFC WND DEHSN W/PACKING	246.23	196.20
12031	Other professional services	INTMD RPR S/A/T/EXT 2.5 CM/<	363.83	210.56
12032	Other professional services	INTMD RPR S/A/T/EXT 2.6-7.5	421.14	264.69
12034	Other professional services	INTMD RPR S/TR/EXT 7.6-12.5	463.67	285.38
12035	Other professional services	INTMD RPR S/A/T/EXT 12.6-20	537.24	333.93
12036	Other professional services	INTMD RPR S/A/T/EXT 20.1-30	597.63	389.33
12037	Other professional services	INTMD RPR S/TR/EXT >30.0 CM	671.34	452.13
12041	Other professional services	INTMD RPR N-HF/GENIT 2.5CM/<	364.97	202.14
12042	Other professional services	INTMD RPR N-HF/GENIT2.6-7.5	430.26	272.43
12044	Other professional services	INTMD RPR N-HF/GENIT7.6-12.5	529.32	297.83
12045	Other professional services	INTMD RPR N-HF/GENIT12.6-20	570.57	378.65
12046	Other professional services	INTMD RPR N-HF/GENIT20.1-30	686.69	436.98
12047	Other professional services	INTMD RPR N-HF/GENIT >30.0CM	752.16	484.73
12051	Other professional services	INTMD RPR FACE/MM 2.5 CM/<	392.46	235.55
12052	Other professional services	INTMD RPR FACE/MM 2.6-5.0 CM	437.57	277.47
12053	Other professional services	INTMD RPR FACE/MM 5.1-7.5 CM	503.51	299.30
12054	Other professional services	INTMD RPR FACE/MM 7.6-12.5CM	529.55	305.78
12055	Other professional services	INTMD RPR FACE/MM 12.6-20 CM	694.11	417.59
12056	Other professional services	INTMD RPR FACE/MM 20.1-30.0	798.99	530.66
12057	Other professional services	INTMD RPR FACE/MM >30.0 CM	836.58	579.15
13100	Other professional services	CMPLX RPR TRUNK 1.1-2.5 CM	471.32	278.01
13101	Other professional services	CMPLX RPR TRUNK 2.6-7.5 CM	549.03	342.08
13102	Major surgery	CMPLX RPR TRUNK ADDL 5CM/<	208.88	128.47
13120	Other professional services	CMPLX RPR S/A/L 1.1-2.5 CM	491.45	320.90
13121	Other professional services	CMPLX RPR S/A/L 2.6-7.5 CM	588.86	357.81
13122	Major surgery	CMPLX RPR S/A/L ADDL 5 CM/>	227.82	148.01
13131	Other professional services	CMPLX RPR F/C/C/M/N/AX/G/H/F	537.53	335.58
13132	Other professional services	CMPLX RPR F/C/C/M/N/AX/G/H/F	652.53	419.66
13133	Major surgery	CMPLX RPR F/C/C/M/N/AX/G/H/F	303.52	225.46
13151	Other professional services	CMPLX RPR E/N/E/L 1.1-2.5 CM	586.02	385.44
13152	Other professional services	CMPLX RPR E/N/E/L 2.6-7.5 CM	688.62	464.85
13153	Major surgery	CMPLX RPR E/N/E/L ADDL 5CM/<	332.63	244.55
13160	Major surgery	SEC CLSR SURG WND/DEHSN XTN	1434.91	1434.91
14000	Major surgery	TIS TRNFR TRUNK 10 SQ CM/<	1147.50	909.81
14001	Major surgery	TIS TRNFR TRUNK 10.1-30SQCM	1461.39	1176.42
14020	Major surgery	TIS TRNFR S/A/L 10 SQ CM/<	1272.45	1025.31
14021	Major surgery	TIS TRNFR S/A/L 10.1-30 SQCM	1569.42	1280.88
14040	Major surgery	TIS TRNFR F/C/C/M/N/A/G/H/F	1377.15	1129.40
14041	Major surgery	TIS TRNFR F/C/C/M/N/A/G/H/F	1673.72	1379.27
14060	Major surgery	TIS TRNFR E/N/E/L 10 SQ CM/<	1393.98	1204.18
14061	Major surgery	TIS TRNFR E/N/E/L10.1-30SQCM	1805.80	1480.62
14301	Major surgery	TIS TRNFR ANY 30.1-60 SQ CM	1952.54	1565.85
14302	Major surgery	TIS TRNFR ADDL 30 SQ CM	384.70	384.70
14350	Major surgery	FILLETED FINGER/TOE FLAP	1232.89	1232.89
15002	Other professional services	WOUND PREP TRK/ARM/LEG	473.27	301.80
15003	Major surgery	WOUND PREP ADDL 100 CM	123.77	80.01
15004	Other professional services	WOUND PREP F/N/HF/G	543.57	359.36
15005	Major surgery	WND PREP F/N/HF/G ADDL CM	207.81	159.33
15040	Other professional services	HARVEST CULTURED SKIN GRAFT	358.85	172.37
15050	Major surgery	PINCH GRAFT UP TO 2 CM DIAM	1054.25	824.25
15100	Major surgery	SKIN SPLT GRFT TRNK/ARM/LEG	1559.59	1286.42
15101	Major surgery	SKIN SPLT GRFT T/A/L ADD-ON	330.54	196.91
15110	Major surgery	EPIDRM AUTOGRFT TRNK/ARM/LEG	1499.12	1286.86
15111	Major surgery	EPIDRM AUTOGRFT T/A/L ADD-ON	202.18	180.30
15115	Major surgery	EPIDRM A-GRFT FACE/NCK/HF/G	1462.25	1260.03
15116	Major surgery	EPIDRM A-GRFT F/N/HF/G ADDL	274.03	245.66
15120	Major surgery	SKN SPLT A-GRFT FAC/NCK/HF/G	1525.49	1245.82
15121	Major surgery	SKN SPLT A-GRFT F/N/HF/G ADD	369.37	234.57
15130	Major surgery	DERM AUTOGRAFT TRNK/ARM/LEG	1293.08	1074.92
15131	Major surgery	DERM AUTOGRAFT T/A/L ADD-ON	174.64	159.28
15135	Major surgery	DERM AUTOGRAFT FACE/NCK/HF/G	1576.24	1369.89
15136	Major surgery	DERM AUTOGRAFT F/N/HF/G ADD	172.28	159.28
15150	Major surgery	CULT SKIN GRFT T/ARM/LEG	1259.45	1142.39
15151	Major surgery	CULT SKIN GRFT T/A/L ADDL	210.25	192.52
15152	Major surgery	CULT SKIN GRAFT T/A/L +%	263.89	247.34
15155	Major surgery	CULT SKIN GRAFT F/N/HF/G	1428.26	1309.41
15156	Major surgery	CULT SKIN GRFT F/N/HFG ADD	283.20	265.45
15157	Major surgery	CULT EPIDERM GRFT F/N/HFG +%	314.71	289.28
15200	Major surgery	FTH GRF FR TRNK 20 SQ CM/<	1512.81	1213.04
15201	Major surgery	FTH GRF FR TRNK EACH ADDL	249.81	136.29
15220	Major surgery	FTH GRF FR S/A/L 20 SQ CM/<	1390.72	1102.76
15221	Major surgery	FTH GRF FR S/A/L EACH ADDL	230.94	123.34
15240	Major surgery	FTH GR FR F/C/C/M/N/AX/G/H/F	1681.31	1439.49
15241	Major surgery	FTH GR F/C/C/M/N/AX/G/H/F EA	312.86	191.65
15260	Major surgery	FTH GRF FR N/E/E/L 20 SQCM/<	1811.53	1530.69
15261	Major surgery	FTH GRF FR N/E/E/L EACH ADDL	368.06	242.72
15271	Other professional services	SKIN SUB GRAFT TRNK/ARM/LEG	213.21	116.34
15272	Major surgery	SKIN SUB GRAFT T/A/L ADD-ON	44.48	30.28
15273	Other professional services	SKIN SUB GRFT T/ARM/LG CHILD	425.67	268.31
15274	Major surgery	SKN SUB GRFT T/A/L CHILD ADD	144.63	78.99
15275	Other professional services	SKIN SUB GRAFT FACE/NK/HF/G	221.16	130.20
15276	Major surgery	SKIN SUB GRAFT F/N/HF/G ADDL	58.54	44.95
15277	Other professional services	SKN SUB GRFT F/N/HF/G CHILD	470.13	305.94
15278	Major surgery	SKN SUB GRFT F/N/HF/G CH ADD	169.32	98.94
15570	Major surgery	SKIN PEDICLE FLAP TRUNK	1628.04	1309.95
15572	Major surgery	SKIN PEDICLE FLAP ARMS/LEGS	1588.98	1327.64
15574	Major surgery	PEDCLE FH/CH/CH/M/N/AX/G/H/F	1599.62	1337.10
15576	Major surgery	PEDICLE E/N/E/L/NTRORAL	1413.98	1173.33
15600	Major surgery	DELAY FLAP TRUNK	607.60	383.51
15610	Major surgery	DELAY FLAP ARMS/LEGS	661.89	441.95
15620	Major surgery	DELAY FLAP F/C/C/N/AX/G/H/F	806.68	591.45
15630	Major surgery	DELAY FLAP EYE/NOS/EAR/LIP	835.95	623.67
15650	Major surgery	TRANSFER SKIN PEDICLE FLAP	975.02	729.05
15730	Major surgery	MDFC FLAP W/PRSRV VASC PEDCL	2560.70	1657.27
15731	Major surgery	FOREHEAD FLAP W/VASC PEDICLE	2028.31	1800.67
15733	Major surgery	MUSC MYOQ/FSCQ FLP H&N PEDCL	1855.46	1855.46
15734	Major surgery	MUSCLE-SKIN GRAFT TRUNK	2686.94	2686.94
15736	Major surgery	MUSCLE-SKIN GRAFT ARM	2187.10	2187.10
15738	Major surgery	MUSCLE-SKIN GRAFT LEG	2274.83	2274.83
15740	Major surgery	ISLAND PEDICLE FLAP GRAFT	1831.15	1521.31
15750	Major surgery	NEUROVASCULAR PEDICLE FLAP	1679.85	1679.85
15756	Major surgery	FREE MYO/SKIN FLAP MICROVASC	4106.47	4106.47
15757	Major surgery	FREE SKIN FLAP MICROVASC	4084.53	4084.53
15758	Major surgery	FREE FASCIAL FLAP MICROVASC	4067.95	4067.95
15760	Major surgery	COMPOSITE SKIN GRAFT	1530.30	1263.64
15769	Major surgery	GRFG AUTOL SOFT TISS DIR EXC	866.72	866.72
15770	Major surgery	DERMA-FAT-FASCIA GRAFT	1219.02	1219.02
15771	Major surgery	GRFG AUTOL FAT LIPO 50 CC/<	1100.66	923.87
15772	Major surgery	GRFG AUTOL FAT LIPO EA ADDL	344.12	264.89
15773	Major surgery	GRFG AUTOL FAT LIPO 25 CC/<	1075.85	906.17
15774	Major surgery	GFRG AUTOL FAT LIPO EA ADDL	334.56	255.94
15775	Other professional services	HAIR TRNSPL 1-15 PUNCH GRFTS	518.94	351.12
15776	Other professional services	HAIR TRNSPL >15 PUNCH GRAFTS	701.73	481.14
15777	Major surgery	ACELLULAR DERM MATRIX IMPLT	382.04	382.04
15778	Major surgery	IMPL ABSRB MSH/PRSTH DLY CLS	685.68	685.68
15780	Major surgery	DERMABRASION TOTAL FACE	1533.64	1204.30
15781	Major surgery	DERMABRASION SEGMENTAL FACE	964.59	770.66
15782	Major surgery	DERMABRASION OTHER THAN FACE	878.92	671.97
15783	Major surgery	DERMABRASION SUPRFL ANY SITE	816.27	646.00
15786	Other professional services	ABRASION LESION SINGLE	318.44	188.36
15787	Major surgery	ABRASION LESIONS ADD-ON	54.44	30.21
15788	Major surgery	CHEMICAL PEEL FACE EPIDERM	699.43	392.55
15789	Major surgery	CHEMICAL PEEL FACE DERMAL	963.26	744.51
15792	Major surgery	CHEMICAL PEEL NONFACIAL	602.55	380.84
15793	Major surgery	CHEMICAL PEEL NONFACIAL	857.49	647.01
15819	Major surgery	PLASTIC SURGERY NECK	1441.09	1441.09
15820	Major surgery	REVISION OF LOWER EYELID	1052.63	936.74
15821	Major surgery	REVISION OF LOWER EYELID	1125.54	997.83
15822	Major surgery	REVISION OF UPPER EYELID	835.61	722.09
15823	Major surgery	REVISION OF UPPER EYELID	1128.00	999.10
15824	Other professional services	REMOVAL OF FOREHEAD WRINKLES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
15825	Other professional services	REMOVAL OF NECK WRINKLES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
15826	Other professional services	REMOVAL OF BROW WRINKLES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
15828	Other professional services	REMOVAL OF FACE WRINKLES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
15829	Other professional services	REMOVAL OF SKIN WRINKLES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
15830	Major surgery	EXC SKIN ABD	2105.16	2105.16
15832	Major surgery	EXCISE EXCESSIVE SKIN THIGH	1659.63	1659.63
15833	Major surgery	EXCISE EXCESSIVE SKIN LEG	1579.91	1579.91
15834	Major surgery	EXCISE EXCESSIVE SKIN HIP	1608.30	1608.30
15835	Major surgery	EXCISE EXCESSIVE SKIN BUTTCK	1676.49	1676.49
15836	Major surgery	EXCISE EXCESSIVE SKIN ARM	1436.51	1436.51
15837	Major surgery	EXCISE EXCESS SKIN ARM/HAND	1561.52	1291.31
15838	Major surgery	EXCISE EXCESS SKIN FAT PAD	1171.35	1171.35
15839	Major surgery	EXCISE EXCESS SKIN & TISSUE	1608.54	1333.61
15840	Major surgery	NERVE PALSY FASCIAL GRAFT	1828.42	1828.42
15841	Major surgery	NERVE PALSY MUSCLE GRAFT	3193.65	3193.65
15842	Major surgery	NERVE PALSY MICROSURG GRAFT	4833.11	4833.11
15845	Major surgery	SKIN AND MUSCLE REPAIR FACE	1911.99	1911.99
15847	Major surgery	EXC SKIN ABD ADD-ON	870.40	870.40
15851	Other professional services	REMOVAL SUTR/STAPLE REQ ANES	79.79	91.16
15852	Other professional services	DRESSING CHANGE NOT FOR BURN	61.82	61.82
15853	Major surgery	REMOVAL SUTR/STAPL XREQ ANES	20.53	20.53
15854	Major surgery	REMOVAL SUTR&STAPL XREQ ANES	28.04	28.04
15860	Other professional services	TEST FOR BLOOD FLOW IN GRAFT	146.07	146.07
15876	Other professional services	SUCTION LIPECTOMY HEAD&NECK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
15877	Other professional services	SUCTION LIPECTOMY TRUNK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
15878	Other professional services	SUCTION LIPECTOMY UPR EXTREM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
15879	Other professional services	SUCTION LIPECTOMY LWR EXTREM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
15920	Major surgery	REMOVAL OF TAIL BONE ULCER	1134.02	1134.02
15922	Major surgery	REMOVAL OF TAIL BONE ULCER	1437.42	1437.42
15931	Major surgery	REMOVE SACRUM PRESSURE SORE	1264.34	1264.34
15933	Major surgery	REMOVE SACRUM PRESSURE SORE	1567.39	1567.39
15934	Major surgery	REMOVE SACRUM PRESSURE SORE	1773.80	1773.80
15935	Major surgery	REMOVE SACRUM PRESSURE SORE	2079.68	2079.68
15936	Major surgery	REMOVE SACRUM PRESSURE SORE	1611.52	1611.52
15937	Major surgery	REMOVE SACRUM PRESSURE SORE	1862.15	1862.15
15940	Major surgery	REMOVE HIP PRESSURE SORE	1275.32	1275.32
15941	Major surgery	REMOVE HIP PRESSURE SORE	1670.47	1670.47
15944	Major surgery	REMOVE HIP PRESSURE SORE	1683.24	1683.24
15945	Major surgery	REMOVE HIP PRESSURE SORE	1837.82	1837.82
15946	Major surgery	REMOVE HIP PRESSURE SORE	2891.79	2891.79
15950	Major surgery	REMOVE THIGH PRESSURE SORE	1148.92	1148.92
15951	Major surgery	REMOVE THIGH PRESSURE SORE	1619.59	1619.59
15952	Major surgery	REMOVE THIGH PRESSURE SORE	1651.03	1651.03
15953	Major surgery	REMOVE THIGH PRESSURE SORE	1818.12	1818.12
15956	Major surgery	REMOVE THIGH PRESSURE SORE	2128.46	2128.46
15958	Major surgery	REMOVE THIGH PRESSURE SORE	2111.30	2111.30
15999	Major surgery	UNLISTED PX EXC PRESSURE ULC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
16000	Other professional services	INITIAL TREATMENT OF BURN(S)	110.60	63.30
16020	Other professional services	DRESS/DEBRID P-THICK BURN S	118.85	77.45
16025	Other professional services	DRESS/DEBRID P-THICK BURN M	218.19	154.52
16030	Other professional services	DRESS/DEBRID P-THICK BURN L	272.34	181.83
16035	Other professional services	INCISION OF BURN SCAB INITI	271.07	271.07
16036	Major surgery	ESCHAROTOMY ADDL INCISION	146.45	146.45
17000	Other professional services	DESTRUCT PREMALG LESION	94.23	76.95
17003	Major surgery	DESTRUCT PREMALG LES 2-14	12.01	3.74
17004	Other professional services	DESTROY PREMAL LESIONS 15/>	232.29	137.24
17106	Major surgery	DESTRUCTION OF SKIN LESIONS	625.19	501.60
17107	Major surgery	DESTRUCTION OF SKIN LESIONS	811.41	652.96
17108	Major surgery	DESTRUCTION OF SKIN LESIONS	1151.67	955.97
17110	Other professional services	DESTRUCT B9 LESION 1-14	157.65	95.79
17111	Other professional services	DESTRUCT LESION 15 OR MORE	184.62	116.40
17250	Other professional services	CHEM CAUT OF GRANLTJ TISSUE	119.96	52.19
17260	Other professional services	DSTRJ MAL LES T/A/L 0.5 CM/<	139.11	98.63
17261	Other professional services	DSTRJ MAL LES T/A/L .6-1.0CM	206.52	121.94
17262	Other professional services	DSTRJ MAL LES T/A/L 1.1-2.0	248.43	154.29
17263	Other professional services	DSTRJ MAL LES T/A/L 2.1-3.0	268.95	170.72
17264	Other professional services	DSTRJ MAL LES T/A/L 3.1-4.0	288.35	182.37
17266	Other professional services	DSTRJ MAL LES T/A/L >4.0 CM	327.95	213.80
17270	Other professional services	DSTR MAL LES S/N/H/F/G .5 /<	208.64	133.59
17271	Other professional services	DSTR MAL LES S/N/H/F/G 0.6-1	231.87	146.82
17272	Other professional services	DSTR MAL LES S/N/H/F/G 1.1-2	262.97	169.28
17273	Other professional services	DSTR MAL LES S/N/H/F/G 2.1-3	291.80	191.28
17274	Other professional services	DSTR MAL LES S/N/H/F/G 3.1-4	341.34	233.55
17276	Other professional services	DSTR MAL LES S/N/H/F/G >4.0	396.20	281.58
17280	Other professional services	DSTR MAL LS F/E/E/N/L/M .5/<	196.07	121.47
17281	Other professional services	DSTR MAL LS F/E/E/N/L/M .6-1	250.97	165.00
17282	Other professional services	DSTR MAL LS F/E/E/N/L/M1.1-2	286.77	190.34
17283	Other professional services	DSTR MAL LS F/E/E/N/L/M2.1-3	339.44	238.02
17284	Other professional services	DSTR MAL LS F/E/E/N/L/M3.1-4	385.68	276.98
17286	Other professional services	DSTR MAL LS F/E/E/N/L/M>4.0	495.56	376.38
17311	Other professional services	MOHS 1 STAGE H/N/HF/G	944.43	492.80
17312	Major surgery	MOHS ADDL STAGE	743.52	340.86
17313	Other professional services	MOHS 1 STAGE T/A/L	886.94	442.13
17314	Major surgery	MOHS ADDL STAGE T/A/L	712.14	316.00
17315	Major surgery	MOHS SURG ADDL BLOCK	144.51	90.11
17340	Other professional services	CRYOTHERAPY OF SKIN	73.50	68.51
17360	Other professional services	SKIN PEEL THERAPY	171.99	130.16
17380	Other professional services	HAIR REMOVAL BY ELECTROLYSIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
17999	Major surgery	UNLISTD PX SKN MUC MEMB SUBQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
19000	Other professional services	PUNCTURE ASPIR CYST BREAST	138.54	58.50
19001	Major surgery	PUNCTURE ASPIR CYST BRST EA	47.85	37.81
19020	Major surgery	MASTOTOMY EXPL DRG ABSC DP	841.02	565.48
19030	Other professional services	NJX PX ONLY MAM DUCTO/GLCTO	226.95	105.06
19081	Other professional services	BX BREAST 1ST LESION STRTCTC	683.13	225.59
19082	Major surgery	BX BREAST ADD LESION STRTCTC	679.59	146.87
19083	Other professional services	BX BREAST 1ST LESION US IMAG	680.16	213.08
19084	Major surgery	BX BREAST ADD LESION US IMAG	668.64	138.27
19085	Other professional services	BX BREAST 1ST LESION MR IMAG	1040.07	248.24
19086	Major surgery	BX BREAST ADD LESION MR IMAG	1041.83	160.84
19100	Other professional services	BX BREAST PERCUT W/O IMAGE	204.41	94.34
19101	Other professional services	BIOPSY OF BREAST OPEN	450.98	308.16
19105	Other professional services	CRYOSURG ABLATE FA EACH	3094.44	286.41
19110	Major surgery	NIPPLE EXPLORATION	871.73	634.63
19112	Major surgery	EXCISE BREAST DUCT FISTULA	825.30	582.29
19120	Major surgery	REMOVAL OF BREAST LESION	933.52	752.02
19125	Major surgery	EXCISION BREAST LESION	1028.10	831.21
19126	Major surgery	EXCISION ADDL BREAST LESION	283.55	283.55
19281	Other professional services	PERQ DEVICE BREAST 1ST IMAG	332.88	136.41
19282	Major surgery	PERQ DEVICE BREAST EA IMAG	304.77	88.96
19283	Other professional services	PERQ DEV BREAST 1ST STRTCTC	356.15	137.39
19284	Major surgery	PERQ DEV BREAST ADD STRTCTC	336.96	89.21
19285	Other professional services	PERQ DEV BREAST 1ST US IMAG	500.21	116.34
19286	Major surgery	PERQ DEV BREAST ADD US IMAG	529.33	75.84
19287	Other professional services	PERQ DEV BREAST 1ST MR GUIDE	862.29	174.15
19288	Major surgery	PERQ DEV BREAST ADD MR GUIDE	860.94	113.00
19294	Other professional services	PREPJ TUM CAV IORT PRTL MAST	223.70	223.70
19296	Other professional services	PLACE PO BREAST CATH FOR RAD	4902.32	287.28
19297	Major surgery	PLACE BREAST CATH FOR RAD	166.08	166.08
19298	Other professional services	PLACE BREAST RAD TUBE/CATHS	1199.93	444.93
19300	Major surgery	REMOVAL OF BREAST TISSUE	1033.81	777.21
19301	Major surgery	PARTIAL MASTECTOMY	1183.59	1183.59
19302	Major surgery	P-MASTECTOMY W/LN REMOVAL	1624.80	1624.80
19303	Major surgery	MAST SIMPLE COMPLETE	1715.61	1715.61
19305	Major surgery	MAST RADICAL	2056.70	2056.70
19306	Major surgery	MAST RAD URBAN TYPE	2183.84	2183.84
19307	Major surgery	MAST MOD RAD	2111.11	2111.11
19316	Major surgery	SUSPENSION OF BREAST	1426.82	1426.82
19318	Major surgery	BREAST REDUCTION	1966.87	1966.87
19325	Major surgery	BREAST AUGMENTATION W/IMPLT	1110.58	1110.58
19328	Major surgery	RMVL INTACT BREAST IMPLANT	999.49	999.49
19330	Major surgery	RMVL RUPTURED BREAST IMPLANT	1164.62	1164.62
19340	Major surgery	INSJ BREAST IMPLT SM D MAST	1367.40	1367.40
19342	Major surgery	INSJ/RPLCMT BRST IMPLT SEP D	1372.78	1372.78
19350	Major surgery	BREAST RECONSTRUCTION	1495.83	1214.38
19355	Major surgery	CORRECT INVERTED NIPPLE(S)	1359.81	1113.26
19357	Major surgery	TISS XPNDR PLMT BRST RCNSTJ	2087.71	2087.71
19361	Major surgery	BRST RCNSTJ LATSMS DRSI FLAP	2797.72	2797.72
19364	Major surgery	BRST RCNSTJ FREE FLAP	4870.36	4870.36
19367	Major surgery	BRST RCNSTJ 1 PDCL TRAM FLAP	3177.23	3177.23
19368	Major surgery	BRST RCNSTJ 1PDCL TRAM ANAST	3887.66	3887.66
19369	Major surgery	BRST RCNSTJ 2 PDCL TRAM FLAP	3612.63	3612.63
19370	Major surgery	REVJ PERI-IMPLT CAPSULE BRST	1212.14	1212.14
19371	Major surgery	PERI-IMPLT CAPSLC BRST COMPL	1283.24	1283.24
19380	Major surgery	REVJ RECONSTRUCTED BREAST	1455.48	1455.48
19396	Other professional services	DESIGN CUSTOM BREAST IMPLANT	374.34	196.97
19499	Major surgery	UNLISTED PROCEDURE BREAST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
20100	Other professional services	EXPLORE WOUND NECK	827.61	827.61
20101	Other professional services	EXPLORE WOUND CHEST	785.66	287.64
20102	Other professional services	EXPLORE WOUND ABDOMEN	838.44	352.70
20103	Other professional services	EXPLORE WOUND EXTREMITY	777.57	478.31
20150	Major surgery	EXCISE EPIPHYSEAL BAR	1809.37	1809.37
20200	Other professional services	MUSCLE BIOPSY SUPERFICIAL	296.19	130.64
20205	Other professional services	DEEP MUSCLE BIOPSY	416.24	212.03
20206	Other professional services	BIOPSY MUSCLE PERQ NEEDLE	300.23	79.19
20220	Other professional services	BONE BIOPSY TROCAR/NDL SUPFC	319.14	120.84
20225	Other professional services	BONE BIOPSY TROCAR/NDL DEEP	520.56	178.98
20240	Other professional services	BONE BIOPSY OPEN SUPERFICIAL	195.75	195.75
20245	Other professional services	BONE BIOPSY OPEN DEEP	474.54	474.54
20250	Other professional services	BIOPSY VRT BDY OPEN THORACIC	538.52	538.52
20251	Other professional services	BIOPSY VRT BDY OPEN LMBR/CRV	577.11	577.11
20500	Other professional services	INJECTION OF SINUS TRACT	172.38	125.07
20501	Other professional services	INJECT SINUS TRACT FOR X-RAY	194.25	50.54
20520	Other professional services	REMOVAL OF FOREIGN BODY	302.46	206.49
20525	Other professional services	REMOVAL OF FOREIGN BODY	638.88	343.25
20526	Other professional services	THER INJECTION CARP TUNNEL	114.03	78.56
20527	Other professional services	INJ DUPUYTREN CORD W/ENZYME	121.28	90.80
20550	Other professional services	INJ TENDON SHEATH/LIGAMENT	80.58	54.21
20551	Other professional services	INJ TENDON ORIGIN/INSERTION	80.25	53.88
20552	Other professional services	INJ TRIGGER POINT 1/2 MUSCL	73.23	51.41
20553	Other professional services	INJECT TRIGGER POINTS 3/>	84.35	58.43
20555	Other professional services	PLACE NDL MUSC/TIS FOR RT	470.60	470.60
20560	Other professional services	NDL INSJ W/O NJX 1 OR 2 MUSC	36.06	21.05
20561	Other professional services	NDL INSJ W/O NJX 3+ MUSC	51.98	31.50
20600	Other professional services	DRAIN/INJ JOINT/BURSA W/O US	74.93	49.91
20604	Other professional services	DRAIN/INJ JOINT/BURSA W/US	115.20	63.81
20605	Other professional services	DRAIN/INJ JOINT/BURSA W/O US	76.82	51.35
20606	Other professional services	DRAIN/INJ JOINT/BURSA W/US	125.22	72.47
20610	Other professional services	DRAIN/INJ JOINT/BURSA W/O US	90.35	63.06
20611	Other professional services	DRAIN/INJ JOINT/BURSA W/US	138.06	82.13
20612	Other professional services	ASPIRATE/INJ GANGLION CYST	90.41	57.21
20615	Other professional services	TREATMENT OF BONE CYST	353.21	227.22
20650	Other professional services	INSERT AND REMOVE BONE PIN	322.37	233.69
20660	Other professional services	APPLY REM FIXATION DEVICE	325.61	325.61
20661	Major surgery	APPLICATION HALO CRANIAL	943.43	943.43
20662	Major surgery	APPLICATION HALO PELVIC	949.61	949.61
20663	Major surgery	APPLICATION HALO FEMORAL	876.88	876.88
20664	Major surgery	APPL HALO CRANIAL 6+PINS	1587.89	1587.89
20665	Other professional services	RMVL TONGS/HALO ANTHR INDIV	165.00	137.25
20670	Other professional services	REMOVAL IMPLANT SUPERFICIAL	488.79	202.26
20680	Major surgery	REMOVAL OF IMPLANT DEEP	1081.28	761.98
20690	Major surgery	APPL UNIPLN UNI EXT FIXJ SYS	1079.46	1079.46
20692	Major surgery	APPL MLTPLN UNI EXT FIXJ SYS	2044.50	2044.50
20693	Major surgery	ADJMT/REVJ EXT FIXJ SYS ANES	814.57	814.57
20694	Major surgery	RMVL EXT FIXJ SYS UNDER ANES	781.77	623.32
20696	Major surgery	APP MLTPLN UNI XTRNL FIX 1ST	2106.88	2106.88
20697	Other professional services	APP MLTPLN UNI XTRNL FIX XCH	2414.70	2414.70
20700	Major surgery	MNL PREP&INSJ DP RX DLVR DEV	151.26	151.26
20701	Major surgery	RMVL DEEP RX DELIVERY DEVICE	114.60	114.60
20702	Major surgery	MNL PREP&INSJ IMED RX DEV	254.34	254.34
20703	Major surgery	RMVL IMED RX DELIVERY DEVICE	185.62	185.62
20704	Major surgery	MNL PREP&INSJ I-ARTIC RX DEV	267.33	267.33
20705	Major surgery	RMVL I-ARTIC RX DELIVERY DEV	221.17	221.17
20802	Major surgery	REPLANTATION ARM COMPLETE	4914.57	4914.57
20805	Major surgery	REPLANT FOREARM COMPLETE	5834.61	5834.61
20808	Major surgery	REPLANTATION HAND COMPLETE	7035.72	7035.72
20816	Major surgery	REPLANTATION DIGIT COMPLETE	3679.44	3679.44
20822	Major surgery	REPLANTATION DIGIT COMPLETE	3182.03	3182.03
20824	Major surgery	REPLANTATION THUMB COMPLETE	3686.53	3686.53
20827	Major surgery	REPLANTATION THUMB COMPLETE	3266.43	3266.43
20838	Major surgery	REPLANTATION FOOT COMPLETE	4987.09	4987.09
20900	Other professional services	REMOVAL OF BONE FOR GRAFT	530.27	249.65
20902	Other professional services	REMOVAL OF BONE FOR GRAFT	379.61	379.61
20910	Major surgery	REMOVE CARTILAGE FOR GRAFT	867.09	867.09
20912	Major surgery	REMOVE CARTILAGE FOR GRAFT	878.16	878.16
20920	Major surgery	REMOVAL OF FASCIA FOR GRAFT	729.90	729.90
20922	Major surgery	REMOVAL OF FASCIA FOR GRAFT	1108.11	899.98
20924	Major surgery	REMOVAL OF TENDON FOR GRAFT	916.71	916.71
20930	Other professional services	SP BONE ALGRFT MORSEL ADD-ON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
20931	Major surgery	SP BONE ALGRFT STRUCT ADD-ON	193.83	193.83
20932	Other professional services	OSTEOART ALGRFT W/SURF & B1	1032.96	1032.96
20933	Other professional services	HEMICRT INTRCLRY ALGRFT PRTL	947.42	947.42
20934	Other professional services	INTERCALARY ALGRFT COMPL	1032.02	1032.02
20936	Other professional services	SP BONE AGRFT LOCAL ADD-ON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
20937	Major surgery	SP BONE AGRFT MORSEL ADD-ON	294.29	294.29
20938	Major surgery	SP BONE AGRFT STRUCT ADD-ON	322.55	322.55
20939	Other professional services	BONE MARROW ASPIR BONE GRFG	94.46	94.46
20950	Other professional services	FLUID PRESSURE MUSCLE	363.80	122.75
20955	Major surgery	FIBULA BONE GRAFT MICROVASC	4400.12	4400.12
20956	Major surgery	ILIAC BONE GRAFT MICROVASC	4725.49	4725.49
20957	Major surgery	MT BONE GRAFT MICROVASC	4923.38	4923.38
20962	Major surgery	OTHER BONE GRAFT MICROVASC	4788.07	4788.07
20969	Major surgery	BONE/SKIN GRAFT MICROVASC	4896.65	4896.65
20970	Major surgery	BONE/SKIN GRAFT ILIAC CREST	5097.50	5097.50
20972	Major surgery	BONE/SKIN GRAFT METATARSAL	5082.56	5082.56
20973	Major surgery	BONE/SKIN GRAFT GREAT TOE	5367.78	5367.78
20974	Other professional services	ELECTRICAL BONE STIMULATION	115.28	70.25
20975	Other professional services	ELECTRICAL BONE STIMULATION	241.34	241.34
20979	Other professional services	US BONE STIMULATION	79.34	44.31
20982	Other professional services	ABLATE BONE TUMOR(S) PERQ	4692.20	503.78
20983	Other professional services	ABLATE BONE TUMOR(S) PERQ	6826.35	472.56
20985	Major surgery	CPTR-ASST DIR MS PX	257.56	257.56
20999	Major surgery	UNLISTED PX MUSCSKEL GENERAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
21010	Major surgery	INCISION OF JAW JOINT	1346.18	1346.18
21011	Major surgery	EXC FACE LES SC <2 CM	673.76	473.32
21012	Major surgery	EXC FACE LES SBQ 2 CM/>	614.27	614.27
21013	Major surgery	EXC FACE TUM DEEP < 2 CM	965.09	729.18
21014	Major surgery	EXC FACE TUM DEEP 2 CM/>	944.21	944.21
21015	Major surgery	RESECT FACE/SCALP TUM < 2 CM	1263.25	1263.25
21016	Major surgery	RESECT FACE/SCALP TUM 2 CM/>	1815.47	1815.47
21025	Major surgery	EXCISION OF BONE LOWER JAW	1439.39	1205.26
21026	Major surgery	EXCISION OF FACIAL BONE(S)	970.22	780.43
21029	Major surgery	CONTOUR OF FACE BONE LESION	1395.21	1132.70
21030	Major surgery	EXCISE MAX/ZYGOMA B9 TUMOR	829.37	656.14
21031	Major surgery	REMOVE EXOSTOSIS MANDIBLE	691.06	494.75
21032	Major surgery	REMOVE EXOSTOSIS MAXILLA	672.17	474.08
21034	Major surgery	EXCISE MAX/ZYGOMA MAL TUMOR	2347.72	2039.66
21040	Major surgery	EXCISE MANDIBLE LESION	837.64	658.50
21044	Major surgery	REMOVAL OF JAW BONE LESION	1564.64	1564.64
21045	Major surgery	EXTENSIVE JAW SURGERY	2171.52	2171.52
21046	Major surgery	REMOVE MANDIBLE CYST COMPLEX	1790.84	1790.84
21047	Major surgery	EXCISE LWR JAW CYST W/REPAIR	2197.88	2197.88
21048	Major surgery	REMOVE MAXILLA CYST COMPLEX	1807.90	1807.90
21049	Major surgery	EXCIS UPPR JAW CYST W/REPAIR	2088.74	2088.74
21050	Major surgery	REMOVAL OF JAW JOINT	1564.23	1564.23
21060	Major surgery	REMOVE JAW JOINT CARTILAGE	1419.05	1419.05
21070	Major surgery	REMOVE CORONOID PROCESS	1111.36	1111.36
21073	Major surgery	MNPJ OF TMJ W/ANESTH	686.79	436.10
21076	Other professional services	PREPARE FACE/ORAL PROSTHESIS	1211.91	989.96
21077	Major surgery	PREPARE FACE/ORAL PROSTHESIS	3857.65	3170.00
21079	Major surgery	PREPARE FACE/ORAL PROSTHESIS	2643.77	2129.97
21080	Major surgery	PREPARE FACE/ORAL PROSTHESIS	3014.88	2402.93
21081	Major surgery	PREPARE FACE/ORAL PROSTHESIS	2788.07	2205.10
21082	Major surgery	PREPARE FACE/ORAL PROSTHESIS	2603.09	2033.71
21083	Major surgery	PREPARE FACE/ORAL PROSTHESIS	2471.98	1880.13
21084	Major surgery	PREPARE FACE/ORAL PROSTHESIS	2821.79	2175.54
21085	Other professional services	PREPARE FACE/ORAL PROSTHESIS	949.88	678.81
21086	Major surgery	PREPARE FACE/ORAL PROSTHESIS	2864.36	2336.35
21087	Major surgery	PREPARE FACE/ORAL PROSTHESIS	2864.36	2336.35
21088	Major surgery	PREPARE FACE/ORAL PROSTHESIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
21089	Major surgery	UNLISTED MAXLFCL PROSTH PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
21100	Major surgery	MAXILLOFACIAL FIXATION	1114.02	648.69
21110	Major surgery	INTERDENTAL FIXATION	1538.61	1279.04
21116	Other professional services	INJECTION JAW JOINT X-RAY	291.18	61.95
21120	Major surgery	RECONSTRUCTION OF CHIN	1187.24	913.50
21121	Major surgery	RECONSTRUCTION OF CHIN	1147.81	964.51
21122	Major surgery	RECONSTRUCTION OF CHIN	1345.25	1345.25
21123	Major surgery	RECONSTRUCTION OF CHIN	1528.62	1528.62
21125	Major surgery	AUGMENTATION LOWER JAW BONE	4613.88	1216.49
21127	Major surgery	AUGMENTATION LOWER JAW BONE	7128.62	1408.15
21137	Major surgery	REDUCTION OF FOREHEAD	1353.90	1353.90
21138	Major surgery	REDUCTION OF FOREHEAD	1646.70	1646.70
21139	Major surgery	REDUCTION OF FOREHEAD	1958.23	1958.23
21141	Major surgery	LEFORT I-1 PIECE W/O GRAFT	2409.24	2409.24
21142	Major surgery	LEFORT I-2 PIECE W/O GRAFT	2472.76	2472.76
21143	Major surgery	LEFORT I-3/> PIECE W/O GRAFT	2548.96	2548.96
21145	Major surgery	LEFORT I-1 PIECE W/ GRAFT	2802.15	2802.15
21146	Major surgery	LEFORT I-2 PIECE W/ GRAFT	2925.92	2925.92
21147	Major surgery	LEFORT I-3/> PIECE W/ GRAFT	3078.62	3078.62
21150	Major surgery	LEFORT II ANTERIOR INTRUSION	2972.23	2972.23
21151	Major surgery	LEFORT II W/BONE GRAFTS	3271.26	3271.26
21154	Major surgery	LEFORT III W/O LEFORT I	3521.27	3521.27
21155	Major surgery	LEFORT III W/ LEFORT I	3906.05	3906.05
21159	Major surgery	LEFORT III W/FHDW/O LEFORT I	4678.93	4678.93
21160	Major surgery	LEFORT III W/FHD W/ LEFORT I	5074.33	5074.33
21172	Major surgery	RECONSTRUCT ORBIT/FOREHEAD	3742.21	3742.21
21175	Major surgery	RECONSTRUCT ORBIT/FOREHEAD	3958.17	3958.17
21179	Major surgery	RECONSTRUCT ENTIRE FOREHEAD	2726.84	2726.84
21180	Major surgery	RECONSTRUCT ENTIRE FOREHEAD	3044.20	3044.20
21181	Major surgery	CONTOUR CRANIAL BONE LESION	1335.59	1335.59
21182	Major surgery	RECONSTRUCT CRANIAL BONE	3789.63	3789.63
21183	Major surgery	RECONSTRUCT CRANIAL BONE	4121.68	4121.68
21184	Major surgery	RECONSTRUCT CRANIAL BONE	4433.17	4433.17
21188	Major surgery	RECONSTRUCTION OF MIDFACE	2851.78	2851.78
21193	Major surgery	RECONST LWR JAW W/O GRAFT	2227.08	2227.08
21194	Major surgery	RECONST LWR JAW W/GRAFT	2574.08	2574.08
21195	Major surgery	RECONST LWR JAW W/O FIXATION	2419.03	2419.03
21196	Major surgery	RECONST LWR JAW W/FIXATION	2585.08	2585.08
21198	Major surgery	RECONSTR LWR JAW SEGMENT	1828.34	1828.34
21199	Major surgery	RECONSTR LWR JAW W/ADVANCE	1842.50	1842.50
21206	Major surgery	RECONSTRUCT UPPER JAW BONE	1762.66	1762.66
21208	Major surgery	AUGMENTATION OF FACIAL BONES	2929.95	1341.23
21209	Major surgery	REDUCTION OF FACIAL BONES	1434.46	1099.80
21210	Major surgery	FACE BONE GRAFT	3148.31	1380.42
21215	Major surgery	LOWER JAW BONE GRAFT	7225.59	1434.77
21230	Major surgery	RIB CARTILAGE GRAFT	1352.36	1352.36
21235	Major surgery	EAR CARTILAGE GRAFT	1333.33	1037.11
21240	Major surgery	RECONSTRUCTION OF JAW JOINT	1898.66	1898.66
21242	Major surgery	RECONSTRUCTION OF JAW JOINT	1832.34	1832.34
21243	Major surgery	RECONSTRUCTION OF JAW JOINT	3033.34	3033.34
21244	Major surgery	RECONSTRUCTION OF LOWER JAW	1820.99	1820.99
21245	Major surgery	RECONSTRUCTION OF JAW	2201.14	1711.57
21246	Major surgery	RECONSTRUCTION OF JAW	1538.32	1538.32
21247	Major surgery	RECONSTRUCT LOWER JAW BONE	2857.74	2857.74
21248	Major surgery	RECONSTRUCTION OF JAW	1778.85	1443.02
21249	Major surgery	RECONSTRUCTION OF JAW	2414.80	2017.47
21255	Major surgery	RECONSTRUCT LOWER JAW BONE	2411.90	2411.90
21256	Major surgery	RECONSTRUCTION OF ORBIT	2230.80	2230.80
21260	Major surgery	REVISE EYE SOCKETS	2453.00	2453.00
21261	Major surgery	REVISE EYE SOCKETS	4345.01	4345.01
21263	Major surgery	REVISE EYE SOCKETS	4019.57	4019.57
21267	Major surgery	REVISE EYE SOCKETS	2868.02	2868.02
21268	Major surgery	REVISE EYE SOCKETS	3600.42	3600.42
21270	Major surgery	AUGMENTATION CHEEK BONE	1829.78	1347.31
21275	Major surgery	REVISION ORBITOFACIAL BONES	1519.44	1519.44
21280	Major surgery	REVISION OF EYELID	1067.90	1067.90
21282	Major surgery	REVISION OF EYELID	724.41	724.41
21295	Major surgery	REVISION OF JAW MUSCLE/BONE	359.83	359.83
21296	Major surgery	REVISION OF JAW MUSCLE/BONE	741.72	741.72
21299	Major surgery	UNLISTED CRANFCL&MAXLFCL PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
21315	Other professional services	CLSD TX NSL FX MNPJ WO STBLJ	210.66	82.85
21320	Other professional services	CLSD TX NSL FX W/MNPJ&STABLJ	299.25	132.33
21325	Major surgery	OPEN TX NOSE FX UNCOMPLICATD	805.00	805.00
21330	Major surgery	OPEN TX NOSE FX W/SKELE FIXJ	968.66	968.66
21335	Major surgery	OPEN TX NOSE & SEPTAL FX	1299.44	1299.44
21336	Major surgery	OPEN TX SEPTAL FX W/WO STABJ	1152.49	1152.49
21337	Major surgery	CLOSED TX SEPTAL&NOSE FX	753.52	547.77
21338	Major surgery	OPEN NASOETHMOID FX W/O FIXJ	1212.18	1212.18
21339	Major surgery	OPEN NASOETHMOID FX W/ FIXJ	1370.54	1370.54
21340	Major surgery	PERQ TX NASOETHMOID FX	1370.99	1370.99
21343	Major surgery	OPEN TX DPRSD FRONT SINUS FX	1969.81	1969.81
21344	Major surgery	OPEN TX COMPL FRONT SINUS FX	2523.26	2523.26
21345	Major surgery	CLOSED TX NOSE/JAW FX	1459.36	1167.86
21346	Major surgery	OPN TX NASOMAX FX W/FIXJ	1843.22	1843.22
21347	Major surgery	OPN TX NASOMAX FX MULTPLE	1875.67	1875.67
21348	Major surgery	OPN TX NASOMAX FX W/GRAFT	1987.73	1987.73
21355	Other professional services	PERQ TX MALAR FRACTURE	626.07	461.42
21356	Other professional services	OPN TX DPRSD ZYGOMATIC ARCH	756.02	560.90
21360	Major surgery	OPN TX DPRSD MALAR FRACTURE	958.19	958.19
21365	Major surgery	OPN TX COMPLX MALAR FX	1953.59	1953.59
21366	Major surgery	OPN TX COMPLX MALAR W/GRFT	2293.90	2293.90
21385	Major surgery	OPN TX ORBIT FX TRANSANTRAL	1320.21	1320.21
21386	Major surgery	OPN TX ORBIT FX PERIORBITAL	1248.66	1248.66
21387	Major surgery	OPN TX ORBIT FX COMBINED	1377.85	1377.85
21390	Major surgery	OPN TX ORBIT PERIORBTL IMPLT	1455.03	1455.03
21395	Major surgery	OPN TX ORBIT PERIORBT W/GRFT	1811.69	1811.69
21400	Major surgery	CLOSED TX ORBIT W/O MANIPULJ	394.00	308.86
21401	Major surgery	CLOSED TX ORBIT W/MANIPULJ	916.01	598.49
21406	Major surgery	OPN TX ORBIT FX W/O IMPLANT	1054.62	1054.62
21407	Major surgery	OPN TX ORBIT FX W/IMPLANT	1165.61	1165.61
21408	Major surgery	OPN TX ORBIT FX W/BONE GRFT	1624.72	1624.72
21421	Major surgery	TREAT MOUTH ROOF FRACTURE	1163.62	985.67
21422	Major surgery	TREAT MOUTH ROOF FRACTURE	1129.69	1129.69
21423	Major surgery	TREAT MOUTH ROOF FRACTURE	1433.84	1433.84
21431	Major surgery	TREAT CRANIOFACIAL FRACTURE	1252.72	1252.72
21432	Major surgery	TREAT CRANIOFACIAL FRACTURE	1280.99	1280.99
21433	Major surgery	TREAT CRANIOFACIAL FRACTURE	3109.68	3109.68
21435	Major surgery	TREAT CRANIOFACIAL FRACTURE	2529.72	2529.72
21436	Major surgery	TREAT CRANIOFACIAL FRACTURE	3655.78	3655.78
21440	Major surgery	TREAT DENTAL RIDGE FRACTURE	1359.52	1088.12
21445	Major surgery	TREAT DENTAL RIDGE FRACTURE	1396.47	1134.55
21450	Major surgery	TREAT LOWER JAW FRACTURE	1059.24	864.12
21451	Major surgery	TREAT LOWER JAW FRACTURE	1380.56	1154.11
21452	Major surgery	TREAT LOWER JAW FRACTURE	1305.76	819.74
21453	Major surgery	TREAT LOWER JAW FRACTURE	1956.73	1667.60
21454	Major surgery	TREAT LOWER JAW FRACTURE	892.69	892.69
21461	Major surgery	TREAT LOWER JAW FRACTURE	3275.03	1909.79
21462	Major surgery	TREAT LOWER JAW FRACTURE	3494.01	2085.62
21465	Major surgery	TREAT LOWER JAW FRACTURE	1455.89	1455.89
21470	Major surgery	TREAT LOWER JAW FRACTURE	2111.44	2111.44
21480	Other professional services	RESET DISLOCATED JAW	193.98	42.98
21485	Major surgery	RESET DISLOCATED JAW	1713.23	1402.23
21490	Major surgery	REPAIR DISLOCATED JAW	1435.14	1435.14
21497	Major surgery	INTERDENTAL WIRING	1269.84	1057.58
21499	Major surgery	UNLISTED MUSCSKEL PX HEAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
21501	Major surgery	DRAIN NECK/CHEST LESION	877.85	611.19
21502	Major surgery	DRAIN CHEST LESION	910.07	910.07
21510	Major surgery	DRAINAGE OF BONE LESION	812.64	812.64
21550	Other professional services	BIOPSY OF NECK/CHEST	369.38	217.46
21552	Major surgery	EXC NECK LES SC 3 CM/>	807.26	807.26
21554	Major surgery	EXC NECK TUM DEEP 5 CM/>	1319.45	1319.45
21555	Major surgery	EXC NECK LES SC < 3 CM	780.96	557.45
21556	Major surgery	EXC NECK TUM DEEP < 5 CM	959.58	959.58
21557	Major surgery	RESECT NECK THORAX TUMOR<5CM	1724.42	1724.42
21558	Major surgery	RESECT NECK TUMOR 5 CM/>	2404.47	2404.47
21600	Major surgery	PARTIAL REMOVAL OF RIB	1022.09	1022.09
21601	Major surgery	EXC CHEST WALL TUMOR W/RIBS	2047.01	2047.01
21602	Major surgery	EXC CH WAL TUM W/O LYMPHADEC	2728.32	2728.32
21603	Major surgery	EXC CH WAL TUM W/LYMPHADEC	2989.49	2989.49
21610	Major surgery	PARTIAL REMOVAL OF RIB	2144.84	2144.84
21615	Major surgery	REMOVAL OF RIB	1109.51	1109.51
21616	Major surgery	REMOVAL OF RIB AND NERVES	1267.87	1267.87
21620	Major surgery	PARTIAL REMOVAL OF STERNUM	902.09	902.09
21627	Major surgery	STERNAL DEBRIDEMENT	984.28	984.28
21630	Major surgery	EXTENSIVE STERNUM SURGERY	2362.82	2362.82
21632	Major surgery	EXTENSIVE STERNUM SURGERY	2156.66	2156.66
21685	Major surgery	HYOID MYOTOMY & SUSPENSION	1785.07	1785.07
21700	Major surgery	REVISION OF NECK MUSCLE	632.17	632.17
21705	Major surgery	REVISION OF NECK MUSCLE/RIB	943.02	943.02
21720	Major surgery	REVISION OF NECK MUSCLE	954.12	954.12
21725	Major surgery	REVISION OF NECK MUSCLE	987.09	987.09
21740	Major surgery	RECONSTRUCTION OF STERNUM	1819.37	1819.37
21742	Major surgery	REPAIR STERN/NUSS W/O SCOPE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
21743	Major surgery	REPAIR STERNUM/NUSS W/SCOPE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
21750	Major surgery	REPAIR OF STERNUM SEPARATION	1202.47	1202.47
21811	Other professional services	OPTX OF RIB FX W/FIXJ SCOPE	809.36	809.36
21812	Other professional services	TREATMENT OF RIB FRACTURE	976.86	976.86
21813	Other professional services	TREATMENT OF RIB FRACTURE	1334.13	1334.13
21820	Major surgery	TREAT STERNUM FRACTURE	277.72	274.17
21825	Major surgery	TREAT STERNUM FRACTURE	992.57	992.57
21899	Major surgery	UNLISTED PX NECK/THORAX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
21920	Other professional services	BIOPSY SOFT TISSUE OF BACK	355.47	215.84
21925	Major surgery	BIOPSY SOFT TISSUE OF BACK	891.87	686.11
21930	Major surgery	EXC BACK LES SC < 3 CM	905.83	661.64
21931	Major surgery	EXC BACK LES SC 3 CM/>	847.14	847.14
21932	Major surgery	EXC BACK TUM DEEP < 5 CM	1194.30	1194.30
21933	Major surgery	EXC BACK TUM DEEP 5 CM/>	1326.86	1326.86
21935	Major surgery	RESECT BACK TUM < 5 CM	1832.18	1832.18
21936	Major surgery	RESECT BACK TUM 5 CM/>	2532.78	2532.78
22010	Major surgery	I&D P-SPINE C/T/CERV-THOR	1741.10	1741.10
22015	Major surgery	I&D ABSCESS P-SPINE L/S/LS	1704.67	1704.67
22100	Major surgery	REMOVE PART OF NECK VERTEBRA	1688.88	1688.88
22101	Major surgery	REMOVE PART THORAX VERTEBRA	1575.54	1575.54
22102	Major surgery	REMOVE PART LUMBAR VERTEBRA	1396.55	1396.55
22103	Major surgery	REMOVE EXTRA SPINE SEGMENT	238.49	238.49
22110	Major surgery	REMOVE PART OF NECK VERTEBRA	1897.49	1897.49
22112	Major surgery	REMOVE PART THORAX VERTEBRA	2027.18	2027.18
22114	Major surgery	REMOVE PART LUMBAR VERTEBRA	2027.18	2027.18
22116	Major surgery	REMOVE EXTRA SPINE SEGMENT	247.38	247.38
22206	Major surgery	INCIS SPINE 3 COLUMN THORAC	4357.74	4357.74
22207	Major surgery	INCIS SPINE 3 COLUMN LUMBAR	4275.02	4275.02
22208	Major surgery	INCIS SPINE 3 COLUMN ADL SEG	1034.71	1034.71
22210	Major surgery	INCIS 1 VERTEBRAL SEG CERV	3194.53	3194.53
22212	Major surgery	INCIS 1 VERTEBRAL SEG THORAC	2710.34	2710.34
22214	Major surgery	INCIS 1 VERTEBRAL SEG LUMBAR	2710.25	2710.25
22216	Major surgery	INCIS ADDL SPINE SEGMENT	638.31	638.31
22220	Major surgery	OSTEOT DSC ANT 1 VRT SGM CRV	2897.23	2897.23
22222	Major surgery	OSTEOT DSC ANT 1VRT SGM THRC	3129.61	3129.61
22224	Major surgery	OSTEOT DSC ANT 1VRT SGM LMBR	2844.21	2844.21
22226	Major surgery	OSTEOT DSC ANT 1VRT SGM EA	633.30	633.30
22310	Major surgery	CLOSED TX VERT FX W/O MANJ	566.94	541.52
22315	Major surgery	CLOSED TX VERT FX W/MANJ	1624.64	1408.23
22318	Major surgery	TREAT ODONTOID FX W/O GRAFT	2936.84	2936.84
22319	Major surgery	TREAT ODONTOID FX W/GRAFT	3248.68	3248.68
22325	Major surgery	TREAT SPINE FRACTURE	2638.12	2638.12
22326	Major surgery	TREAT NECK SPINE FRACTURE	2693.20	2693.20
22327	Major surgery	TREAT THORAX SPINE FRACTURE	2746.28	2746.28
22328	Major surgery	TREAT EACH ADD SPINE FX	493.58	493.58
22505	Other professional services	MANIPULATION OF SPINE	179.90	179.90
22510	Other professional services	PERQ CERVICOTHORACIC INJECT	2443.16	597.50
22511	Other professional services	PERQ LUMBOSACRAL INJECTION	2438.93	562.35
22512	Major surgery	VERTEBROPLASTY ADDL INJECT	1287.57	369.35
22513	Other professional services	PERQ VERTEBRAL AUGMENTATION	7665.12	702.32
22514	Other professional services	PERQ VERTEBRAL AUGMENTATION	7630.73	654.74
22515	Major surgery	PERQ VERTEBRAL AUGMENTATION	5102.25	386.94
22526	Other professional services	IDET SINGLE LEVEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
22527	Major surgery	IDET 1 OR MORE LEVELS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
22532	Major surgery	ARTHRD LAT XTRCVTRY TQ THRC	3193.65	3193.65
22533	Major surgery	ARTHRD LAT XTRCVTRY TQ LMBR	2975.17	2975.17
22534	Major surgery	ARTHRD LAT XTRCVTRY TQ EA AD	635.10	635.10
22548	Major surgery	ARTHRD ANT TORAL/XORAL C1-C2	3483.30	3483.30
22551	Major surgery	ARTHRD ANT NTRBDY CERVICAL	3024.29	3024.29
22552	Major surgery	ARTHRD ANT NTRBD CERVICAL EA	695.86	695.86
22554	Major surgery	ARTHRD ANT NTRBD MIN DSC CRV	2252.66	2252.66
22556	Major surgery	ARTHRD ANT NTRBD MIN DSC THC	3004.62	3004.62
22558	Major surgery	ARTHRD ANT NTRBD MIN DSC LUM	2725.28	2725.28
22585	Major surgery	ARTHRD ANT NTRBD MIN DSC EA	572.01	572.01
22586	Major surgery	ARTHRD PRE-SAC NTRBDY L5-S1	3602.20	3602.20
22590	Major surgery	ARTHRD PST TQ CRANIOCERVICAL	2830.64	2830.64
22595	Major surgery	ARTHRD PST TQ ATLAS-AXIS	2706.91	2706.91
22600	Major surgery	ARTHRD PST TQ 1NTRSPC CRV	2327.54	2327.54
22610	Major surgery	ARTHRD PST TQ 1NTRSPC THRC	2291.58	2291.58
22612	Major surgery	ARTHRD PST TQ 1NTRSPC LUMBAR	2824.50	2824.50
22614	Major surgery	ARTHRD PST TQ 1NTRSPC EA ADD	687.49	687.49
22630	Major surgery	ARTHRD PST TQ 1NTRSPC LUM	2774.54	2774.54
22632	Major surgery	ARTHRD PST TQ 1NTRSPC LM EA	562.79	562.79
22633	Major surgery	ARTHRD CMBN 1NTRSPC LUMBAR	3219.43	3219.43
22634	Major surgery	ARTHRD CMBN 1NTRSPC EA ADDL	851.35	851.35
22800	Major surgery	ARTHRD PST DFRM<6 VRT SGM	2447.13	2447.13
22802	Major surgery	ARTHRD PST DFRM 7-12 VRT SGM	3778.75	3778.75
22804	Major surgery	ARTHRD PST DFRM 13+ VRT SGM	4337.07	4337.07
22808	Major surgery	ARTHRD ANT DFRM 2-3 VRT SGM	3258.49	3258.49
22810	Major surgery	ARTHRD ANT DFRM 4-7 VRT SGM	3601.51	3601.51
22812	Major surgery	ARTHRD ANT DFRM 8+ VRT SGM	3946.76	3946.76
22818	Major surgery	KYPHECTOMY 1-2 SEGMENTS	3852.21	3852.21
22819	Major surgery	KYPHECTOMY 3 OR MORE	4434.03	4434.03
22830	Major surgery	EXPLORATION OF SPINAL FUSION	1476.03	1476.03
22836	Major surgery	ANT THRC VRT BODY TETHRG <7	3133.08	3133.08
22837	Major surgery	ANT THRC VRT BODY TETHRG 8+	3451.85	3451.85
22838	Major surgery	REV RPLC/RMV THRC VRT TETHRG	3497.56	3497.56
22840	Major surgery	INSERT SPINE FIXATION DEVICE	1331.25	1331.25
22841	Other professional services	INSERT SPINE FIXATION DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
22842	Major surgery	INSERT SPINE FIXATION DEVICE	1341.19	1341.19
22843	Major surgery	INSERT SPINE FIXATION DEVICE	1436.14	1436.14
22844	Major surgery	INSERT SPINE FIXATION DEVICE	1734.78	1734.78
22845	Major surgery	INSERT SPINE FIXATION DEVICE	1275.98	1275.98
22846	Major surgery	INSERT SPINE FIXATION DEVICE	1327.60	1327.60
22847	Major surgery	INSERT SPINE FIXATION DEVICE	1421.00	1421.00
22848	Major surgery	INSERT PELV FIXATION DEVICE	634.32	634.32
22849	Major surgery	REINSERT SPINAL FIXATION	2331.52	2331.52
22850	Major surgery	REMOVE SPINE FIXATION DEVICE	1320.15	1320.15
22852	Major surgery	REMOVE SPINE FIXATION DEVICE	1272.88	1272.88
22853	Other professional services	INSJ BIOMECHANICAL DEVICE	348.48	348.48
22854	Other professional services	INSJ BIOMECHANICAL DEVICE	452.72	452.72
22855	Major surgery	REMOVAL ANTERIOR INSTRMJ	1980.11	1980.11
22856	Major surgery	TOT DISC ARTHRP 1NTRSPC CRV	2892.59	2892.59
22857	Major surgery	TOT DISC ARTHRP 1NTRSPC LMBR	3134.10	3134.10
22858	Major surgery	TOT DISC ARTHRP 2ND LVL CRV	890.76	890.76
22859	Other professional services	INSJ BIOMECHANICAL DEVICE	450.68	450.68
22860	Major surgery	TOT DISC ARTHRP 2NTRSPC LMBR	626.71	626.71
22861	Major surgery	REV RPLCM ARTHRP 1NTRSPC CRV	4093.79	4093.79
22862	Major surgery	REV RPLCM RTHRP 1NTRSPC LMBR	4098.30	4098.30
22864	Major surgery	RMVL TOT ARTHRP 1NTRSPC CRV	3658.53	3658.53
22865	Major surgery	RMVL TOT ARTHRP 1NTRSPC LMBR	4000.54	4000.54
22867	Major surgery	INSJ STABLJ DEV W/DCMPRN	1912.21	1912.21
22868	Other professional services	INSJ STABLJ DEV W/DCMPRN	327.75	327.75
22869	Major surgery	INSJ STABLJ DEV W/O DCMPRN	790.78	790.78
22870	Other professional services	INSJ STABLJ DEV W/O DCMPRN	164.30	164.30
22899	Major surgery	UNLISTED PROCEDURE SPINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
22900	Major surgery	EXC ABDL TUM DEEP < 5 CM	1020.83	1020.83
22901	Major surgery	EXC ABDL TUM DEEP 5 CM/>	1199.00	1199.00
22902	Major surgery	EXC ABD LES SC < 3 CM	847.55	603.93
22903	Major surgery	EXC ABD LES SC 3 CM/>	793.53	793.53
22904	Major surgery	RADICAL RESECT ABD TUMOR<5CM	1880.64	1880.64
22905	Major surgery	RAD RESECT ABD TUMOR 5 CM/>	2380.33	2380.33
22999	Major surgery	UNLISTED PX ABDOMEN MUSCSKEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
23000	Major surgery	REMOVAL OF CALCIUM DEPOSITS	994.48	654.52
23020	Major surgery	RELEASE SHOULDER JOINT	1254.55	1254.55
23030	Other professional services	DRAIN SHOULDER LESION	606.72	355.22
23031	Other professional services	DRAIN SHOULDER BURSA	595.92	310.74
23035	Major surgery	DRAIN SHOULDER BONE LESION	1230.88	1230.88
23040	Major surgery	EXPLORATORY SHOULDER SURGERY	1303.11	1303.11
23044	Major surgery	EXPLORATORY SHOULDER SURGERY	1027.94	1027.94
23065	Other professional services	BIOPSY SHOULDER TISSUES	313.61	223.55
23066	Major surgery	BIOPSY SHOULDER TISSUES	1030.40	672.09
23071	Major surgery	EXC SHOULDER LES SC 3 CM/>	759.37	759.37
23073	Major surgery	EXC SHOULDER TUM DEEP 5 CM/>	1257.59	1257.59
23075	Major surgery	EXC SHOULDER LES SC < 3 CM	925.31	598.36
23076	Major surgery	EXC SHOULDER TUM DEEP < 5 CM	983.85	983.85
23077	Major surgery	RESECT SHOULDER TUMOR < 5 CM	2026.36	2026.36
23078	Major surgery	RESECT SHOULDER TUMOR 5 CM/>	2575.11	2575.11
23100	Major surgery	BIOPSY OF SHOULDER JOINT	926.19	926.19
23101	Major surgery	SHOULDER JOINT SURGERY	837.76	837.76
23105	Major surgery	REMOVE SHOULDER JOINT LINING	1168.50	1168.50
23106	Major surgery	INCISION OF COLLARBONE JOINT	919.09	919.09
23107	Major surgery	EXPLORE TREAT SHOULDER JOINT	1210.40	1210.40
23120	Major surgery	PARTIAL REMOVAL COLLAR BONE	1074.02	1074.02
23125	Major surgery	REMOVAL OF COLLAR BONE	1291.11	1291.11
23130	Major surgery	REMOVE SHOULDER BONE PART	1127.10	1127.10
23140	Major surgery	REMOVAL OF BONE LESION	1014.12	1014.12
23145	Major surgery	REMOVAL OF BONE LESION	1265.73	1265.73
23146	Major surgery	REMOVAL OF BONE LESION	1137.88	1137.88
23150	Major surgery	REMOVAL OF HUMERUS LESION	1214.81	1214.81
23155	Major surgery	REMOVAL OF HUMERUS LESION	1447.95	1447.95
23156	Major surgery	REMOVAL OF HUMERUS LESION	1235.79	1235.79
23170	Major surgery	REMOVE COLLAR BONE LESION	1031.36	1031.36
23172	Major surgery	REMOVE SHOULDER BLADE LESION	1041.55	1041.55
23174	Major surgery	REMOVE HUMERUS LESION	1390.62	1390.62
23180	Major surgery	REMOVE COLLAR BONE LESION	1200.60	1200.60
23182	Major surgery	REMOVE SHOULDER BLADE LESION	1223.86	1223.86
23184	Major surgery	REMOVE HUMERUS LESION	1347.59	1347.59
23190	Major surgery	PARTIAL REMOVAL OF SCAPULA	1049.67	1049.67
23195	Major surgery	REMOVAL OF HEAD OF HUMERUS	1358.72	1358.72
23200	Major surgery	RESECT CLAVICLE TUMOR	2704.94	2704.94
23210	Major surgery	RESECT SCAPULA TUMOR	3170.37	3170.37
23220	Major surgery	RESECT PROX HUMERUS TUMOR	3471.08	3471.08
23330	Other professional services	REMOVE SHOULDER FOREIGN BODY	415.79	234.32
23333	Major surgery	REMOVE SHOULDER FB DEEP	864.59	864.59
23334	Major surgery	SHOULDER PROSTHESIS REMOVAL	1913.85	1913.85
23335	Major surgery	SHOULDER PROSTHESIS REMOVAL	2283.96	2283.96
23350	Other professional services	INJECTION FOR SHOULDER X-RAY	222.95	69.21
23395	Major surgery	MUSCLE TRANSFER SHOULDER/ARM	2317.34	2317.34
23397	Major surgery	MUSCLE TRANSFERS	2058.26	2058.26
23400	Major surgery	FIXATION OF SHOULDER BLADE	1758.72	1758.72
23405	Major surgery	INCISION OF TENDON & MUSCLE	1120.76	1120.76
23406	Major surgery	INCISE TENDON(S) & MUSCLE(S)	1332.49	1332.49
23410	Major surgery	REPAIR ROTATOR CUFF ACUTE	1485.71	1485.71
23412	Major surgery	REPAIR ROTATOR CUFF CHRONIC	1544.19	1544.19
23415	Major surgery	RELEASE OF SHOULDER LIGAMENT	1269.47	1269.47
23420	Major surgery	REPAIR OF SHOULDER	1763.97	1763.97
23430	Major surgery	REPAIR BICEPS TENDON	1352.58	1352.58
23440	Major surgery	REMOVE/TRANSPLANT TENDON	1374.44	1374.44
23450	Major surgery	REPAIR SHOULDER CAPSULE	1709.51	1709.51
23455	Major surgery	REPAIR SHOULDER CAPSULE	1783.12	1783.12
23460	Major surgery	REPAIR SHOULDER CAPSULE	1968.47	1968.47
23462	Major surgery	REPAIR SHOULDER CAPSULE	1926.35	1926.35
23465	Major surgery	REPAIR SHOULDER CAPSULE	2018.13	2018.13
23466	Major surgery	REPAIR SHOULDER CAPSULE	2029.68	2029.68
23470	Major surgery	RECONSTRUCT SHOULDER JOINT	2159.82	2159.82
23472	Major surgery	RECONSTRUCT SHOULDER JOINT	2599.43	2599.43
23473	Major surgery	REVIS RECONST SHOULDER JOINT	2891.34	2891.34
23474	Major surgery	REVIS RECONST SHOULDER JOINT	3120.57	3120.57
23480	Major surgery	REVISION OF COLLAR BONE	1486.68	1486.68
23485	Major surgery	REVISION OF COLLAR BONE	1724.68	1724.68
23490	Major surgery	REINFORCE CLAVICLE	1558.99	1558.99
23491	Major surgery	REINFORCE SHOULDER BONES	1835.83	1835.83
23500	Major surgery	CLTX CLAVICULAR FX W/O MNPJ	418.18	427.64
23505	Major surgery	CLTX CLAVICULAR FX W/MNPJ	669.84	621.95
23515	Major surgery	OPTX CLAVICULAR FX W/INT FIX	1310.26	1310.26
23520	Major surgery	CLTX STRNCLAV DISLC W/O MNPJ	449.98	446.43
23525	Major surgery	CLTX STRNCLAV DISLC W/MNPJ	738.66	674.82
23530	Major surgery	OPTX STRNCLAV DISLC AQT/CHRN	1050.31	1050.31
23532	Major surgery	OPTX STRCLV DSLC AQ/CHRN GRF	1142.25	1142.25
23540	Major surgery	CLTX ACROMCLAV DISLC WO MNPJ	446.18	442.63
23545	Major surgery	CLTX ACROMCLAV DISLC W/MNPJ	672.01	602.82
23550	Major surgery	OPTX ACROMCLV DISLC AQT/CHRN	1043.64	1043.64
23552	Major surgery	OPTX ACRCLV DSLC AQ/CHRN GRF	1183.28	1183.28
23570	Major surgery	CLTX SCAPULAR FX W/O MNPJ	439.08	453.86
23575	Major surgery	CLTX SCAP FX W/MNPJ +-TRACTJ	762.72	704.18
23585	Major surgery	OPTX SCAPULAR FX W/INT FIXJ	1764.79	1764.79
23600	Major surgery	CLTX PROX HUMRL FX W/O MNPJ	622.21	590.28
23605	Major surgery	CLTX PRX HMRL FX MNPJ+-TRACT	870.83	790.43
23615	Major surgery	OPTX PROX HUMRL FX W/INT FIX	1600.95	1600.95
23616	Major surgery	OPTX PRX HMRL FX FIX RPR RPL	2229.28	2229.28
23620	Major surgery	CLTX GR HMRL TBRS FX WO MNPJ	506.88	485.59
23625	Major surgery	CLTX GR HMRL TBRS FX W/MNPJ	717.68	656.19
23630	Major surgery	OPTX GR HMRL TBRS FX INT FIX	1419.44	1419.44
23650	Major surgery	CLTX SHO DSLC W/MNPJ WO ANES	620.61	560.29
23655	Major surgery	CLTX SHO DSLC W/MNPJ W/ANES	751.32	751.32
23660	Major surgery	OPTX ACUTE SHOULDER DISLC	1067.70	1067.70
23665	Major surgery	CLTX SHO DSLC FX GR HMRL TBR	808.20	742.56
23670	Major surgery	OPTX SHO DISLC FX	1581.61	1581.61
23675	Major surgery	CLTX SHO DISLC NECK FX MNPJ	1023.50	925.94
23680	Major surgery	OPTX SHO DISLC NECK FX FIXJ	1669.08	1669.08
23700	Other professional services	MNPJ ANES SHO JT FIXJ APRATS	274.01	274.01
23800	Major surgery	ARTHRODESIS GLENOHUMERAL JT	1855.99	1855.99
23802	Major surgery	ARTHRD GLENOHUMERAL JT W/GRF	2314.85	2314.85
23900	Major surgery	INTERTHORACOSCPLR AMPUTATION	2491.55	2491.55
23920	Major surgery	DISARTICULATION SHOULDER	2027.43	2027.43
23921	Major surgery	DISARTICULATION SHO SEC CLSR	862.58	862.58
23929	Major surgery	UNLISTED PROCEDURE SHOULDER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
23930	Other professional services	I&D UPR A/E DP ABSC/HMTMA	495.81	299.79
23931	Other professional services	I&D UPR A/E BURSA	418.82	225.98
23935	Major surgery	INC DP OPN B1 CRTX HUM/ELBW	939.63	939.63
24000	Major surgery	ARTHRT ELBW EXPL DRG/RMVL FB	875.78	875.78
24006	Major surgery	ARTHRT ELBW CAPSL EXC RLS	1299.75	1299.75
24065	Other professional services	BIOPSY ARM/ELBOW SOFT TISSUE	359.31	227.87
24066	Major surgery	BIOPSY ARM/ELBOW SOFT TISSUE	1128.33	769.43
24071	Major surgery	EXC ARM/ELBOW LES SC 3 CM/>	733.86	733.86
24073	Major surgery	EX ARM/ELBOW TUM DEEP 5 CM/>	1251.00	1251.00
24075	Major surgery	EXC ARM/ELBOW LES SC < 3 CM	952.24	599.25
24076	Major surgery	EX ARM/ELBOW TUM DEEP < 5 CM	993.04	993.04
24077	Major surgery	RAD RESCJ TUM TISS A/E <5CM	1846.85	1846.85
24079	Major surgery	RAD RESCJ TUM TISS A/E 5 CM+	2378.10	2378.10
24100	Major surgery	ARTHRT ELBW SYNOVIAL BX ONLY	770.80	770.80
24101	Major surgery	ARTHRT ELBW JT EXPL BX RMVL	921.00	921.00
24102	Major surgery	ARTHRT ELBOW W/SYNOVECTOMY	1126.30	1126.30
24105	Major surgery	EXCISION OLECRANON BURSA	662.84	662.84
24110	Major surgery	EXC/CURTG B1 CST/B9 TUM HUM	1078.23	1078.23
24115	Major surgery	EXC/CRTG B1 CST/TUM HUM AGRF	1340.37	1340.37
24116	Major surgery	EXC/CRTG B1 CST/TUM HUM ALGR	1558.23	1558.23
24120	Major surgery	EXC/CRTG B1 CST/B9 TUM RDS	974.08	974.08
24125	Major surgery	EXC/CRTG B1 CST/TUM RDS AGRF	1136.23	1136.23
24126	Major surgery	EXC/CRTG B1 CST/TUM RDS ALGR	1185.48	1185.48
24130	Major surgery	EXCISION RADIAL HEAD	935.16	935.16
24134	Major surgery	SEQUESTRECTOMY SHFT/DSTL HUM	1358.25	1358.25
24136	Major surgery	SEQUESTRECTOMY RADIAL H/N	1152.76	1152.76
24138	Major surgery	SEQUESTRECTOMY OLECRN PROCES	1254.01	1254.01
24140	Major surgery	PARTIAL EXC BONE HUMERUS	1278.93	1278.93
24145	Major surgery	PRTL EXC BONE RADIAL H/N	1084.40	1084.40
24147	Major surgery	PRTL EXC BONE OLECRN PROCESS	1146.17	1146.17
24149	Major surgery	RADICAL RESECTION OF ELBOW	2139.01	2139.01
24150	Major surgery	RAD RESCJ TUM DSTL/SHFT HUM	2775.42	2775.42
24152	Major surgery	RAD RESECTION TUM RADIAL H/N	2417.86	2417.86
24155	Major surgery	RESECTION OF ELBOW JOINT	1542.86	1542.86
24160	Major surgery	RMVL PROSTHHUMRL&ULNAR CMPNT	2263.74	2263.74
24164	Major surgery	REMOVAL PROSTH RADIAL HEAD	1316.66	1316.66
24200	Other professional services	RMVL FB UPPER ARM/ELBW SUBQ	304.80	197.93
24201	Major surgery	RMVL FB UPPER ARM/ELBW DEEP	1109.92	731.52
24220	Other professional services	INJECTION PX FOR ELBOW ARTHG	260.97	92.24
24300	Major surgery	MNPJ ELBOW UNDER ANES	810.11	810.11
24301	Major surgery	MUSC/TDN TRANSFER UPR A/E 1	1363.30	1363.30
24305	Major surgery	TENDON LNGTH UPR A/E EA TDN	1059.55	1059.55
24310	Major surgery	TNOT OPN ELBW TO SHO EA TDN	868.20	868.20
24320	Major surgery	TENOPLASTY ELBOW TO SHO 1	1416.03	1416.03
24330	Major surgery	FLEXOR-PLASTY ELBOW	1305.68	1305.68
24331	Major surgery	FLEXOR-PLASTY ELBW W/ADVMNT	1425.00	1425.00
24332	Major surgery	TENOLYSIS TRICEPS	1123.55	1123.55
24340	Major surgery	TENODESIS BICEPS TDN AT ELBW	1091.55	1091.55
24341	Major surgery	RPR TDN/MUSC UPR A/E EACH	1366.81	1366.81
24342	Major surgery	REPAIR OF RUPTURED TENDON	1406.05	1406.05
24343	Major surgery	REPR ELBOW LAT LIGMNT W/TISS	1302.99	1302.99
24344	Major surgery	RECONSTRUCT ELBOW LAT LIGMNT	1999.51	1999.51
24345	Major surgery	REPR ELBW MED LIGMNT W/TISSU	1296.91	1296.91
24346	Major surgery	RECONSTRUCT ELBOW MED LIGMNT	1999.51	1999.51
24357	Major surgery	REPAIR ELBOW PERC	766.12	766.12
24358	Major surgery	REPAIR ELBOW W/DEB OPEN	969.58	969.58
24359	Major surgery	REPAIR ELBOW DEB/ATTCH OPEN	1209.98	1209.98
24360	Major surgery	RECONSTRUCT ELBOW JOINT	1635.08	1635.08
24361	Major surgery	RECONSTRUCT ELBOW JOINT	1820.93	1820.93
24362	Major surgery	RECONSTRUCT ELBOW JOINT	1915.74	1915.74
24363	Major surgery	REPLACE ELBOW JOINT	2609.96	2609.96
24365	Major surgery	RECONSTRUCT HEAD OF RADIUS	1167.15	1167.15
24366	Major surgery	RECONSTRUCT HEAD OF RADIUS	1237.98	1237.98
24370	Major surgery	REVISE RECONST ELBOW JOINT	2765.82	2765.82
24371	Major surgery	REVISE RECONST ELBOW JOINT	3177.12	3177.12
24400	Major surgery	REVISION OF HUMERUS	1501.05	1501.05
24410	Major surgery	REVISION OF HUMERUS	1912.03	1912.03
24420	Major surgery	REVISION OF HUMERUS	1922.33	1922.33
24430	Major surgery	REPAIR OF HUMERUS	1907.78	1907.78
24435	Major surgery	REPAIR HUMERUS WITH GRAFT	1955.97	1955.97
24470	Major surgery	REVISION OF ELBOW JOINT	1224.37	1224.37
24495	Major surgery	DECOMPRESSION OF FOREARM	1660.09	1660.09
24498	Major surgery	REINFORCE HUMERUS	1570.63	1570.63
24500	Major surgery	TREAT HUMERUS FRACTURE	677.47	624.25
24505	Major surgery	TREAT HUMERUS FRACTURE	934.91	836.18
24515	Major surgery	TREAT HUMERUS FRACTURE	1596.47	1596.47
24516	Major surgery	TREAT HUMERUS FRACTURE	1555.50	1555.50
24530	Major surgery	TREAT HUMERUS FRACTURE	714.62	654.91
24535	Major surgery	TREAT HUMERUS FRACTURE	1149.21	1054.62
24538	Major surgery	TREAT HUMERUS FRACTURE	1434.48	1434.48
24545	Major surgery	TREAT HUMERUS FRACTURE	1681.78	1681.78
24546	Major surgery	TREAT HUMERUS FRACTURE	1875.57	1875.57
24560	Major surgery	TREAT HUMERUS FRACTURE	620.94	550.58
24565	Major surgery	TREAT HUMERUS FRACTURE	1001.66	914.14
24566	Major surgery	TREAT HUMERUS FRACTURE	1313.77	1313.77
24575	Major surgery	TREAT HUMERUS FRACTURE	1334.60	1334.60
24576	Major surgery	TREAT HUMERUS FRACTURE	658.22	586.68
24577	Major surgery	TREAT HUMERUS FRACTURE	1028.84	937.19
24579	Major surgery	TREAT HUMERUS FRACTURE	1516.26	1516.26
24582	Major surgery	TREAT HUMERUS FRACTURE	1487.09	1487.09
24586	Major surgery	TREAT ELBOW FRACTURE	1963.01	1963.01
24587	Major surgery	TREAT ELBOW FRACTURE	1965.37	1965.37
24600	Major surgery	TREAT ELBOW DISLOCATION	701.98	635.76
24605	Major surgery	TREAT ELBOW DISLOCATION	878.85	878.85
24615	Major surgery	TREAT ELBOW DISLOCATION	1297.41	1297.41
24620	Major surgery	TREAT ELBOW FRACTURE	1078.70	1078.70
24635	Major surgery	TREAT ELBOW FRACTURE	1231.17	1231.17
24640	Other professional services	TREAT ELBOW DISLOCATION	147.11	113.46
24650	Major surgery	TREAT RADIUS FRACTURE	494.75	461.06
24655	Major surgery	TREAT RADIUS FRACTURE	837.31	754.53
24665	Major surgery	TREAT RADIUS FRACTURE	1199.43	1199.43
24666	Major surgery	TREAT RADIUS FRACTURE	1331.85	1331.85
24670	Major surgery	TREAT ULNAR FRACTURE	547.25	500.55
24675	Major surgery	TREAT ULNAR FRACTURE	853.98	773.57
24685	Major surgery	TREAT ULNAR FRACTURE	1192.46	1192.46
24800	Major surgery	FUSION OF ELBOW JOINT	1513.01	1513.01
24802	Major surgery	FUSION/GRAFT OF ELBOW JOINT	1811.96	1811.96
24900	Major surgery	AMPUTATION OF UPPER ARM	1341.00	1341.00
24920	Major surgery	AMPUTATION OF UPPER ARM	1330.95	1330.95
24925	Major surgery	AMPUTATION FOLLOW-UP SURGERY	1039.31	1039.31
24930	Major surgery	AMPUTATION FOLLOW-UP SURGERY	1402.89	1402.89
24931	Major surgery	AMPUTATE UPPER ARM & IMPLANT	1682.34	1682.34
24935	Major surgery	REVISION OF AMPUTATION	2204.59	2204.59
24940	Major surgery	REVISION OF UPPER ARM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
24999	Major surgery	UNLISTED PX HUMERUS/ELBOW	UCR or Pay Per Agreement	UCR or Pay Per Agreement
25000	Major surgery	INCISION OF TENDON SHEATH	636.91	636.91
25001	Major surgery	INCISE FLEXOR CARPI RADIALIS	640.34	640.34
25020	Major surgery	DECOMPRESS FOREARM 1 SPACE	1334.00	1334.00
25023	Major surgery	DECOMPRESS FOREARM 1 SPACE	2357.55	2357.55
25024	Major surgery	DECOMPRESS FOREARM 2 SPACES	1415.52	1415.52
25025	Major surgery	DECOMPRESS FOREARM 2 SPACES	2213.13	2213.13
25028	Major surgery	DRAINAGE OF FOREARM LESION	1248.96	1248.96
25031	Major surgery	DRAINAGE OF FOREARM BURSA	676.55	676.55
25035	Major surgery	TREAT FOREARM BONE LESION	1075.85	1075.85
25040	Major surgery	EXPLORE/TREAT WRIST JOINT	1019.79	1019.79
25065	Other professional services	BIOPSY FOREARM SOFT TISSUES	355.14	220.97
25066	Major surgery	BIOPSY FOREARM SOFT TISSUES	673.45	673.45
25071	Major surgery	EXC FOREARM LES SC 3 CM/>	770.07	770.07
25073	Major surgery	EXC FOREARM TUM DEEP 3 CM/>	974.73	974.73
25075	Major surgery	EXC FOREARM LES SC < 3 CM	930.87	576.11
25076	Major surgery	EXC FOREARM TUM DEEP < 3 CM	946.57	946.57
25077	Major surgery	RESECT FOREARM/WRIST TUM<3CM	1540.52	1540.52
25078	Major surgery	RESECT FORARM/WRIST TUM 3CM>	2096.31	2096.31
25085	Major surgery	INCISION OF WRIST CAPSULE	823.58	823.58
25100	Major surgery	BIOPSY OF WRIST JOINT	643.31	643.31
25101	Major surgery	EXPLORE/TREAT WRIST JOINT	746.07	746.07
25105	Major surgery	REMOVE WRIST JOINT LINING	893.04	893.04
25107	Major surgery	REMOVE WRIST JOINT CARTILAGE	1131.06	1131.06
25109	Major surgery	EXCISE TENDON FOREARM/WRIST	981.40	981.40
25110	Major surgery	REMOVE WRIST TENDON LESION	636.54	636.54
25111	Major surgery	REMOVE WRIST TENDON LESION	598.98	598.98
25112	Major surgery	REREMOVE WRIST TENDON LESION	718.95	718.95
25115	Major surgery	REMOVE WRIST/FOREARM LESION	1379.47	1379.47
25116	Major surgery	REMOVE WRIST/FOREARM LESION	1106.31	1106.31
25118	Major surgery	EXCISE WRIST TENDON SHEATH	704.83	704.83
25119	Major surgery	PARTIAL REMOVAL OF ULNA	919.15	919.15
25120	Major surgery	REMOVAL OF FOREARM LESION	919.41	919.41
25125	Major surgery	REMOVE/GRAFT FOREARM LESION	1087.79	1087.79
25126	Major surgery	REMOVE/GRAFT FOREARM LESION	1095.47	1095.47
25130	Major surgery	REMOVAL OF WRIST LESION	828.73	828.73
25135	Major surgery	REMOVE & GRAFT WRIST LESION	1026.52	1026.52
25136	Major surgery	REMOVE & GRAFT WRIST LESION	911.47	911.47
25145	Major surgery	REMOVE FOREARM BONE LESION	953.82	953.82
25150	Major surgery	PARTIAL REMOVAL OF ULNA	1035.37	1035.37
25151	Major surgery	PARTIAL REMOVAL OF RADIUS	1067.96	1067.96
25170	Major surgery	RESECT RADIUS/ULNAR TUMOR	2638.45	2638.45
25210	Major surgery	REMOVAL OF WRIST BONE	904.59	904.59
25215	Major surgery	REMOVAL OF WRIST BONES	1132.05	1132.05
25230	Major surgery	PARTIAL REMOVAL OF RADIUS	795.35	795.35
25240	Major surgery	PARTIAL REMOVAL OF ULNA	790.34	790.34
25246	Other professional services	INJECTION FOR WRIST X-RAY	268.97	101.60
25248	Major surgery	REMOVE FOREARM FOREIGN BODY	775.91	775.91
25250	Major surgery	REMOVAL OF WRIST PROSTHESIS	976.13	976.13
25251	Major surgery	REMOVAL OF WRIST PROSTHESIS	1308.61	1308.61
25259	Major surgery	MANIPULATE WRIST W/ANESTHES	796.69	796.69
25260	Major surgery	REPAIR FOREARM TENDON/MUSCLE	1159.37	1159.37
25263	Major surgery	REPAIR FOREARM TENDON/MUSCLE	1157.36	1157.36
25265	Major surgery	REPAIR FOREARM TENDON/MUSCLE	1370.42	1370.42
25270	Major surgery	REPAIR FOREARM TENDON/MUSCLE	905.50	905.50
25272	Major surgery	REPAIR FOREARM TENDON/MUSCLE	1023.09	1023.09
25274	Major surgery	REPAIR FOREARM TENDON/MUSCLE	1213.23	1213.23
25275	Major surgery	REPAIR FOREARM TENDON SHEATH	1226.51	1226.51
25280	Major surgery	REVISE WRIST/FOREARM TENDON	1035.65	1035.65
25290	Major surgery	INCISE WRIST/FOREARM TENDON	800.79	800.79
25295	Major surgery	RELEASE WRIST/FOREARM TENDON	964.88	964.88
25300	Major surgery	FUSION OF TENDONS AT WRIST	1257.57	1257.57
25301	Major surgery	FUSION OF TENDONS AT WRIST	1175.25	1175.25
25310	Major surgery	TRANSPLANT FOREARM TENDON	1135.66	1135.66
25312	Major surgery	TRANSPLANT FOREARM TENDON	1306.56	1306.56
25315	Major surgery	REVISE PALSY HAND TENDON(S)	1397.78	1397.78
25316	Major surgery	REVISE PALSY HAND TENDON(S)	1659.57	1659.57
25320	Major surgery	REPAIR/REVISE WRIST JOINT	1801.39	1801.39
25332	Major surgery	REVISE WRIST JOINT	1536.25	1536.25
25335	Major surgery	REALIGNMENT OF HAND	1708.86	1708.86
25337	Major surgery	RECONSTRUCT ULNA/RADIOULNAR	1616.36	1616.36
25350	Major surgery	REVISION OF RADIUS	1229.92	1229.92
25355	Major surgery	REVISION OF RADIUS	1390.06	1390.06
25360	Major surgery	REVISION OF ULNA	1196.93	1196.93
25365	Major surgery	REVISE RADIUS & ULNA	1660.80	1660.80
25370	Major surgery	REVISE RADIUS OR ULNA	1831.87	1831.87
25375	Major surgery	REVISE RADIUS & ULNA	1725.69	1725.69
25390	Major surgery	SHORTEN RADIUS OR ULNA	1397.92	1397.92
25391	Major surgery	LENGTHEN RADIUS OR ULNA	1800.71	1800.71
25392	Major surgery	SHORTEN RADIUS & ULNA	1831.87	1831.87
25393	Major surgery	LENGTHEN RADIUS & ULNA	2037.28	2037.28
25394	Major surgery	REPAIR CARPAL BONE SHORTEN	1424.85	1424.85
25400	Major surgery	REPAIR RADIUS OR ULNA	1456.69	1456.69
25405	Major surgery	REPAIR/GRAFT RADIUS OR ULNA	1875.78	1875.78
25415	Major surgery	REPAIR RADIUS & ULNA	1751.02	1751.02
25420	Major surgery	REPAIR/GRAFT RADIUS & ULNA	2104.28	2104.28
25425	Major surgery	REPAIR/GRAFT RADIUS OR ULNA	1743.12	1743.12
25426	Major surgery	REPAIR/GRAFT RADIUS & ULNA	2026.03	2026.03
25430	Major surgery	VASC GRAFT INTO CARPAL BONE	1332.24	1332.24
25431	Major surgery	REPAIR NONUNION CARPAL BONE	1430.79	1430.79
25440	Major surgery	REPAIR/GRAFT WRIST BONE	1398.25	1398.25
25441	Major surgery	RECONSTRUCT WRIST JOINT	1698.10	1698.10
25442	Major surgery	RECONSTRUCT WRIST JOINT	1470.71	1470.71
25443	Major surgery	RECONSTRUCT WRIST JOINT	1427.42	1427.42
25444	Major surgery	RECONSTRUCT WRIST JOINT	1494.77	1494.77
25445	Major surgery	RECONSTRUCT WRIST JOINT	1311.82	1311.82
25446	Major surgery	WRIST REPLACEMENT	2119.55	2119.55
25447	Major surgery	REPAIR WRIST JOINTS	1514.55	1514.55
25449	Major surgery	REMOVE WRIST JOINT IMPLANT	1870.44	1870.44
25450	Major surgery	REVISION OF WRIST JOINT	1127.31	1127.31
25455	Major surgery	REVISION OF WRIST JOINT	1329.30	1329.30
25490	Major surgery	REINFORCE RADIUS	1307.92	1307.92
25491	Major surgery	REINFORCE ULNA	1343.90	1343.90
25492	Major surgery	REINFORCE RADIUS AND ULNA	1642.72	1642.72
25500	Major surgery	TREAT FRACTURE OF RADIUS	533.72	483.46
25505	Major surgery	TREAT FRACTURE OF RADIUS	943.49	854.20
25515	Major surgery	TREAT FRACTURE OF RADIUS	1224.07	1224.07
25520	Major surgery	TREAT FRACTURE OF RADIUS	1064.97	1004.07
25525	Major surgery	TREAT FRACTURE OF RADIUS	1438.61	1438.61
25526	Major surgery	TREAT FRACTURE OF RADIUS	1734.58	1734.58
25530	Major surgery	TREAT FRACTURE OF ULNA	496.53	455.73
25535	Major surgery	TREAT FRACTURE OF ULNA	918.04	847.08
25545	Major surgery	TREAT FRACTURE OF ULNA	1142.02	1142.02
25560	Major surgery	TREAT FRACTURE RADIUS & ULNA	543.56	485.61
25565	Major surgery	TREAT FRACTURE RADIUS & ULNA	961.78	859.48
25574	Major surgery	TREAT FRACTURE RADIUS & ULNA	1231.43	1231.43
25575	Major surgery	TREAT FRACTURE RADIUS/ULNA	1641.86	1641.86
25600	Major surgery	TREAT FRACTURE RADIUS/ULNA	633.24	606.04
25605	Major surgery	TREAT FRACTURE RADIUS/ULNA	999.75	943.59
25606	Major surgery	TREAT FX DISTAL RADIAL	1222.16	1222.16
25607	Major surgery	TREAT FX RAD EXTRA-ARTICUL	1350.26	1350.26
25608	Major surgery	TREAT FX RAD INTRA-ARTICUL	1507.72	1507.72
25609	Major surgery	TREAT FX RADIAL 3+ FRAG	1910.10	1910.10
25622	Major surgery	TREAT WRIST BONE FRACTURE	576.11	531.77
25624	Major surgery	TREAT WRIST BONE FRACTURE	911.86	825.53
25628	Major surgery	TREAT WRIST BONE FRACTURE	1310.99	1310.99
25630	Major surgery	TREAT WRIST BONE FRACTURE	571.66	531.47
25635	Major surgery	TREAT WRIST BONE FRACTURE	865.49	785.07
25645	Major surgery	TREAT WRIST BONE FRACTURE	1043.68	1043.68
25650	Major surgery	TREAT WRIST BONE FRACTURE	616.12	571.19
25651	Major surgery	PIN ULNAR STYLOID FRACTURE	901.89	901.89
25652	Major surgery	TREAT FRACTURE ULNAR STYLOID	1138.53	1138.53
25660	Major surgery	TREAT WRIST DISLOCATION	829.82	829.82
25670	Major surgery	TREAT WRIST DISLOCATION	1109.10	1109.10
25671	Major surgery	PIN RADIOULNAR DISLOCATION	981.57	981.57
25675	Major surgery	TREAT WRIST DISLOCATION	848.48	765.71
25676	Major surgery	TREAT WRIST DISLOCATION	1152.80	1152.80
25680	Major surgery	TREAT WRIST FRACTURE	975.99	975.99
25685	Major surgery	TREAT WRIST FRACTURE	1336.84	1336.84
25690	Major surgery	TREAT WRIST DISLOCATION	906.93	906.93
25695	Major surgery	TREAT WRIST DISLOCATION	1156.31	1156.31
25800	Major surgery	FUSION OF WRIST JOINT	1330.29	1330.29
25805	Major surgery	FUSION/GRAFT OF WRIST JOINT	1537.77	1537.77
25810	Major surgery	FUSION/GRAFT OF WRIST JOINT	1576.19	1576.19
25820	Major surgery	FUSION OF HAND BONES	1181.54	1181.54
25825	Major surgery	FUSE HAND BONES WITH GRAFT	1442.77	1442.77
25830	Major surgery	FUSION RADIOULNAR JNT/ULNA	1860.01	1860.01
25900	Major surgery	AMPUTATION OF FOREARM	1304.47	1304.47
25905	Major surgery	AMPUTATION OF FOREARM	1276.28	1276.28
25907	Major surgery	AMPUTATION FOLLOW-UP SURGERY	1121.37	1121.37
25909	Major surgery	AMPUTATION FOLLOW-UP SURGERY	1246.13	1246.13
25915	Major surgery	AMPUTATION OF FOREARM	2103.27	2103.27
25920	Major surgery	AMPUTATE HAND AT WRIST	1325.03	1325.03
25922	Major surgery	AMPUTATE HAND AT WRIST	1175.19	1175.19
25924	Major surgery	AMPUTATION FOLLOW-UP SURGERY	1294.51	1294.51
25927	Major surgery	AMPUTATION OF HAND	1559.71	1559.71
25929	Major surgery	AMPUTATION FOLLOW-UP SURGERY	1092.72	1092.72
25931	Major surgery	AMPUTATION FOLLOW-UP SURGERY	1444.13	1444.13
25999	Major surgery	UNLISTED PX FOREARM/WRIST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
26010	Other professional services	DRAINAGE OF FINGER ABSCESS	473.51	197.90
26011	Other professional services	DRAINAGE OF FINGER ABSCESS	654.65	258.95
26020	Major surgery	DRAIN HAND TENDON SHEATH	1016.22	1016.22
26025	Major surgery	DRAINAGE OF PALM BURSA	766.35	766.35
26030	Major surgery	DRAINAGE OF PALM BURSAS	898.62	898.62
26034	Major surgery	TREAT HAND BONE LESION	1008.38	1008.38
26035	Major surgery	DECOMPRESS FINGERS/HAND	1563.84	1563.84
26037	Major surgery	DECOMPRESS FINGERS/HAND	1024.10	1024.10
26040	Major surgery	RELEASE PALM CONTRACTURE	582.76	582.76
26045	Major surgery	RELEASE PALM CONTRACTURE	866.17	866.17
26055	Major surgery	INCISE FINGER TENDON SHEATH	1057.89	535.82
26060	Major surgery	INCISION OF FINGER TENDON	470.91	470.91
26070	Major surgery	EXPLORE/TREAT HAND JOINT	595.24	595.24
26075	Major surgery	EXPLORE/TREAT FINGER JOINT	622.83	622.83
26080	Major surgery	EXPLORE/TREAT FINGER JOINT	733.61	733.61
26100	Major surgery	BIOPSY HAND JOINT LINING	625.15	625.15
26105	Major surgery	BIOPSY FINGER JOINT LINING	628.88	628.88
26110	Major surgery	BIOPSY FINGER JOINT LINING	599.22	599.22
26111	Major surgery	EXC HAND LES SC 1.5 CM/>	759.60	759.60
26113	Major surgery	EXC HAND TUM DEEP 1.5 CM/>	999.36	999.36
26115	Major surgery	EXC HAND LES SC < 1.5 CM	990.66	609.30
26116	Major surgery	EXC HAND TUM DEEP < 1.5 CM	959.83	959.83
26117	Major surgery	RAD RESECT HAND TUMOR < 3 CM	1352.54	1352.54
26118	Major surgery	RAD RESECT HAND TUMOR 3 CM/>	1895.71	1895.71
26121	Major surgery	RELEASE PALM CONTRACTURE	1095.65	1095.65
26123	Major surgery	RELEASE PALM CONTRACTURE	1527.32	1527.32
26125	Major surgery	RELEASE PALM CONTRACTURE	480.25	480.25
26130	Major surgery	REMOVE WRIST JOINT LINING	860.11	860.11
26135	Major surgery	REVISE FINGER JOINT EACH	1012.95	1012.95
26140	Major surgery	REVISE FINGER JOINT EACH	931.91	931.91
26145	Major surgery	TENDON EXCISION PALM/FINGER	945.54	945.54
26160	Major surgery	REMOVE TENDON SHEATH LESION	1105.28	581.43
26170	Major surgery	REMOVAL OF PALM TENDON EACH	750.50	750.50
26180	Major surgery	REMOVAL OF FINGER TENDON	826.76	826.76
26185	Major surgery	REMOVE FINGER BONE	1021.31	1021.31
26200	Major surgery	REMOVE HAND BONE LESION	827.00	827.00
26205	Major surgery	REMOVE/GRAFT BONE LESION	1103.54	1103.54
26210	Major surgery	REMOVAL OF FINGER LESION	823.06	823.06
26215	Major surgery	REMOVE/GRAFT FINGER LESION	1036.21	1036.21
26230	Major surgery	PARTIAL REMOVAL OF HAND BONE	915.29	915.29
26235	Major surgery	PARTIAL REMOVAL FINGER BONE	903.30	903.30
26236	Major surgery	PARTIAL REMOVAL FINGER BONE	810.48	810.48
26250	Major surgery	EXTENSIVE HAND SURGERY	1925.00	1925.00
26260	Major surgery	RESECT PROX FINGER TUMOR	1444.25	1444.25
26262	Major surgery	RESECT DISTAL FINGER TUMOR	1148.84	1148.84
26320	Major surgery	REMOVAL OF IMPLANT FROM HAND	641.73	641.73
26340	Major surgery	MANIPULATE FINGER W/ANESTH	657.91	657.91
26341	Other professional services	MANIPULAT PALM CORD POST INJ	163.05	109.38
26350	Major surgery	REPAIR FINGER/HAND TENDON	1352.70	1352.70
26352	Major surgery	REPAIR/GRAFT HAND TENDON	1505.89	1505.89
26356	Major surgery	REPAIR FINGER/HAND TENDON	1449.14	1449.14
26357	Major surgery	REPAIR FINGER/HAND TENDON	1619.59	1619.59
26358	Major surgery	REPAIR/GRAFT HAND TENDON	1784.68	1784.68
26370	Major surgery	REPAIR FINGER/HAND TENDON	1418.18	1418.18
26372	Major surgery	REPAIR/GRAFT HAND TENDON	1653.68	1653.68
26373	Major surgery	REPAIR FINGER/HAND TENDON	1591.51	1591.51
26390	Major surgery	REVISE HAND/FINGER TENDON	1587.18	1587.18
26392	Major surgery	REPAIR/GRAFT HAND TENDON	1808.53	1808.53
26410	Major surgery	REPAIR HAND TENDON	1089.82	1089.82
26412	Major surgery	REPAIR/GRAFT HAND TENDON	1296.54	1296.54
26415	Major surgery	EXCISION HAND/FINGER TENDON	1538.28	1538.28
26416	Major surgery	GRAFT HAND OR FINGER TENDON	1664.75	1664.75
26418	Major surgery	REPAIR FINGER TENDON	1132.56	1132.56
26420	Major surgery	REPAIR/GRAFT FINGER TENDON	1345.87	1345.87
26426	Major surgery	REPAIR FINGER/HAND TENDON	923.19	923.19
26428	Major surgery	REPAIR/GRAFT FINGER TENDON	1441.50	1441.50
26432	Major surgery	REPAIR FINGER TENDON	986.39	986.39
26433	Major surgery	REPAIR FINGER TENDON	1036.76	1036.76
26434	Major surgery	REPAIR/GRAFT FINGER TENDON	1260.38	1260.38
26437	Major surgery	REALIGNMENT OF TENDONS	1209.57	1209.57
26440	Major surgery	RELEASE PALM/FINGER TENDON	1177.74	1177.74
26442	Major surgery	RELEASE PALM & FINGER TENDON	1793.49	1793.49
26445	Major surgery	RELEASE HAND/FINGER TENDON	1093.93	1093.93
26449	Major surgery	RELEASE FOREARM/HAND TENDON	1278.89	1278.89
26450	Major surgery	INCISION OF PALM TENDON	843.73	843.73
26455	Major surgery	INCISION OF FINGER TENDON	838.27	838.27
26460	Major surgery	INCISE HAND/FINGER TENDON	821.11	821.11
26471	Major surgery	FUSION OF FINGER TENDONS	1197.48	1197.48
26474	Major surgery	FUSION OF FINGER TENDONS	1181.62	1181.62
26476	Major surgery	TENDON LENGTHENING	1167.27	1167.27
26477	Major surgery	TENDON SHORTENING	1141.76	1141.76
26478	Major surgery	LENGTHENING OF HAND TENDON	1193.67	1193.67
26479	Major surgery	SHORTENING OF HAND TENDON	1224.83	1224.83
26480	Major surgery	TRANSPLANT HAND TENDON	1422.45	1422.45
26483	Major surgery	TRANSPLANT/GRAFT HAND TENDON	1577.73	1577.73
26485	Major surgery	TRANSPLANT PALM TENDON	1514.10	1514.10
26489	Major surgery	TRANSPLANT/GRAFT PALM TENDON	1742.03	1742.03
26490	Major surgery	REVISE THUMB TENDON	1518.43	1518.43
26492	Major surgery	TENDON TRANSFER WITH GRAFT	1678.83	1678.83
26494	Major surgery	HAND TENDON/MUSCLE TRANSFER	1524.88	1524.88
26496	Major surgery	REVISE THUMB TENDON	1640.89	1640.89
26497	Major surgery	FINGER TENDON TRANSFER	1638.59	1638.59
26498	Major surgery	FINGER TENDON TRANSFER	2129.28	2129.28
26499	Major surgery	REVISION OF FINGER	1577.06	1577.06
26500	Major surgery	HAND TENDON RECONSTRUCTION	1246.65	1246.65
26502	Major surgery	HAND TENDON RECONSTRUCTION	1369.11	1369.11
26508	Major surgery	RELEASE THUMB CONTRACTURE	1229.22	1229.22
26510	Major surgery	THUMB TENDON TRANSFER	1162.01	1162.01
26516	Major surgery	FUSION OF KNUCKLE JOINT	1348.27	1348.27
26517	Major surgery	FUSION OF KNUCKLE JOINTS	1568.11	1568.11
26518	Major surgery	FUSION OF KNUCKLE JOINTS	1587.85	1587.85
26520	Major surgery	RELEASE KNUCKLE CONTRACTURE	1234.19	1234.19
26525	Major surgery	RELEASE FINGER CONTRACTURE	1241.10	1241.10
26530	Major surgery	REVISE KNUCKLE JOINT	993.10	993.10
26531	Major surgery	REVISE KNUCKLE WITH IMPLANT	1154.05	1154.05
26535	Major surgery	REVISE FINGER JOINT	805.08	805.08
26536	Major surgery	REVISE/IMPLANT FINGER JOINT	1357.98	1357.98
26540	Major surgery	REPAIR HAND JOINT	1268.55	1268.55
26541	Major surgery	REPAIR HAND JOINT WITH GRAFT	1515.01	1515.01
26542	Major surgery	REPAIR HAND JOINT WITH GRAFT	1310.34	1310.34
26545	Major surgery	RECONSTRUCT FINGER JOINT	1333.49	1333.49
26546	Major surgery	REPAIR NONUNION HAND	1880.66	1880.66
26548	Major surgery	RECONSTRUCT FINGER JOINT	1450.20	1450.20
26550	Major surgery	CONSTRUCT THUMB REPLACEMENT	2973.03	2973.03
26551	Major surgery	GREAT TOE-HAND TRANSFER	5905.03	5905.03
26553	Major surgery	SINGLE TRANSFER TOE-HAND	5865.54	5865.54
26554	Major surgery	DOUBLE TRANSFER TOE-HAND	6826.54	6826.54
26555	Major surgery	POSITIONAL CHANGE OF FINGER	2499.26	2499.26
26556	Major surgery	TOE JOINT TRANSFER	6102.41	6102.41
26560	Major surgery	REPAIR OF WEB FINGER	1152.63	1152.63
26561	Major surgery	REPAIR OF WEB FINGER	1777.00	1777.00
26562	Major surgery	REPAIR OF WEB FINGER	2486.29	2486.29
26565	Major surgery	CORRECT METACARPAL FLAW	1289.30	1289.30
26567	Major surgery	CORRECT FINGER DEFORMITY	1304.71	1304.71
26568	Major surgery	LENGTHEN METACARPAL/FINGER	1680.69	1680.69
26580	Major surgery	REPAIR HAND DEFORMITY	2780.02	2780.02
26587	Major surgery	RECONSTRUCT EXTRA FINGER	1889.61	1889.61
26590	Major surgery	REPAIR FINGER DEFORMITY	2581.86	2581.86
26591	Major surgery	REPAIR MUSCLES OF HAND	887.21	887.21
26593	Major surgery	RELEASE MUSCLES OF HAND	1169.30	1169.30
26596	Major surgery	EXCISION CONSTRICTING TISSUE	1482.33	1482.33
26600	Major surgery	TREAT METACARPAL FRACTURE	563.88	537.26
26605	Major surgery	TREAT METACARPAL FRACTURE	615.85	554.95
26607	Major surgery	TREAT METACARPAL FRACTURE	927.91	927.91
26608	Major surgery	TREAT METACARPAL FRACTURE	885.50	885.50
26615	Major surgery	TREAT METACARPAL FRACTURE	1053.31	1053.31
26641	Major surgery	TREAT THUMB DISLOCATION	779.14	709.98
26645	Major surgery	TREAT THUMB FRACTURE	804.61	732.48
26650	Major surgery	TREAT THUMB FRACTURE	884.79	884.79
26665	Major surgery	TREAT THUMB FRACTURE	1147.71	1147.71
26670	Major surgery	TREAT HAND DISLOCATION	654.48	584.71
26675	Major surgery	TREAT HAND DISLOCATION	857.42	782.32
26676	Major surgery	PIN HAND DISLOCATION	937.50	937.50
26685	Major surgery	TREAT HAND DISLOCATION	1056.65	1056.65
26686	Major surgery	TREAT HAND DISLOCATION	1135.19	1135.19
26700	Major surgery	TREAT KNUCKLE DISLOCATION	634.53	584.86
26705	Major surgery	TREAT KNUCKLE DISLOCATION	812.60	735.74
26706	Major surgery	PIN KNUCKLE DISLOCATION	824.52	824.52
26715	Major surgery	TREAT KNUCKLE DISLOCATION	1049.57	1049.57
26720	Major surgery	TREAT FINGER FRACTURE EACH	377.93	355.47
26725	Major surgery	TREAT FINGER FRACTURE EACH	638.18	568.43
26727	Major surgery	TREAT FINGER FRACTURE EACH	873.13	873.13
26735	Major surgery	TREAT FINGER FRACTURE EACH	1088.51	1088.51
26740	Major surgery	TREAT FINGER FRACTURE EACH	437.27	413.61
26742	Major surgery	TREAT FINGER FRACTURE EACH	694.67	623.12
26746	Major surgery	TREAT FINGER FRACTURE EACH	1351.31	1351.31
26750	Major surgery	TREAT FINGER FRACTURE EACH	353.28	357.44
26755	Major surgery	TREAT FINGER FRACTURE EACH	596.45	511.31
26756	Major surgery	PIN FINGER FRACTURE EACH	781.52	781.52
26765	Major surgery	TREAT FINGER FRACTURE EACH	924.12	924.12
26770	Major surgery	TREAT FINGER DISLOCATION	541.42	492.34
26775	Major surgery	TREAT FINGER DISLOCATION	736.89	661.81
26776	Major surgery	PIN FINGER DISLOCATION	827.66	827.66
26785	Major surgery	TREAT FINGER DISLOCATION	1002.92	1002.92
26820	Major surgery	THUMB FUSION WITH GRAFT	1502.85	1502.85
26841	Major surgery	FUSION OF THUMB	1405.52	1405.52
26842	Major surgery	THUMB FUSION WITH GRAFT	1507.02	1507.02
26843	Major surgery	FUSION OF HAND JOINT	1417.30	1417.30
26844	Major surgery	FUSION/GRAFT OF HAND JOINT	1557.91	1557.91
26850	Major surgery	FUSION OF KNUCKLE	1332.28	1332.28
26852	Major surgery	FUSION OF KNUCKLE WITH GRAFT	1512.67	1512.67
26860	Major surgery	FUSION OF FINGER JOINT	1111.44	1111.44
26861	Major surgery	FUSION OF FINGER JNT ADD-ON	181.88	181.88
26862	Major surgery	FUSION/GRAFT OF FINGER JOINT	1391.31	1391.31
26863	Major surgery	FUSE/GRAFT ADDED JOINT	405.74	405.74
26910	Major surgery	AMPUTATE METACARPAL BONE	1380.25	1380.25
26951	Major surgery	AMPUTATION OF FINGER/THUMB	1273.84	1273.84
26952	Major surgery	AMPUTATION OF FINGER/THUMB	1239.95	1239.95
26989	Major surgery	UNLISTED PX HANDS/FINGERS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
26990	Major surgery	DRAINAGE OF PELVIS LESION	1232.13	1232.13
26991	Major surgery	DRAINAGE OF PELVIS BURSA	1276.63	957.92
26992	Major surgery	DRAINAGE OF BONE LESION	1826.19	1826.19
27000	Major surgery	INCISION OF HIP TENDON	719.12	719.12
27001	Major surgery	INCISION OF HIP TENDON	983.05	983.05
27003	Major surgery	INCISION OF HIP TENDON	1092.66	1092.66
27005	Major surgery	INCISION OF HIP TENDON	1307.92	1307.92
27006	Major surgery	INCISION OF HIP TENDONS	1304.04	1304.04
27025	Major surgery	INCISION OF HIP/THIGH FASCIA	1679.71	1679.71
27027	Major surgery	BUTTOCK FASCIOTOMY	1599.86	1599.86
27030	Major surgery	DRAINAGE OF HIP JOINT	1691.27	1691.27
27033	Major surgery	EXPLORATION OF HIP JOINT	1754.79	1754.79
27035	Major surgery	DENERVATION OF HIP JOINT	2070.35	2070.35
27036	Major surgery	EXCISION OF HIP JOINT/MUSCLE	1841.23	1841.23
27040	Other professional services	BIOPSY OF SOFT TISSUES	468.63	277.16
27041	Major surgery	BIOPSY OF SOFT TISSUES	1283.45	1283.45
27043	Major surgery	EXC HIP PELVIS LES SC 3 CM/>	846.38	846.38
27045	Major surgery	EXC HIP/PELV TUM DEEP 5 CM/>	1323.15	1323.15
27047	Major surgery	EXC HIP/PELVIS LES SC < 3 CM	891.58	655.65
27048	Major surgery	EXC HIP/PELV TUM DEEP < 5 CM	1106.47	1106.47
27049	Major surgery	RESECT HIP/PELV TUM < 5 CM	2563.16	2563.16
27050	Major surgery	BIOPSY OF SACROILIAC JOINT	743.96	743.96
27052	Major surgery	BIOPSY OF HIP JOINT	1056.69	1056.69
27054	Major surgery	REMOVAL OF HIP JOINT LINING	1251.47	1251.47
27057	Major surgery	BUTTOCK FASCIOTOMY W/DBRDMT	1817.91	1817.91
27059	Major surgery	RESECT HIP/PELV TUM 5 CM/>	3246.79	3246.79
27060	Major surgery	REMOVAL OF ISCHIAL BURSA	852.33	852.33
27062	Major surgery	REMOVE FEMUR LESION/BURSA	829.69	829.69
27065	Major surgery	REMOVE HIP BONE LES SUPER	954.54	954.54
27066	Major surgery	REMOVE HIP BONE LES DEEP	1479.23	1479.23
27067	Major surgery	REMOVE/GRAFT HIP BONE LESION	1872.08	1872.08
27070	Major surgery	PART REMOVE HIP BONE SUPER	1599.60	1599.60
27071	Major surgery	PART REMOVAL HIP BONE DEEP	1755.37	1755.37
27075	Major surgery	RESECT HIP TUMOR	3730.19	3730.19
27076	Major surgery	RESECT HIP TUM INCL ACETABUL	4503.70	4503.70
27077	Major surgery	RESECT HIP TUM W/INNOM BONE	5020.51	5020.51
27078	Major surgery	RSECT HIP TUM INCL FEMUR	3678.66	3678.66
27080	Major surgery	REMOVAL OF TAIL BONE	919.99	919.99
27086	Other professional services	REMOVE HIP FOREIGN BODY	429.38	236.09
27087	Major surgery	REMOVE HIP FOREIGN BODY	1112.20	1112.20
27090	Major surgery	REMOVAL OF HIP PROSTHESIS	1501.58	1501.58
27091	Major surgery	REMOVAL OF HIP PROSTHESIS	2860.16	2860.16
27093	Other professional services	INJECTION FOR HIP X-RAY	316.62	94.22
27095	Other professional services	INJECTION FOR HIP X-RAY	419.25	113.15
27096	Other professional services	INJECT SACROILIAC JOINT	227.81	115.92
27097	Major surgery	REVISION OF HIP TENDON	1241.96	1241.96
27098	Major surgery	TRANSFER TENDON TO PELVIS	1264.50	1264.50
27100	Major surgery	TRANSFER OF ABDOMINAL MUSCLE	1505.97	1505.97
27105	Major surgery	TRANSFER OF SPINAL MUSCLE	1577.67	1577.67
27110	Major surgery	TRANSFER OF ILIOPSOAS MUSCLE	1755.62	1755.62
27111	Major surgery	TRANSFER OF ILIOPSOAS MUSCLE	1635.68	1635.68
27120	Major surgery	RECONSTRUCTION OF HIP SOCKET	2338.40	2338.40
27122	Major surgery	RECONSTRUCTION OF HIP SOCKET	1990.19	1990.19
27125	Major surgery	PARTIAL HIP REPLACEMENT	2039.78	2039.78
27130	Major surgery	TOTAL HIP ARTHROPLASTY	2309.50	2309.50
27132	Major surgery	TOTAL HIP ARTHROPLASTY	2999.16	2999.16
27134	Major surgery	REVISE HIP JOINT REPLACEMENT	3411.64	3411.64
27137	Major surgery	REVISE HIP JOINT REPLACEMENT	2630.39	2630.39
27138	Major surgery	REVISE HIP JOINT REPLACEMENT	2731.72	2731.72
27140	Major surgery	TRANSPLANT FEMUR RIDGE	1622.26	1622.26
27146	Major surgery	INCISION OF HIP BONE	2303.71	2303.71
27147	Major surgery	REVISION OF HIP BONE	2629.85	2629.85
27151	Major surgery	INCISION OF HIP BONES	2840.23	2840.23
27156	Major surgery	REVISION OF HIP BONES	3058.52	3058.52
27158	Major surgery	REVISION OF PELVIS	2516.30	2516.30
27161	Major surgery	INCISION OF NECK OF FEMUR	2198.72	2198.72
27165	Major surgery	INCISION/FIXATION OF FEMUR	2470.14	2470.14
27170	Major surgery	REPAIR/GRAFT FEMUR HEAD/NECK	2105.22	2105.22
27175	Major surgery	TREAT SLIPPED EPIPHYSIS	1209.47	1209.47
27176	Major surgery	TREAT SLIPPED EPIPHYSIS	1668.54	1668.54
27177	Major surgery	TREAT SLIPPED EPIPHYSIS	2013.67	2013.67
27178	Major surgery	TREAT SLIPPED EPIPHYSIS	1668.54	1668.54
27179	Major surgery	REVISE HEAD/NECK OF FEMUR	1768.32	1768.32
27181	Major surgery	TREAT SLIPPED EPIPHYSIS	2022.05	2022.05
27185	Major surgery	REVISION OF FEMUR EPIPHYSIS	1305.68	1305.68
27187	Major surgery	REINFORCE HIP BONES	1800.38	1800.38
27197	Other professional services	CLSD TX PELVIC RING FX	185.34	185.34
27198	Other professional services	CLSD TX PELVIC RING FX	438.06	438.06
27200	Major surgery	TREAT TAIL BONE FRACTURE	352.17	356.32
27202	Major surgery	TREAT TAIL BONE FRACTURE	959.36	959.36
27215	Major surgery	TREAT PELVIC FRACTURE(S)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
27216	Major surgery	TREAT PELVIC RING FRACTURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
27217	Major surgery	TREAT PELVIC RING FRACTURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
27218	Major surgery	TREAT PELVIC RING FRACTURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
27220	Major surgery	TREAT HIP SOCKET FRACTURE	763.80	753.75
27222	Major surgery	TREAT HIP SOCKET FRACTURE	1771.34	1771.34
27226	Major surgery	TREAT HIP WALL FRACTURE	1908.56	1908.56
27227	Major surgery	TREAT HIP FRACTURE(S)	2964.55	2964.55
27228	Major surgery	TREAT HIP FRACTURE(S)	3366.99	3366.99
27230	Major surgery	TREAT THIGH FRACTURE	894.78	878.22
27232	Major surgery	TREAT THIGH FRACTURE	1313.95	1313.95
27235	Major surgery	TREAT THIGH FRACTURE	1639.27	1639.27
27236	Major surgery	TREAT THIGH FRACTURE	2151.16	2151.16
27238	Major surgery	TREAT THIGH FRACTURE	858.16	858.16
27240	Major surgery	TREAT THIGH FRACTURE	1722.44	1722.44
27244	Major surgery	TREAT THIGH FRACTURE	2211.57	2211.57
27245	Major surgery	TREAT THIGH FRACTURE	2208.96	2208.96
27246	Major surgery	TREAT THIGH FRACTURE	718.20	711.11
27248	Major surgery	TREAT THIGH FRACTURE	1346.81	1346.81
27250	Other professional services	TREAT HIP DISLOCATION	248.00	248.00
27252	Major surgery	TREAT HIP DISLOCATION	1356.62	1356.62
27253	Major surgery	TREAT HIP DISLOCATION	1696.85	1696.85
27254	Major surgery	TREAT HIP DISLOCATION	2289.46	2289.46
27256	Other professional services	TREAT HIP DISLOCATION	441.30	334.41
27257	Other professional services	TREAT HIP DISLOCATION	501.74	501.74
27258	Major surgery	TREAT HIP DISLOCATION	2005.50	2005.50
27259	Major surgery	TREAT HIP DISLOCATION	2774.13	2774.13
27265	Major surgery	TREAT HIP DISLOCATION	768.98	768.98
27266	Major surgery	TREAT HIP DISLOCATION	1062.13	1062.13
27267	Major surgery	CLTX THIGH FX	811.28	811.28
27268	Major surgery	CLTX THIGH FX W/MNPJ	994.01	994.01
27269	Major surgery	OPTX THIGH FX	2229.84	2229.84
27275	Other professional services	MANIPULATION OF HIP JOINT	257.94	257.94
27278	Major surgery	ARTHRD SI JT PRQ WO TFXJ DEV	21577.08	853.34
27279	Major surgery	ARTHRD SI JT PERQ/MIN NVAS	1445.30	1445.30
27280	Major surgery	ARTHR SI JT OPN B1GRF INSTRM	2427.30	2427.30
27282	Major surgery	ARTHRODESIS SYMPHYSIS PUBIS	1557.93	1557.93
27284	Major surgery	ARTHRODESIS HIP JOINT	2876.48	2876.48
27286	Major surgery	ARTHRD HIP JT SBTRCHC OSTEOT	2948.97	2948.97
27290	Major surgery	AMPUTATION OF LEG AT HIP	2918.04	2918.04
27295	Major surgery	AMPUTATION OF LEG AT HIP	2267.48	2267.48
27299	Major surgery	UNLISTED PX PELVIS/HIP JOINT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
27301	Major surgery	DRAIN THIGH/KNEE LESION	1215.22	923.73
27303	Major surgery	DRAINAGE OF BONE LESION	1166.02	1166.02
27305	Major surgery	INCISE THIGH TENDON & FASCIA	882.41	882.41
27306	Major surgery	INCISION OF THIGH TENDON	633.87	633.87
27307	Major surgery	INCISION OF THIGH TENDONS	752.91	752.91
27310	Major surgery	EXPLORATION OF KNEE JOINT	1331.17	1331.17
27323	Other professional services	BIOPSY THIGH SOFT TISSUES	380.57	244.58
27324	Major surgery	BIOPSY THIGH SOFT TISSUES	746.52	746.52
27325	Major surgery	NEURECTOMY HAMSTRING	1030.30	1030.30
27326	Major surgery	NEURECTOMY POPLITEAL	955.01	955.01
27327	Major surgery	EXC THIGH/KNEE LES SC < 3 CM	898.79	573.01
27328	Major surgery	EXC THIGH/KNEE TUM DEEP <5CM	1128.66	1128.66
27329	Major surgery	RESECT THIGH/KNEE TUM < 5 CM	1869.84	1869.84
27330	Major surgery	BIOPSY KNEE JOINT LINING	774.95	774.95
27331	Major surgery	EXPLORE/TREAT KNEE JOINT	871.79	871.79
27332	Major surgery	REMOVAL OF KNEE CARTILAGE	1176.51	1176.51
27333	Major surgery	REMOVAL OF KNEE CARTILAGE	1075.72	1075.72
27334	Major surgery	REMOVE KNEE JOINT LINING	1248.59	1248.59
27335	Major surgery	REMOVE KNEE JOINT LINING	1391.33	1391.33
27337	Major surgery	EXC THIGH/KNEE LES SC 3 CM/>	758.20	758.20
27339	Major surgery	EXC THIGH/KNEE TUM DEP 5CM/>	1362.97	1362.97
27340	Major surgery	REMOVAL OF KNEECAP BURSA	688.66	688.66
27345	Major surgery	REMOVAL OF KNEE CYST	889.41	889.41
27347	Major surgery	REMOVE KNEE CYST	963.77	963.77
27350	Major surgery	REMOVAL OF KNEECAP	1192.07	1192.07
27355	Major surgery	REMOVE FEMUR LESION	1107.27	1107.27
27356	Major surgery	REMOVE FEMUR LESION/GRAFT	1345.13	1345.13
27357	Major surgery	REMOVE FEMUR LESION/GRAFT	1484.44	1484.44
27358	Major surgery	REMOVE FEMUR LESION/FIXATION	487.89	487.89
27360	Major surgery	PARTIAL REMOVAL LEG BONE(S)	1634.20	1634.20
27364	Major surgery	RESECT THIGH/KNEE TUM 5 CM/>	2802.38	2802.38
27365	Major surgery	RESECT FEMUR/KNEE TUMOR	3676.96	3676.96
27369	Other professional services	NJX CNTRST KNE ARTHG/CT/MRI	251.34	55.77
27372	Major surgery	REMOVAL OF FOREIGN BODY	1054.42	726.86
27380	Major surgery	REPAIR OF KNEECAP TENDON	1132.85	1132.85
27381	Major surgery	REPAIR/GRAFT KNEECAP TENDON	1487.52	1487.52
27385	Major surgery	REPAIR OF THIGH MUSCLE	1105.36	1105.36
27386	Major surgery	REPAIR/GRAFT OF THIGH MUSCLE	1552.71	1552.71
27390	Major surgery	INCISION OF THIGH TENDON	825.10	825.10
27391	Major surgery	INCISION OF THIGH TENDONS	1056.43	1056.43
27392	Major surgery	INCISION OF THIGH TENDONS	1297.57	1297.57
27393	Major surgery	LENGTHENING OF THIGH TENDON	916.21	916.21
27394	Major surgery	LENGTHENING OF THIGH TENDONS	1192.87	1192.87
27395	Major surgery	LENGTHENING OF THIGH TENDONS	1599.08	1599.08
27396	Major surgery	TRANSPLANT OF THIGH TENDON	1126.81	1126.81
27397	Major surgery	TRANSPLANTS OF THIGH TENDONS	1658.69	1658.69
27400	Major surgery	REVISE THIGH MUSCLES/TENDONS	1265.57	1265.57
27403	Major surgery	REPAIR OF KNEE CARTILAGE	1175.01	1175.01
27405	Major surgery	REPAIR OF KNEE LIGAMENT	1231.17	1231.17
27407	Major surgery	REPAIR OF KNEE LIGAMENT	1446.72	1446.72
27409	Major surgery	REPAIR OF KNEE LIGAMENTS	1749.17	1749.17
27412	Major surgery	AUTOCHONDROCYTE IMPLANT KNEE	2962.62	2962.62
27415	Major surgery	OSTEOCHONDRAL KNEE ALLOGRAFT	2473.50	2473.50
27416	Major surgery	OSTEOCHONDRAL KNEE AUTOGRAFT	1771.50	1771.50
27418	Major surgery	REPAIR DEGENERATED KNEECAP	1492.49	1492.49
27420	Major surgery	REVISION OF UNSTABLE KNEECAP	1362.41	1362.41
27422	Major surgery	REVISION OF UNSTABLE KNEECAP	1347.80	1347.80
27424	Major surgery	REVISION/REMOVAL OF KNEECAP	1360.13	1360.13
27425	Major surgery	LAT RETINACULAR RELEASE OPEN	832.38	832.38
27427	Major surgery	RECONSTRUCTION KNEE	1288.60	1288.60
27428	Major surgery	RECONSTRUCTION KNEE	2020.96	2020.96
27429	Major surgery	RECONSTRUCTION KNEE	2277.62	2277.62
27430	Major surgery	REVISION OF THIGH MUSCLES	1349.01	1349.01
27435	Major surgery	INCISION OF KNEE JOINT	1465.54	1465.54
27437	Major surgery	REVISE KNEECAP	1203.85	1203.85
27438	Major surgery	REVISE KNEECAP WITH IMPLANT	1523.73	1523.73
27440	Major surgery	REVISION OF KNEE JOINT	1447.04	1447.04
27441	Major surgery	REVISION OF KNEE JOINT	1493.19	1493.19
27442	Major surgery	REVISION OF KNEE JOINT	1572.99	1572.99
27443	Major surgery	REVISION OF KNEE JOINT	1480.48	1480.48
27445	Major surgery	REVISION OF KNEE JOINT	2258.55	2258.55
27446	Major surgery	REVISION OF KNEE JOINT	2067.62	2067.62
27447	Major surgery	TOTAL KNEE ARTHROPLASTY	2306.28	2306.28
27448	Major surgery	INCISION OF THIGH	1500.23	1500.23
27450	Major surgery	INCISION OF THIGH	1824.48	1824.48
27454	Major surgery	REALIGNMENT OF THIGH BONE	2329.92	2329.92
27455	Major surgery	REALIGNMENT OF KNEE	1736.69	1736.69
27457	Major surgery	REALIGNMENT OF KNEE	1706.99	1706.99
27465	Major surgery	SHORTENING OF THIGH BONE	2246.44	2246.44
27466	Major surgery	LENGTHENING OF THIGH BONE	2136.50	2136.50
27468	Major surgery	SHORTEN/LENGTHEN THIGHS	2413.22	2413.22
27470	Major surgery	REPAIR OF THIGH	2130.59	2130.59
27472	Major surgery	REPAIR/GRAFT OF THIGH	2278.77	2278.77
27475	Major surgery	SURGERY TO STOP LEG GROWTH	1207.23	1207.23
27477	Major surgery	SURGERY TO STOP LEG GROWTH	1332.18	1332.18
27479	Major surgery	SURGERY TO STOP LEG GROWTH	1661.32	1661.32
27485	Major surgery	SURGERY TO STOP LEG GROWTH	1221.69	1221.69
27486	Major surgery	REVISE/REPLACE KNEE JOINT	2525.11	2525.11
27487	Major surgery	REVISE/REPLACE KNEE JOINT	3145.74	3145.74
27488	Major surgery	REMOVAL OF KNEE PROSTHESIS	2163.95	2163.95
27495	Major surgery	REINFORCE THIGH	2037.69	2037.69
27496	Major surgery	DECOMPRESSION OF THIGH/KNEE	1003.22	1003.22
27497	Major surgery	DECOMPRESSION OF THIGH/KNEE	1057.70	1057.70
27498	Major surgery	DECOMPRESSION OF THIGH/KNEE	1196.73	1196.73
27499	Major surgery	DECOMPRESSION OF THIGH/KNEE	1276.76	1276.76
27500	Major surgery	TREATMENT OF THIGH FRACTURE	958.43	879.78
27501	Major surgery	TREATMENT OF THIGH FRACTURE	923.91	910.32
27502	Major surgery	TREATMENT OF THIGH FRACTURE	1365.72	1365.72
27503	Major surgery	TREATMENT OF THIGH FRACTURE	1450.08	1450.08
27506	Major surgery	TREATMENT OF THIGH FRACTURE	2411.00	2411.00
27507	Major surgery	TREATMENT OF THIGH FRACTURE	1743.38	1743.38
27508	Major surgery	TREATMENT OF THIGH FRACTURE	966.30	914.86
27509	Major surgery	TREATMENT OF THIGH FRACTURE	1227.35	1227.35
27510	Major surgery	TREATMENT OF THIGH FRACTURE	1240.10	1240.10
27511	Major surgery	TREATMENT OF THIGH FRACTURE	1792.93	1792.93
27513	Major surgery	TREATMENT OF THIGH FRACTURE	2218.28	2218.28
27514	Major surgery	TREATMENT OF THIGH FRACTURE	1738.87	1738.87
27516	Major surgery	TREAT THIGH FX GROWTH PLATE	956.48	894.41
27517	Major surgery	TREAT THIGH FX GROWTH PLATE	1257.13	1257.13
27519	Major surgery	TREAT THIGH FX GROWTH PLATE	1604.66	1604.66
27520	Major surgery	TREAT KNEECAP FRACTURE	608.05	561.33
27524	Major surgery	TREAT KNEECAP FRACTURE	1367.24	1367.24
27530	Major surgery	TREAT KNEE FRACTURE	574.43	539.55
27532	Major surgery	TREAT KNEE FRACTURE	1137.96	1061.11
27535	Major surgery	TREAT KNEE FRACTURE	1616.47	1616.47
27536	Major surgery	TREAT KNEE FRACTURE	2141.76	2141.76
27538	Major surgery	TREAT KNEE FRACTURE(S)	893.02	830.35
27540	Major surgery	TREAT KNEE FRACTURE	1474.88	1474.88
27550	Major surgery	TREAT KNEE DISLOCATION	943.14	865.68
27552	Major surgery	TREAT KNEE DISLOCATION	1158.46	1158.46
27556	Major surgery	TREAT KNEE DISLOCATION	1579.31	1579.31
27557	Major surgery	TREAT KNEE DISLOCATION	1878.63	1878.63
27558	Major surgery	TREAT KNEE DISLOCATION	2135.13	2135.13
27560	Major surgery	TREAT KNEECAP DISLOCATION	695.19	634.30
27562	Major surgery	TREAT KNEECAP DISLOCATION	900.57	900.57
27566	Major surgery	TREAT KNEECAP DISLOCATION	1616.18	1616.18
27570	Other professional services	FIXATION OF KNEE JOINT	215.52	215.52
27580	Major surgery	FUSION OF KNEE	2658.16	2658.16
27590	Major surgery	AMPUTATE LEG AT THIGH	1395.07	1395.07
27591	Major surgery	AMPUTATE LEG AT THIGH	1741.14	1741.14
27592	Major surgery	AMPUTATE LEG AT THIGH	1194.88	1194.88
27594	Major surgery	AMPUTATION FOLLOW-UP SURGERY	906.18	906.18
27596	Major surgery	AMPUTATION FOLLOW-UP SURGERY	1270.35	1270.35
27598	Major surgery	AMPUTATE LOWER LEG AT KNEE	1238.09	1238.09
27599	Major surgery	UNLISTED PX FEMUR/KNEE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
27600	Major surgery	DECOMPRESSION OF LOWER LEG	720.90	720.90
27601	Major surgery	DECOMPRESSION OF LOWER LEG	801.47	801.47
27602	Major surgery	DECOMPRESSION OF LOWER LEG	850.28	850.28
27603	Major surgery	DRAIN LOWER LEG LESION	945.44	707.75
27604	Major surgery	DRAIN LOWER LEG BURSA	812.19	589.29
27605	Other professional services	INCISION OF ACHILLES TENDON	456.71	257.96
27606	Other professional services	INCISION OF ACHILLES TENDON	377.34	377.34
27607	Major surgery	TREAT LOWER LEG BONE LESION	1088.80	1088.80
27610	Major surgery	EXPLORE/TREAT ANKLE JOINT	1173.67	1173.67
27612	Major surgery	EXPLORATION OF ANKLE JOINT	1044.69	1044.69
27613	Other professional services	BIOPSY LOWER LEG SOFT TISSUE	352.35	226.37
27614	Major surgery	BIOPSY LOWER LEG SOFT TISSUE	1064.60	758.34
27615	Major surgery	RESECT LEG/ANKLE TUM < 5 CM	1823.66	1823.66
27616	Major surgery	RESECT LEG/ANKLE TUM 5 CM/>	2261.71	2261.71
27618	Major surgery	EXC LEG/ANKLE TUM < 3 CM	874.61	557.10
27619	Major surgery	EXC LEG/ANKLE TUM DEEP <5 CM	857.73	857.73
27620	Major surgery	EXPLORE/TREAT ANKLE JOINT	819.88	819.88
27625	Major surgery	REMOVE ANKLE JOINT LINING	1046.90	1046.90
27626	Major surgery	REMOVE ANKLE JOINT LINING	1129.65	1129.65
27630	Major surgery	REMOVAL OF TENDON LESION	972.89	654.81
27632	Major surgery	EXC LEG/ANKLE LES SC 3 CM/>	740.01	740.01
27634	Major surgery	EXC LEG/ANKLE TUM DEP 5 CM/>	1217.50	1217.50
27635	Major surgery	REMOVE LOWER LEG BONE LESION	1055.50	1055.50
27637	Major surgery	REMOVE/GRAFT LEG BONE LESION	1357.20	1357.20
27638	Major surgery	REMOVE/GRAFT LEG BONE LESION	1350.00	1350.00
27640	Major surgery	PARTIAL REMOVAL OF TIBIA	1508.46	1508.46
27641	Major surgery	PARTIAL REMOVAL OF FIBULA	1188.33	1188.33
27645	Major surgery	RESECT TIBIA TUMOR	3170.37	3170.37
27646	Major surgery	RESECT FIBULA TUMOR	2756.91	2756.91
27647	Major surgery	RESECT TALUS/CALCANEUS TUM	1829.84	1829.84
27648	Other professional services	INJECTION FOR ANKLE X-RAY	289.59	71.28
27650	Major surgery	REPAIR ACHILLES TENDON	1198.67	1198.67
27652	Major surgery	REPAIR/GRAFT ACHILLES TENDON	1229.22	1229.22
27654	Major surgery	REPAIR OF ACHILLES TENDON	1306.03	1306.03
27656	Major surgery	REPAIR LEG FASCIA DEFECT	952.46	625.48
27658	Major surgery	REPAIR OF LEG TENDON EACH	676.61	676.61
27659	Major surgery	REPAIR OF LEG TENDON EACH	866.01	866.01
27664	Major surgery	REPAIR OF LEG TENDON EACH	662.77	662.77
27665	Major surgery	REPAIR OF LEG TENDON EACH	775.22	775.22
27675	Major surgery	REPAIR LOWER LEG TENDONS	907.24	907.24
27676	Major surgery	REPAIR LOWER LEG TENDONS	1110.76	1110.76
27680	Major surgery	RELEASE OF LOWER LEG TENDON	769.94	769.94
27681	Major surgery	RELEASE OF LOWER LEG TENDONS	926.89	926.89
27685	Major surgery	REVISION OF LOWER LEG TENDON	1188.58	853.92
27686	Major surgery	REVISE LOWER LEG TENDONS	972.09	972.09
27687	Major surgery	REVISION OF CALF TENDON	830.99	830.99
27690	Major surgery	REVISE LOWER LEG TENDON	1164.83	1164.83
27691	Major surgery	REVISE LOWER LEG TENDON	1351.92	1351.92
27692	Major surgery	REVISE ADDITIONAL LEG TENDON	182.48	182.48
27695	Major surgery	REPAIR OF ANKLE LIGAMENT	888.48	888.48
27696	Major surgery	REPAIR OF ANKLE LIGAMENTS	1004.13	1004.13
27698	Major surgery	REPAIR OF ANKLE LIGAMENT	1162.30	1162.30
27700	Major surgery	REVISION OF ANKLE JOINT	1292.40	1292.40
27702	Major surgery	RECONSTRUCT ANKLE JOINT	1741.16	1741.16
27703	Major surgery	RECONSTRUCTION ANKLE JOINT	2007.17	2007.17
27704	Major surgery	REMOVAL OF ANKLE IMPLANT	1032.39	1032.39
27705	Major surgery	INCISION OF TIBIA	1360.48	1360.48
27707	Major surgery	INCISION OF FIBULA	741.08	741.08
27709	Major surgery	INCISION OF TIBIA & FIBULA	2068.56	2068.56
27712	Major surgery	REALIGNMENT OF LOWER LEG	1990.40	1990.40
27715	Major surgery	REVISION OF LOWER LEG	1935.43	1935.43
27720	Major surgery	REPAIR OF TIBIA	1580.51	1580.51
27722	Major surgery	REPAIR/GRAFT OF TIBIA	1620.68	1620.68
27724	Major surgery	REPAIR/GRAFT OF TIBIA	2257.01	2257.01
27725	Major surgery	REPAIR OF LOWER LEG	2195.15	2195.15
27726	Major surgery	REPAIR FIBULA NONUNION	1727.88	1727.88
27727	Major surgery	REPAIR OF LOWER LEG	1876.88	1876.88
27730	Major surgery	REPAIR OF TIBIA EPIPHYSIS	1072.97	1072.97
27732	Major surgery	REPAIR OF FIBULA EPIPHYSIS	831.01	831.01
27734	Major surgery	REPAIR LOWER LEG EPIPHYSES	1197.63	1197.63
27740	Major surgery	REPAIR OF LEG EPIPHYSES	1287.60	1287.60
27742	Major surgery	REPAIR OF LEG EPIPHYSES	1411.31	1411.31
27745	Major surgery	REINFORCE TIBIA	1352.75	1352.75
27750	Major surgery	TREATMENT OF TIBIA FRACTURE	648.04	601.93
27752	Major surgery	TREATMENT OF TIBIA FRACTURE	986.66	900.94
27756	Major surgery	TREATMENT OF TIBIA FRACTURE	1054.77	1054.77
27758	Major surgery	TREATMENT OF TIBIA FRACTURE	1623.04	1623.04
27759	Major surgery	TREATMENT OF TIBIA FRACTURE	1800.75	1800.75
27760	Major surgery	CLTX MEDIAL ANKLE FX	622.36	574.47
27762	Major surgery	CLTX MED ANKLE FX W/MNPJ	903.96	814.67
27766	Major surgery	OPTX MEDIAL ANKLE FX	1101.56	1101.56
27767	Major surgery	CLTX POST ANKLE FX	540.75	540.15
27768	Major surgery	CLTX POST ANKLE FX W/MNPJ	826.96	826.96
27769	Major surgery	OPTX POST ANKLE FX	1318.65	1318.65
27780	Major surgery	TREATMENT OF FIBULA FRACTURE	577.30	531.78
27781	Major surgery	TREATMENT OF FIBULA FRACTURE	812.84	747.81
27784	Major surgery	TREATMENT OF FIBULA FRACTURE	1300.79	1300.79
27786	Major surgery	TREATMENT OF ANKLE FRACTURE	584.71	535.63
27788	Major surgery	TREATMENT OF ANKLE FRACTURE	788.99	713.31
27792	Major surgery	TREATMENT OF ANKLE FRACTURE	1174.41	1174.41
27808	Major surgery	TREATMENT OF ANKLE FRACTURE	626.83	570.65
27810	Major surgery	TREATMENT OF ANKLE FRACTURE	879.51	791.41
27814	Major surgery	TREATMENT OF ANKLE FRACTURE	1387.33	1387.33
27816	Major surgery	TREATMENT OF ANKLE FRACTURE	618.40	549.22
27818	Major surgery	TREATMENT OF ANKLE FRACTURE	912.60	813.29
27822	Major surgery	TREATMENT OF ANKLE FRACTURE	1582.97	1582.97
27823	Major surgery	TREATMENT OF ANKLE FRACTURE	1782.40	1782.40
27824	Major surgery	TREAT LOWER LEG FRACTURE	587.87	567.76
27825	Major surgery	TREAT LOWER LEG FRACTURE	1004.11	904.20
27826	Major surgery	TREAT LOWER LEG FRACTURE	1549.29	1549.29
27827	Major surgery	TREAT LOWER LEG FRACTURE	2025.35	2025.35
27828	Major surgery	TREAT LOWER LEG FRACTURE	2394.76	2394.76
27829	Major surgery	TREAT LOWER LEG JOINT	1284.29	1284.29
27830	Major surgery	TREAT LOWER LEG DISLOCATION	723.59	668.01
27831	Major surgery	TREAT LOWER LEG DISLOCATION	753.97	753.97
27832	Major surgery	TREAT LOWER LEG DISLOCATION	1377.69	1377.69
27840	Major surgery	TREAT ANKLE DISLOCATION	715.88	715.88
27842	Major surgery	TREAT ANKLE DISLOCATION	903.26	903.26
27846	Major surgery	TREAT ANKLE DISLOCATION	1320.91	1320.91
27848	Major surgery	TREAT ANKLE DISLOCATION	1433.64	1433.64
27860	Other professional services	FIXATION OF ANKLE JOINT	229.59	229.59
27870	Major surgery	FUSION OF ANKLE JOINT OPEN	1827.36	1827.36
27871	Major surgery	FUSION OF TIBIOFIBULAR JOINT	1255.04	1255.04
27880	Major surgery	AMPUTATION OF LOWER LEG	1598.57	1598.57
27881	Major surgery	AMPUTATION OF LOWER LEG	1502.40	1502.40
27882	Major surgery	AMPUTATION OF LOWER LEG	1052.71	1052.71
27884	Major surgery	AMPUTATION FOLLOW-UP SURGERY	1035.61	1035.61
27886	Major surgery	AMPUTATION FOLLOW-UP SURGERY	1159.70	1159.70
27888	Major surgery	AMPUTATION OF FOOT AT ANKLE	1018.25	1018.25
27889	Major surgery	AMPUTATION OF FOOT AT ANKLE	1146.70	1146.70
27892	Major surgery	DECOMPRESSION OF LEG	969.29	969.29
27893	Major surgery	DECOMPRESSION OF LEG	1118.77	1118.77
27894	Major surgery	DECOMPRESSION OF LEG	1463.55	1463.55
27899	Major surgery	UNLISTED PX LEG/ANKLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
28001	Other professional services	DRAINAGE OF BURSA OF FOOT	238.41	135.17
28002	Other professional services	TREATMENT OF FOOT INFECTION	341.69	197.51
28003	Major surgery	TREATMENT OF FOOT INFECTION	684.16	471.32
28005	Major surgery	TREAT FOOT BONE LESION	1048.18	1048.18
28008	Major surgery	INCISION OF FOOT FASCIA	773.45	541.67
28010	Major surgery	INCISION OF TOE TENDON	429.08	383.55
28011	Major surgery	INCISION OF TOE TENDONS	578.37	514.53
28020	Major surgery	EXPLORATION OF FOOT JOINT	976.33	668.28
28022	Major surgery	EXPLORATION OF FOOT JOINT	878.75	600.85
28024	Major surgery	EXPLORATION OF TOE JOINT	834.37	566.51
28035	Major surgery	DECOMPRESSION OF TIBIA NERVE	952.38	656.74
28039	Major surgery	EXC FOOT/TOE TUM SC 1.5 CM/>	862.72	620.30
28041	Major surgery	EXC FOOT/TOE TUM DEP 1.5CM/>	825.42	825.42
28043	Major surgery	EXC FOOT/TOE TUM SC < 1.5 CM	692.76	479.90
28045	Major surgery	EXC FOOT/TOE TUM DEEP <1.5CM	869.68	637.90
28046	Major surgery	RESECT FOOT/TOE TUMOR < 3 CM	1280.68	1280.68
28047	Major surgery	RESECT FOOT/TOE TUMOR 3 CM/>	1877.79	1877.79
28050	Major surgery	BIOPSY OF FOOT JOINT LINING	752.80	514.53
28052	Major surgery	BIOPSY OF FOOT JOINT LINING	705.04	472.08
28054	Major surgery	BIOPSY OF TOE JOINT LINING	662.16	431.57
28055	Major surgery	NEURECTOMY FOOT	714.64	714.64
28060	Major surgery	PARTIAL REMOVAL FOOT FASCIA	936.45	661.50
28062	Major surgery	REMOVAL OF FOOT FASCIA	1046.10	743.96
28070	Major surgery	REMOVAL OF FOOT JOINT LINING	916.25	629.50
28072	Major surgery	REMOVAL OF FOOT JOINT LINING	885.42	596.88
28080	Major surgery	REMOVAL OF FOOT LESION	962.85	693.83
28086	Major surgery	EXCISE FOOT TENDON SHEATH	943.82	640.50
28088	Major surgery	EXCISE FOOT TENDON SHEATH	835.61	538.80
28090	Major surgery	REMOVAL OF FOOT LESION	841.43	567.08
28092	Major surgery	REMOVAL OF TOE LESIONS	762.26	500.94
28100	Major surgery	REMOVAL OF ANKLE/HEEL LESION	1101.81	763.02
28102	Major surgery	REMOVE/GRAFT FOOT LESION	1112.96	1112.96
28103	Major surgery	REMOVE/GRAFT FOOT LESION	714.03	714.03
28104	Major surgery	REMOVAL OF FOOT LESION	947.52	650.13
28106	Major surgery	REMOVE/GRAFT FOOT LESION	784.84	784.84
28107	Major surgery	REMOVE/GRAFT FOOT LESION	918.88	638.04
28108	Major surgery	REMOVAL OF TOE LESIONS	784.08	531.00
28110	Major surgery	PART REMOVAL OF METATARSAL	834.46	539.43
28111	Major surgery	PART REMOVAL OF METATARSAL	858.21	585.64
28112	Major surgery	PART REMOVAL OF METATARSAL	869.10	574.65
28113	Major surgery	PART REMOVAL OF METATARSAL	1057.29	783.53
28114	Major surgery	REMOVAL OF METATARSAL HEADS	1925.12	1526.01
28116	Major surgery	REVISION OF FOOT	1391.01	1064.64
28118	Major surgery	REMOVAL OF HEEL BONE	1091.40	773.29
28119	Major surgery	REMOVAL OF HEEL SPUR	951.56	670.12
28120	Major surgery	PART REMOVAL OF ANKLE/HEEL	1209.94	906.03
28122	Major surgery	PARTIAL REMOVAL OF FOOT BONE	1072.23	806.15
28124	Major surgery	PARTIAL REMOVAL OF TOE	863.99	615.67
28126	Major surgery	PARTIAL REMOVAL OF TOE	705.69	460.32
28130	Major surgery	REMOVAL OF ANKLE BONE	1131.31	1131.31
28140	Major surgery	REMOVAL OF METATARSAL	1026.93	777.43
28150	Major surgery	REMOVAL OF TOE	755.61	513.79
28153	Major surgery	PARTIAL REMOVAL OF TOE	730.51	485.73
28160	Major surgery	PARTIAL REMOVAL OF TOE	737.06	491.09
28171	Major surgery	RESECT TARSAL TUMOR	1994.67	1994.67
28173	Major surgery	RESECT METATARSAL TUMOR	1333.90	1333.90
28175	Major surgery	RESECT PHALANX OF TOE TUMOR	864.22	864.22
28190	Other professional services	REMOVAL OF FOOT FOREIGN BODY	333.12	186.68
28192	Major surgery	REMOVAL OF FOOT FOREIGN BODY	828.67	569.69
28193	Major surgery	REMOVAL OF FOOT FOREIGN BODY	942.16	671.97
28200	Major surgery	REPAIR OF FOOT TENDON	890.84	599.33
28202	Major surgery	REPAIR/GRAFT OF FOOT TENDON	1081.45	787.00
28208	Major surgery	REPAIR OF FOOT TENDON	873.78	588.78
28210	Major surgery	REPAIR/GRAFT OF FOOT TENDON	1072.36	777.33
28220	Major surgery	RELEASE OF FOOT TENDON	815.14	562.07
28222	Major surgery	RELEASE OF FOOT TENDONS	972.04	679.95
28225	Major surgery	RELEASE OF FOOT TENDON	744.96	486.56
28226	Major surgery	RELEASE OF FOOT TENDONS	1106.84	728.42
28230	Major surgery	INCISION OF FOOT TENDON(S)	780.47	523.87
28232	Major surgery	INCISION OF TOE TENDON	680.57	444.05
28234	Major surgery	INCISION OF FOOT TENDON	739.17	495.55
28238	Major surgery	REVISION OF FOOT TENDON	1215.03	896.92
28240	Major surgery	RELEASE OF BIG TOE	800.22	540.05
28250	Major surgery	REVISION OF FOOT FASCIA	1061.33	753.87
28260	Major surgery	RELEASE OF MIDFOOT JOINT	1317.01	987.09
28261	Major surgery	REVISION OF FOOT TENDON	1937.13	1533.89
28262	Major surgery	REVISION OF FOOT AND ANKLE	2474.41	2005.54
28264	Major surgery	RELEASE OF MIDFOOT JOINT	1573.92	1222.71
28270	Major surgery	RELEASE OF FOOT CONTRACTURE	878.96	614.07
28272	Major surgery	RELEASE OF TOE JOINT EACH	691.96	463.14
28280	Major surgery	FUSION OF TOES	912.37	633.30
28285	Major surgery	REPAIR OF HAMMERTOE	976.35	710.27
28286	Major surgery	REPAIR OF HAMMERTOE	801.92	548.87
28288	Major surgery	PARTIAL REMOVAL OF FOOT BONE	1090.58	798.51
28289	Major surgery	CORRJ HALUX RIGDUS W/O IMPLT	1241.99	845.85
28291	Major surgery	CORRJ HALUX RIGDUS W/IMPLT	1247.65	884.03
28292	Major surgery	COR HLX VLGS RSC PRX PHLX BS	1265.65	893.16
28295	Major surgery	COR HLX VLGS PRX MTAR OSTEOT	1878.92	1097.87
28296	Major surgery	COR HLX VLGS DSTL MTAR OSTEO	1594.18	944.39
28297	Major surgery	COR HLX VLGS JT ARTHRD	1838.46	1100.56
28298	Major surgery	COR HLX VLGS PRX PHLX OSTEOT	1503.84	930.31
28299	Major surgery	COR HLX VLGS DOUBLE OSTEOT	1821.55	1090.75
28300	Major surgery	INCISION OF HEEL BONE	1184.76	1184.76
28302	Major surgery	INCISION OF ANKLE BONE	1300.30	1300.30
28304	Major surgery	INCISION OF MIDFOOT BONES	1494.30	1120.02
28305	Major surgery	INCISE/GRAFT MIDFOOT BONES	1232.40	1232.40
28306	Major surgery	INCISION OF METATARSAL	1100.40	745.66
28307	Major surgery	INCISION OF METATARSAL	1407.32	941.99
28308	Major surgery	INCISION OF METATARSAL	1031.10	711.24
28309	Major surgery	INCISION OF METATARSALS	1646.58	1646.58
28310	Major surgery	REVISION OF BIG TOE	987.27	667.97
28312	Major surgery	REVISION OF TOE	979.72	631.47
28313	Major surgery	REPAIR DEFORMITY OF TOE	952.19	661.87
28315	Major surgery	REMOVAL OF SESAMOID BONE	863.58	598.71
28320	Major surgery	REPAIR OF FOOT BONES	1124.92	1124.92
28322	Major surgery	REPAIR OF METATARSALS	1419.17	1054.95
28340	Major surgery	RESECT ENLARGED TOE TISSUE	1030.77	752.90
28341	Major surgery	RESECT ENLARGED TOE	1197.44	895.30
28344	Major surgery	REPAIR EXTRA TOE(S)	758.76	515.17
28345	Major surgery	REPAIR WEBBED TOE(S)	930.74	667.62
28360	Major surgery	RECONSTRUCT CLEFT FOOT	1986.47	1986.47
28400	Major surgery	TREATMENT OF HEEL FRACTURE	460.18	427.67
28405	Major surgery	TREATMENT OF HEEL FRACTURE	833.84	748.68
28406	Major surgery	TREATMENT OF HEEL FRACTURE	1076.91	1076.91
28415	Major surgery	TREAT HEEL FRACTURE	2034.44	2034.44
28420	Major surgery	TREAT/GRAFT HEEL FRACTURE	2340.37	2340.37
28430	Major surgery	TREATMENT OF ANKLE FRACTURE	445.58	391.77
28435	Major surgery	TREATMENT OF ANKLE FRACTURE	685.11	607.64
28436	Major surgery	TREATMENT OF ANKLE FRACTURE	907.06	907.06
28445	Major surgery	TREAT ANKLE FRACTURE	1903.61	1903.61
28446	Major surgery	OSTEOCHONDRAL TALUS AUTOGRFT	2209.17	2209.17
28450	Major surgery	TREAT MIDFOOT FRACTURE EACH	392.96	356.30
28455	Major surgery	TREAT MIDFOOT FRACTURE EACH	474.69	426.21
28456	Major surgery	TREAT MIDFOOT FRACTURE	677.88	677.88
28465	Major surgery	TREAT MIDFOOT FRACTURE EACH	1171.70	1171.70
28470	Major surgery	TREAT METATARSAL FRACTURE	405.03	381.99
28475	Major surgery	TREAT METATARSAL FRACTURE	483.42	426.66
28476	Major surgery	TREAT METATARSAL FRACTURE	708.49	708.49
28485	Major surgery	TREAT METATARSAL FRACTURE	1032.25	1032.25
28490	Major surgery	TREAT BIG TOE FRACTURE	263.02	231.68
28495	Major surgery	TREAT BIG TOE FRACTURE	333.51	277.93
28496	Major surgery	TREAT BIG TOE FRACTURE	906.24	501.81
28505	Major surgery	TREAT BIG TOE FRACTURE	1180.47	909.68
28510	Major surgery	TREATMENT OF TOE FRACTURE	225.52	224.91
28515	Major surgery	TREATMENT OF TOE FRACTURE	306.07	267.66
28525	Major surgery	TREAT TOE FRACTURE	1030.24	747.63
28530	Major surgery	TREAT SESAMOID BONE FRACTURE	217.29	190.09
28531	Major surgery	TREAT SESAMOID BONE FRACTURE	595.34	335.19
28540	Major surgery	TREAT FOOT DISLOCATION	365.24	328.58
28545	Major surgery	TREAT FOOT DISLOCATION	572.83	502.48
28546	Major surgery	TREAT FOOT DISLOCATION	1056.08	647.52
28555	Major surgery	REPAIR FOOT DISLOCATION	1558.81	1207.62
28570	Major surgery	TREAT FOOT DISLOCATION	437.33	366.95
28575	Major surgery	TREAT FOOT DISLOCATION	699.82	627.69
28576	Major surgery	TREAT FOOT DISLOCATION	713.06	713.06
28585	Major surgery	REPAIR FOOT DISLOCATION	1631.06	1295.81
28600	Major surgery	TREAT FOOT DISLOCATION	348.04	299.56
28605	Major surgery	TREAT FOOT DISLOCATION	633.52	565.52
28606	Major surgery	TREAT FOOT DISLOCATION	718.73	718.73
28615	Major surgery	REPAIR FOOT DISLOCATION	1507.49	1507.49
28630	Other professional services	TREAT TOE DISLOCATION	218.03	156.18
28635	Other professional services	TREAT TOE DISLOCATION	241.40	185.00
28636	Other professional services	TREAT TOE DISLOCATION	490.91	312.17
28645	Major surgery	REPAIR TOE DISLOCATION	1182.05	894.11
28660	Other professional services	TREAT TOE DISLOCATION	177.14	132.57
28665	Other professional services	TREAT TOE DISLOCATION	214.40	179.37
28666	Other professional services	TREAT TOE DISLOCATION	248.03	248.03
28675	Major surgery	REPAIR OF TOE DISLOCATION	1042.26	758.45
28705	Major surgery	FUSION OF FOOT BONES	2215.51	2215.51
28715	Major surgery	FUSION OF FOOT BONES	1703.68	1703.68
28725	Major surgery	FUSION OF FOOT BONES	1415.37	1415.37
28730	Major surgery	FUSION OF FOOT BONES	1320.54	1320.54
28735	Major surgery	FUSION OF FOOT BONES	1413.95	1413.95
28737	Major surgery	REVISION OF FOOT BONES	1262.10	1262.10
28740	Major surgery	FUSION OF FOOT BONES	1491.42	1125.44
28750	Major surgery	FUSION OF BIG TOE JOINT	1407.08	1051.73
28755	Major surgery	FUSION OF BIG TOE JOINT	909.91	613.68
28760	Major surgery	FUSION OF BIG TOE JOINT	1396.82	1049.16
28800	Major surgery	AMPUTATION OF MIDFOOT	963.96	963.96
28805	Major surgery	AMPUTATION THRU METATARSAL	1285.26	1285.26
28810	Major surgery	AMPUTATION TOE & METATARSAL	768.14	768.14
28820	Major surgery	AMPUTATION OF TOE	535.39	323.12
28825	Major surgery	PARTIAL AMPUTATION OF TOE	526.79	315.12
28890	Major surgery	HI ENRGY ESWT PLANTAR FASCIA	567.68	411.00
28899	Major surgery	UNLISTED PX FOOT/TOES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
29000	Other professional services	APPLICATION OF BODY CAST	500.07	271.29
29010	Other professional services	APPLICATION OF BODY CAST	389.61	222.24
29015	Other professional services	APPLICATION OF BODY CAST	417.27	249.90
29035	Other professional services	APPLICATION OF BODY CAST	366.92	199.53
29040	Other professional services	APPLICATION OF BODY CAST	417.56	240.17
29044	Other professional services	APPLICATION OF BODY CAST	409.71	231.87
29046	Other professional services	APPLICATION OF BODY CAST	447.75	260.36
29049	Other professional services	APPLICATION OF FIGURE EIGHT	140.55	96.90
29055	Other professional services	APPLICATION OF SHOULDER CAST	317.37	190.94
29058	Other professional services	APPLICATION OF SHOULDER CAST	173.81	129.69
29065	Other professional services	APPLICATION OF LONG ARM CAST	136.52	94.68
29075	Other professional services	APPLICATION OF FOREARM CAST	123.23	86.84
29085	Other professional services	APPLY HAND/WRIST CAST	135.29	93.90
29086	Other professional services	APPLY FINGER CAST	108.69	69.12
29105	Other professional services	APPLY LONG ARM SPLINT	116.39	57.71
29125	Other professional services	APPLY FOREARM SPLINT	93.90	56.15
29126	Other professional services	APPLY FOREARM SPLINT	110.34	68.96
29130	Other professional services	APPLICATION OF FINGER SPLINT	58.88	40.23
29131	Other professional services	APPLICATION OF FINGER SPLINT	75.89	48.15
29200	Other professional services	STRAPPING OF CHEST	44.82	25.73
29240	Other professional services	STRAPPING OF SHOULDER	41.64	25.26
29260	Other professional services	STRAPPING OF ELBOW OR WRIST	40.61	26.51
29280	Other professional services	STRAPPING OF HAND OR FINGER	41.72	28.07
29305	Other professional services	APPLICATION OF HIP CAST	350.97	219.53
29325	Other professional services	APPLICATION OF HIP CASTS	387.63	245.73
29345	Other professional services	APPLICATION OF LONG LEG CAST	189.60	137.30
29355	Other professional services	APPLICATION OF LONG LEG CAST	198.65	147.26
29358	Other professional services	APPLY LONG LEG CAST BRACE	227.85	142.80
29365	Other professional services	APPLICATION OF LONG LEG CAST	174.95	121.74
29405	Other professional services	APPLY SHORT LEG CAST	113.13	81.75
29425	Other professional services	APPLY SHORT LEG CAST	106.23	75.77
29435	Other professional services	APPLY SHORT LEG CAST	174.05	119.93
29440	Other professional services	ADDITION OF WALKER TO CAST	61.01	39.63
29445	Other professional services	APPLY RIGID LEG CAST	180.38	138.08
29450	Other professional services	APPLICATION OF LEG CAST	205.19	157.89
29505	Other professional services	APPLICATION LONG LEG SPLINT	126.05	72.83
29515	Other professional services	APPLICATION LOWER LEG SPLINT	101.76	69.47
29520	Other professional services	STRAPPING OF HIP	48.47	25.73
29530	Other professional services	STRAPPING OF KNEE	41.19	25.26
29540	Other professional services	STRAPPING OF ANKLE AND/OR FT	39.24	24.23
29550	Other professional services	STRAPPING OF TOES	27.03	15.66
29580	Other professional services	APPLICATION OF PASTE BOOT	88.43	36.57
29581	Other professional services	APPLY MULTLAY COMPRS LWR LEG	122.13	37.98
29584	Other professional services	APPL MULTLAY COMPRS ARM/HAND	110.30	22.07
29700	Other professional services	REMOVAL/REVISION OF CAST	89.48	45.81
29705	Other professional services	REMOVAL/REVISION OF CAST	88.55	61.71
29710	Other professional services	REMOVAL/REVISION OF CAST	171.51	113.30
29720	Other professional services	REPAIR OF BODY CAST	121.20	60.26
29730	Other professional services	WINDOWING OF CAST	91.11	62.01
29740	Other professional services	WEDGING OF CAST	138.48	94.82
29750	Other professional services	WEDGING OF CLUBFOOT CAST	149.19	105.99
29799	Major surgery	UNLISTED PX CASTING/STRPG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
29800	Major surgery	JAW ARTHROSCOPY/SURGERY	967.08	967.08
29804	Major surgery	JAW ARTHROSCOPY/SURGERY	1083.17	1083.17
29805	Major surgery	SHO ARTHRS DX +- SYNOVIAL BX	851.97	851.97
29806	Major surgery	SHO ARTHRS SRG CAPSULORRAPHY	1914.43	1914.43
29807	Major surgery	SHO ARTHRS SRG RPR SLAP LES	1869.37	1869.37
29819	Major surgery	SHO ARTHRS SRG RMVL LOOSE/FB	1067.72	1067.72
29820	Major surgery	SHO ARTHRS SRG PRTL SYNVCT	970.52	970.52
29821	Major surgery	SHO ARTHRS SRG COMPL SYNVCT	1077.34	1077.34
29822	Major surgery	SHO ARTHRS SRG LMTD DBRDMT	985.47	985.47
29823	Major surgery	SHO ARTHRS SRG XTNSV DBRDMT	1078.17	1078.17
29824	Major surgery	SHO ARTHRS SRG DSTL CLAVICLC	1230.33	1230.33
29825	Major surgery	SHO ARTHRS SRG LSS&RESCJ ADS	1065.69	1065.69
29826	Major surgery	SHO ARTHRS SRG DECOMPRESSION	306.05	306.05
29827	Major surgery	SHO ARTHRS SRG RT8TR CUF RPR	1929.92	1929.92
29828	Major surgery	SHO ARTHRS SRG BICP TENODSIS	1657.40	1657.40
29830	Major surgery	ELBOW ARTHROSCOPY	833.41	833.41
29834	Major surgery	ELBOW ARTHROSCOPY/SURGERY	895.81	895.81
29835	Major surgery	ELBOW ARTHROSCOPY/SURGERY	928.61	928.61
29836	Major surgery	ELBOW ARTHROSCOPY/SURGERY	1063.10	1063.10
29837	Major surgery	ELBOW ARTHROSCOPY/SURGERY	956.32	956.32
29838	Major surgery	ELBOW ARTHROSCOPY/SURGERY	1083.36	1083.36
29840	Major surgery	WRIST ARTHROSCOPY	823.50	823.50
29843	Major surgery	WRIST ARTHROSCOPY/SURGERY	888.28	888.28
29844	Major surgery	WRIST ARTHROSCOPY/SURGERY	910.59	910.59
29845	Major surgery	WRIST ARTHROSCOPY/SURGERY	1068.52	1068.52
29846	Major surgery	WRIST ARTHROSCOPY/SURGERY	953.36	953.36
29847	Major surgery	WRIST ARTHROSCOPY/SURGERY	991.20	991.20
29848	Major surgery	WRIST ENDOSCOPY/SURGERY	936.80	936.80
29850	Major surgery	KNEE ARTHROSCOPY/SURGERY	1135.76	1135.76
29851	Major surgery	KNEE ARTHROSCOPY/SURGERY	1680.98	1680.98
29855	Major surgery	TIBIAL ARTHROSCOPY/SURGERY	1413.95	1413.95
29856	Major surgery	TIBIAL ARTHROSCOPY/SURGERY	1793.03	1793.03
29860	Major surgery	HIP ARTHROSCOPY DX	1191.16	1191.16
29861	Major surgery	HIP ARTHRO W/FB REMOVAL	1295.07	1295.07
29862	Major surgery	HIP ARTHR0 W/DEBRIDEMENT	1477.96	1477.96
29863	Major surgery	HIP ARTHR0 W/SYNOVECTOMY	1476.95	1476.95
29866	Major surgery	AUTGRFT IMPLNT KNEE W/SCOPE	1903.34	1903.34
29867	Major surgery	ALLGRFT IMPLNT KNEE W/SCOPE	2307.18	2307.18
29868	Major surgery	MENISCAL TRNSPL KNEE W/SCPE	3000.23	3000.23
29870	Major surgery	KNEE ARTHROSCOPY DX	1000.68	748.80
29871	Major surgery	KNEE ARTHROSCOPY/DRAINAGE	938.57	938.57
29873	Major surgery	KNEE ARTHROSCOPY/SURGERY	980.52	980.52
29874	Major surgery	KNEE ARTHROSCOPY/SURGERY	979.49	979.49
29875	Major surgery	KNEE ARTHROSCOPY/SURGERY	904.57	904.57
29876	Major surgery	KNEE ARTHROSCOPY/SURGERY	1186.07	1186.07
29877	Major surgery	KNEE ARTHROSCOPY/SURGERY	1128.45	1128.45
29879	Major surgery	KNEE ARTHROSCOPY/SURGERY	1201.94	1201.94
29880	Major surgery	KNEE ARTHROSCOPY/SURGERY	1022.50	1022.50
29881	Major surgery	KNEE ARTHROSCOPY/SURGERY	985.47	985.47
29882	Major surgery	KNEE ARTHROSCOPY/SURGERY	1250.11	1250.11
29883	Major surgery	KNEE ARTHROSCOPY/SURGERY	1526.71	1526.71
29884	Major surgery	KNEE ARTHROSCOPY/SURGERY	1126.57	1126.57
29885	Major surgery	KNEE ARTHROSCOPY/SURGERY	1372.98	1372.98
29886	Major surgery	KNEE ARTHROSCOPY/SURGERY	1158.16	1158.16
29887	Major surgery	KNEE ARTHROSCOPY/SURGERY	1368.18	1368.18
29888	Major surgery	KNEE ARTHROSCOPY/SURGERY	1760.89	1760.89
29889	Major surgery	KNEE ARTHROSCOPY/SURGERY	2212.29	2212.29
29891	Major surgery	ANKLE ARTHROSCOPY/SURGERY	1227.90	1227.90
29892	Major surgery	ANKLE ARTHROSCOPY/SURGERY	1175.34	1175.34
29893	Major surgery	SCOPE PLANTAR FASCIOTOMY	1204.57	806.66
29894	Major surgery	ANKLE ARTHROSCOPY/SURGERY	919.37	919.37
29895	Major surgery	ANKLE ARTHROSCOPY/SURGERY	846.22	846.22
29897	Major surgery	ANKLE ARTHROSCOPY/SURGERY	903.16	903.16
29898	Major surgery	ANKLE ARTHROSCOPY/SURGERY	1022.23	1022.23
29899	Major surgery	ANKLE ARTHROSCOPY/SURGERY	1819.68	1819.68
29900	Major surgery	MCP JOINT ARTHROSCOPY DX	922.14	922.14
29901	Major surgery	MCP JOINT ARTHROSCOPY SURG	987.60	987.60
29902	Major surgery	MCP JOINT ARTHROSCOPY SURG	1046.66	1046.66
29904	Major surgery	SUBTALAR ARTHRO W/FB RMVL	1162.57	1162.57
29905	Major surgery	SUBTALAR ARTHRO W/EXC	948.85	948.85
29906	Major surgery	SUBTALAR ARTHRO W/DEB	1190.71	1190.71
29907	Major surgery	SUBTALAR ARTHRO W/FUSION	1589.07	1589.07
29914	Major surgery	HIP ARTHRO W/FEMOROPLASTY	1794.92	1794.92
29915	Major surgery	HIP ARTHRO ACETABULOPLASTY	1838.99	1838.99
29916	Major surgery	HIP ARTHRO W/LABRAL REPAIR	1831.81	1831.81
29999	Major surgery	UNLISTED PX ARTHROSCOPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
30000	Other professional services	DRAINAGE OF NOSE LESION	365.96	169.47
30020	Other professional services	DRAINAGE OF NOSE LESION	372.78	171.75
30100	Other professional services	INTRANASAL BIOPSY	194.60	95.45
30110	Other professional services	REMOVAL OF NOSE POLYP(S)	345.05	186.32
30115	Major surgery	REMOVAL OF NOSE POLYP(S)	844.58	844.58
30117	Major surgery	REMOVAL OF INTRANASAL LESION	1766.97	748.22
30118	Major surgery	REMOVAL OF INTRANASAL LESION	1285.13	1285.13
30120	Major surgery	REVISION OF NOSE	924.03	762.02
30124	Major surgery	REMOVAL OF NOSE LESION	554.37	554.37
30125	Major surgery	REMOVAL OF NOSE LESION	1187.78	1187.78
30130	Major surgery	EXCISE INFERIOR TURBINATE	753.23	753.23
30140	Other professional services	RESECT INFERIOR TURBINATE	410.64	247.82
30150	Major surgery	PARTIAL REMOVAL OF NOSE	1448.44	1448.44
30160	Major surgery	REMOVAL OF NOSE	1479.74	1479.74
30200	Other professional services	INJECTION TREATMENT OF NOSE	152.88	83.30
30210	Other professional services	NASAL SINUS THERAPY	210.03	144.09
30220	Other professional services	INSERT NASAL SEPTAL BUTTON	419.45	179.76
30300	Other professional services	REMOVE NASAL FOREIGN BODY	290.27	171.11
30310	Other professional services	REMOVE NASAL FOREIGN BODY	290.13	290.13
30320	Major surgery	REMOVE NASAL FOREIGN BODY	885.07	885.07
30400	Major surgery	RECONSTRUCTION OF NOSE	2207.85	2207.85
30410	Major surgery	RECONSTRUCTION OF NOSE	2541.77	2541.77
30420	Major surgery	RECONSTRUCTION OF NOSE	2627.92	2627.92
30430	Major surgery	REVISION OF NOSE	1929.29	1929.29
30435	Major surgery	REVISION OF NOSE	2406.30	2406.30
30450	Major surgery	REVISION OF NOSE	3143.61	3143.61
30460	Major surgery	REVISION OF NOSE	1492.30	1492.30
30462	Major surgery	REVISION OF NOSE	2866.07	2866.07
30465	Major surgery	REPAIR NASAL STENOSIS	1860.98	1860.98
30468	Other professional services	RPR NSL VLV COLLAPSE W/IMPLT	3415.26	235.19
30469	Other professional services	RPR NSL VLV COLLAPSE W/RMDLG	3337.61	209.37
30520	Major surgery	REPAIR OF NASAL SEPTUM	1223.74	1223.74
30540	Major surgery	RPR CHOANAL ATRESIA NTRANASL	1339.98	1339.98
30545	Major surgery	RPR CHOANAL ATRESIA TRSNPLTN	1816.48	1816.48
30560	Other professional services	LYSIS INTRANASAL SYNECHIA	442.92	210.51
30580	Major surgery	REPAIR UPPER JAW FISTULA	1102.35	838.66
30600	Major surgery	REPAIR MOUTH/NOSE FISTULA	938.69	702.78
30620	Major surgery	INTRANASAL RECONSTRUCTION	1221.46	1221.46
30630	Major surgery	REPAIR NASAL SEPTUM DEFECT	1213.00	1213.00
30801	Other professional services	ABLATE INF TURBINATE SUPERF	301.70	211.19
30802	Other professional services	ABLATE INF TURBINATE SUBMUC	384.86	282.06
30901	Other professional services	CONTROL OF NOSEBLEED	215.33	78.42
30903	Other professional services	CONTROL OF NOSEBLEED	335.19	106.88
30905	Other professional services	CONTROL OF NOSEBLEED	480.69	146.40
30906	Other professional services	REPEAT CONTROL OF NOSEBLEED	516.81	183.89
30915	Major surgery	LIGATION NASAL SINUS ARTERY	1096.47	1096.47
30920	Major surgery	LIGATION UPPER JAW ARTERY	1583.03	1583.03
30930	Other professional services	THER FX NASAL INF TURBINATE	165.60	165.60
30999	Major surgery	UNLISTED PROCEDURE NOSE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
31000	Other professional services	IRRIGATION MAXILLARY SINUS	257.34	154.55
31002	Other professional services	IRRIGATION SPHENOID SINUS	264.14	264.14
31020	Major surgery	EXPLORATION MAXILLARY SINUS	756.62	618.27
31030	Major surgery	EXPLORATION MAXILLARY SINUS	1159.47	933.02
31032	Major surgery	EXPLORE SINUS REMOVE POLYPS	1078.35	1078.35
31040	Major surgery	EXPLORATION BEHIND UPPER JAW	1461.39	1461.39
31050	Major surgery	EXPLORATION SPHENOID SINUS	937.11	937.11
31051	Major surgery	SPHENOID SINUS SURGERY	1256.89	1256.89
31070	Major surgery	EXPLORATION OF FRONTAL SINUS	861.71	861.71
31075	Major surgery	EXPLORATION OF FRONTAL SINUS	1500.68	1500.68
31080	Major surgery	REMOVAL OF FRONTAL SINUS	1974.61	1974.61
31081	Major surgery	REMOVAL OF FRONTAL SINUS	2116.74	2116.74
31084	Major surgery	REMOVAL OF FRONTAL SINUS	2191.23	2191.23
31085	Major surgery	REMOVAL OF FRONTAL SINUS	2258.02	2258.02
31086	Major surgery	REMOVAL OF FRONTAL SINUS	2133.18	2133.18
31087	Major surgery	REMOVAL OF FRONTAL SINUS	2032.99	2032.99
31090	Major surgery	EXPLORATION OF SINUSES	2003.98	2003.98
31200	Major surgery	REMOVAL OF ETHMOID SINUS	1134.28	1134.28
31201	Major surgery	REMOVAL OF ETHMOID SINUS	1412.23	1412.23
31205	Major surgery	REMOVAL OF ETHMOID SINUS	1708.86	1708.86
31225	Major surgery	REMOVAL OF UPPER JAW	3258.45	3258.45
31230	Major surgery	REMOVAL OF UPPER JAW	3637.30	3637.30
31231	Other professional services	NASAL ENDOSCOPY DX	258.02	89.73
31233	Other professional services	NSL/SINS NDSC DX MAX SINUSC	379.05	188.48
31235	Other professional services	NSL/SINS NDSC DX SPHN SINUSC	431.48	222.26
31237	Other professional services	NSL/SINS NDSC SURG BX POLYPC	356.61	222.44
31238	Other professional services	NSL/SINS NDSC SRG NSL HEMRRG	347.31	232.70
31239	Other professional services	NSL/SINUS ENDOSCOPY SURG DCR	846.77	846.77
31240	Other professional services	NSL/SNS NDSC CNCH BULL RESCJ	221.12	221.12
31241	Other professional services	NSL/SNS NDSC LIG SPHNPTN ART	617.24	617.24
31242	Other professional services	NSL/SINUS NDSC RF ABLTJ PNN	3419.00	219.36
31243	Other professional services	NSL/SINUS NDSC CRYOABLTJ PNN	3318.93	219.36
31253	Other professional services	NSL/SINS NDSC TOTAL	692.69	692.69
31254	Other professional services	NSL/SINS NDSC W/PRTL ETHMDCT	604.88	337.44
31255	Other professional services	NSL/SINS NDSC W/TOT ETHMDCT	448.25	448.25
31256	Other professional services	EXPLORATION MAXILLARY SINUS	249.90	249.90
31257	Other professional services	NSL/SINS NDSC TOT W/SPHENDT	617.94	617.94
31259	Other professional services	NSL/SINS NDSC SPHN TISS RMVL	653.16	653.16
31267	Other professional services	ENDOSCOPY MAXILLARY SINUS	368.39	368.39
31276	Other professional services	NSL/SINS NDSC FRNT TISS RMVL	524.42	524.42
31287	Other professional services	NASAL/SINUS ENDOSCOPY SURG	279.20	279.20
31288	Other professional services	NASAL/SINUS ENDOSCOPY SURG	324.68	324.68
31290	Other professional services	NASAL/SINUS ENDOSCOPY SURG	1588.40	1588.40
31291	Other professional services	NASAL/SINUS ENDOSCOPY SURG	1694.72	1694.72
31292	Other professional services	NSL/SINS NDSC MED/INF DCMPRN	1377.87	1377.87
31293	Other professional services	NSL/SINS NDSC MED&INF DCMPRN	1496.22	1496.22
31294	Other professional services	NSL/SINS NDSC SURG ON DCMPRN	1708.82	1708.82
31295	Other professional services	NSL/SINS NDSC SURG MAX SINS	2246.61	219.03
31296	Other professional services	NSL/SINS NDSC SURG FRNT SINS	2281.53	248.96
31297	Other professional services	NSL/SINS NDSC SURG SPHN SINS	2226.50	199.83
31298	Other professional services	NSL/SINS NDSC SURG FRNT&SPHN	4223.15	354.92
31299	Major surgery	UNLISTED PX ACCESSORY SINUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
31300	Major surgery	REMOVAL OF LARYNX LESION	2261.01	2261.01
31360	Major surgery	REMOVAL OF LARYNX	3713.23	3713.23
31365	Major surgery	REMOVAL OF LARYNX	4582.31	4582.31
31367	Major surgery	PARTIAL REMOVAL OF LARYNX	3923.54	3923.54
31368	Major surgery	PARTIAL REMOVAL OF LARYNX	4337.42	4337.42
31370	Major surgery	PARTIAL REMOVAL OF LARYNX	3680.02	3680.02
31375	Major surgery	PARTIAL REMOVAL OF LARYNX	3498.63	3498.63
31380	Major surgery	PARTIAL REMOVAL OF LARYNX	3450.14	3450.14
31382	Major surgery	PARTIAL REMOVAL OF LARYNX	3778.03	3778.03
31390	Major surgery	REMOVAL OF LARYNX & PHARYNX	5054.09	5054.09
31395	Major surgery	RECONSTRUCT LARYNX & PHARYNX	5300.02	5300.02
31400	Major surgery	REVISION OF LARYNX	1829.41	1829.41
31420	Major surgery	REMOVAL OF EPIGLOTTIS	1509.65	1509.65
31500	Other professional services	INSERT EMERGENCY AIRWAY	195.05	195.05
31502	Other professional services	CHANGE OF WINDPIPE AIRWAY	48.51	48.51
31505	Other professional services	DIAGNOSTIC LARYNGOSCOPY	123.99	68.96
31510	Other professional services	LARYNGOSCOPY WITH BIOPSY	299.15	168.62
31511	Other professional services	REMOVE FOREIGN BODY LARYNX	292.56	187.04
31512	Other professional services	REMOVAL OF LARYNX LESION	301.13	180.15
31513	Other professional services	INJECTION INTO VOCAL CORD	182.40	182.40
31515	Other professional services	LARYNGOSCOPY FOR ASPIRATION	294.56	154.47
31520	Other professional services	DX LARYNGOSCOPY NEWBORN	217.29	217.29
31525	Other professional services	DX LARYNGOSCOPY EXCL NB	347.49	222.42
31526	Other professional services	DX LARYNGOSCOPY W/OPER SCOPE	217.79	217.79
31527	Other professional services	LARYNGOSCOPY FOR TREATMENT	270.11	270.11
31528	Other professional services	LARYNGOSCOPY AND DILATION	200.16	200.16
31529	Other professional services	LARYNGOSCOPY AND DILATION	223.52	223.52
31530	Other professional services	LARYNGOSCOPY W/FB REMOVAL	275.46	275.46
31531	Other professional services	LARYNGOSCOPY W/FB & OP SCOPE	292.56	292.56
31535	Other professional services	LARYNGOSCOPY W/BIOPSY	262.11	262.11
31536	Other professional services	LARYNGOSCOPY W/BX & OP SCOPE	291.08	291.08
31540	Other professional services	LARYNGOSCOPY W/EXC OF TUMOR	333.84	333.84
31541	Other professional services	LARYNSCOP W/TUMR EXC + SCOPE	364.10	364.10
31545	Other professional services	REMOVE VC LESION W/SCOPE	500.49	500.49
31546	Other professional services	REMOVE VC LESION SCOPE/GRAFT	758.39	758.39
31551	Major surgery	LARYNGOPLASTY LARYNGEAL STEN	2793.90	2793.90
31552	Major surgery	LARYNGOPLASTY LARYNGEAL STEN	2696.81	2696.81
31553	Major surgery	LARYNGOPLASTY LARYNGEAL STEN	3039.29	3039.29
31554	Major surgery	LARYNGOPLASTY LARYNGEAL STEN	3040.46	3040.46
31560	Other professional services	LARYNGOSCOP W/ARYTENOIDECTOM	431.75	431.75
31561	Other professional services	LARYNSCOP REMVE CART + SCOP	472.26	472.26
31570	Other professional services	LARYNGOSCOPE W/VC INJ	476.49	316.85
31571	Other professional services	LARYNGOSCOP W/VC INJ + SCOPE	344.55	344.55
31572	Other professional services	LARGSC W/LASER DSTRJ LES	719.94	250.58
31573	Other professional services	LARGSC W/THER INJECTION	397.76	206.75
31574	Other professional services	LARGSC W/NJX AUGMENTATION	1278.62	207.53
31575	Other professional services	DIAGNOSTIC LARYNGOSCOPY	178.10	95.31
31576	Other professional services	LARYNGOSCOPY WITH BIOPSY	373.64	166.23
31577	Other professional services	LARGSC W/RMVL FOREIGN BDY(S)	378.05	185.21
31578	Other professional services	LARGSC W/REMOVAL LESION	423.56	207.53
31579	Other professional services	LARYNGOSCOPY TELESCOPIC	274.25	166.46
31580	Major surgery	LARYNGOPLASTY LARYNGEAL WEB	2317.54	2317.54
31584	Major surgery	LARYNGOPLASTY FX RDCTJ FIXJ	2550.15	2550.15
31587	Major surgery	LARYNGOPLASTY CRICOID SPLIT	2186.16	2186.16
31590	Major surgery	REINNERVATE LARYNX	1667.97	1667.97
31591	Major surgery	LARYNGOPLASTY MEDIALIZATION	1993.13	1993.13
31592	Major surgery	CRICOTRACHEAL RESECTION	3136.75	3136.75
31599	Major surgery	UNLISTED PROCEDURE LARYNX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
31600	Other professional services	INCISION OF WINDPIPE	418.88	418.88
31601	Other professional services	INCISION OF WINDPIPE	623.87	623.87
31603	Other professional services	INCISION OF WINDPIPE	439.98	439.98
31605	Other professional services	INCISION OF WINDPIPE	452.55	452.55
31610	Major surgery	INCISION OF WINDPIPE	1729.46	1729.46
31611	Major surgery	SURGERY/SPEECH PROSTHESIS	971.78	971.78
31612	Other professional services	PUNCTURE/CLEAR WINDPIPE	128.87	66.56
31613	Major surgery	REPAIR WINDPIPE OPENING	766.23	766.23
31614	Major surgery	REPAIR WINDPIPE OPENING	1288.81	1288.81
31615	Other professional services	VISUALIZATION OF WINDPIPE	239.09	160.85
31622	Other professional services	DX BRONCHOSCOPE/WASH	345.42	182.60
31623	Other professional services	DX BRONCHOSCOPE/BRUSH	380.01	182.63
31624	Other professional services	DX BRONCHOSCOPE/LAVAGE	353.97	184.77
31625	Other professional services	BRONCHOSCOPY W/BIOPSY(S)	481.83	215.76
31626	Other professional services	BRONCHOSCOPY W/MARKERS	1074.41	271.20
31627	Major surgery	NAVIGATIONAL BRONCHOSCOPY	1886.76	172.69
31628	Other professional services	BRONCHOSCOPY/LUNG BX EACH	514.23	243.17
31629	Other professional services	BRONCHOSCOPY/NEEDLE BX EACH	623.93	257.81
31630	Other professional services	BRONCHOSCOPY DILATE/FX REPR	272.66	272.66
31631	Other professional services	BRONCHOSCOPY DILATE W/STENT	310.73	310.73
31632	Major surgery	BRONCHOSCOPY/LUNG BX ADDL	117.49	87.93
31633	Major surgery	BRONCHOSCOPY/NEEDLE BX ADDL	145.98	112.87
31634	Other professional services	BRONCH W/BALLOON OCCLUSION	2001.90	259.49
31635	Other professional services	BRONCHOSCOPY W/FB REMOVAL	406.44	241.79
31636	Other professional services	BRONCHOSCOPY BRONCH STENTS	298.08	298.08
31637	Major surgery	BRONCHOSCOPY STENT ADD-ON	136.23	136.23
31638	Other professional services	BRONCHOSCOPY REVISE STENT	338.79	338.79
31640	Other professional services	BRONCHOSCOPY W/TUMOR EXCISE	340.80	340.80
31641	Other professional services	BRONCHOSCOPY TREAT BLOCKAGE	349.83	349.83
31643	Other professional services	DIAG BRONCHOSCOPE/CATHETER	234.81	234.81
31645	Other professional services	BRNCHSC W/THER ASPIR 1ST	380.16	203.24
31646	Other professional services	BRNCHSC W/THER ASPIR SBSQ	196.31	196.31
31647	Other professional services	BRONCHIAL VALVE INIT INSERT	283.56	283.56
31648	Other professional services	BRONCHIAL VALVE REMOV INIT	273.29	273.29
31649	Major surgery	BRONCHIAL VALVE REMOV ADDL	120.28	120.28
31651	Major surgery	BRONCHIAL VALVE ADDL INSERT	136.23	136.23
31652	Other professional services	BRONCH EBUS SAMPLNG 1/2 NODE	1698.20	304.19
31653	Other professional services	BRONCH EBUS SAMPLNG 3/> NODE	1763.37	337.07
31654	Other professional services	BRONCH EBUS IVNTJ PERPH LES	167.16	92.57
31660	Other professional services	BRONCH THERMOPLSTY 1 LOBE	262.86	262.86
31661	Other professional services	BRONCH THERMOPLSTY 2/> LOBES	277.61	277.61
31717	Other professional services	BRONCHIAL BRUSH BIOPSY	394.40	147.44
31720	Other professional services	CLEARANCE OF AIRWAYS	67.86	67.86
31725	Other professional services	CLEARANCE OF AIRWAYS	109.94	109.94
31730	Other professional services	INTRO WINDPIPE WIRE/TUBE	1431.51	202.59
31750	Major surgery	REPAIR OF WINDPIPE	2434.73	2434.73
31755	Major surgery	REPAIR OF WINDPIPE	3116.55	3116.55
31760	Major surgery	REPAIR OF WINDPIPE	2424.86	2424.86
31766	Major surgery	RECONSTRUCTION OF WINDPIPE	3119.14	3119.14
31770	Major surgery	REPAIR/GRAFT OF BRONCHUS	2334.52	2334.52
31775	Major surgery	RECONSTRUCT BRONCHUS	2459.73	2459.73
31780	Major surgery	RECONSTRUCT WINDPIPE	2173.10	2173.10
31781	Major surgery	RECONSTRUCT WINDPIPE	2604.24	2604.24
31785	Major surgery	REMOVE WINDPIPE LESION	1947.09	1947.09
31786	Major surgery	REMOVE WINDPIPE LESION	2534.82	2534.82
31800	Major surgery	REPAIR OF WINDPIPE INJURY	1277.29	1277.29
31805	Major surgery	REPAIR OF WINDPIPE INJURY	1447.80	1447.80
31820	Major surgery	CLOSURE OF WINDPIPE LESION	805.17	604.73
31825	Major surgery	REPAIR OF WINDPIPE DEFECT	1114.89	884.89
31830	Major surgery	REVISE WINDPIPE SCAR	897.39	669.75
31899	Major surgery	UNLISTED PX TRACHEA BRONCHI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
32035	Major surgery	THORACOSTOMY W/RIB RESECTION	1303.07	1303.07
32036	Major surgery	THORACOSTOMY W/FLAP DRAINAGE	1404.76	1404.76
32096	Major surgery	OPEN WEDGE/BX LUNG INFILTR	1411.96	1411.96
32097	Major surgery	OPEN WEDGE/BX LUNG NODULE	1414.32	1414.32
32098	Major surgery	OPEN BIOPSY OF LUNG PLEURA	1338.07	1338.07
32100	Major surgery	EXPLORATION OF CHEST	1433.64	1433.64
32110	Major surgery	EXPLORE/REPAIR CHEST	2609.10	2609.10
32120	Major surgery	RE-EXPLORATION OF CHEST	1543.56	1543.56
32124	Major surgery	EXPLORE CHEST FREE ADHESIONS	1631.97	1631.97
32140	Major surgery	REMOVAL OF LUNG LESION(S)	1749.13	1749.13
32141	Major surgery	REMOVE/TREAT LUNG LESIONS	2675.56	2675.56
32150	Major surgery	REMOVAL OF LUNG LESION(S)	1798.60	1798.60
32151	Major surgery	REMOVE LUNG FOREIGN BODY	1774.71	1774.71
32160	Major surgery	OPEN CHEST HEART MASSAGE	1414.30	1414.30
32200	Major surgery	DRAIN OPEN LUNG LESION	2015.38	2015.38
32215	Major surgery	TREAT CHEST LINING	1420.52	1420.52
32220	Major surgery	RELEASE OF LUNG	2821.69	2821.69
32225	Major surgery	PARTIAL RELEASE OF LUNG	1757.22	1757.22
32310	Major surgery	REMOVAL OF CHEST LINING	1622.93	1622.93
32320	Major surgery	FREE/REMOVE CHEST LINING	2830.64	2830.64
32400	Other professional services	NEEDLE BIOPSY CHEST LINING	233.31	115.98
32408	Other professional services	CORE NDL BX LNG/MED PERQ	1152.69	210.30
32440	Major surgery	REMOVE LUNG PNEUMONECTOMY	2760.69	2760.69
32442	Major surgery	SLEEVE PNEUMONECTOMY	5344.99	5344.99
32445	Major surgery	REMOVAL OF LUNG EXTRAPLEURAL	6188.48	6188.48
32480	Major surgery	PARTIAL REMOVAL OF LUNG	2603.68	2603.68
32482	Major surgery	BILOBECTOMY	2782.32	2782.32
32484	Major surgery	SEGMENTECTOMY	2520.34	2520.34
32486	Major surgery	SLEEVE LOBECTOMY	4101.45	4101.45
32488	Major surgery	COMPLETION PNEUMONECTOMY	4195.23	4195.23
32491	Major surgery	LUNG VOLUME REDUCTION	2595.12	2595.12
32501	Major surgery	REPAIR BRONCHUS ADD-ON	424.77	424.77
32503	Major surgery	RESECT APICAL LUNG TUMOR	3153.01	3153.01
32504	Major surgery	RESECT APICAL LUNG TUM/CHEST	3589.93	3589.93
32505	Major surgery	WEDGE RESECT OF LUNG INITIAL	1643.07	1643.07
32506	Major surgery	WEDGE RESECT OF LUNG ADD-ON	272.81	272.81
32507	Major surgery	WEDGE RESECT OF LUNG DIAG	272.22	272.22
32540	Major surgery	REMOVAL OF LUNG LESION	3038.26	3038.26
32550	Other professional services	INSERT PLEURAL CATH	1055.22	280.22
32551	Other professional services	INSERTION OF CHEST TUBE	213.02	213.02
32552	Other professional services	REMOVE LUNG CATHETER	252.78	216.39
32553	Other professional services	INS MARK THOR FOR RT PERQ	692.34	241.61
32554	Other professional services	ASPIRATE PLEURA W/O IMAGING	322.76	122.63
32555	Other professional services	ASPIRATE PLEURA W/ IMAGING	430.68	150.98
32556	Other professional services	INSERT CATH PLEURA W/O IMAGE	1009.49	170.81
32557	Other professional services	INSERT CATH PLEURA W/ IMAGE	898.80	206.12
32560	Other professional services	TREAT PLEURODESIS W/AGENT	346.37	104.40
32561	Other professional services	LYSE CHEST FIBRIN INIT DAY	132.17	93.06
32562	Other professional services	LYSE CHEST FIBRIN SUBQ DAY	118.23	83.22
32601	Other professional services	THORACOSCOPY DIAGNOSTIC	416.49	416.49
32604	Other professional services	THORACOSCOPY WBX SAC	645.81	645.81
32606	Other professional services	THORACOSCOPY W/BX MED SPACE	622.19	622.19
32607	Other professional services	THORACOSCOPY W/BX INFILTRATE	415.59	415.59
32608	Other professional services	THORACOSCOPY W/BX NODULE	510.45	510.45
32609	Other professional services	THORACOSCOPY W/BX PLEURA	347.34	347.34
32650	Major surgery	THORACOSCOPY W/PLEURODESIS	1184.20	1184.20
32651	Major surgery	THORACOSCOPY REMOVE CORTEX	1930.03	1930.03
32652	Major surgery	THORACOSCOPY REM TOTL CORTEX	2923.52	2923.52
32653	Major surgery	THORACOSCOPY REMOV FB/FIBRIN	1868.22	1868.22
32654	Major surgery	THORACOSCOPY CONTRL BLEEDING	2088.14	2088.14
32655	Major surgery	THORACOSCOPY RESECT BULLAE	1687.98	1687.98
32656	Major surgery	THORACOSCOPY W/PLEURECTOMY	1419.58	1419.58
32658	Major surgery	THORACOSCOPY W/SAC FB REMOVE	1263.76	1263.76
32659	Major surgery	THORACOSCOPY W/SAC DRAINAGE	1299.40	1299.40
32661	Major surgery	THORACOSCOPY W/PERICARD EXC	1410.45	1410.45
32662	Major surgery	THORACOSCOPY W/MEDIAST EXC	1577.96	1577.96
32663	Major surgery	THORACOSCOPY W/LOBECTOMY	2456.92	2456.92
32664	Major surgery	THORACOSCOPY W/ TH NRV EXC	1496.86	1496.86
32665	Major surgery	THORACOSCOP W/ESOPH MUSC EXC	2165.44	2165.44
32666	Major surgery	THORACOSCOPY W/WEDGE RESECT	1535.82	1535.82
32667	Major surgery	THORACOSCOPY W/W RESECT ADDL	273.23	273.23
32668	Major surgery	THORACOSCOPY W/W RESECT DIAG	273.23	273.23
32669	Major surgery	THORACOSCOPY REMOVE SEGMENT	2359.03	2359.03
32670	Major surgery	THORACOSCOPY BILOBECTOMY	2810.79	2810.79
32671	Major surgery	THORACOSCOPY PNEUMONECTOMY	3108.67	3108.67
32672	Major surgery	THORACOSCOPY FOR LVRS	2665.61	2665.61
32673	Major surgery	THORACOSCOPY W/THYMUS RESECT	2138.35	2138.35
32674	Major surgery	THORACOSCOPY LYMPH NODE EXC	375.39	375.39
32701	Other professional services	THORAX STEREO RAD TARGETW/TX	285.24	285.24
32800	Major surgery	REPAIR LUNG HERNIA	1663.33	1663.33
32810	Major surgery	CLOSE CHEST AFTER DRAINAGE	1593.56	1593.56
32815	Major surgery	CLOSE BRONCHIAL FISTULA	4917.33	4917.33
32820	Major surgery	RECONSTRUCT INJURED CHEST	2350.37	2350.37
32850	Other professional services	DONOR PNEUMONECTOMY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
32851	Major surgery	LUNG TRANSPLANT SINGLE	5737.58	5737.58
32852	Major surgery	LUNG TRANSPLANT WITH BYPASS	6189.85	6189.85
32853	Major surgery	LUNG TRANSPLANT DOUBLE	8015.63	8015.63
32854	Major surgery	LUNG TRANSPLANT WITH BYPASS	8487.80	8487.80
32855	Other professional services	PREPARE DONOR LUNG SINGLE	307.95	307.95
32856	Other professional services	PREPARE DONOR LUNG DOUBLE	461.93	461.93
32900	Major surgery	REMOVAL OF RIB(S)	2395.95	2395.95
32905	Major surgery	REVISE & REPAIR CHEST WALL	2348.52	2348.52
32906	Major surgery	REVISE & REPAIR CHEST WALL	2893.94	2893.94
32940	Major surgery	REVISION OF LUNG	2171.29	2171.29
32960	Other professional services	THERAPEUTIC PNEUMOTHORAX	177.14	126.20
32994	Other professional services	ABLATE PULM TUMOR PERQ CRYBL	6495.17	601.19
32997	Other professional services	TOTAL LUNG LAVAGE	468.62	468.62
32998	Other professional services	ABLATE PULM TUMOR PERQ RF	4154.67	602.10
32999	Major surgery	UNLISTED PX LUNGS & PLEURA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
33016	Other professional services	PERICARDIOCENTESIS W/IMAGING	316.02	316.02
33017	Other professional services	PRCRD DRG 6YR+ W/O CGEN CAR	333.20	333.20
33018	Other professional services	PRCRD DRG 0-5YR OR W/ANOMLY	388.97	388.97
33019	Other professional services	PERQ PRCRD DRG INSJ CATH CT	288.65	288.65
33020	Major surgery	INCISION OF HEART SAC	1452.52	1452.52
33025	Major surgery	INCISION OF HEART SAC	1358.21	1358.21
33030	Major surgery	PARTIAL REMOVAL OF HEART SAC	3509.16	3509.16
33031	Major surgery	PARTIAL REMOVAL OF HEART SAC	4333.08	4333.08
33050	Major surgery	RESECT HEART SAC LESION	1776.45	1776.45
33120	Major surgery	REMOVAL OF HEART LESION	3661.92	3661.92
33130	Major surgery	REMOVAL OF HEART LESION	2396.75	2396.75
33140	Major surgery	HEART REVASCULARIZE (TMR)	2723.10	2723.10
33141	Major surgery	HEART TMR W/OTHER PROCEDURE	229.91	229.91
33202	Major surgery	INSERT EPICARD ELTRD OPEN	1358.21	1358.21
33203	Major surgery	INSERT EPICARD ELTRD ENDO	1425.61	1425.61
33206	Major surgery	INSERT HEART PM ATRIAL	799.79	799.79
33207	Major surgery	INSERT HEART PM VENTRICULAR	840.45	840.45
33208	Major surgery	INSRT HEART PM ATRIAL & VENT	909.77	909.77
33210	Other professional services	INSERT ELECTRD/PM CATH SNGL	217.68	217.68
33211	Other professional services	INSERT CARD ELECTRODES DUAL	227.51	227.51
33212	Major surgery	INSERT PULSE GEN SNGL LEAD	569.17	569.17
33213	Major surgery	INSERT PULSE GEN DUAL LEADS	596.04	596.04
33214	Major surgery	UPGRADE OF PACEMAKER SYSTEM	842.99	842.99
33215	Major surgery	REPOSITION PACING-DEFIB LEAD	546.60	546.60
33216	Major surgery	INSERT 1 ELECTRODE PM-DEFIB	654.60	654.60
33217	Major surgery	INSERT 2 ELECTRODE PM-DEFIB	649.72	649.72
33218	Major surgery	REPAIR LEAD PACE-DEFIB ONE	686.63	686.63
33220	Major surgery	REPAIR LEAD PACE-DEFIB DUAL	670.98	670.98
33221	Major surgery	INSERT PULSE GEN MULT LEADS	629.77	629.77
33222	Major surgery	RELOCATION POCKET PACEMAKER	606.16	606.16
33223	Major surgery	RELOCATE POCKET FOR DEFIB	720.45	720.45
33224	Other professional services	INSERT PACING LEAD & CONNECT	688.35	688.35
33225	Major surgery	L VENTRIC PACING LEAD ADD-ON	806.66	806.66
33226	Other professional services	REPOSITION L VENTRIC LEAD	658.58	658.58
33227	Major surgery	REMOVE&REPLACE PM GEN SINGL	597.68	597.68
33228	Major surgery	REMV&REPLC PM GEN DUAL LEAD	624.14	624.14
33229	Major surgery	REMV&REPLC PM GEN MULT LEADS	656.33	656.33
33230	Major surgery	INSRT PULSE GEN W/DUAL LEADS	658.69	658.69
33231	Major surgery	INSRT PULSE GEN W/MULT LEADS	706.17	706.17
33233	Major surgery	REMOVAL OF PM GENERATOR	412.00	412.00
33234	Major surgery	REMOVAL OF PACEMAKER SYSTEM	851.68	851.68
33235	Major surgery	REMOVAL PACEMAKER ELECTRODE	1118.91	1118.91
33236	Major surgery	REMOVE ELECTRODE/THORACOTOMY	1383.21	1383.21
33237	Major surgery	REMOVE ELECTRODE/THORACOTOMY	1483.72	1483.72
33238	Major surgery	REMOVE ELECTRODE/THORACOTOMY	1677.60	1677.60
33240	Major surgery	INSRT PULSE GEN W/SINGL LEAD	648.53	648.53
33241	Major surgery	REMOVE PULSE GENERATOR	379.33	379.33
33243	Major surgery	REMOVE ELTRD/THORACOTOMY	2420.36	2420.36
33244	Major surgery	REMOVE ELCTRD TRANSVENOUSLY	1516.44	1516.44
33249	Major surgery	INSJ/RPLCMT DEFIB W/LEAD(S)	1601.38	1601.38
33250	Major surgery	ABLATE HEART DYSRHYTHM FOCUS	2551.81	2551.81
33251	Major surgery	ABLATE HEART DYSRHYTHM FOCUS	2859.52	2859.52
33254	Major surgery	ABLATE ATRIA LMTD	2394.17	2394.17
33255	Major surgery	ABLATE ATRIA W/O BYPASS EXT	2847.49	2847.49
33256	Major surgery	ABLATE ATRIA W/BYPASS EXTEN	3371.63	3371.63
33257	Major surgery	ABLATE ATRIA LMTD ADD-ON	1027.10	1027.10
33258	Major surgery	ABLATE ATRIA X10SV ADD-ON	1142.51	1142.51
33259	Major surgery	ABLATE ATRIA W/BYPASS ADD-ON	1492.51	1492.51
33261	Major surgery	ABLATE HEART DYSRHYTHM FOCUS	2821.40	2821.40
33262	Major surgery	RMVL& REPLC PULSE GEN 1 LEAD	655.26	655.26
33263	Major surgery	RMVL & RPLCMT DFB GEN 2 LEAD	680.78	680.78
33264	Major surgery	RMVL & RPLCMT DFB GEN MLT LD	709.86	709.86
33265	Major surgery	ABLATE ATRIA LMTD ENDO	2392.73	2392.73
33266	Major surgery	ABLATE ATRIA X10SV ENDO	3228.11	3228.11
33267	Major surgery	EXCL LAA OPEN ANY METHOD	1835.85	1835.85
33268	Major surgery	EXCL LAA OPN OTH PX ANY METH	226.06	226.06
33269	Major surgery	EXCL LAA THRSCP ANY METHOD	1458.72	1458.72
33270	Major surgery	INS/REP SUBQ DEFIBRILLATOR	984.24	984.24
33271	Major surgery	INSJ SUBQ IMPLTBL DFB ELCTRD	800.85	800.85
33272	Major surgery	RMVL OF SUBQ DEFIBRILLATOR	611.58	611.58
33273	Major surgery	REPOS PREV IMPLTBL SUBQ DFB	708.55	708.55
33274	Major surgery	TCAT INSJ/RPL PERM LDLS PM	839.85	839.85
33275	Major surgery	TCAT RMVL PERM LDLS PM W/IMG	887.23	887.23
33276	Major surgery	INSJ PHRNC NRV STIM SYS	1016.98	1016.98
33277	Major surgery	INSJ PHRNC NRV STIM TRANSVNS	532.23	532.23
33278	Major surgery	RMVL PHRNC NRV STIM SYS	1011.66	1011.66
33279	Major surgery	RMVL PHRNC NRV STIM TRANSVNS	610.82	610.82
33280	Major surgery	RMVL PHRNC NRV STIM PG ONLY	374.01	374.01
33281	Major surgery	REPOSG PHRNC NRV STIM TRNSVN	661.07	661.07
33285	Other professional services	INSJ SUBQ CAR RHYTHM MNTR	5656.28	117.96
33286	Other professional services	RMVL SUBQ CAR RHYTHM MNTR	177.11	115.71
33287	Major surgery	RMV&RPLCMT PHRNC NRV STIM PG	681.82	681.82
33288	Major surgery	RMV&RPLCMT PHRNC NRV STIM LD	899.16	899.16
33289	Other professional services	TCAT IMPL WRLS P-ART PRS SNR	449.76	449.76
33300	Major surgery	REPAIR OF HEART WOUND	4276.58	4276.58
33305	Major surgery	REPAIR OF HEART WOUND	7160.15	7160.15
33310	Major surgery	EXPLORATORY HEART SURGERY	2053.23	2053.23
33315	Major surgery	EXPLORATORY HEART SURGERY	3359.95	3359.95
33320	Major surgery	REPAIR MAJOR BLOOD VESSEL(S)	1881.59	1881.59
33321	Major surgery	REPAIR MAJOR VESSEL	2084.80	2084.80
33322	Major surgery	REPAIR MAJOR BLOOD VESSEL(S)	2455.26	2455.26
33330	Major surgery	INSERT MAJOR VESSEL GRAFT	2497.03	2497.03
33335	Major surgery	INSERT MAJOR VESSEL GRAFT	3267.91	3267.91
33340	Other professional services	PERQ CLSR TCAT L ATR APNDGE	1048.80	1048.80
33361	Other professional services	REPLACE AORTIC VALVE PERQ	1625.46	1625.46
33362	Other professional services	REPLACE AORTIC VALVE OPEN	1771.20	1771.20
33363	Other professional services	REPLACE AORTIC VALVE OPEN	1837.79	1837.79
33364	Other professional services	REPLACE AORTIC VALVE OPEN	1831.16	1831.16
33365	Other professional services	REPLACE AORTIC VALVE OPEN	1915.50	1915.50
33366	Other professional services	TRCATH REPLACE AORTIC VALVE	2108.28	2108.28
33367	Major surgery	REPLACE AORTIC VALVE W/BYP	1062.32	1062.32
33368	Major surgery	REPLACE AORTIC VALVE W/BYP	1287.25	1287.25
33369	Major surgery	REPLACE AORTIC VALVE W/BYP	1699.35	1699.35
33370	Major surgery	TCAT PLMT&RMVL CEPD PERQ	232.91	232.91
33390	Major surgery	VALVULOPLASTY AORTIC VALVE	3367.49	3367.49
33391	Major surgery	VALVULOPLASTY AORTIC VALVE	3990.01	3990.01
33404	Major surgery	PREPARE HEART-AORTA CONDUIT	3062.01	3062.01
33405	Major surgery	REPLACEMENT AORTIC VALVE OPN	3977.18	3977.18
33406	Major surgery	REPLACEMENT AORTIC VALVE OPN	5045.92	5045.92
33410	Major surgery	REPLACEMENT AORTIC VALVE OPN	4447.68	4447.68
33411	Major surgery	REPLACEMENT OF AORTIC VALVE	5864.16	5864.16
33412	Major surgery	REPLACEMENT OF AORTIC VALVE	5487.03	5487.03
33413	Major surgery	REPLACEMENT OF AORTIC VALVE	5623.62	5623.62
33414	Major surgery	REPAIR OF AORTIC VALVE	3760.73	3760.73
33415	Major surgery	REVISION SUBVALVULAR TISSUE	3554.05	3554.05
33416	Major surgery	REVISE VENTRICLE MUSCLE	3547.89	3547.89
33417	Major surgery	REPAIR OF AORTIC VALVE	2934.13	2934.13
33418	Major surgery	REPAIR TCAT MITRAL VALVE	3152.96	3152.96
33419	Major surgery	REPAIR TCAT MITRAL VALVE	739.28	739.28
33420	Major surgery	REVISION OF MITRAL VALVE	2542.74	2542.74
33422	Major surgery	REVISION OF MITRAL VALVE	2914.47	2914.47
33425	Major surgery	REPAIR OF MITRAL VALVE	4779.94	4779.94
33426	Major surgery	REPAIR OF MITRAL VALVE	4174.58	4174.58
33427	Major surgery	REPAIR OF MITRAL VALVE	4274.48	4274.48
33430	Major surgery	REPLACEMENT OF MITRAL VALVE	4907.55	4907.55
33440	Major surgery	RPLCMT A-VALVE TLCJ AUTOL PV	5933.32	5933.32
33460	Major surgery	REVISION OF TRICUSPID VALVE	4187.27	4187.27
33463	Major surgery	VALVULOPLASTY TRICUSPID	5389.06	5389.06
33464	Major surgery	VALVULOPLASTY TRICUSPID	4272.39	4272.39
33465	Major surgery	REPLACE TRICUSPID VALVE	4821.06	4821.06
33468	Major surgery	REVISION OF TRICUSPID VALVE	4287.97	4287.97
33471	Major surgery	VLVT PV CLSD HRT VIA P-ART	2332.77	2332.77
33474	Major surgery	REVISION OF PULMONARY VALVE	3820.60	3820.60
33475	Major surgery	REPLACEMENT PULMONARY VALVE	4069.18	4069.18
33476	Major surgery	REVISION OF HEART CHAMBER	2682.05	2682.05
33477	Other professional services	IMPLANT TCAT PULM VLV PERQ	1780.49	1780.49
33478	Major surgery	REVISION OF HEART CHAMBER	2769.29	2769.29
33496	Major surgery	REPAIR PROSTH VALVE CLOT	2915.66	2915.66
33500	Major surgery	REPAIR HEART VESSEL FISTULA	2733.94	2733.94
33501	Major surgery	REPAIR HEART VESSEL FISTULA	1958.89	1958.89
33502	Major surgery	CORONARY ARTERY CORRECTION	2254.14	2254.14
33503	Major surgery	CORONARY ARTERY GRAFT	2343.28	2343.28
33504	Major surgery	CORONARY ARTERY GRAFT	2582.74	2582.74
33505	Major surgery	REPAIR ARTERY W/TUNNEL	3600.52	3600.52
33506	Major surgery	REPAIR ARTERY TRANSLOCATION	3590.79	3590.79
33507	Major surgery	REPAIR ART INTRAMURAL	3014.37	3014.37
33508	Major surgery	ENDOSCOPIC VEIN HARVEST	28.08	28.08
33509	Major surgery	NDSC HRV UXTR ART 1 SGM CAB	301.20	301.20
33510	Major surgery	CABG VEIN SINGLE	3389.39	3389.39
33511	Major surgery	CABG VEIN TWO	3721.54	3721.54
33512	Major surgery	CABG VEIN THREE	4238.48	4238.48
33513	Major surgery	CABG VEIN FOUR	4328.90	4328.90
33514	Major surgery	CABG VEIN FIVE	4557.42	4557.42
33516	Major surgery	CABG VEIN SIX OR MORE	4716.72	4716.72
33517	Major surgery	CABG ARTERY-VEIN SINGLE	326.57	326.57
33518	Major surgery	CABG ARTERY-VEIN TWO	715.49	715.49
33519	Major surgery	CABG ARTERY-VEIN THREE	946.67	946.67
33521	Major surgery	CABG ARTERY-VEIN FOUR	1134.67	1134.67
33522	Major surgery	CABG ARTERY-VEIN FIVE	1275.03	1275.03
33523	Major surgery	CABG ART-VEIN SIX OR MORE	1437.33	1437.33
33530	Major surgery	CORONARY ARTERY BYPASS/REOP	913.52	913.52
33533	Major surgery	CABG ARTERIAL SINGLE	3281.75	3281.75
33534	Major surgery	CABG ARTERIAL TWO	3853.82	3853.82
33535	Major surgery	CABG ARTERIAL THREE	4283.53	4283.53
33536	Major surgery	CABG ARTERIAL FOUR OR MORE	4616.08	4616.08
33542	Major surgery	REMOVAL OF HEART LESION	4590.07	4590.07
33545	Major surgery	REPAIR OF HEART DAMAGE	5351.74	5351.74
33548	Major surgery	RESTORE/REMODEL VENTRICLE	5152.80	5152.80
33572	Major surgery	OPEN CORONARY ENDARTERECTOMY	402.09	402.09
33600	Major surgery	CLOSURE OF VALVE	3022.85	3022.85
33602	Major surgery	CLOSURE OF VALVE	2934.77	2934.77
33606	Major surgery	ANASTOMOSIS/ARTERY-AORTA	3124.47	3124.47
33608	Major surgery	REPAIR ANOMALY W/CONDUIT	3164.23	3164.23
33610	Major surgery	REPAIR BY ENLARGEMENT	3120.80	3120.80
33611	Major surgery	REPAIR DOUBLE VENTRICLE	3415.25	3415.25
33612	Major surgery	REPAIR DOUBLE VENTRICLE	3506.70	3506.70
33615	Major surgery	REPAIR MODIFIED FONTAN	3504.72	3504.72
33617	Major surgery	REPAIR SINGLE VENTRICLE	3795.05	3795.05
33619	Major surgery	REPAIR SINGLE VENTRICLE	4819.48	4819.48
33620	Major surgery	APPLY R&L PULM ART BANDS	2887.91	2887.91
33621	Major surgery	TRANSTHOR CATH FOR STENT	1634.74	1634.74
33622	Major surgery	REDO COMPL CARDIAC ANOMALY	5992.27	5992.27
33641	Major surgery	REPAIR HEART SEPTUM DEFECT	2873.40	2873.40
33645	Major surgery	REVISION OF HEART VEINS	3034.34	3034.34
33647	Major surgery	REPAIR HEART SEPTUM DEFECTS	3182.01	3182.01
33660	Major surgery	REPAIR OF HEART DEFECTS	3076.65	3076.65
33665	Major surgery	REPAIR OF HEART DEFECTS	3350.24	3350.24
33670	Major surgery	REPAIR OF HEART CHAMBERS	3446.35	3446.35
33675	Major surgery	CLOSE MULT VSD	3450.86	3450.86
33676	Major surgery	CLOSE MULT VSD W/RESECTION	3542.31	3542.31
33677	Major surgery	CL MULT VSD W/REM PUL BAND	3678.03	3678.03
33681	Major surgery	REPAIR HEART SEPTUM DEFECT	3242.03	3242.03
33684	Major surgery	REPAIR HEART SEPTUM DEFECT	3306.38	3306.38
33688	Major surgery	REPAIR HEART SEPTUM DEFECT	3292.32	3292.32
33690	Major surgery	REINFORCE PULMONARY ARTERY	2120.82	2120.82
33692	Major surgery	REPAIR OF HEART DEFECTS	3419.05	3419.05
33694	Major surgery	REPAIR OF HEART DEFECTS	3415.25	3415.25
33697	Major surgery	REPAIR OF HEART DEFECTS	3597.13	3597.13
33702	Major surgery	REPAIR OF HEART DEFECTS	2720.39	2720.39
33710	Major surgery	REPAIR OF HEART DEFECTS	3589.79	3589.79
33720	Major surgery	REPAIR OF HEART DEFECT	2722.26	2722.26
33724	Major surgery	REPAIR VENOUS ANOMALY	2696.07	2696.07
33726	Major surgery	REPAIR PUL VENOUS STENOSIS	3556.80	3556.80
33730	Major surgery	REPAIR HEART-VEIN DEFECT(S)	3518.93	3518.93
33732	Major surgery	REPAIR HEART-VEIN DEFECT	2900.33	2900.33
33735	Major surgery	REVISION OF HEART CHAMBER	2287.39	2287.39
33736	Major surgery	REVISION OF HEART CHAMBER	2479.72	2479.72
33737	Major surgery	REVISION OF HEART CHAMBER	2288.27	2288.27
33741	Other professional services	TAS CONGENITAL CAR ANOMAL	1009.62	1009.62
33745	Other professional services	TIS CGEN CAR ANOMAL 1ST SHNT	1442.63	1442.63
33746	Other professional services	TIS CGEN CAR ANOMAL EA ADDL	576.74	576.74
33750	Major surgery	MAJOR VESSEL SHUNT	2218.91	2218.91
33755	Major surgery	MAJOR VESSEL SHUNT	2323.68	2323.68
33762	Major surgery	MAJOR VESSEL SHUNT	2253.93	2253.93
33764	Major surgery	MAJOR VESSEL SHUNT & GRAFT	2323.68	2323.68
33766	Major surgery	MAJOR VESSEL SHUNT	2340.99	2340.99
33767	Major surgery	MAJOR VESSEL SHUNT	2498.09	2498.09
33768	Major surgery	CAVOPULMONARY SHUNTING	724.95	724.95
33770	Major surgery	REPAIR GREAT VESSELS DEFECT	3700.52	3700.52
33771	Major surgery	REPAIR GREAT VESSELS DEFECT	3802.75	3802.75
33774	Major surgery	REPAIR GREAT VESSELS DEFECT	3164.79	3164.79
33775	Major surgery	REPAIR GREAT VESSELS DEFECT	3256.21	3256.21
33776	Major surgery	REPAIR GREAT VESSELS DEFECT	3444.87	3444.87
33777	Major surgery	REPAIR GREAT VESSELS DEFECT	3316.33	3316.33
33778	Major surgery	REPAIR GREAT VESSELS DEFECT	4119.08	4119.08
33779	Major surgery	REPAIR GREAT VESSELS DEFECT	4060.72	4060.72
33780	Major surgery	REPAIR GREAT VESSELS DEFECT	4138.68	4138.68
33781	Major surgery	REPAIR GREAT VESSELS DEFECT	4036.38	4036.38
33782	Major surgery	NIKAIDOH PROC	5636.24	5636.24
33783	Major surgery	NIKAIDOH PROC W/OSTIA IMPLT	6090.44	6090.44
33786	Major surgery	REPAIR ARTERIAL TRUNK	3983.95	3983.95
33788	Major surgery	REVISION OF PULMONARY ARTERY	2690.42	2690.42
33800	Major surgery	AORTIC SUSPENSION	1734.60	1734.60
33802	Major surgery	REPAIR VESSEL DEFECT	1917.38	1917.38
33803	Major surgery	REPAIR VESSEL DEFECT	2023.36	2023.36
33813	Major surgery	REPAIR SEPTAL DEFECT	2187.18	2187.18
33814	Major surgery	REPAIR SEPTAL DEFECT	2683.82	2683.82
33820	Major surgery	REVISE MAJOR VESSEL	1704.75	1704.75
33822	Major surgery	REVISE MAJOR VESSEL	1797.06	1797.06
33824	Major surgery	REVISE MAJOR VESSEL	2083.61	2083.61
33840	Major surgery	REMOVE AORTA CONSTRICTION	2184.88	2184.88
33845	Major surgery	REMOVE AORTA CONSTRICTION	2353.47	2353.47
33851	Major surgery	REMOVE AORTA CONSTRICTION	2243.61	2243.61
33852	Major surgery	REPAIR SEPTAL DEFECT	2464.27	2464.27
33853	Major surgery	REPAIR SEPTAL DEFECT	3221.89	3221.89
33858	Major surgery	AS-AORT GRF F/AORTIC DSJ	5926.19	5926.19
33859	Major surgery	AS-AORT GRF F/DS OTH/THN DSJ	4260.18	4260.18
33863	Major surgery	ASCENDING AORTIC GRAFT	5493.56	5493.56
33864	Major surgery	ASCENDING AORTIC GRAFT	5608.71	5608.71
33866	Other professional services	AORTIC HEMIARCH GRAFT	1232.58	1232.58
33871	Major surgery	TRANSVRS A-ARCH GRF HYPTHRM	5685.83	5685.83
33875	Major surgery	THORACIC AORTIC GRAFT	4797.53	4797.53
33877	Major surgery	THORACOABDOMINAL GRAFT	6291.52	6291.52
33880	Major surgery	ENDOVASC TAA REPR INCL SUBCL	3114.35	3114.35
33881	Major surgery	ENDOVASC TAA REPR W/O SUBCL	2674.78	2674.78
33883	Major surgery	INSERT ENDOVASC PROSTH TAA	1941.83	1941.83
33884	Major surgery	ENDOVASC PROSTH TAA ADD-ON	685.87	685.87
33886	Major surgery	ENDOVASC PROSTH DELAYED	1675.54	1675.54
33889	Other professional services	ARTERY TRANSPOSE/ENDOVAS TAA	1063.58	1063.58
33891	Other professional services	CAR-CAR BP GRFT/ENDOVAS TAA	1286.10	1286.10
33894	Other professional services	EVASC ST RPR THRC/AA ACRS BR	1318.08	1318.08
33895	Other professional services	EVASC ST RPR THRC/AA X CRSG	1049.03	1049.03
33897	Other professional services	PERQ TRLUML ANGP NT/RECR COA	779.66	779.66
33900	Other professional services	PERQ P-ART REVSC 1 NM NT UNI	785.06	785.06
33901	Other professional services	PERQ P-ART REVSC 1 NM NT BI	1031.75	1031.75
33902	Other professional services	PERQ P-ART REVSC 1 ABNOR UNI	996.20	996.20
33903	Other professional services	PERQ P-ART REVSC 1 ABNOR BI	1174.04	1174.04
33904	Other professional services	PERQ P-ART REVSC EACH ADDL	394.14	394.14
33910	Major surgery	REMOVE LUNG ARTERY EMBOLI	4566.41	4566.41
33915	Major surgery	REMOVE LUNG ARTERY EMBOLI	2407.04	2407.04
33916	Major surgery	SURGERY OF GREAT VESSEL	7282.74	7282.74
33917	Major surgery	REPAIR PULMONARY ARTERY	2568.46	2568.46
33920	Major surgery	REPAIR PULMONARY ATRESIA	3171.89	3171.89
33922	Major surgery	TRANSECT PULMONARY ARTERY	2447.48	2447.48
33924	Major surgery	REMOVE PULMONARY SHUNT	496.55	496.55
33925	Major surgery	RPR PUL ART UNIFOCAL W/O CPB	3005.36	3005.36
33926	Major surgery	REPR PUL ART UNIFOCAL W/CPB	4223.13	4223.13
33927	Other professional services	IMPLTJ TOT RPLCMT HRT SYS	3415.41	3415.41
33928	Other professional services	RMVL & RPLCMT TOT HRT SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
33929	Other professional services	RMVL RPLCMT HRT SYS F/TRNSPL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
33930	Other professional services	REMOVAL OF DONOR HEART/LUNG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
33933	Other professional services	PREPARE DONOR HEART/LUNG	307.95	307.95
33935	Major surgery	TRANSPLANTATION HEART/LUNG	8599.19	8599.19
33940	Other professional services	REMOVAL OF DONOR HEART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
33944	Other professional services	PREPARE DONOR HEART	307.95	307.95
33945	Major surgery	TRANSPLANTATION OF HEART	8503.33	8503.33
33946	Other professional services	ECMO/ECLS INITIATION VENOUS	417.80	417.80
33947	Other professional services	ECMO/ECLS INITIATION ARTERY	462.27	462.27
33948	Other professional services	ECMO/ECLS DAILY MGMT-VENOUS	323.94	323.94
33949	Other professional services	ECMO/ECLS DAILY MGMT ARTERY	316.07	316.07
33951	Other professional services	ECMO/ECLS INSJ PRPH CANNULA	565.53	565.53
33952	Other professional services	ECMO/ECLS INSJ PRPH CANNULA	574.56	574.56
33953	Other professional services	ECMO/ECLS INSJ PRPH CANNULA	631.56	631.56
33954	Other professional services	ECMO/ECLS INSJ PRPH CANNULA	638.40	638.40
33955	Other professional services	ECMO/ECLS INSJ CTR CANNULA	1105.92	1105.92
33956	Other professional services	ECMO/ECLS INSJ CTR CANNULA	1121.03	1121.03
33957	Other professional services	ECMO/ECLS REPOS PERPH CNULA	246.29	246.29
33958	Other professional services	ECMO/ECLS REPOS PERPH CNULA	246.29	246.29
33959	Other professional services	ECMO/ECLS REPOS PERPH CNULA	313.43	313.43
33962	Other professional services	ECMO/ECLS REPOS PERPH CNULA	313.43	313.43
33963	Other professional services	ECMO/ECLS REPOS PERPH CNULA	624.15	624.15
33964	Other professional services	ECMO/ECLS REPOS PERPH CNULA	659.00	659.00
33965	Other professional services	ECMO/ECLS RMVL PERPH CANNULA	246.29	246.29
33966	Other professional services	ECMO/ECLS RMVL PRPH CANNULA	318.66	318.66
33967	Other professional services	INSERT I-AORT PERCUT DEVICE	347.66	347.66
33968	Other professional services	REMOVE AORTIC ASSIST DEVICE	45.56	45.56
33969	Other professional services	ECMO/ECLS RMVL PERPH CANNULA	364.13	364.13
33970	Other professional services	AORTIC CIRCULATION ASSIST	474.26	474.26
33971	Major surgery	AORTIC CIRCULATION ASSIST	1248.25	1248.25
33973	Other professional services	INSERT BALLOON DEVICE	670.31	670.31
33974	Major surgery	REMOVE INTRA-AORTIC BALLOON	1568.64	1568.64
33975	Other professional services	IMPLANT VENTRICULAR DEVICE	1749.27	1749.27
33976	Other professional services	IMPLANT VENTRICULAR DEVICE	2115.83	2115.83
33977	Other professional services	REMOVE VENTRICULAR DEVICE	1510.52	1510.52
33978	Other professional services	REMOVE VENTRICULAR DEVICE	1781.58	1781.58
33979	Other professional services	INSERT INTRACORPOREAL DEVICE	2607.02	2607.02
33980	Other professional services	REMOVE INTRACORPOREAL DEVICE	2394.15	2394.15
33981	Other professional services	REPLACE VAD PUMP EXT	1107.89	1107.89
33982	Other professional services	REPLACE VAD INTRA W/O BP	2604.90	2604.90
33983	Other professional services	REPLACE VAD INTRA W/BP	3065.37	3065.37
33984	Other professional services	ECMO/ECLS RMVL PRPH CANNULA	380.55	380.55
33985	Other professional services	ECMO/ECLS RMVL CTR CANNULA	685.31	685.31
33986	Other professional services	ECMO/ECLS RMVL CTR CANNULA	702.36	702.36
33987	Major surgery	ARTERY EXPOS/GRAFT ARTERY	361.73	361.73
33988	Other professional services	INSERTION OF LEFT HEART VENT	1037.01	1037.01
33989	Other professional services	REMOVAL OF LEFT HEART VENT	659.00	659.00
33990	Other professional services	INSJ PERQ VAD L HRT ARTERIAL	484.62	484.62
33991	Other professional services	INSJ PERQ VAD L HRT ARTL&VEN	608.16	608.16
33992	Other professional services	RMVL PERQ LEFT HEART VAD	252.68	252.68
33993	Other professional services	REPOSG PERQ R/L HRT VAD	223.85	223.85
33995	Other professional services	INSJ PERQ VAD R HRT VENOUS	477.80	477.80
33997	Other professional services	RMVL PERQ RIGHT HEART VAD	216.60	216.60
33999	Major surgery	UNLISTED PX CARDIAC SURGERY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
34001	Major surgery	REMOVAL OF ARTERY CLOT	1596.86	1596.86
34051	Major surgery	REMOVAL OF ARTERY CLOT	1747.36	1747.36
34101	Major surgery	REMOVAL OF ARTERY CLOT	1041.18	1041.18
34111	Major surgery	REMOVAL OF ARM ARTERY CLOT	1040.01	1040.01
34151	Major surgery	REMOVAL OF ARTERY CLOT	2426.89	2426.89
34201	Major surgery	REMOVAL OF ARTERY CLOT	1781.19	1781.19
34203	Major surgery	REMOVAL OF LEG ARTERY CLOT	1655.02	1655.02
34401	Major surgery	REMOVAL OF VEIN CLOT	2631.41	2631.41
34421	Major surgery	REMOVAL OF VEIN CLOT	1215.03	1215.03
34451	Major surgery	REMOVAL OF VEIN CLOT	2504.31	2504.31
34471	Major surgery	REMOVAL OF VEIN CLOT	1884.19	1884.19
34490	Major surgery	REMOVAL OF VEIN CLOT	1006.80	1006.80
34501	Major surgery	REPAIR VALVE FEMORAL VEIN	1566.59	1566.59
34502	Major surgery	RECONSTRUCT VENA CAVA	2719.12	2719.12
34510	Major surgery	TRANSPOSITION OF VEIN VALVE	1783.59	1783.59
34520	Major surgery	CROSS-OVER VEIN GRAFT	1727.90	1727.90
34530	Major surgery	LEG VEIN FUSION	1646.00	1646.00
34701	Major surgery	EVASC RPR A-AO NDGFT	2151.75	2151.75
34702	Major surgery	EVASC RPR A-AO NDGFT RPT	3211.28	3211.28
34703	Major surgery	EVASC RPR A-UNILAC NDGFT	2389.71	2389.71
34704	Major surgery	EVASC RPR A-UNILAC NDGFT RPT	3984.32	3984.32
34705	Major surgery	EVAC RPR A-BIILIAC NDGFT	2657.30	2657.30
34706	Major surgery	EVASC RPR A-BIILIAC RPT	3960.10	3960.10
34707	Major surgery	EVASC RPR ILIO-ILIAC NDGFT	2020.67	2020.67
34708	Major surgery	EVASC RPR ILIO-ILIAC RPT	3164.38	3164.38
34709	Other professional services	PLMT XTN PROSTH EVASC RPR	430.58	430.58
34710	Major surgery	DLYD PLMT XTN PROSTH 1ST VSL	1388.03	1388.03
34711	Other professional services	DLYD PLMT XTN PROSTH EA ADDL	393.20	393.20
34712	Major surgery	TCAT DLVR ENHNCD FIXJ DEV	1144.26	1144.26
34713	Other professional services	PERQ ACCESS & CLSR FEM ART	164.67	164.67
34714	Other professional services	OPN FEM ART EXPOS CNDT CRTJ	360.74	360.74
34715	Other professional services	OPN AX/SUBCLA ART EXPOS	398.85	398.85
34716	Other professional services	OPN AX/SUBCLA ART EXPOS CNDT	498.47	498.47
34717	Major surgery	EVASC RPR A-ILIAC NDGFT	769.18	769.18
34718	Major surgery	EVASC RPR N/A A-ILIAC NDGFT	2154.77	2154.77
34808	Major surgery	ENDOVAS ILIAC A DEVICE ADDON	351.74	351.74
34812	Other professional services	OPN FEM ART EXPOS	275.15	275.15
34813	Major surgery	FEMORAL ENDOVAS GRAFT ADD-ON	407.82	407.82
34820	Other professional services	OPN ILIAC ART EXPOS	449.90	449.90
34830	Major surgery	OPEN AORTIC TUBE PROSTH REPR	3070.88	3070.88
34831	Major surgery	OPEN AORTOILIAC PROSTH REPR	3357.96	3357.96
34832	Major surgery	OPEN AORTOFEMOR PROSTH REPR	3301.19	3301.19
34833	Other professional services	OPN ILAC ART EXPOS CNDT CRTJ	524.85	524.85
34834	Other professional services	OPN BRACH ART EXPOS	172.64	172.64
34839	Major surgery	PLNNING PT SPEC FENEST GRAFT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
34841	Major surgery	ENDOVASC VISC AORTA 1 GRAFT	2054.09	2054.09
34842	Major surgery	ENDOVASC VISC AORTA 2 GRAFT	2249.09	2249.09
34843	Major surgery	ENDOVASC VISC AORTA 3 GRAFT	2444.09	2444.09
34844	Major surgery	ENDOVASC VISC AORTA 4 GRAFT	2639.09	2639.09
34845	Major surgery	VISC & INFRAREN ABD 1 PROSTH	2054.09	2054.09
34846	Major surgery	VISC & INFRAREN ABD 2 PROSTH	2249.09	2249.09
34847	Major surgery	VISC & INFRAREN ABD 3 PROSTH	2444.09	2444.09
34848	Major surgery	VISC & INFRAREN ABD 4+ PROST	2639.09	2639.09
35001	Major surgery	REPAIR DEFECT OF ARTERY	1958.03	1958.03
35002	Major surgery	REPAIR ARTERY RUPTURE NECK	1986.93	1986.93
35005	Major surgery	REPAIR DEFECT OF ARTERY	1740.16	1740.16
35011	Major surgery	REPAIR DEFECT OF ARTERY	1765.16	1765.16
35013	Major surgery	REPAIR ARTERY RUPTURE ARM	2215.22	2215.22
35021	Major surgery	REPAIR DEFECT OF ARTERY	2210.48	2210.48
35022	Major surgery	REPAIR ARTERY RUPTURE CHEST	2527.28	2527.28
35045	Major surgery	REPAIR DEFECT OF ARM ARTERY	1696.77	1696.77
35081	Major surgery	REPAIR DEFECT OF ARTERY	3015.54	3015.54
35082	Major surgery	REPAIR ARTERY RUPTURE AORTA	3764.63	3764.63
35091	Major surgery	REPAIR DEFECT OF ARTERY	3097.81	3097.81
35092	Major surgery	REPAIR ARTERY RUPTURE AORTA	4518.97	4518.97
35102	Major surgery	REPAIR DEFECT OF ARTERY	3278.55	3278.55
35103	Major surgery	REPAIR ARTERY RUPTURE AORTA	3858.80	3858.80
35111	Major surgery	REPAIR DEFECT OF ARTERY	2317.40	2317.40
35112	Major surgery	REPAIR ARTERY RUPTURE SPLEEN	2847.94	2847.94
35121	Major surgery	REPAIR DEFECT OF ARTERY	2754.47	2754.47
35122	Major surgery	REPAIR ARTERY RUPTURE BELLY	3294.02	3294.02
35131	Major surgery	REPAIR DEFECT OF ARTERY	2408.85	2408.85
35132	Major surgery	REPAIR ARTERY RUPTURE GROIN	2847.94	2847.94
35141	Major surgery	REPAIR DEFECT OF ARTERY	1904.35	1904.35
35142	Major surgery	REPAIR ARTERY RUPTURE THIGH	2299.79	2299.79
35151	Major surgery	REPAIR DEFECT OF ARTERY	2164.42	2164.42
35152	Major surgery	REPAIR RUPTD POPLITEAL ART	2436.84	2436.84
35180	Major surgery	REPAIR BLOOD VESSEL LESION	1372.31	1372.31
35182	Major surgery	REPAIR BLOOD VESSEL LESION	3147.53	3147.53
35184	Major surgery	REPAIR BLOOD VESSEL LESION	1684.37	1684.37
35188	Major surgery	REPAIR BLOOD VESSEL LESION	2273.08	2273.08
35189	Major surgery	REPAIR BLOOD VESSEL LESION	2632.15	2632.15
35190	Major surgery	REPAIR BLOOD VESSEL LESION	1325.84	1325.84
35201	Major surgery	REPAIR BLOOD VESSEL LESION	1640.50	1640.50
35206	Major surgery	REPAIR BLOOD VESSEL LESION	1394.09	1394.09
35207	Major surgery	REPAIR BLOOD VESSEL LESION	1362.15	1362.15
35211	Major surgery	REPAIR BLOOD VESSEL LESION	2446.98	2446.98
35216	Major surgery	REPAIR BLOOD VESSEL LESION	3703.52	3703.52
35221	Major surgery	REPAIR BLOOD VESSEL LESION	2589.70	2589.70
35226	Major surgery	REPAIR BLOOD VESSEL LESION	1450.02	1450.02
35231	Major surgery	REPAIR BLOOD VESSEL LESION	2225.36	2225.36
35236	Major surgery	REPAIR BLOOD VESSEL LESION	1755.00	1755.00
35241	Major surgery	REPAIR BLOOD VESSEL LESION	2516.57	2516.57
35246	Major surgery	REPAIR BLOOD VESSEL LESION	2736.69	2736.69
35251	Major surgery	REPAIR BLOOD VESSEL LESION	3050.17	3050.17
35256	Major surgery	REPAIR BLOOD VESSEL LESION	1768.69	1768.69
35261	Major surgery	REPAIR BLOOD VESSEL LESION	1713.50	1713.50
35266	Major surgery	REPAIR BLOOD VESSEL LESION	1516.16	1516.16
35271	Major surgery	REPAIR BLOOD VESSEL LESION	2434.97	2434.97
35276	Major surgery	REPAIR BLOOD VESSEL LESION	2556.96	2556.96
35281	Major surgery	REPAIR BLOOD VESSEL LESION	2831.38	2831.38
35286	Major surgery	REPAIR BLOOD VESSEL LESION	1618.64	1618.64
35301	Major surgery	RECHANNELING OF ARTERY	1967.90	1967.90
35302	Major surgery	RECHANNELING OF ARTERY	1948.09	1948.09
35303	Major surgery	RECHANNELING OF ARTERY	2135.31	2135.31
35304	Major surgery	RECHANNELING OF ARTERY	2222.43	2222.43
35305	Major surgery	RECHANNELING OF ARTERY	2137.92	2137.92
35306	Major surgery	RECHANNELING OF ARTERY	772.41	772.41
35311	Major surgery	RECHANNELING OF ARTERY	2717.42	2717.42
35321	Major surgery	RECHANNELING OF ARTERY	1569.48	1569.48
35331	Major surgery	RECHANNELING OF ARTERY	2534.59	2534.59
35341	Major surgery	RECHANNELING OF ARTERY	2417.98	2417.98
35351	Major surgery	RECHANNELING OF ARTERY	2239.81	2239.81
35355	Major surgery	RECHANNELING OF ARTERY	1792.30	1792.30
35361	Major surgery	RECHANNELING OF ARTERY	2654.09	2654.09
35363	Major surgery	RECHANNELING OF ARTERY	2829.39	2829.39
35371	Major surgery	RECHANNELING OF ARTERY	1420.52	1420.52
35372	Major surgery	RECHANNELING OF ARTERY	1702.14	1702.14
35390	Major surgery	REOPERATION CAROTID ADD-ON	275.83	275.83
35400	Major surgery	ANGIOSCOPY	256.68	256.68
35500	Major surgery	HARVEST VEIN FOR BYPASS	552.79	552.79
35501	Major surgery	ART BYP GRFT IPSILAT CAROTID	2542.33	2542.33
35506	Major surgery	ART BYP GRFT SUBCLAV-CAROTID	2220.09	2220.09
35508	Major surgery	ART BYP GRFT CAROTID-VERTBRL	2317.93	2317.93
35509	Major surgery	ART BYP GRFT CONTRAL CAROTID	2458.91	2458.91
35510	Major surgery	ART BYP GRFT CAROTID-BRCHIAL	2143.64	2143.64
35511	Major surgery	ART BYP GRFT SUBCLAV-SUBCLAV	1953.26	1953.26
35512	Major surgery	ART BYP GRFT SUBCLAV-BRCHIAL	2101.89	2101.89
35515	Major surgery	ART BYP GRFT SUBCLAV-VERTBRL	2317.93	2317.93
35516	Major surgery	ART BYP GRFT SUBCLAV-AXILARY	2127.08	2127.08
35518	Major surgery	ART BYP GRFT AXILLARY-AXILRY	1990.79	1990.79
35521	Major surgery	ART BYP GRFT AXILL-FEMORAL	2142.41	2142.41
35522	Major surgery	ART BYP GRFT AXILL-BRACHIAL	2039.06	2039.06
35523	Major surgery	ART BYP GRFT BRCHL-ULNR-RDL	2145.35	2145.35
35525	Major surgery	ART BYP GRFT BRACHIAL-BRCHL	1974.80	1974.80
35526	Major surgery	ART BYP GRFT AOR/CAROT/INNOM	3026.13	3026.13
35531	Major surgery	ART BYP GRFT AORCEL/AORMESEN	3396.32	3396.32
35533	Major surgery	ART BYP GRFT AXILL/FEM/FEM	2627.31	2627.31
35535	Major surgery	ART BYP GRFT HEPATORENAL	3314.84	3314.84
35536	Major surgery	ART BYP GRFT SPLENORENAL	2944.52	2944.52
35537	Major surgery	ART BYP GRFT AORTOILIAC	3630.10	3630.10
35538	Major surgery	ART BYP GRFT AORTOBI-ILIAC	4065.65	4065.65
35539	Major surgery	ART BYP GRFT AORTOFEMORAL	3816.11	3816.11
35540	Major surgery	ART BYP GRFT AORTBIFEMORAL	4251.92	4251.92
35556	Major surgery	ART BYP GRFT FEM-POPLITEAL	2425.88	2425.88
35558	Major surgery	ART BYP GRFT FEM-FEMORAL	2160.07	2160.07
35560	Major surgery	ART BYP GRFT AORTORENAL	2970.45	2970.45
35563	Major surgery	ART BYP GRFT ILIOILIAC	2309.01	2309.01
35565	Major surgery	ART BYP GRFT ILIOFEMORAL	2287.21	2287.21
35566	Major surgery	ART BYP FEM-ANT-POST TIB/PRL	2892.40	2892.40
35570	Major surgery	ART BYP TIBIAL-TIB/PERONEAL	2569.48	2569.48
35571	Major surgery	ART BYP POP-TIBL-PRL-OTHER	2304.88	2304.88
35572	Major surgery	HARVEST FEMOROPOPLITEAL VEIN	596.19	596.19
35583	Major surgery	VEIN BYP GRFT FEM-POPLITEAL	2509.90	2509.90
35585	Major surgery	VEIN BYP FEM-TIBIAL PERONEAL	2906.26	2906.26
35587	Major surgery	VEIN BYP POP-TIBL PERONEAL	2323.89	2323.89
35600	Major surgery	OPEN HRV UXTR ART 1 SGM CAB	324.29	324.29
35601	Major surgery	ART BYP COMMON IPSI CAROTID	2439.68	2439.68
35606	Major surgery	ART BYP CAROTID-SUBCLAVIAN	2050.19	2050.19
35612	Major surgery	ART BYP SUBCLAV-SUBCLAVIAN	1825.65	1825.65
35616	Major surgery	ART BYP SUBCLAV-AXILLARY	1921.20	1921.20
35621	Major surgery	ART BYP AXILLARY-FEMORAL	1910.65	1910.65
35623	Major surgery	ART BYP AXILLARY-POP-TIBIAL	2291.93	2291.93
35626	Major surgery	ART BYP AORSUBCL/CAROT/INNOM	2770.68	2770.68
35631	Major surgery	ART BYP AOR-CELIAC-MSN-RENAL	3228.07	3228.07
35632	Major surgery	ART BYP ILIO-CELIAC	3147.16	3147.16
35633	Major surgery	ART BYP ILIO-MESENTERIC	3451.64	3451.64
35634	Major surgery	ART BYP ILIORENAL	3079.89	3079.89
35636	Major surgery	ART BYP SPENORENAL	2779.39	2779.39
35637	Major surgery	ART BYP AORTOILIAC	2889.59	2889.59
35638	Major surgery	ART BYP AORTOBI-ILIAC	3020.59	3020.59
35642	Major surgery	ART BYP CAROTID-VERTEBRAL	1727.17	1727.17
35645	Major surgery	ART BYP SUBCLAV-VERTEBRL	1654.46	1654.46
35646	Major surgery	ART BYP AORTOBIFEMORAL	2968.89	2968.89
35647	Major surgery	ART BYP AORTOFEMORAL	2699.87	2699.87
35650	Major surgery	ART BYP AXILLARY-AXILLARY	1782.01	1782.01
35654	Major surgery	ART BYP AXILL-FEM-FEMORAL	2375.24	2375.24
35656	Major surgery	ART BYP FEMORAL-POPLITEAL	1868.63	1868.63
35661	Major surgery	ART BYP FEMORAL-FEMORAL	1887.05	1887.05
35663	Major surgery	ART BYP ILIOILIAC	2126.16	2126.16
35665	Major surgery	ART BYP ILIOFEMORAL	2047.03	2047.03
35666	Major surgery	ART BYP FEM-ANT-POST TIB/PRL	2243.46	2243.46
35671	Major surgery	ART BYP POP-TIBL-PRL-OTHER	1975.31	1975.31
35681	Major surgery	COMPOSITE BYP GRFT PROS&VEIN	138.66	138.66
35682	Major surgery	COMPOSITE BYP GRFT 2 VEINS	612.71	612.71
35683	Major surgery	COMPOSITE BYP GRFT 3/> SEGMT	709.74	709.74
35685	Major surgery	BYPASS GRAFT PATENCY/PATCH	343.24	343.24
35686	Major surgery	BYPASS GRAFT/AV FIST PATENCY	278.83	278.83
35691	Major surgery	ART TRNSPOSJ VERTBRL CAROTID	1652.18	1652.18
35693	Major surgery	ART TRNSPOSJ SUBCLAVIAN	1464.86	1464.86
35694	Major surgery	ART TRNSPOSJ SUBCLAV CAROTID	1725.34	1725.34
35695	Major surgery	ART TRNSPOSJ CAROTID SUBCLAV	1790.31	1790.31
35697	Major surgery	REIMPLANT ARTERY EACH	254.32	254.32
35700	Major surgery	REOPERATION BYPASS GRAFT	263.23	263.23
35701	Major surgery	EXPL N/FLWD SURG NECK ART	783.18	783.18
35702	Major surgery	EXPL N/FLWD SURG UXTR ART	721.25	721.25
35703	Major surgery	EXPL N/FLWD SURG LXTR ART	729.32	729.32
35800	Major surgery	EXPLORE NECK VESSELS	1310.21	1310.21
35820	Major surgery	EXPLORE CHEST VESSELS	3528.35	3528.35
35840	Major surgery	EXPLORE ABDOMINAL VESSELS	2154.42	2154.42
35860	Major surgery	EXPLORE LIMB VESSELS	1476.38	1476.38
35870	Major surgery	REPAIR VESSEL GRAFT DEFECT	2176.94	2176.94
35875	Major surgery	REMOVAL OF CLOT IN GRAFT	1033.52	1033.52
35876	Major surgery	REMOVAL OF CLOT IN GRAFT	1643.67	1643.67
35879	Major surgery	REVISE GRAFT W/VEIN	1605.75	1605.75
35881	Major surgery	REVISE GRAFT W/VEIN	1795.44	1795.44
35883	Major surgery	REVJ FEM ANAST NONAUTOG GRF	2083.15	2083.15
35884	Major surgery	REVJ FEM ANAST AUTOG VN GRF	2159.84	2159.84
35901	Major surgery	EXCISION GRAFT NECK	836.84	836.84
35903	Major surgery	EXCISION GRAFT EXTREMITY	989.57	989.57
35905	Major surgery	EXCISION GRAFT THORAX	2927.65	2927.65
35907	Major surgery	EXCISION GRAFT ABDOMEN	3325.26	3325.26
36000	Other professional services	PLACE NEEDLE IN VEIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
36002	Other professional services	PSEUDOANEURYSM INJECTION TRT	211.91	142.32
36005	Other professional services	INJECTION EXT VENOGRAPHY	341.61	64.62
36010	Other professional services	PLACE CATHETER IN VEIN	725.96	146.97
36011	Other professional services	PLACE CATHETER IN VEIN	1074.48	211.70
36012	Other professional services	PLACE CATHETER IN VEIN	1122.48	236.04
36013	Other professional services	PLACE CATHETER IN ARTERY	1050.30	171.59
36014	Other professional services	PLACE CATHETER IN ARTERY	1055.45	205.40
36015	Other professional services	PLACE CATHETER IN ARTERY	1135.52	234.08
36100	Other professional services	ESTABLISH ACCESS TO ARTERY	720.69	204.02
36140	Other professional services	INTRO NDL ICATH UPR/LXTR ART	688.10	120.03
36160	Other professional services	ESTABLISH ACCESS TO AORTA	745.11	167.96
36200	Other professional services	PLACE CATHETER IN AORTA	796.82	187.37
36215	Other professional services	PLACE CATHETER IN ARTERY	1395.57	289.91
36216	Other professional services	PLACE CATHETER IN ARTERY	1436.04	367.67
36217	Other professional services	PLACE CATHETER IN ARTERY	2436.05	448.95
36218	Major surgery	PLACE CATHETER IN ARTERY	369.04	92.33
36221	Other professional services	PLACE CATH THORACIC AORTA	1327.40	269.04
36222	Other professional services	PLACE CATH CAROTID/INOM ART	1663.07	385.49
36223	Other professional services	PLACE CATH CAROTID/INOM ART	2257.13	442.41
36224	Other professional services	PLACE CATH CAROTD ART	2785.35	495.35
36225	Other professional services	PLACE CATH SUBCLAVIAN ART	2144.01	438.90
36226	Other professional services	PLACE CATH VERTEBRAL ART	2714.33	492.54
36227	Major surgery	PLACE CATH XTRNL CAROTID	429.82	211.05
36228	Major surgery	PLACE CATH INTRACRANIAL ART	2274.36	433.78
36245	Other professional services	INS CATH ABD/L-EXT ART 1ST	1666.35	319.17
36246	Other professional services	INS CATH ABD/L-EXT ART 2ND	1122.86	340.58
36247	Other professional services	INS CATH ABD/L-EXT ART 3RD	1908.06	403.98
36248	Major surgery	INS CATH ABD/L-EXT ART ADDL	205.57	85.55
36251	Other professional services	INS CATH REN ART 1ST UNILAT	1727.31	346.04
36252	Other professional services	INS CATH REN ART 1ST BILAT	1871.97	479.78
36253	Other professional services	INS CATH REN ART 2ND+ UNILAT	2699.58	483.26
36254	Other professional services	INS CATH REN ART 2ND+ BILAT	2652.33	559.73
36260	Major surgery	INSERTION OF INFUSION PUMP	1174.43	1174.43
36261	Major surgery	REVISION OF INFUSION PUMP	739.58	739.58
36262	Major surgery	REMOVAL OF INFUSION PUMP	565.66	565.66
36299	Major surgery	UNLISTED PX VASCULAR NJX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
36400	Other professional services	BL DRAW < 3 YRS FEM/JUGULAR	38.30	26.01
36405	Other professional services	BL DRAW <3 YRS SCALP VEIN	33.62	20.88
36406	Other professional services	BL DRAW <3 YRS OTHER VEIN	24.63	12.35
36410	Other professional services	NON-ROUTINE BL DRAW 3/> YRS	24.51	12.68
36415	Clinical Laboratory	ROUTINE VENIPUNCTURE	13.25	13.25
36416	Other professional services	COLLJ CAPILLARY BLOOD SPEC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
36420	Other professional services	VENIPUNCTURE CUTDOWN < 1 YR	64.98	64.98
36425	Other professional services	VENIPUNCTURE CUTDOWN 1 YR/>	54.57	54.57
36430	Other professional services	TRANSFUSION BLD/BLD COMPNT	57.38	57.38
36440	Other professional services	BLD PUSH TFUJ 2 YR/<	70.16	70.16
36450	Other professional services	BLD EXCHANGE TRUJ NEWBORN	238.41	238.41
36455	Other professional services	BLD EXCHANGE TRUJ OTH THN NB	169.10	169.10
36456	Other professional services	PRTL EXCHANGE TRANSFUSE NB	136.01	136.01
36460	Other professional services	INTRAUTERINE TRANSFUSION FTL	475.16	475.16
36465	Other professional services	NJX NONCMPND SCLRSNT 1 VEIN	1740.96	161.37
36466	Other professional services	NJX NONCMPND SCLRSNT MLT VN	1838.52	205.74
36468	Other professional services	NJX SCLRSNT SPIDER VEINS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
36470	Other professional services	NJX SCLRSNT 1 INCMPTNT VEIN	158.18	51.75
36471	Other professional services	NJX SCLRSNT MLT INCMPTNT VN	274.04	103.04
36473	Other professional services	ENDOVENOUS MCHNCHEM 1ST VEIN	1624.20	245.19
36474	Other professional services	ENDOVENOUS MCHNCHEM ADD-ON	341.75	120.26
36475	Other professional services	ENDOVENOUS RF 1ST VEIN	1446.75	375.20
36476	Major surgery	ENDOVENOUS RF VEIN ADD-ON	496.90	233.79
36478	Other professional services	ENDOVENOUS LASER 1ST VEIN	1322.45	375.96
36479	Major surgery	ENDOVENOUS LASER VEIN ADDON	534.30	238.68
36481	Other professional services	INSERTION OF CATHETER VEIN	2323.62	445.68
36482	Other professional services	ENDOVEN THER CHEM ADHES 1ST	2244.38	242.73
36483	Other professional services	ENDOVEN THER CHEM ADHES SBSQ	187.38	119.16
36500	Other professional services	INSERTION OF CATHETER VEIN	246.59	246.59
36510	Other professional services	INSERTION OF CATHETER VEIN	120.29	74.34
36511	Other professional services	APHERESIS WBC	154.79	154.79
36512	Other professional services	APHERESIS RBC	147.63	147.63
36513	Other professional services	APHERESIS PLATELETS	147.20	147.20
36514	Other professional services	APHERESIS PLASMA	911.57	129.74
36516	Other professional services	APHERESIS IMMUNOADS SLCTV	2424.05	117.23
36522	Other professional services	PHOTOPHERESIS	1820.00	133.08
36555	Other professional services	INSERT NON-TUNNEL CV CATH	259.67	117.77
36556	Other professional services	INSERT NON-TUNNEL CV CATH	292.22	116.66
36557	Other professional services	INSERT TUNNELED CV CATH	1554.50	438.38
36558	Other professional services	INSERT TUNNELED CV CATH	1113.69	355.50
36560	Other professional services	INSERT TUNNELED CV CATH	1658.99	523.76
36561	Other professional services	INSERT TUNNELED CV CATH	1315.88	454.92
36563	Other professional services	INSERT TUNNELED CV CATH	1475.52	493.56
36565	Other professional services	INSERT TUNNELED CV CATH	1118.87	458.93
36566	Other professional services	INSERT TUNNELED CV CATH	5646.87	488.34
36568	Other professional services	INSJ PICC <5 YR W/O IMAGING	127.26	127.26
36569	Other professional services	INSJ PICC 5 YR+ W/O IMAGING	130.08	130.08
36570	Other professional services	INSERT PICVAD CATH	1950.21	454.77
36571	Other professional services	INSERT PICVAD CATH	1684.10	427.44
36572	Other professional services	INSJ PICC RS&I <5 YR	504.87	111.92
36573	Other professional services	INSJ PICC RS&I 5 YR+	516.12	114.98
36575	Other professional services	REPAIR TUNNELED CV CATH	196.20	46.11
36576	Other professional services	REPAIR TUNNELED CV CATH	468.39	250.53
36578	Other professional services	REPLACE TUNNELED CV CATH	582.93	278.21
36580	Other professional services	REPLACE CVAD CATH	256.37	89.45
36581	Other professional services	REPLACE TUNNELED CV CATH	1042.89	251.04
36582	Other professional services	REPLACE TUNNELED CV CATH	1176.90	392.79
36583	Other professional services	REPLACE TUNNELED CV CATH	1542.24	449.33
36584	Other professional services	COMPL RPLCMT PICC RS&I	438.09	80.60
36585	Other professional services	REPLACE PICVAD CATH	1533.30	383.06
36589	Other professional services	REMOVAL TUNNELED CV CATH	227.25	187.22
36590	Other professional services	REMOVAL TUNNELED CV CATH	306.35	259.95
36591	Other professional services	DRAW BLOOD OFF VENOUS DEVICE	37.62	37.62
36592	Other professional services	COLLECT BLOOD FROM PICC	40.80	40.80
36593	Other professional services	DECLOT VASCULAR DEVICE	47.04	47.04
36595	Other professional services	MECH REMOV TUNNELED CV CATH	802.68	248.27
36596	Other professional services	MECH REMOV TUNNELED CV CATH	157.77	61.80
36597	Other professional services	REPOSITION VENOUS CATHETER	152.12	82.53
36598	Other professional services	INJ W/FLUOR EVAL CV DEVICE	163.25	49.10
36600	Other professional services	WITHDRAWAL OF ARTERIAL BLOOD	38.21	20.93
36620	Other professional services	INSERTION CATHETER ARTERY	61.61	61.61
36625	Other professional services	INSERTION CATHETER ARTERY	144.44	144.44
36640	Other professional services	INSERTION CATHETER ARTERY	164.78	164.78
36660	Other professional services	INSERTION CATHETER ARTERY	95.22	95.22
36680	Other professional services	INSERT NEEDLE BONE CAVITY	82.05	82.05
36800	Other professional services	INSERTION OF CANNULA	167.03	167.03
36810	Other professional services	INSERTION OF CANNULA	290.67	290.67
36815	Other professional services	INSERTION OF CANNULA	181.88	181.88
36818	Major surgery	AV FUSE UPPR ARM CEPHALIC	1205.61	1205.61
36819	Major surgery	AV FUSE UPPR ARM BASILIC	1275.89	1275.89
36820	Major surgery	AV FUSION/FOREARM VEIN	1269.68	1269.68
36821	Major surgery	AV FUSION DIRECT ANY SITE	1153.85	1153.85
36823	Major surgery	INSERTION OF CANNULA(S)	2497.79	2497.79
36825	Major surgery	ARTERY-VEIN AUTOGRAFT	1386.96	1386.96
36830	Major surgery	ARTERY-VEIN NONAUTOGRAFT	1165.03	1165.03
36831	Major surgery	OPEN THROMBECT AV FISTULA	1079.03	1079.03
36832	Major surgery	AV FISTULA REVISION OPEN	1322.51	1322.51
36833	Major surgery	AV FISTULA REVISION	1410.40	1410.40
36835	Major surgery	ARTERY TO VEIN SHUNT	856.83	856.83
36836	Other professional services	PRQ AV FSTL CRTJ UXTR 1 ACS	10952.48	486.23
36837	Other professional services	PRQ AV FSTL CRT UXTR SEP ACS	13036.74	627.98
36838	Major surgery	DIST REVAS LIGATION HEMO	1987.30	1987.30
36860	Other professional services	EXTERNAL CANNULA DECLOTTING	317.78	149.04
36861	Other professional services	CANNULA DECLOTTING	186.98	186.98
36901	Other professional services	INTRO CATH DIALYSIS CIRCUIT	951.24	228.54
36902	Other professional services	INTRO CATH DIALYSIS CIRCUIT	1624.29	326.24
36903	Other professional services	INTRO CATH DIALYSIS CIRCUIT	5672.94	428.00
36904	Other professional services	THRMBC/NFS DIALYSIS CIRCUIT	2430.71	500.46
36905	Other professional services	THRMBC/NFS DIALYSIS CIRCUIT	3057.27	602.16
36906	Other professional services	THRMBC/NFS DIALYSIS CIRCUIT	7226.00	694.38
36907	Other professional services	BALO ANGIOP CTR DIALYSIS SEG	793.34	198.44
36908	Other professional services	STENT PLMT CTR DIALYSIS SEG	1895.21	280.61
36909	Other professional services	DIALYSIS CIRCUIT EMBOLJ	2532.44	272.46
37140	Major surgery	REVISION OF CIRCULATION	4114.29	4114.29
37145	Major surgery	REVISION OF CIRCULATION	3817.91	3817.91
37160	Major surgery	REVISION OF CIRCULATION	3921.35	3921.35
37180	Major surgery	REVISION OF CIRCULATION	3769.23	3769.23
37181	Major surgery	SPLICE SPLEEN/KIDNEY VEINS	4114.29	4114.29
37182	Other professional services	INSERT HEPATIC SHUNT (TIPS)	1113.86	1113.86
37183	Other professional services	REVISION TIPS	7758.41	511.35
37184	Other professional services	PRIM ART M-THRMBC 1ST VSL	2295.90	581.24
37185	Major surgery	PRIM ART M-THRMBC SBSQ VSL	829.80	285.27
37186	Major surgery	SEC ART THROMBECTOMY ADD-ON	2065.77	426.21
37187	Other professional services	VENOUS MECH THROMBECTOMY	2271.08	532.76
37188	Other professional services	VEN MECHNL THRMBC REPEAT TX	1942.65	379.91
37191	Other professional services	INS ENDOVAS VENA CAVA FILTR	2700.65	300.12
37192	Other professional services	REDO ENDOVAS VENA CAVA FILTR	1718.49	460.47
37193	Other professional services	REM ENDOVAS VENA CAVA FILTER	2013.41	471.12
37195	Other professional services	THROMBOLYTIC THERAPY STROKE	73.32	73.32
37197	Other professional services	REMOVE INTRVAS FOREIGN BODY	2098.44	407.43
37200	Other professional services	TRANSCATHETER BIOPSY	293.87	293.87
37211	Other professional services	THROMBOLYTIC ART THERAPY	522.36	522.36
37212	Other professional services	THROMBOLYTIC VENOUS THERAPY	456.71	456.71
37213	Other professional services	THROMBLYTIC ART/VEN THERAPY	312.53	312.53
37214	Other professional services	CESSJ THERAPY CATH REMOVAL	164.75	164.75
37215	Major surgery	TRANSCATH STENT CCA W/EPS	1724.56	1724.56
37216	Major surgery	TRANSCATH STENT CCA W/O EPS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
37217	Major surgery	STENT PLACEMT RETRO CAROTID	1880.50	1880.50
37218	Major surgery	STENT PLACEMT ANTE CAROTID	1447.29	1447.29
37220	Other professional services	ILIAC REVASC	3356.13	535.82
37221	Other professional services	ILIAC REVASC W/STENT	4119.11	659.31
37222	Major surgery	ILIAC REVASC ADD-ON	1079.03	322.22
37223	Major surgery	ILIAC REVASC W/STENT ADD-ON	2208.57	367.97
37224	Other professional services	FEM/POPL REVAS W/TLA	3900.44	594.83
37225	Other professional services	FEM/POPL REVAS W/ATHER	11685.30	801.98
37226	Other professional services	FEM/POPL REVASC W/STENT	10821.99	693.68
37227	Other professional services	FEM/POPL REVASC STNT & ATHER	14921.34	959.82
37228	Other professional services	TIB/PER REVASC W/TLA	5526.86	723.99
37229	Other professional services	TIB/PER REVASC W/ATHER	11893.76	930.86
37230	Other professional services	TIB/PER REVASC W/STENT	11909.78	928.22
37231	Other professional services	TIB/PER REVASC STENT & ATHER	15728.18	990.29
37232	Major surgery	TIB/PER REVASC ADD-ON	1432.55	347.57
37233	Major surgery	TIBPER REVASC W/ATHER ADD-ON	1843.39	563.30
37234	Major surgery	REVSC OPN/PRQ TIB/PERO STENT	6313.91	489.98
37235	Major surgery	TIB/PER REVASC STNT & ATHER	6869.48	650.58
37236	Other professional services	OPEN/PERQ PLACE STENT 1ST	3677.24	591.30
37237	Major surgery	OPEN/PERQ PLACE STENT EA ADD	2247.34	367.71
37238	Other professional services	OPEN/PERQ PLACE STENT SAME	4613.42	413.18
37239	Major surgery	OPEN/PERQ PLACE STENT EA ADD	2996.58	263.17
37241	Other professional services	VASC EMBOLIZE/OCCLUDE VENOUS	6185.31	580.61
37242	Other professional services	VASC EMBOLIZE/OCCLUDE ARTERY	9446.51	645.35
37243	Other professional services	VASC EMBOLIZE/OCCLUDE ORGAN	11455.10	766.44
37244	Other professional services	VASC EMBOLIZE/OCCLUDE BLEED	8760.96	902.63
37246	Other professional services	TRLUML BALO ANGIOP 1ST ART	2434.19	469.83
37247	Other professional services	TRLUML BALO ANGIOP ADDL ART	792.66	233.69
37248	Other professional services	TRLUML BALO ANGIOP 1ST VEIN	1818.95	403.56
37249	Other professional services	TRLUML BALO ANGIOP ADDL VEIN	595.71	196.85
37252	Other professional services	INTRVASC US NONCORONARY 1ST	1268.72	119.85
37253	Other professional services	INTRVASC US NONCORONARY ADDL	234.65	95.46
37500	Major surgery	ENDOSCOPY LIGATE PERF VEINS	1104.95	1104.95
37501	Major surgery	UNLISTED VASC ENDOSCOPY PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
37565	Major surgery	LIGATION OF NECK VEIN	1301.08	1301.08
37600	Major surgery	LIGATION OF NECK ARTERY	1344.66	1344.66
37605	Major surgery	LIGATION OF NECK ARTERY	1291.78	1291.78
37606	Major surgery	LIGATION OF NECK ARTERY	1303.71	1303.71
37607	Major surgery	LIGATION OF A-V FISTULA	659.06	659.06
37609	Other professional services	TEMPORAL ARTERY PROCEDURE	427.23	280.77
37615	Major surgery	LIGATION OF NECK ARTERY	924.69	924.69
37616	Major surgery	LIGATION OF CHEST ARTERY	1993.19	1993.19
37617	Major surgery	LIGATION OF ABDOMEN ARTERY	2345.50	2345.50
37618	Major surgery	LIGATION OF EXTREMITY ARTERY	698.04	698.04
37619	Major surgery	LIGATION OF INF VENA CAVA	3058.52	3058.52
37650	Major surgery	REVISION OF MAJOR VEIN	806.70	806.70
37660	Major surgery	REVISION OF MAJOR VEIN	2334.62	2334.62
37700	Major surgery	REVISE LEG VEIN	431.48	431.48
37718	Major surgery	LIGATE/STRIP SHORT LEG VEIN	690.81	690.81
37722	Major surgery	LIGATE/STRIP LONG LEG VEIN	810.62	810.62
37735	Major surgery	REMOVAL OF LEG VEINS/LESION	1021.53	1021.53
37760	Major surgery	LIGATE LEG VEINS RADICAL	1011.43	1011.43
37761	Major surgery	LIGATE LEG VEINS OPEN	946.26	946.26
37765	Major surgery	STAB PHLEB VEINS XTR 10-20	746.56	476.35
37766	Major surgery	PHLEB VEINS - EXTREM 20+	878.55	584.10
37780	Major surgery	REVISION OF LEG VEIN	416.72	416.72
37785	Major surgery	LIGATE/DIVIDE/EXCISE VEIN	620.28	450.59
37788	Major surgery	REVASCULARIZATION PENIS	2280.31	2280.31
37790	Major surgery	PENILE VENOUS OCCLUSION	882.20	882.20
37799	Major surgery	UNLISTED PX VASCULAR SURGERY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38100	Major surgery	REMOVAL OF SPLEEN TOTAL	2050.95	2050.95
38101	Major surgery	REMOVAL OF SPLEEN PARTIAL	2071.47	2071.47
38102	Major surgery	REMOVAL OF SPLEEN TOTAL	464.72	464.72
38115	Major surgery	REPAIR OF RUPTURED SPLEEN	2296.98	2296.98
38120	Major surgery	LAPAROSCOPY SPLENECTOMY	1891.73	1891.73
38129	Major surgery	UNLISTED LAPS PX SPLEEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38200	Other professional services	INJECTION FOR SPLEEN X-RAY	180.26	180.26
38204	Other professional services	BL DONOR SEARCH MANAGEMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38205	Other professional services	HARVEST ALLOGENEIC STEM CELL	117.42	117.42
38206	Other professional services	HARVEST AUTO STEM CELLS	115.14	115.14
38207	Other professional services	CRYOPRESERVE STEM CELLS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38208	Other professional services	THAW PRESERVED STEM CELLS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38209	Other professional services	WASH HARVEST STEM CELLS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38210	Other professional services	T-CELL DEPLETION OF HARVEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38211	Other professional services	TUMOR CELL DEPLETE OF HARVST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38212	Other professional services	RBC DEPLETION OF HARVEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38213	Other professional services	PLATELET DEPLETE OF HARVEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38214	Other professional services	VOLUME DEPLETE OF HARVEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38215	Other professional services	HARVEST STEM CELL CONCENTRTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38220	Other professional services	DX BONE MARROW ASPIRATIONS	217.76	93.59
38221	Other professional services	DX BONE MARROW BIOPSIES	225.32	97.97
38222	Other professional services	DX BONE MARROW BX & ASPIR	242.93	104.67
38230	Other professional services	BONE MARROW HARVEST ALLOGEN	278.07	278.07
38232	Other professional services	BONE MARROW HARVEST AUTOLOG	261.33	261.33
38240	Other professional services	TRANSPLT ALLO HCT/DONOR	336.86	336.86
38241	Other professional services	TRANSPLT AUTOL HCT/DONOR	248.94	248.94
38242	Other professional services	TRANSPLT ALLO LYMPHOCYTES	175.98	175.98
38243	Other professional services	TRANSPLJ HEMATOPOIETIC BOOST	172.86	172.86
38300	Other professional services	DRAINAGE LYMPH NODE LESION	464.34	290.15
38305	Major surgery	DRAINAGE LYMPH NODE LESION	889.79	889.79
38308	Major surgery	INCISION OF LYMPH CHANNELS	844.78	844.78
38380	Major surgery	THORACIC DUCT PROCEDURE	1047.40	1047.40
38381	Major surgery	THORACIC DUCT PROCEDURE	1426.41	1426.41
38382	Major surgery	THORACIC DUCT PROCEDURE	1215.03	1215.03
38500	Other professional services	BIOPSY/REMOVAL LYMPH NODES	463.88	352.44
38505	Other professional services	NEEDLE BIOPSY LYMPH NODES	240.69	118.80
38510	Other professional services	BIOPSY/REMOVAL LYMPH NODES	731.58	580.13
38520	Major surgery	BIOPSY/REMOVAL LYMPH NODES	842.83	842.83
38525	Major surgery	BIOPSY/REMOVAL LYMPH NODES	792.29	792.29
38530	Major surgery	BIOPSY/REMOVAL LYMPH NODES	1019.69	1019.69
38531	Major surgery	OPEN BX/EXC INGUINOFEM NODES	804.24	804.24
38542	Major surgery	EXPLORE DEEP NODE(S) NECK	949.18	949.18
38550	Major surgery	REMOVAL NECK/ARMPIT LESION	939.24	939.24
38555	Major surgery	REMOVAL NECK/ARMPIT LESION	1834.42	1834.42
38562	Major surgery	REMOVAL PELVIC LYMPH NODES	1277.46	1277.46
38564	Major surgery	REMOVAL ABDOMEN LYMPH NODES	1257.96	1257.96
38570	Other professional services	LAPAROSCOPY LYMPH NODE BIOP	718.10	718.10
38571	Other professional services	LAPAROSCOPY LYMPHADENECTOMY	922.79	922.79
38572	Other professional services	LAPAROSCOPY LYMPHADENECTOMY	1249.53	1249.53
38573	Other professional services	LAPS PELVIC LYMPHADEC	1635.39	1635.39
38589	Major surgery	UNLISTED LAPS PX LYMPHTC SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
38700	Major surgery	REMOVAL OF LYMPH NODES NECK	1463.69	1463.69
38720	Major surgery	REMOVAL OF LYMPH NODES NECK	2428.92	2428.92
38724	Major surgery	REMOVAL OF LYMPH NODES NECK	2628.91	2628.91
38740	Major surgery	REMOVE ARMPIT LYMPH NODES	1259.37	1259.37
38745	Major surgery	REMOVE ARMPIT LYMPH NODES	1581.49	1581.49
38746	Major surgery	REMOVE THORACIC LYMPH NODES	374.54	374.54
38747	Major surgery	REMOVE ABDOMINAL LYMPH NODES	471.51	471.51
38760	Major surgery	REMOVE GROIN LYMPH NODES	1505.40	1505.40
38765	Major surgery	REMOVE GROIN LYMPH NODES	2347.57	2347.57
38770	Major surgery	REMOVE PELVIS LYMPH NODES	1460.61	1460.61
38780	Major surgery	REMOVE ABDOMEN LYMPH NODES	1892.90	1892.90
38790	Other professional services	INJECT FOR LYMPHATIC X-RAY	113.10	113.10
38792	Other professional services	RA TRACER ID OF SENTINL NODE	113.67	44.55
38794	Major surgery	ACCESS THORACIC LYMPH DUCT	507.80	507.80
38900	Major surgery	IO MAP OF SENT LYMPH NODE	243.81	243.81
38999	Major surgery	UNLISTD PX HEMIC/LYMPHTC SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
39000	Major surgery	EXPLORATION OF CHEST	903.20	903.20
39010	Major surgery	EXPLORATION OF CHEST	1397.02	1397.02
39200	Major surgery	RESECT MEDIASTINAL CYST	1534.77	1534.77
39220	Major surgery	RESECT MEDIASTINAL TUMOR	2011.02	2011.02
39401	Other professional services	MEDIASTINOSCPY W/MEDSTNL BX	417.57	417.57
39402	Other professional services	MEDIASTINOSCPY W/LMPH NOD BX	544.56	544.56
39499	Major surgery	UNLISTED PX MEDIASTINUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
39501	Major surgery	REPAIR DIAPHRAGM LACERATION	1520.90	1520.90
39503	Major surgery	REPAIR OF DIAPHRAGM HERNIA	10176.06	10176.06
39540	Major surgery	REPAIR OF DIAPHRAGM HERNIA	1544.01	1544.01
39541	Major surgery	REPAIR OF DIAPHRAGM HERNIA	1658.36	1658.36
39545	Major surgery	REVISION OF DIAPHRAGM	1586.21	1586.21
39560	Major surgery	RESECT DIAPHRAGM SIMPLE	1435.20	1435.20
39561	Major surgery	RESECT DIAPHRAGM COMPLEX	2232.13	2232.13
39599	Major surgery	UNLISTED PX DIAPHRAGM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
40490	Other professional services	BIOPSY OF LIP	170.15	96.47
40500	Major surgery	PARTIAL EXCISION OF LIP	957.31	675.29
40510	Major surgery	PARTIAL EXCISION OF LIP	885.92	636.40
40520	Major surgery	PARTIAL EXCISION OF LIP	908.76	649.19
40525	Major surgery	RECONSTRUCT LIP WITH FLAP	1002.20	1002.20
40527	Major surgery	RECONSTRUCT LIP WITH FLAP	1144.77	1144.77
40530	Major surgery	PARTIAL REMOVAL OF LIP	1007.62	737.41
40650	Major surgery	RPR LIP FTH VERMILION ONLY	867.59	574.31
40652	Major surgery	RPR LIP FTH	934.01	656.12
40654	Major surgery	RPR LIP FTH>1HALF VER HT/CPX	1060.47	775.48
40700	Major surgery	REPAIR CLEFT LIP/NASAL	1814.22	1814.22
40701	Major surgery	REPAIR CLEFT LIP/NASAL	2139.64	2139.64
40702	Major surgery	REPAIR CLEFT LIP/NASAL	1798.41	1798.41
40720	Major surgery	REPAIR CLEFT LIP/NASAL	1845.48	1845.48
40761	Major surgery	REPAIR CLEFT LIP/NASAL	1937.89	1937.89
40799	Major surgery	UNLISTED PROCEDURE LIPS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
40800	Other professional services	DRAINAGE OF MOUTH LESION	279.33	165.63
40801	Other professional services	DRAINAGE OF MOUTH LESION	404.97	278.09
40804	Other professional services	REMOVAL FOREIGN BODY MOUTH	262.05	159.26
40805	Other professional services	REMOVAL FOREIGN BODY MOUTH	395.67	276.98
40806	Other professional services	INCISION OF LIP FOLD	136.94	40.97
40808	Other professional services	BIOPSY OF MOUTH LESION	234.11	124.50
40810	Other professional services	EXCISION OF MOUTH LESION	299.76	171.05
40812	Other professional services	EXCISE/REPAIR MOUTH LESION	384.15	254.52
40814	Major surgery	EXCISE/REPAIR MOUTH LESION	670.41	513.73
40816	Major surgery	EXCISION OF MOUTH LESION	728.95	552.16
40818	Major surgery	EXCISE ORAL MUCOSA FOR GRAFT	654.38	479.95
40819	Major surgery	EXCISE LIP OR CHEEK FOLD	487.97	363.21
40820	Other professional services	TREATMENT OF MOUTH LESION	357.38	230.94
40830	Other professional services	REPAIR MOUTH LACERATION	310.02	202.68
40831	Other professional services	REPAIR MOUTH LACERATION	408.14	279.89
40840	Major surgery	RECONSTRUCTION OF MOUTH	1561.33	1148.02
40842	Major surgery	RECONSTRUCTION OF MOUTH	1674.15	1222.44
40843	Major surgery	RECONSTRUCTION OF MOUTH	2156.15	1567.84
40844	Major surgery	RECONSTRUCTION OF MOUTH	2707.75	2120.63
40845	Major surgery	RECONSTRUCTION OF MOUTH	2678.11	2187.96
40899	Major surgery	UNLISTED PX VESTIBULE MOUTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
41000	Other professional services	DRAINAGE OF MOUTH LESION	201.74	145.80
41005	Other professional services	DRAINAGE OF MOUTH LESION	314.52	162.15
41006	Major surgery	DRAINAGE OF MOUTH LESION	612.03	421.04
41007	Major surgery	DRAINAGE OF MOUTH LESION	593.52	403.73
41008	Major surgery	DRAINAGE OF MOUTH LESION	708.22	468.76
41009	Major surgery	DRAINAGE OF MOUTH LESION	764.05	518.68
41010	Other professional services	INCISION OF TONGUE FOLD	298.53	153.44
41015	Major surgery	DRAINAGE OF MOUTH LESION	721.54	543.56
41016	Major surgery	DRAINAGE OF MOUTH LESION	838.56	624.51
41017	Major surgery	DRAINAGE OF MOUTH LESION	838.29	621.29
41018	Major surgery	DRAINAGE OF MOUTH LESION	946.06	724.93
41019	Other professional services	PLACE NEEDLES H&N FOR RT	685.25	685.25
41100	Other professional services	BIOPSY OF TONGUE	259.70	150.09
41105	Other professional services	BIOPSY OF TONGUE	260.79	154.37
41108	Other professional services	BIOPSY OF FLOOR OF MOUTH	232.67	127.61
41110	Other professional services	EXCISION OF TONGUE LESION	318.05	181.59
41112	Major surgery	EXCISION OF TONGUE LESION	611.05	440.76
41113	Major surgery	EXCISION OF TONGUE LESION	652.94	479.10
41114	Major surgery	EXCISION OF TONGUE LESION	1127.78	1127.78
41115	Other professional services	EXCISION OF TONGUE FOLD	361.25	204.33
41116	Major surgery	EXCISION OF MOUTH LESION	601.05	392.93
41120	Major surgery	PARTIAL REMOVAL OF TONGUE	1899.77	1899.77
41130	Major surgery	PARTIAL REMOVAL OF TONGUE	2353.71	2353.71
41135	Major surgery	TONGUE AND NECK SURGERY	3889.31	3889.31
41140	Major surgery	REMOVAL OF TONGUE	3914.84	3914.84
41145	Major surgery	TONGUE REMOVAL NECK SURGERY	4931.69	4931.69
41150	Major surgery	TONGUE MOUTH JAW SURGERY	3944.50	3944.50
41153	Major surgery	TONGUE MOUTH NECK SURGERY	4293.69	4293.69
41155	Major surgery	TONGUE JAW & NECK SURGERY	5357.96	5357.96
41250	Other professional services	REPAIR TONGUE LACERATION	390.21	213.29
41251	Other professional services	REPAIR TONGUE LACERATION	431.04	254.12
41252	Other professional services	REPAIR TONGUE LACERATION	451.20	290.64
41510	Major surgery	TONGUE TO LIP SURGERY	816.50	816.50
41512	Major surgery	TONGUE SUSPENSION	1199.11	1199.11
41520	Major surgery	RECONSTRUCTION TONGUE FOLD	660.64	456.65
41530	Other professional services	TONGUE BASE VOL REDUCTION	1249.13	522.33
41599	Major surgery	UNLISTED PX TONGUE FLR MOUTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
41800	Other professional services	DRAINAGE OF GUM LESION	400.22	213.74
41805	Other professional services	REMOVAL FOREIGN BODY GUM	422.42	269.60
41806	Other professional services	REMOVAL FOREIGN BODY JAWBONE	563.12	383.46
41820	Other professional services	EXCISION GUM EACH QUADRANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
41821	Other professional services	EXCISION OF GUM FLAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
41822	Other professional services	EXCISION OF GUM LESION	488.87	279.65
41823	Major surgery	EXCISION OF GUM LESION	950.39	663.62
41825	Other professional services	EXCISION OF GUM LESION	305.07	170.00
41826	Other professional services	EXCISION OF GUM LESION	413.21	272.21
41827	Major surgery	EXCISION OF GUM LESION	779.14	524.32
41828	Other professional services	EXCISION OF GUM LESION	487.13	307.92
41830	Other professional services	REMOVAL OF GUM TISSUE	646.22	434.27
41850	Other professional services	TREATMENT OF GUM LESION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
41870	Other professional services	GUM GRAFT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
41872	Major surgery	REPAIR GUM	845.25	550.19
41874	Major surgery	REPAIR TOOTH SOCKET	690.96	443.24
41899	Major surgery	UNLISTED PX DENTALVLR STRUX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
42000	Other professional services	DRAINAGE MOUTH ROOF LESION	223.26	152.76
42100	Other professional services	BIOPSY ROOF OF MOUTH	203.21	154.10
42104	Other professional services	EXCISION LESION MOUTH ROOF	301.56	188.76
42106	Other professional services	EXCISION LESION MOUTH ROOF	347.67	224.42
42107	Major surgery	EXCISION LESION MOUTH ROOF	802.97	588.94
42120	Major surgery	REMOVE PALATE/LESION	1805.29	1805.29
42140	Major surgery	EXCISION OF UVULA	558.64	296.71
42145	Major surgery	REPAIR PALATE PHARYNX/UVULA	1251.45	1251.45
42160	Other professional services	TREATMENT MOUTH ROOF LESION	313.83	196.95
42180	Other professional services	REPAIR LAC PALATE<2 CM	354.74	262.41
42182	Other professional services	REPAIR PALATE	459.89	361.65
42200	Major surgery	RECONSTRUCT CLEFT PALATE	1666.78	1666.78
42205	Major surgery	RECONSTRUCT CLEFT PALATE	1734.08	1734.08
42210	Major surgery	RECONSTRUCT CLEFT PALATE	1935.22	1935.22
42215	Major surgery	RECONSTRUCT CLEFT PALATE	1265.34	1265.34
42220	Major surgery	RECONSTRUCT CLEFT PALATE	1043.00	1043.00
42225	Major surgery	RECONSTRUCT CLEFT PALATE	1759.37	1759.37
42226	Major surgery	LENGTHENING OF PALATE	1635.95	1635.95
42227	Major surgery	LENGTHENING OF PALATE	1525.02	1525.02
42235	Major surgery	REPAIR PALATE	1340.84	1340.84
42260	Major surgery	REPAIR NOSE TO LIP FISTULA	1562.34	1221.19
42280	Other professional services	PREPARATION PALATE MOLD	244.79	152.00
42281	Other professional services	INSERTION PALATE PROSTHESIS	311.18	224.76
42299	Major surgery	UNLISTED PX PALATE UVULA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
42300	Other professional services	DRAINAGE OF SALIVARY GLAND	299.57	219.06
42305	Major surgery	DRAINAGE OF SALIVARY GLAND	790.80	790.80
42310	Other professional services	DRAINAGE OF SALIVARY GLAND	237.90	188.79
42320	Other professional services	DRAINAGE OF SALIVARY GLAND	363.09	251.21
42330	Other professional services	REMOVAL OF SALIVARY STONE	326.12	231.98
42335	Major surgery	REMOVAL OF SALIVARY STONE	782.07	480.54
42340	Major surgery	REMOVAL OF SALIVARY STONE	963.92	629.85
42400	Other professional services	BIOPSY OF SALIVARY GLAND	132.35	73.67
42405	Other professional services	BIOPSY OF SALIVARY GLAND	425.00	318.12
42408	Major surgery	EXCISION OF SALIVARY CYST	976.76	634.41
42409	Major surgery	DRAINAGE OF SALIVARY CYST	713.31	424.18
42410	Major surgery	EXCISE PAROTID GLAND/LESION	1146.25	1146.25
42415	Major surgery	EXCISE PAROTID GLAND/LESION	1924.38	1924.38
42420	Major surgery	EXCISE PAROTID GLAND/LESION	2153.15	2153.15
42425	Major surgery	EXCISE PAROTID GLAND/LESION	1526.07	1526.07
42426	Major surgery	EXCISE PAROTID GLAND/LESION	2446.39	2446.39
42440	Major surgery	EXCISE SUBMAXILLARY GLAND	759.25	759.25
42450	Major surgery	EXCISE SUBLINGUAL GLAND	857.26	663.92
42500	Major surgery	REPAIR SALIVARY DUCT	814.83	629.77
42505	Major surgery	REPAIR SALIVARY DUCT	1045.26	836.55
42507	Major surgery	PAROTID DUCT DIVERSION	899.91	899.91
42509	Major surgery	PAROTID DUCT DIVERSION	1485.12	1485.12
42510	Major surgery	PAROTID DUCT DIVERSION	1105.28	1105.28
42550	Other professional services	INJECTION FOR SALIVARY X-RAY	211.89	85.01
42600	Major surgery	CLOSURE OF SALIVARY FISTULA	987.52	651.09
42650	Other professional services	DILATION OF SALIVARY DUCT	103.73	82.35
42660	Other professional services	DILATION OF SALIVARY DUCT	153.92	118.91
42665	Major surgery	LIGATION OF SALIVARY DUCT	678.78	397.35
42699	Major surgery	UNLISTED PX SALIVRY GLND/DUX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
42700	Other professional services	DRAINAGE OF TONSIL ABSCESS	267.57	190.25
42720	Other professional services	DRAINAGE OF THROAT ABSCESS	624.81	538.86
42725	Major surgery	DRAINAGE OF THROAT ABSCESS	1450.90	1450.90
42800	Other professional services	BIOPSY OF THROAT	220.86	164.00
42804	Other professional services	BIOPSY OF UPPER NOSE/THROAT	299.25	172.35
42806	Other professional services	BIOPSY OF UPPER NOSE/THROAT	334.41	198.42
42808	Other professional services	EXCISE PHARYNX LESION	324.38	232.95
42809	Other professional services	REMOVE PHARYNX FOREIGN BODY	287.63	177.57
42810	Major surgery	EXCISION OF NECK CYST	706.68	516.28
42815	Major surgery	EXCISION OF NECK CYST	979.21	979.21
42820	Major surgery	REMOVE TONSILS AND ADENOIDS	533.03	533.03
42821	Major surgery	REMOVE TONSILS AND ADENOIDS	556.43	556.43
42825	Major surgery	REMOVAL OF TONSILS	491.32	491.32
42826	Major surgery	REMOVAL OF TONSILS	467.96	467.96
42830	Major surgery	REMOVAL OF ADENOIDS	389.75	389.75
42831	Major surgery	REMOVAL OF ADENOIDS	423.44	423.44
42835	Major surgery	REMOVAL OF ADENOIDS	363.71	363.71
42836	Major surgery	REMOVAL OF ADENOIDS	449.24	449.24
42842	Major surgery	EXTENSIVE SURGERY OF THROAT	1821.94	1821.94
42844	Major surgery	EXTENSIVE SURGERY OF THROAT	2481.49	2481.49
42845	Major surgery	EXTENSIVE SURGERY OF THROAT	3967.29	3967.29
42860	Major surgery	EXCISION OF TONSIL TAGS	355.82	355.82
42870	Major surgery	EXCISION OF LINGUAL TONSIL	1061.05	1061.05
42890	Major surgery	PARTIAL REMOVAL OF PHARYNX	2552.55	2552.55
42892	Major surgery	REVISION OF PHARYNGEAL WALLS	3355.37	3355.37
42894	Major surgery	REVISION OF PHARYNGEAL WALLS	4256.23	4256.23
42900	Other professional services	REPAIR THROAT WOUND	464.18	464.18
42950	Major surgery	RECONSTRUCTION OF THROAT	1435.41	1435.41
42953	Major surgery	REPAIR THROAT ESOPHAGUS	1718.59	1718.59
42955	Major surgery	SURGICAL OPENING OF THROAT	1367.44	1367.44
42960	Other professional services	CONTROL THROAT BLEEDING	225.53	225.53
42961	Major surgery	CONTROL THROAT BLEEDING	765.18	765.18
42962	Major surgery	CONTROL THROAT BLEEDING	942.71	942.71
42970	Major surgery	CONTROL NOSE/THROAT BLEEDING	750.63	750.63
42971	Major surgery	CONTROL NOSE/THROAT BLEEDING	826.82	826.82
42972	Major surgery	CONTROL NOSE/THROAT BLEEDING	924.20	924.20
42975	Major surgery	DISE EVAL SLP DO BRTH FLX DX	175.70	175.70
42999	Major surgery	UNLISTED PX PHRNX ADND/TNSL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
43020	Major surgery	INCISION OF ESOPHAGUS	1015.21	1015.21
43030	Major surgery	THROAT MUSCLE SURGERY	954.23	954.23
43045	Major surgery	INCISION OF ESOPHAGUS	2307.32	2307.32
43100	Major surgery	EXCISION OF ESOPHAGUS LESION	1160.15	1160.15
43101	Major surgery	EXCISION OF ESOPHAGUS LESION	1779.73	1779.73
43107	Major surgery	REMOVAL OF ESOPHAGUS	5244.60	5244.60
43108	Major surgery	REMOVAL OF ESOPHAGUS	7780.68	7780.68
43112	Major surgery	ESPHG TOT W/THRCM	6083.81	6083.81
43113	Major surgery	REMOVAL OF ESOPHAGUS	7614.11	7614.11
43116	Major surgery	PARTIAL REMOVAL OF ESOPHAGUS	8697.37	8697.37
43117	Major surgery	PARTIAL REMOVAL OF ESOPHAGUS	5730.17	5730.17
43118	Major surgery	PARTIAL REMOVAL OF ESOPHAGUS	6350.21	6350.21
43121	Major surgery	PARTIAL REMOVAL OF ESOPHAGUS	5020.35	5020.35
43122	Major surgery	PARTIAL REMOVAL OF ESOPHAGUS	4546.11	4546.11
43123	Major surgery	PARTIAL REMOVAL OF ESOPHAGUS	7890.83	7890.83
43124	Major surgery	REMOVAL OF ESOPHAGUS	6680.76	6680.76
43130	Major surgery	REMOVAL OF ESOPHAGUS POUCH	1435.08	1435.08
43135	Major surgery	REMOVAL OF ESOPHAGUS POUCH	2587.83	2587.83
43180	Major surgery	ESOPHAGOSCOPY RIGID TRNSO	993.14	993.14
43191	Other professional services	ESOPHAGOSCOPY RIGID TRNSO DX	216.12	216.12
43192	Other professional services	ESOPHAGOSCP RIG TRNSO INJECT	236.39	236.39
43193	Other professional services	ESOPHAGOSCP RIG TRNSO BIOPSY	235.47	235.47
43194	Other professional services	ESOPHAGOSCP RIG TRNSO REM FB	263.91	263.91
43195	Other professional services	ESOPHAGOSCOPY RIGID BALLOON	257.36	257.36
43196	Other professional services	ESOPHAGOSCP GUIDE WIRE DILAT	272.79	272.79
43197	Other professional services	ESOPHAGOSCOPY FLEX DX BRUSH	262.61	113.43
43198	Other professional services	ESOPHAGOSC FLEX TRNSN BIOPSY	291.77	135.77
43200	Other professional services	ESOPHAGOSCOPY FLEXIBLE BRUSH	361.65	121.50
43201	Other professional services	ESOPH SCOPE W/SUBMUCOUS INJ	357.48	143.27
43202	Other professional services	ESOPHAGOSCOPY FLEX BIOPSY	488.15	142.47
43204	Other professional services	ESOPH SCOPE W/SCLEROSIS INJ	186.48	186.48
43205	Other professional services	ESOPHAGUS ENDOSCOPY/LIGATION	194.81	194.81
43206	Other professional services	ESOPH OPTICAL ENDOMICROSCOPY	418.43	183.29
43210	Other professional services	EGD ESOPHAGOGASTRC FNDOPLSTY	589.91	589.91
43211	Other professional services	ESOPHAGOSCOP MUCOSAL RESECT	323.72	323.72
43212	Other professional services	ESOPHAGOSCOP STENT PLACEMENT	259.10	259.10
43213	Other professional services	ESOPHAGOSCOPY RETRO BALLOON	1661.51	356.64
43214	Other professional services	ESOPHAGOSC DILATE BALLOON 30	267.21	267.21
43215	Other professional services	ESOPHAGOSCOPY FLEX REMOVE FB	538.41	194.57
43216	Other professional services	ESOPHAGOSCOPY LESION REMOVAL	560.69	184.55
43217	Other professional services	ESOPHAGOSCOPY SNARE LES REMV	578.57	221.07
43220	Other professional services	ESOPHAGOSCOPY BALLOON <30MM	1217.72	162.99
43226	Other professional services	ESOPH ENDOSCOPY DILATION	528.84	179.54
43227	Other professional services	ESOPHAGOSCOPY CONTROL BLEED	812.61	227.72
43229	Other professional services	ESOPHAGOSCOPY LESION ABLATE	969.44	271.29
43231	Other professional services	ESOPHAGOSCOP ULTRASOUND EXAM	217.25	217.25
43232	Other professional services	ESOPHAGOSCOPY W/US NEEDLE BX	274.77	274.77
43233	Other professional services	EGD BALLOON DIL ESOPH30 MM/>	314.63	314.63
43235	Other professional services	EGD DIAGNOSTIC BRUSH WASH	396.77	169.37
43236	Other professional services	UPPR GI SCOPE W/SUBMUC INJ	551.54	191.31
43237	Other professional services	ENDOSCOPIC US EXAM ESOPH	269.91	269.91
43238	Other professional services	EGD US FINE NEEDLE BX/ASPIR	320.06	320.06
43239	Other professional services	EGD BIOPSY SINGLE/MULTIPLE	517.88	191.31
43240	Other professional services	EGD W/TRANSMURAL DRAIN CYST	539.96	539.96
43241	Other professional services	EGD TUBE/CATH INSERTION	196.31	196.31
43242	Other professional services	EGD US FINE NEEDLE BX/ASPIR	362.18	362.18
43243	Other professional services	EGD INJECTION VARICES	327.05	327.05
43244	Other professional services	EGD VARICES LIGATION	337.83	337.83
43245	Other professional services	EGD DILATE STRICTURE	811.49	241.61
43246	Other professional services	EGD PLACE GASTROSTOMY TUBE	275.15	275.15
43247	Other professional services	EGD REMOVE FOREIGN BODY	528.77	243.59
43248	Other professional services	EGD GUIDE WIRE INSERTION	569.03	229.28
43249	Other professional services	ESOPH EGD DILATION <30 MM	1462.58	211.83
43250	Other professional services	EGD CAUTERY TUMOR POLYP	617.01	234.06
43251	Other professional services	EGD REMOVE LESION SNARE	679.91	270.11
43252	Other professional services	EGD OPTICAL ENDOMICROSCOPY	469.14	232.19
43253	Other professional services	EGD US TRANSMURAL INJXN/MARK	361.71	361.71
43254	Other professional services	EGD ENDO MUCOSAL RESECTION	371.97	371.97
43255	Other professional services	EGD CONTROL BLEEDING ANY	857.28	276.03
43257	Other professional services	EGD W/THRML TXMNT GERD	321.54	321.54
43259	Other professional services	EGD US EXAM DUODENUM/JEJUNUM	311.24	311.24
43260	Other professional services	ERCP W/SPECIMEN COLLECTION	444.36	444.36
43261	Other professional services	ENDO CHOLANGIOPANCREATOGRAPH	466.32	466.32
43262	Other professional services	ENDO CHOLANGIOPANCREATOGRAPH	491.45	491.45
43263	Other professional services	ERCP SPHINCTER PRESSURE MEAS	492.23	492.23
43264	Other professional services	ERCP REMOVE DUCT CALCULI	501.21	501.21
43265	Other professional services	ERCP LITHOTRIPSY CALCULI	596.21	596.21
43266	Other professional services	EGD ENDOSCOPIC STENT PLACE	299.58	299.58
43270	Other professional services	EGD LESION ABLATION	998.69	309.18
43273	Major surgery	ENDOSCOPIC PANCREATOSCOPY	213.19	213.19
43274	Other professional services	ERCP DUCT STENT PLACEMENT	636.75	636.75
43275	Other professional services	ERCP REMOVE FORGN BODY DUCT	518.03	518.03
43276	Other professional services	ERCP STENT EXCHANGE W/DILATE	663.02	663.02
43277	Other professional services	ERCP EA DUCT/AMPULLA DILATE	520.91	520.91
43278	Other professional services	ERCP LESION ABLATE W/DILATE	596.04	596.04
43279	Major surgery	LAP MYOTOMY HELLER	2281.87	2281.87
43280	Major surgery	LAPAROSCOPY FUNDOPLASTY	1920.65	1920.65
43281	Major surgery	LAP PARAESOPHAG HERN REPAIR	2729.96	2729.96
43282	Major surgery	LAP PARAESOPH HER RPR W/MESH	3074.43	3074.43
43283	Major surgery	LAP ESOPH LENGTHENING	277.72	277.72
43284	Major surgery	LAPS ESOPHGL SPHNCTR AGMNTJ	1167.97	1167.97
43285	Major surgery	RMVL ESOPHGL SPHNCTR DEV	1200.60	1200.60
43286	Major surgery	ESPHG TOT W/LAPS MOBLJ	5591.37	5591.37
43287	Major surgery	ESPHG DSTL 2/3 W/LAPS MOBLJ	6250.86	6250.86
43288	Major surgery	ESPHG THRSC MOBLJ	6594.24	6594.24
43289	Major surgery	UNLISTED LAPS PX ESOPH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
43290	Other professional services	EGD FLX TRNSORL DPLMNT BALO	3550.04	247.16
43291	Other professional services	EGD FLX TRNSORL RMVL BALO	631.26	221.01
43300	Major surgery	REPAIR OF ESOPHAGUS	1141.86	1141.86
43305	Major surgery	REPAIR ESOPHAGUS AND FISTULA	1989.14	1989.14
43310	Major surgery	REPAIR OF ESOPHAGUS	2610.97	2610.97
43312	Major surgery	REPAIR ESOPHAGUS AND FISTULA	2788.03	2788.03
43313	Major surgery	ESOPHAGOPLASTY CONGENITAL	5159.70	5159.70
43314	Major surgery	TRACHEO-ESOPHAGOPLASTY CONG	5520.96	5520.96
43320	Major surgery	FUSE ESOPHAGUS & STOMACH	2489.14	2489.14
43325	Major surgery	REVISE ESOPHAGUS & STOMACH	2419.95	2419.95
43327	Major surgery	ESOPH FUNDOPLASTY LAP	1456.34	1456.34
43328	Major surgery	ESOPH FUNDOPLASTY THOR	1977.01	1977.01
43330	Major surgery	ESOPHAGOMYOTOMY ABDOMINAL	2381.24	2381.24
43331	Major surgery	ESOPHAGOMYOTOMY THORACIC	2365.58	2365.58
43332	Major surgery	TRANSAB ESOPH HIAT HERN RPR	2043.87	2043.87
43333	Major surgery	TRANSAB ESOPH HIAT HERN RPR	2238.50	2238.50
43334	Major surgery	TRANSTHOR DIAPHRAG HERN RPR	2185.81	2185.81
43335	Major surgery	TRANSTHOR DIAPHRAG HERN RPR	2346.20	2346.20
43336	Major surgery	THORABD DIAPHR HERN REPAIR	2548.77	2548.77
43337	Major surgery	THORABD DIAPHR HERN REPAIR	2714.93	2714.93
43338	Major surgery	ESOPH LENGTHENING	200.11	200.11
43340	Major surgery	FUSE ESOPHAGUS & INTESTINE	2458.81	2458.81
43341	Major surgery	FUSE ESOPHAGUS & INTESTINE	2472.97	2472.97
43351	Major surgery	SURGICAL OPENING ESOPHAGUS	2335.24	2335.24
43352	Major surgery	SURGICAL OPENING ESOPHAGUS	1890.02	1890.02
43360	Major surgery	GASTROINTESTINAL REPAIR	3959.73	3959.73
43361	Major surgery	GASTROINTESTINAL REPAIR	4793.80	4793.80
43400	Major surgery	LIGATE ESOPHAGUS VEINS	2710.68	2710.68
43405	Major surgery	LIGATE/STAPLE ESOPHAGUS	2577.39	2577.39
43410	Major surgery	REPAIR ESOPHAGUS WOUND	1879.49	1879.49
43415	Major surgery	REPAIR ESOPHAGUS WOUND	4553.09	4553.09
43420	Major surgery	REPAIR ESOPHAGUS OPENING	1849.07	1849.07
43425	Major surgery	REPAIR ESOPHAGUS OPENING	2545.34	2545.34
43450	Other professional services	DILATE ESOPHAGUS 1/MULT PASS	258.21	110.40
43453	Other professional services	DILATE ESOPHAGUS	1081.97	120.03
43460	Other professional services	PRESSURE TREATMENT ESOPHAGUS	292.85	292.85
43496	Major surgery	FREE JEJUNUM FLAP MICROVASC	1984.09	1984.09
43497	Major surgery	TRANSORL LWR ESOPHGL MYOTOMY	1420.01	1420.01
43499	Major surgery	UNLISTED PROCEDURE ESOPHAGUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
43500	Major surgery	SURGICAL OPENING OF STOMACH	1407.37	1407.37
43501	Major surgery	SURGICAL REPAIR OF STOMACH	2411.47	2411.47
43502	Major surgery	SURGICAL REPAIR OF STOMACH	2717.27	2717.27
43510	Major surgery	SURGICAL OPENING OF STOMACH	1698.90	1698.90
43520	Major surgery	INCISION OF PYLORIC MUSCLE	1239.67	1239.67
43605	Major surgery	BIOPSY OF STOMACH	1495.59	1495.59
43610	Major surgery	EXCISION OF STOMACH LESION	1746.32	1746.32
43611	Major surgery	EXCISION OF STOMACH LESION	2193.48	2193.48
43620	Major surgery	REMOVAL OF STOMACH	3522.48	3522.48
43621	Major surgery	REMOVAL OF STOMACH	4040.87	4040.87
43622	Major surgery	REMOVAL OF STOMACH	4101.26	4101.26
43631	Major surgery	REMOVAL OF STOMACH PARTIAL	2584.71	2584.71
43632	Major surgery	REMOVAL OF STOMACH PARTIAL	3619.67	3619.67
43633	Major surgery	REMOVAL OF STOMACH PARTIAL	3424.94	3424.94
43634	Major surgery	REMOVAL OF STOMACH PARTIAL	3774.13	3774.13
43635	Major surgery	REMOVAL OF STOMACH PARTIAL	198.55	198.55
43640	Major surgery	VAGOTOMY & PYLORUS REPAIR	2125.73	2125.73
43641	Major surgery	VAGOTOMY & PYLORUS REPAIR	2150.17	2150.17
43644	Major surgery	LAP GASTRIC BYPASS/ROUX-EN-Y	3092.97	3092.97
43645	Major surgery	LAP GASTR BYPASS INCL SMLL I	3288.87	3288.87
43647	Major surgery	LAP IMPL ELECTRODE ANTRUM	647.79	647.79
43648	Major surgery	LAP REVISE/REMV ELTRD ANTRUM	603.41	603.41
43651	Major surgery	LAPAROSCOPY VAGUS NERVE	1178.62	1178.62
43652	Major surgery	LAPAROSCOPY VAGUS NERVE	1371.55	1371.55
43653	Major surgery	LAPAROSCOPY GASTROSTOMY	1037.93	1037.93
43659	Major surgery	UNLISTED LAPS PX STOMACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
43752	Other professional services	NASAL/OROGASTRIC W/TUBE PLMT	55.34	55.34
43753	Other professional services	TX GASTRO INTUB W/ASP	29.72	29.72
43754	Other professional services	DX GASTR INTUB W/ASP SPEC	320.09	52.20
43755	Other professional services	DX GASTR INTUB W/ASP SPECS	278.99	82.97
43756	Other professional services	DX DUOD INTUB W/ASP SPEC	377.33	70.77
43757	Other professional services	DX DUOD INTUB W/ASP SPECS	507.05	106.82
43761	Other professional services	REPOSITION GASTROSTOMY TUBE	170.97	143.24
43762	Other professional services	RPLC GTUBE NO REVJ TRC	308.39	51.42
43763	Other professional services	RPLC GTUBE REVJ GSTRST TRC	456.48	120.38
43770	Major surgery	LAP PLACE GASTR ADJ DEVICE	2011.25	2011.25
43771	Major surgery	LAP REVISE GASTR ADJ DEVICE	2280.70	2280.70
43772	Major surgery	LAP RMVL GASTR ADJ DEVICE	1696.60	1696.60
43773	Major surgery	LAP REPLACE GASTR ADJ DEVICE	2280.70	2280.70
43774	Major surgery	LAP RMVL GASTR ADJ ALL PARTS	1716.21	1716.21
43775	Major surgery	LAP SLEEVE GASTRECTOMY	1962.58	1962.58
43800	Major surgery	RECONSTRUCTION OF PYLORUS	1660.66	1660.66
43810	Major surgery	FUSION OF STOMACH AND BOWEL	1814.32	1814.32
43820	Major surgery	FUSION OF STOMACH AND BOWEL	2400.82	2400.82
43825	Major surgery	FUSION OF STOMACH AND BOWEL	2338.30	2338.30
43830	Major surgery	PLACE GASTROSTOMY TUBE	1259.66	1259.66
43831	Major surgery	PLACE GASTROSTOMY TUBE	1094.67	1094.67
43832	Major surgery	PLACE GASTROSTOMY TUBE	1869.39	1869.39
43840	Major surgery	REPAIR OF STOMACH LESION	2425.72	2425.72
43842	Major surgery	V-BAND GASTROPLASTY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
43843	Major surgery	GASTROPLASTY W/O V-BAND	2290.90	2290.90
43845	Major surgery	GASTROPLASTY DUODENAL SWITCH	3489.25	3489.25
43846	Major surgery	GASTRIC BYPASS FOR OBESITY	2943.76	2943.76
43847	Major surgery	GASTRIC BYPASS INCL SMALL I	3220.09	3220.09
43848	Major surgery	REVISION GASTROPLASTY	3449.04	3449.04
43860	Major surgery	REVISE STOMACH-BOWEL FUSION	2915.23	2915.23
43865	Major surgery	REVISE STOMACH-BOWEL FUSION	3041.90	3041.90
43870	Major surgery	REPAIR STOMACH OPENING	1270.31	1270.31
43880	Major surgery	REPAIR STOMACH-BOWEL FISTULA	2860.05	2860.05
43881	Major surgery	IMPL/REDO ELECTRD ANTRUM	1234.72	1234.72
43882	Major surgery	REVISE/REMOVE ELECTRD ANTRUM	1234.72	1234.72
43886	Major surgery	REVISE GASTRIC PORT OPEN	663.98	663.98
43887	Major surgery	REMOVE GASTRIC PORT OPEN	599.94	599.94
43888	Major surgery	CHANGE GASTRIC PORT OPEN	836.61	836.61
43999	Major surgery	UNLISTED PROCEDURE STOMACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
44005	Major surgery	FREEING OF BOWEL ADHESION	1946.59	1946.59
44010	Major surgery	INCISION OF SMALL BOWEL	1530.07	1530.07
44015	Major surgery	INSERT NEEDLE CATH BOWEL	249.44	249.44
44020	Major surgery	EXPLORE SMALL INTESTINE	1736.96	1736.96
44021	Major surgery	DECOMPRESS SMALL BOWEL	1732.83	1732.83
44025	Major surgery	INCISION OF LARGE BOWEL	1753.19	1753.19
44050	Major surgery	REDUCE BOWEL OBSTRUCTION	1672.30	1672.30
44055	Major surgery	CORRECT MALROTATION OF BOWEL	2651.30	2651.30
44100	Other professional services	BIOPSY OF BOWEL	147.50	147.50
44110	Major surgery	EXCISE INTESTINE LESION(S)	1525.00	1525.00
44111	Major surgery	EXCISION OF BOWEL LESION(S)	1751.04	1751.04
44120	Major surgery	REMOVAL OF SMALL INTESTINE	2177.47	2177.47
44121	Major surgery	REMOVAL OF SMALL INTESTINE	425.90	425.90
44125	Major surgery	REMOVAL OF SMALL INTESTINE	2099.39	2099.39
44126	Major surgery	ENTERECTOMY W/O TAPER CONG	4385.12	4385.12
44127	Major surgery	ENTERECTOMY W/TAPER CONG	5061.30	5061.30
44128	Major surgery	ENTERECTOMY CONG ADD-ON	428.53	428.53
44130	Major surgery	BOWEL TO BOWEL FUSION	2347.39	2347.39
44132	Other professional services	ENTERECTOMY CADAVER DONOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
44133	Other professional services	ENTERECTOMY LIVE DONOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
44135	Other professional services	INTESTINE TRANSPLNT CADAVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
44136	Other professional services	INTESTINE TRANSPLANT LIVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
44137	Other professional services	REMOVE INTESTINAL ALLOGRAFT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
44139	Major surgery	MOBILIZATION OF COLON	212.69	212.69
44140	Major surgery	PARTIAL REMOVAL OF COLON	2393.27	2393.27
44141	Major surgery	PARTIAL REMOVAL OF COLON	3226.04	3226.04
44143	Major surgery	PARTIAL REMOVAL OF COLON	2939.43	2939.43
44144	Major surgery	PARTIAL REMOVAL OF COLON	3139.25	3139.25
44145	Major surgery	PARTIAL REMOVAL OF COLON	2943.08	2943.08
44146	Major surgery	PARTIAL REMOVAL OF COLON	3737.16	3737.16
44147	Major surgery	PARTIAL REMOVAL OF COLON	3437.73	3437.73
44150	Major surgery	REMOVAL OF COLON	3298.93	3298.93
44151	Major surgery	REMOVAL OF COLON/ILEOSTOMY	3816.07	3816.07
44155	Major surgery	REMOVAL OF COLON/ILEOSTOMY	3685.73	3685.73
44156	Major surgery	REMOVAL OF COLON/ILEOSTOMY	4079.15	4079.15
44157	Major surgery	COLECTOMY W/ILEOANAL ANAST	3879.10	3879.10
44158	Major surgery	COLECTOMY W/NEO-RECTUM POUCH	3975.70	3975.70
44160	Major surgery	REMOVAL OF COLON	2215.61	2215.61
44180	Major surgery	LAP ENTEROLYSIS	1642.89	1642.89
44186	Major surgery	LAP JEJUNOSTOMY	1165.77	1165.77
44187	Major surgery	LAP ILEO/JEJUNO-STOMY	1952.38	1952.38
44188	Major surgery	LAP COLOSTOMY	2166.70	2166.70
44202	Major surgery	LAP ENTERECTOMY	2471.94	2471.94
44203	Major surgery	LAP RESECT S/INTESTINE ADDL	424.46	424.46
44204	Major surgery	LAPARO PARTIAL COLECTOMY	2737.33	2737.33
44205	Major surgery	LAP COLECTOMY PART W/ILEUM	2379.47	2379.47
44206	Major surgery	LAP PART COLECTOMY W/STOMA	3099.08	3099.08
44207	Major surgery	L COLECTOMY/COLOPROCTOSTOMY	3228.01	3228.01
44208	Major surgery	L COLECTOMY/COLOPROCTOSTOMY	3513.43	3513.43
44210	Major surgery	LAPARO TOTAL PROCTOCOLECTOMY	3163.93	3163.93
44211	Major surgery	LAP COLECTOMY W/PROCTECTOMY	3798.42	3798.42
44212	Major surgery	LAPARO TOTAL PROCTOCOLECTOMY	3621.15	3621.15
44213	Major surgery	LAP MOBIL SPLENIC FL ADD-ON	330.49	330.49
44227	Major surgery	LAP CLOSE ENTEROSTOMY	2950.14	2950.14
44238	Major surgery	UNLISTED LAPS PX INTESTINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
44300	Major surgery	OPEN BOWEL TO SKIN	1504.19	1504.19
44310	Major surgery	ILEOSTOMY/JEJUNOSTOMY	1858.45	1858.45
44312	Major surgery	REVISION OF ILEOSTOMY	1075.48	1075.48
44314	Major surgery	REVISION OF ILEOSTOMY	1802.62	1802.62
44316	Major surgery	DEVISE BOWEL POUCH	2520.63	2520.63
44320	Major surgery	COLOSTOMY	2145.00	2145.00
44322	Major surgery	COLOSTOMY WITH BIOPSIES	1792.58	1792.58
44340	Major surgery	REVISION OF COLOSTOMY	1132.42	1132.42
44345	Major surgery	REVISION OF COLOSTOMY	1880.99	1880.99
44346	Major surgery	REVISION OF COLOSTOMY	2114.33	2114.33
44360	Other professional services	SMALL BOWEL ENDOSCOPY	198.50	198.50
44361	Other professional services	SMALL BOWEL ENDOSCOPY/BIOPSY	218.69	218.69
44363	Other professional services	SMALL BOWEL ENDOSCOPY	264.17	264.17
44364	Other professional services	SMALL BOWEL ENDOSCOPY	281.61	281.61
44365	Other professional services	SMALL BOWEL ENDOSCOPY	251.36	251.36
44366	Other professional services	SMALL BOWEL ENDOSCOPY	330.45	330.45
44369	Other professional services	SMALL BOWEL ENDOSCOPY	338.33	338.33
44370	Other professional services	SMALL BOWEL ENDOSCOPY/STENT	367.94	367.94
44372	Other professional services	SMALL BOWEL ENDOSCOPY	329.55	329.55
44373	Other professional services	SMALL BOWEL ENDOSCOPY	263.33	263.33
44376	Other professional services	SMALL BOWEL ENDOSCOPY	391.05	391.05
44377	Other professional services	SMALL BOWEL ENDOSCOPY/BIOPSY	411.93	411.93
44378	Other professional services	SMALL BOWEL ENDOSCOPY	529.40	529.40
44379	Other professional services	S BOWEL ENDOSCOPE W/STENT	563.99	563.99
44380	Other professional services	SMALL BOWEL ENDOSCOPY BR/WA	270.56	79.53
44381	Other professional services	SMALL BOWEL ENDOSCOPY BR/WA	1327.59	117.32
44382	Other professional services	SMALL BOWEL ENDOSCOPY	408.48	102.39
44384	Other professional services	SMALL BOWEL ENDOSCOPY	210.54	210.54
44385	Other professional services	ENDOSCOPY OF BOWEL POUCH	297.36	100.88
44386	Other professional services	ENDOSCOPY BOWEL POUCH/BIOP	426.00	123.54
44388	Other professional services	COLONOSCOPY THRU STOMA SPX	435.80	214.76
44388-53	Other professional services	COLONOSCOPY THRU STOMA SPX	217.83	107.78
44389	Other professional services	COLONOSCOPY WITH BIOPSY	566.64	236.45
44390	Other professional services	COLONOSCOPY FOR FOREIGN BODY	559.19	289.94
44391	Other professional services	COLONOSCOPY FOR BLEEDING	876.23	317.72
44392	Other professional services	COLONOSCOPY & POLYPECTOMY	536.37	273.93
44394	Other professional services	COLONOSCOPY W/SNARE	604.91	310.19
44401	Other professional services	COLONOSCOPY WITH ABLATION	3201.14	333.98
44402	Other professional services	COLONOSCOPY W/STENT PLCMT	360.24	360.24
44403	Other professional services	COLONOSCOPY W/RESECTION	419.04	419.04
44404	Other professional services	COLONOSCOPY W/INJECTION	578.93	236.45
44405	Other professional services	COLONOSCOPY W/DILATION	761.28	252.80
44406	Other professional services	COLONOSCOPY W/ULTRASOUND	316.20	316.20
44407	Other professional services	COLONOSCOPY W/NDL ASPIR/BX	378.99	378.99
44408	Other professional services	COLONOSCOPY W/DECOMPRESSION	319.08	319.08
44500	Other professional services	INTRO GASTROINTESTINAL TUBE	26.37	26.37
44602	Major surgery	SUTURE SMALL INTESTINE	2501.36	2501.36
44603	Major surgery	SUTURE SMALL INTESTINE	2878.75	2878.75
44604	Major surgery	SUTURE LARGE INTESTINE	1880.05	1880.05
44605	Major surgery	REPAIR OF BOWEL LESION	2295.09	2295.09
44615	Major surgery	INTESTINAL STRICTUROPLASTY	1907.30	1907.30
44620	Major surgery	REPAIR BOWEL OPENING	1546.02	1546.02
44625	Major surgery	REPAIR BOWEL OPENING	1808.08	1808.08
44626	Major surgery	REPAIR BOWEL OPENING	2830.91	2830.91
44640	Major surgery	REPAIR BOWEL-SKIN FISTULA	2486.62	2486.62
44650	Major surgery	REPAIR BOWEL FISTULA	2566.92	2566.92
44660	Major surgery	REPAIR BOWEL-BLADDER FISTULA	2401.54	2401.54
44661	Major surgery	REPAIR BOWEL-BLADDER FISTULA	2749.64	2749.64
44680	Major surgery	SURGICAL REVISION INTESTINE	1918.41	1918.41
44700	Major surgery	SUSPEND BOWEL W/PROSTHESIS	1799.81	1799.81
44701	Major surgery	INTRAOP COLON LAVAGE ADD-ON	298.90	298.90
44705	Other professional services	PREPARE FECAL MICROBIOTA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
44715	Other professional services	PREPARE DONOR INTESTINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
44720	Other professional services	PREP DONOR INTESTINE/VENOUS	370.62	370.62
44721	Other professional services	PREP DONOR INTESTINE/ARTERY	518.72	518.72
44799	Other professional services	UNLISTED PX SMALL INTESTINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
44800	Major surgery	EXCISION OF BOWEL POUCH	1393.33	1393.33
44820	Major surgery	EXCISION OF MESENTERY LESION	1521.88	1521.88
44850	Major surgery	REPAIR OF MESENTERY	1340.49	1340.49
44899	Major surgery	UNLISTED PX MECKEL'S DVRTCLM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
44900	Major surgery	DRAIN APPENDIX ABSCESS OPEN	1401.54	1401.54
44950	Major surgery	APPENDECTOMY	1148.90	1148.90
44955	Major surgery	APPENDECTOMY ADD-ON	148.20	148.20
44960	Major surgery	APPENDECTOMY	1565.99	1565.99
44970	Major surgery	LAPAROSCOPY APPENDECTOMY	1080.57	1080.57
44979	Major surgery	UNLISTED LAPS PX APPENDIX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
45000	Major surgery	DRAINAGE OF PELVIC ABSCESS	775.94	775.94
45005	Other professional services	DRAINAGE OF RECTAL ABSCESS	431.97	228.21
45020	Major surgery	DRAINAGE OF RECTAL ABSCESS	1026.29	1026.29
45100	Major surgery	BIOPSY OF RECTUM	549.37	549.37
45108	Major surgery	REMOVAL OF ANORECTAL LESION	674.04	674.04
45110	Major surgery	REMOVAL OF RECTUM	3251.64	3251.64
45111	Major surgery	PARTIAL REMOVAL OF RECTUM	1949.16	1949.16
45112	Major surgery	REMOVAL OF RECTUM	3264.55	3264.55
45113	Major surgery	PARTIAL PROCTECTOMY	3354.02	3354.02
45114	Major surgery	PARTIAL REMOVAL OF RECTUM	3229.79	3229.79
45116	Major surgery	PARTIAL REMOVAL OF RECTUM	2782.81	2782.81
45119	Major surgery	REMOVE RECTUM W/RESERVOIR	3378.65	3378.65
45120	Major surgery	REMOVAL OF RECTUM	2850.24	2850.24
45121	Major surgery	REMOVAL OF RECTUM AND COLON	3109.86	3109.86
45123	Major surgery	PARTIAL PROCTECTOMY	1999.96	1999.96
45126	Major surgery	PELVIC EXENTERATION	4921.27	4921.27
45130	Major surgery	EXCISION OF RECTAL PROLAPSE	1947.91	1947.91
45135	Major surgery	EXCISION OF RECTAL PROLAPSE	2340.39	2340.39
45136	Major surgery	EXCISE ILEOANAL RESERVIOR	3210.68	3210.68
45150	Major surgery	EXCISION OF RECTAL STRICTURE	762.26	762.26
45160	Major surgery	EXCISION OF RECTAL LESION	1834.33	1834.33
45171	Major surgery	EXC RECT TUM TRANSANAL PART	1111.73	1111.73
45172	Major surgery	EXC RECT TUM TRANSANAL FULL	1484.87	1484.87
45190	Major surgery	DESTRUCTION RECTAL TUMOR	1262.78	1262.78
45300	Other professional services	PROCTOSIGMOIDOSCOPY DX	176.34	66.74
45303	Other professional services	PROCTOSIGMOIDOSCOPY DILATE	1278.69	118.44
45305	Other professional services	PROCTOSIGMOIDOSCOPY W/BX	249.03	100.77
45307	Other professional services	PROCTOSIGMOIDOSCOPY FB	292.23	137.60
45308	Other professional services	PROCTOSIGMOIDOSCOPY REMOVAL	279.63	115.89
45309	Other professional services	PROCTOSIGMOIDOSCOPY REMOVAL	288.38	122.82
45315	Other professional services	PROCTOSIGMOIDOSCOPY REMOVAL	311.31	144.84
45317	Other professional services	PROCTOSIGMOIDOSCOPY BLEED	304.61	153.60
45320	Other professional services	PROCTOSIGMOIDOSCOPY ABLATE	304.55	143.54
45321	Other professional services	PROCTOSIGMOIDOSCOPY VOLVUL	141.60	141.60
45327	Other professional services	PROCTOSIGMOIDOSCOPY W/STENT	159.95	159.95
45330	Other professional services	DIAGNOSTIC SIGMOIDOSCOPY	255.75	78.38
45331	Other professional services	SIGMOIDOSCOPY AND BIOPSY	392.46	100.01
45332	Other professional services	SIGMOIDOSCOPY W/FB REMOVAL	381.74	145.68
45333	Other professional services	SIGMOIDOSCOPY & POLYPECTOMY	449.64	129.90
45334	Other professional services	SIGMOIDOSCOPY FOR BLEEDING	671.87	162.47
45335	Other professional services	SIGMOIDOSCOPY W/SUBMUC INJ	398.13	92.49
45337	Other professional services	SIGMOIDOSCOPY & DECOMPRESS	157.91	157.91
45338	Other professional services	SIGMOIDOSCOPY W/TUMR REMOVE	412.10	166.04
45340	Other professional services	SIG W/TNDSC BALLOON DILATION	621.24	108.21
45341	Other professional services	SIGMOIDOSCOPY W/ULTRASOUND	171.42	171.42
45342	Other professional services	SIGMOIDOSCOPY W/US GUIDE BX	234.93	234.93
45346	Other professional services	SIGMOIDOSCOPY W/ABLATION	3091.20	221.31
45347	Other professional services	SIGMOIDOSCOPY W/PLCMT STENT	212.60	212.60
45349	Other professional services	SIGMOIDOSCOPY W/RESECTION	273.15	273.15
45350	Other professional services	SGMDSC W/BAND LIGATION	911.88	139.61
45378	Other professional services	DIAGNOSTIC COLONOSCOPY	469.92	254.34
45378-53	Other professional services	DIAGNOSTIC COLONOSCOPY	234.74	127.40
45379	Other professional services	COLONOSCOPY W/FB REMOVAL	600.60	328.62
45380	Other professional services	COLONOSCOPY AND BIOPSY	598.11	276.56
45381	Other professional services	COLONOSCOPY SUBMUCOUS NJX	610.38	276.09
45382	Other professional services	COLONOSCOPY W/CONTROL BLEED	913.16	356.46
45384	Other professional services	COLONOSCOPY W/LESION REMOVAL	671.79	313.40
45385	Other professional services	COLONOSCOPY W/LESION REMOVAL	627.98	350.09
45386	Other professional services	COLONOSCOPY W/BALLOON DILAT	835.32	291.81
45388	Other professional services	COLONOSCOPY W/ABLATION	3307.08	372.15
45389	Other professional services	COLONOSCOPY W/STENT PLCMT	398.93	398.93
45390	Other professional services	COLONOSCOPY W/RESECTION	458.00	458.00
45391	Other professional services	COLONOSCOPY W/ENDOSCOPE US	355.16	355.16
45392	Other professional services	COLONOSCOPY W/ENDOSCOPIC FNB	419.04	419.04
45393	Other professional services	COLONOSCOPY W/DECOMPRESSION	346.22	346.22
45395	Major surgery	LAP REMOVAL OF RECTUM	3497.75	3497.75
45397	Major surgery	LAP REMOVE RECTUM W/POUCH	3795.15	3795.15
45398	Other professional services	COLONOSCOPY W/BAND LIGATION	1122.41	323.28
45399	Other professional services	UNLISTED PROCEDURE COLON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
45400	Major surgery	LAPAROSCOPIC PROC	2033.89	2033.89
45402	Major surgery	LAP PROCTOPEXY W/SIG RESECT	2712.82	2712.82
45499	Major surgery	LAPAROSCOPE PROC RECTUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
45500	Major surgery	REPAIR OF RECTUM	1021.35	1021.35
45505	Major surgery	REPAIR OF RECTUM	1088.14	1088.14
45520	Other professional services	TREATMENT OF RECTAL PROLAPSE	222.15	56.60
45540	Major surgery	CORRECT RECTAL PROLAPSE	1888.05	1888.05
45541	Major surgery	CORRECT RECTAL PROLAPSE	1685.03	1685.03
45550	Major surgery	REPAIR RECTUM/REMOVE SIGMOID	2603.84	2603.84
45560	Major surgery	REPAIR OF RECTOCELE	1251.55	1251.55
45562	Major surgery	EXPLORATION/REPAIR OF RECTUM	2084.47	2084.47
45563	Major surgery	EXPLORATION/REPAIR OF RECTUM	2948.89	2948.89
45800	Major surgery	REPAIR RECT/BLADDER FISTULA	2264.63	2264.63
45805	Major surgery	REPAIR FISTULA W/COLOSTOMY	2612.18	2612.18
45820	Major surgery	REPAIR RECTOURETHRAL FISTULA	2270.50	2270.50
45825	Major surgery	REPAIR FISTULA W/COLOSTOMY	2735.67	2735.67
45900	Other professional services	REDUCTION OF RECTAL PROLAPSE	293.12	293.12
45905	Other professional services	DILATION OF ANAL SPHINCTER	236.94	236.94
45910	Other professional services	DILATION OF RECTAL NARROWING	268.91	268.91
45915	Other professional services	REMOVE RECTAL OBSTRUCTION	487.38	317.27
45990	Other professional services	SURG DX EXAM ANORECTAL	146.16	146.16
45999	Major surgery	UNLISTED PROCEDURE RECTUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
46020	Other professional services	PLACEMENT OF SETON	161.46	161.46
46030	Other professional services	REMOVAL OF RECTAL MARKER	348.42	120.11
46040	Major surgery	INCISION OF RECTAL ABSCESS	996.24	768.61
46045	Major surgery	INCISION OF RECTAL ABSCESS	794.70	794.70
46050	Other professional services	INCISION OF ANAL ABSCESS	325.26	141.06
46060	Major surgery	INCISION OF RECTAL ABSCESS	880.60	880.60
46070	Major surgery	INCISION OF ANAL SEPTUM	487.21	487.21
46080	Other professional services	INCISION OF ANAL SPHINCTER	396.30	218.91
46083	Other professional services	INCISE EXTERNAL HEMORRHOID	286.98	153.27
46200	Major surgery	REMOVAL OF ANAL FISSURE	854.08	613.43
46220	Other professional services	EXCISE ANAL EXT TAG/PAPILLA	345.86	169.38
46221	Other professional services	LIGATION OF HEMORRHOID(S)	392.06	267.89
46230	Other professional services	REMOVAL OF ANAL TAGS	432.39	241.82
46250	Major surgery	REMOVE EXT HEM GROUPS 2+	858.43	575.80
46255	Major surgery	REMOVE INT/EXT HEM 1 GROUP	933.27	641.76
46257	Major surgery	REMOVE IN/EX HEM GRP & FISS	758.02	758.02
46258	Major surgery	REMOVE IN/EX HEM GRP W/FISTU	867.81	867.81
46260	Major surgery	REMOVE IN/EX HEM GROUPS 2+	870.52	870.52
46261	Major surgery	REMOVE IN/EX HEM GRPS & FISS	965.19	965.19
46262	Major surgery	REMOVE IN/EX HEM GRPS W/FIST	1051.85	1051.85
46270	Major surgery	REMOVE ANAL FIST SUBQ	958.85	725.30
46275	Major surgery	REMOVE ANAL FIST INTER	1015.35	765.84
46280	Major surgery	REMOVE ANAL FIST COMPLEX	870.46	870.46
46285	Major surgery	REMOVE ANAL FIST 2 STAGE	1014.43	767.87
46288	Major surgery	REPAIR ANAL FISTULA	1012.46	1012.46
46320	Other professional services	REMOVAL OF HEMORRHOID CLOT	295.14	158.25
46500	Other professional services	INJECTION INTO HEMORRHOID(S)	429.62	254.96
46505	Other professional services	CHEMODENERVATION ANAL MUSC	435.80	348.02
46600	Other professional services	DIAGNOSTIC ANOSCOPY SPX	161.85	57.24
46601	Other professional services	DIAGNOSTIC ANOSCOPY	207.66	130.35
46604	Other professional services	ANOSCOPY AND DILATION	875.15	91.49
46606	Other professional services	ANOSCOPY AND BIOPSY	383.72	104.46
46607	Other professional services	DIAGNOSTIC ANOSCOPY & BIOPSY	287.25	173.09
46608	Other professional services	ANOSCOPY REMOVE FOR BODY	395.60	115.89
46610	Other professional services	ANOSCOPY REMOVE LESION	375.44	110.73
46611	Other professional services	ANOSCOPY	306.44	111.77
46612	Other professional services	ANOSCOPY REMOVE LESIONS	451.64	130.53
46614	Other professional services	ANOSCOPY CONTROL BLEEDING	231.27	89.37
46615	Other professional services	ANOSCOPY	244.73	126.02
46700	Major surgery	REPAIR OF ANAL STRICTURE	1182.95	1182.95
46705	Major surgery	REPAIR OF ANAL STRICTURE	1025.74	1025.74
46706	Other professional services	REPR OF ANAL FISTULA W/GLUE	248.79	248.79
46707	Major surgery	REPAIR ANORECTAL FIST W/PLUG	905.13	905.13
46710	Major surgery	REPR PER/VAG POUCH SNGL PROC	1981.30	1981.30
46712	Major surgery	REPR PER/VAG POUCH DBL PROC	3936.66	3936.66
46715	Major surgery	REP PERF ANOPER FISTU	995.48	995.48
46716	Major surgery	REP PERF ANOPER/VESTIB FISTU	2210.93	2210.93
46730	Major surgery	CONSTRUCTION OF ABSENT ANUS	3547.89	3547.89
46735	Major surgery	CONSTRUCTION OF ABSENT ANUS	4078.43	4078.43
46740	Major surgery	CONSTRUCTION OF ABSENT ANUS	3868.96	3868.96
46742	Major surgery	REPAIR OF IMPERFORATED ANUS	4464.92	4464.92
46744	Major surgery	REPAIR OF CLOACAL ANOMALY	6284.11	6284.11
46746	Major surgery	REPAIR OF CLOACAL ANOMALY	6919.65	6919.65
46748	Major surgery	REPAIR OF CLOACAL ANOMALY	7496.35	7496.35
46750	Major surgery	REPAIR OF ANAL SPHINCTER	1353.83	1353.83
46751	Major surgery	REPAIR OF ANAL SPHINCTER	1199.21	1199.21
46753	Major surgery	RECONSTRUCTION OF ANUS	1110.25	1110.25
46754	Other professional services	REMOVAL OF SUTURE FROM ANUS	484.74	339.20
46760	Major surgery	REPAIR OF ANAL SPHINCTER	1997.25	1997.25
46761	Major surgery	REPAIR OF ANAL SPHINCTER	1648.37	1648.37
46900	Other professional services	DESTRUCTION ANAL LESION(S)	333.35	192.36
46910	Other professional services	DESTRUCTION ANAL LESION(S)	365.33	188.87
46916	Other professional services	CRYOSURGERY ANAL LESION(S)	361.61	198.78
46917	Other professional services	LASER SURGERY ANAL LESIONS	608.91	180.48
46922	Other professional services	EXCISION OF ANAL LESION(S)	431.67	191.99
46924	Other professional services	DESTRUCTION ANAL LESION(S)	764.25	253.04
46930	Major surgery	DESTROY INTERNAL HEMORRHOIDS	389.28	274.58
46940	Other professional services	TREATMENT OF ANAL FISSURE	369.86	202.49
46942	Other professional services	TREATMENT OF ANAL FISSURE	352.07	181.97
46945	Major surgery	INT HRHC LIG 1 HROID W/O IMG	614.91	614.91
46946	Major surgery	INT HRHC LIG 2+HROID W/O IMG	688.19	688.19
46947	Major surgery	HEMORRHOIDOPEXY BY STAPLING	702.49	702.49
46948	Major surgery	INT HRHC TRANAL DARTLZJ 2+	800.28	800.28
46999	Major surgery	UNLISTED PROCEDURE ANUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
47000	Other professional services	NEEDLE BIOPSY OF LIVER	409.97	121.16
47001	Major surgery	NEEDLE BIOPSY LIVER ADD-ON	182.66	182.66
47010	Major surgery	OPEN DRAINAGE LIVER LESION	2164.21	2164.21
47015	Major surgery	INJECT/ASPIRATE LIVER CYST	2077.24	2077.24
47100	Major surgery	WEDGE BIOPSY OF LIVER	1520.71	1520.71
47120	Major surgery	PARTIAL REMOVAL OF LIVER	4156.68	4156.68
47122	Major surgery	EXTENSIVE REMOVAL OF LIVER	6067.85	6067.85
47125	Major surgery	PARTIAL REMOVAL OF LIVER	5461.66	5461.66
47130	Major surgery	PARTIAL REMOVAL OF LIVER	5859.42	5859.42
47133	Other professional services	REMOVAL OF DONOR LIVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
47135	Major surgery	TRANSPLANTATION OF LIVER	9593.84	9593.84
47140	Major surgery	PARTIAL REMOVAL DONOR LIVER	6353.47	6353.47
47141	Major surgery	PARTIAL REMOVAL DONOR LIVER	7589.22	7589.22
47142	Major surgery	PARTIAL REMOVAL DONOR LIVER	8354.03	8354.03
47143	Other professional services	PREP DONOR LIVER WHOLE	276.48	276.48
47144	Major surgery	PREP DONOR LIVER 3-SEGMENT	359.42	359.42
47145	Other professional services	PREP DONOR LIVER LOBE SPLIT	776.24	776.24
47146	Other professional services	PREP DONOR LIVER/VENOUS	443.96	443.96
47147	Other professional services	PREP DONOR LIVER/ARTERIAL	518.64	518.64
47300	Major surgery	SURGERY FOR LIVER LESION	2029.05	2029.05
47350	Major surgery	REPAIR LIVER WOUND	2433.17	2433.17
47360	Major surgery	REPAIR LIVER WOUND	3330.60	3330.60
47361	Major surgery	REPAIR LIVER WOUND	5341.44	5341.44
47362	Major surgery	REPAIR LIVER WOUND	2581.47	2581.47
47370	Major surgery	LAPARO ABLATE LIVER TUMOR RF	2237.82	2237.82
47371	Major surgery	LAPARO ABLATE LIVER CRYOSURG	2245.11	2245.11
47379	Major surgery	UNLISTED LAPS PX LIVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
47380	Major surgery	OPEN ABLATE LIVER TUMOR RF	2581.96	2581.96
47381	Major surgery	OPEN ABLATE LIVER TUMOR CRYO	2637.88	2637.88
47382	Other professional services	PERCUT ABLATE LIVER RF	4912.07	1012.47
47383	Other professional services	PERQ ABLTJ LVR CRYOABLATION	7876.86	616.62
47399	Major surgery	UNLISTED PROCEDURE LIVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
47400	Major surgery	INCISION OF LIVER DUCT	3818.31	3818.31
47420	Major surgery	INCISION OF BILE DUCT	2388.20	2388.20
47425	Major surgery	INCISION OF BILE DUCT	2435.12	2435.12
47460	Major surgery	INCISE BILE DUCT SPHINCTER	2262.27	2262.27
47480	Major surgery	INCISION OF GALLBLADDER	1568.35	1568.35
47490	Other professional services	INCISION OF GALLBLADDER	456.54	456.54
47531	Other professional services	INJECTION FOR CHOLANGIOGRAM	570.68	96.75
47532	Other professional services	INJECTION FOR CHOLANGIOGRAM	1135.55	288.68
47533	Other professional services	PLMT BILIARY DRAINAGE CATH	1570.25	359.99
47534	Other professional services	PLMT BILIARY DRAINAGE CATH	1728.78	503.96
47535	Other professional services	CONVERSION EXT BIL DRG CATH	1195.40	267.57
47536	Other professional services	EXCHANGE BILIARY DRG CATH	855.63	180.23
47537	Other professional services	REMOVAL BILIARY DRG CATH	661.92	132.06
47538	Other professional services	PERQ PLMT BILE DUCT STENT	5011.70	320.27
47539	Other professional services	PERQ PLMT BILE DUCT STENT	5642.66	581.45
47540	Other professional services	PERQ PLMT BILE DUCT STENT	5631.59	599.04
47541	Other professional services	PLMT ACCESS BIL TREE SM BWL	1574.42	458.30
47542	Other professional services	DILATE BILIARY DUCT/AMPULLA	672.83	185.25
47543	Other professional services	ENDOLUMINAL BX BILIARY TREE	532.25	195.68
47544	Other professional services	REMOVAL DUCT GLBLDR CALCULI	1124.46	213.47
47550	Major surgery	BILE DUCT ENDOSCOPY ADD-ON	289.03	289.03
47552	Other professional services	BILIARY ENDO PERQ DX W/SPECI	382.65	382.65
47553	Other professional services	BILIARY ENDOSCOPY THRU SKIN	383.72	383.72
47554	Other professional services	BILIARY ENDOSCOPY THRU SKIN	614.24	614.24
47555	Other professional services	BILIARY ENDOSCOPY THRU SKIN	457.02	457.02
47556	Other professional services	BILIARY ENDOSCOPY THRU SKIN	517.67	517.67
47562	Major surgery	LAPAROSCOPIC CHOLECYSTECTOMY	1183.26	1183.26
47563	Major surgery	LAPARO CHOLECYSTECTOMY/GRAPH	1286.12	1286.12
47564	Major surgery	LAPARO CHOLECYSTECTOMY/EXPLR	1998.65	1998.65
47570	Major surgery	LAPARO CHOLECYSTOENTEROSTOMY	1387.29	1387.29
47579	Major surgery	UNLISTED LAPS PX BILIARY TRC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
47600	Major surgery	REMOVAL OF GALLBLADDER	1912.37	1912.37
47605	Major surgery	REMOVAL OF GALLBLADDER	2012.60	2012.60
47610	Major surgery	REMOVAL OF GALLBLADDER	2226.65	2226.65
47612	Major surgery	REMOVAL OF GALLBLADDER	2267.85	2267.85
47620	Major surgery	REMOVAL OF GALLBLADDER	2447.62	2447.62
47700	Major surgery	EXPLORATION OF BILE DUCTS	1892.09	1892.09
47701	Major surgery	BILE DUCT REVISION	3089.01	3089.01
47711	Major surgery	EXCISION OF BILE DUCT TUMOR	2778.03	2778.03
47712	Major surgery	EXCISION OF BILE DUCT TUMOR	3546.11	3546.11
47715	Major surgery	EXCISION OF BILE DUCT CYST	2372.02	2372.02
47720	Major surgery	FUSE GALLBLADDER & BOWEL	2061.77	2061.77
47721	Major surgery	FUSE UPPER GI STRUCTURES	2414.67	2414.67
47740	Major surgery	FUSE GALLBLADDER & BOWEL	2341.09	2341.09
47741	Major surgery	FUSE GALLBLADDER & BOWEL	2628.68	2628.68
47760	Major surgery	FUSE BILE DUCTS AND BOWEL	4008.77	4008.77
47765	Major surgery	FUSE LIVER DUCTS & BOWEL	5375.41	5375.41
47780	Major surgery	FUSE BILE DUCTS AND BOWEL	4400.29	4400.29
47785	Major surgery	FUSE BILE DUCTS AND BOWEL	5747.35	5747.35
47800	Major surgery	RECONSTRUCTION OF BILE DUCTS	2777.85	2777.85
47801	Major surgery	PLACEMENT BILE DUCT SUPPORT	1990.93	1990.93
47802	Major surgery	FUSE LIVER DUCT & INTESTINE	2715.24	2715.24
47900	Major surgery	SUTURE BILE DUCT INJURY	2457.70	2457.70
47999	Major surgery	UNLISTED PX BILIARY TRACT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
48000	Major surgery	DRAINAGE OF ABDOMEN	3345.58	3345.58
48001	Major surgery	PLACEMENT OF DRAIN PANCREAS	4092.87	4092.87
48020	Major surgery	REMOVAL OF PANCREATIC STONE	2104.99	2104.99
48100	Major surgery	BIOPSY OF PANCREAS OPEN	1595.02	1595.02
48102	Other professional services	NEEDLE BIOPSY PANCREAS	701.93	325.34
48105	Major surgery	RESECT/DEBRIDE PANCREAS	5027.14	5027.14
48120	Major surgery	REMOVAL OF PANCREAS LESION	1986.09	1986.09
48140	Major surgery	PARTIAL REMOVAL OF PANCREAS	2793.12	2793.12
48145	Major surgery	PARTIAL REMOVAL OF PANCREAS	2905.99	2905.99
48146	Major surgery	PANCREATECTOMY	3352.13	3352.13
48148	Major surgery	REMOVAL OF PANCREATIC DUCT	2230.39	2230.39
48150	Major surgery	PARTIAL REMOVAL OF PANCREAS	5539.58	5539.58
48152	Major surgery	PANCREATECTOMY	5121.38	5121.38
48153	Major surgery	PANCREATECTOMY	5513.29	5513.29
48154	Major surgery	PANCREATECTOMY	5143.92	5143.92
48155	Major surgery	REMOVAL OF PANCREAS	3241.15	3241.15
48160	Other professional services	PANCREAS REMOVAL/TRANSPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
48400	Major surgery	INJECTION INTRAOP ADD-ON	187.88	187.88
48500	Major surgery	SURGERY OF PANCREATIC CYST	2051.56	2051.56
48510	Major surgery	DRAIN PANCREATIC PSEUDOCYST	1957.70	1957.70
48520	Major surgery	FUSE PANCREAS CYST AND BOWEL	1961.04	1961.04
48540	Major surgery	FUSE PANCREAS CYST AND BOWEL	2327.25	2327.25
48545	Major surgery	PANCREATORRHAPHY	2400.18	2400.18
48547	Major surgery	DUODENAL EXCLUSION	3185.93	3185.93
48548	Major surgery	FUSE PANCREAS AND BOWEL	2974.12	2974.12
48550	Other professional services	DONOR PANCREATECTOMY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
48551	Other professional services	PREP DONOR PANCREAS	317.60	317.60
48552	Other professional services	PREP DONOR PANCREAS/VENOUS	319.19	319.19
48554	Major surgery	TRANSPL ALLOGRAFT PANCREAS	4695.93	4695.93
48556	Major surgery	REMOVAL ALLOGRAFT PANCREAS	2306.32	2306.32
48999	Major surgery	UNLISTED PROCEDURE PANCREAS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
49000	Major surgery	EXPLORATION OF ABDOMEN	1375.90	1375.90
49002	Major surgery	REOPENING OF ABDOMEN	1859.73	1859.73
49010	Major surgery	EXPLORATION BEHIND ABDOMEN	1645.86	1645.86
49013	Other professional services	PRPERTL PEL PACK HEMRRG TRMA	619.52	619.52
49014	Other professional services	REEXPLORATION PELVIC WOUND	515.90	515.90
49020	Major surgery	DRAINAGE ABDOM ABSCESS OPEN	2846.67	2846.67
49040	Major surgery	DRAIN OPEN ABDOM ABSCESS	1792.36	1792.36
49060	Major surgery	DRAIN OPEN RETROPERI ABSCESS	1957.66	1957.66
49062	Major surgery	DRAIN TO PERITONEAL CAVITY	1375.78	1375.78
49082	Other professional services	ABD PARACENTESIS	290.88	101.22
49083	Other professional services	ABD PARACENTESIS W/IMAGING	400.85	146.61
49084	Other professional services	PERITONEAL LAVAGE	145.68	145.68
49180	Other professional services	BIOPSY ABDOMINAL MASS	240.17	114.18
49185	Other professional services	SCLEROTX FLUID COLLECTION	1692.90	163.82
49203	Major surgery	EXC ABD TUM 5 CM OR LESS	2140.63	2140.63
49204	Major surgery	EXC ABD TUM OVER 5 CM	2728.11	2728.11
49205	Major surgery	EXC ABD TUM OVER 10 CM	3128.83	3128.83
49215	Major surgery	EXCISE SACRAL SPINE TUMOR	3968.25	3968.25
49250	Major surgery	EXCISION OF UMBILICUS	1069.65	1069.65
49255	Major surgery	REMOVAL OF OMENTUM	1425.78	1425.78
49320	Other professional services	DIAG LAPARO SEPARATE PROC	455.13	455.13
49321	Other professional services	LAPAROSCOPY BIOPSY	476.69	476.69
49322	Other professional services	LAPAROSCOPY ASPIRATION	517.97	517.97
49323	Major surgery	LAPARO DRAIN LYMPHOCELE	1147.85	1147.85
49324	Other professional services	LAP INSERT TUNNEL IP CATH	531.54	531.54
49325	Other professional services	LAP REVISION PERM IP CATH	566.72	566.72
49326	Major surgery	LAP W/OMENTOPEXY ADD-ON	332.22	332.22
49327	Major surgery	LAP INS DEVICE FOR RT	229.30	229.30
49329	Major surgery	UNLSTD LAPS PX ABD PERTM&OMN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
49400	Other professional services	AIR INJECTION INTO ABDOMEN	206.54	124.22
49402	Major surgery	REMOVE FOREIGN BODY ADBOMEN	1527.77	1527.77
49405	Other professional services	IMAGE CATH FLUID COLXN VISC	1196.49	267.29
49406	Other professional services	IMAGE CATH FLUID PERI/RETRO	1196.94	267.29
49407	Other professional services	IMAGE CATH FLUID TRNS/VGNL	1022.63	282.65
49411	Other professional services	INS MARK ABD/PEL FOR RT PERQ	660.38	256.04
49412	Major surgery	INS DEVICE FOR RT GUIDE OPEN	144.87	144.87
49418	Other professional services	INSERT TUN IP CATH PERC	1324.22	274.95
49419	Major surgery	INSERT TUN IP CATH W/PORT	745.68	745.68
49421	Other professional services	INS TUN IP CATH FOR DIAL OPN	308.45	308.45
49422	Other professional services	REMOVE TUNNELED IP CATH	301.64	301.64
49423	Other professional services	EXCHANGE DRAINAGE CATHETER	787.37	96.95
49424	Other professional services	ASSESS CYST CONTRAST INJECT	245.07	51.32
49425	Major surgery	INSERT ABDOMEN-VENOUS DRAIN	1397.08	1397.08
49426	Major surgery	REVISE ABDOMEN-VENOUS SHUNT	1200.65	1200.65
49427	Other professional services	INJECTION ABDOMINAL SHUNT	53.67	53.67
49428	Other professional services	LIGATION OF SHUNT	592.31	592.31
49429	Other professional services	REMOVAL OF SHUNT	628.07	628.07
49435	Major surgery	INSERT SUBQ EXTEN TO IP CATH	207.66	207.66
49436	Other professional services	EMBEDDED IP CATH EXIT-SITE	732.39	256.20
49440	Other professional services	PLACE GASTROSTOMY TUBE PERC	1122.42	278.73
49441	Other professional services	PLACE DUOD/JEJ TUBE PERC	1296.72	329.78
49442	Other professional services	PLACE CECOSTOMY TUBE PERC	1072.76	285.02
49446	Other professional services	CHANGE G-TUBE TO G-J PERC	1076.16	200.64
49450	Other professional services	REPLACE G/C TUBE PERC	799.86	89.90
49451	Other professional services	REPLACE DUOD/JEJ TUBE PERC	855.99	121.47
49452	Other professional services	REPLACE G-J TUBE PERC	1040.81	187.11
49460	Other professional services	FIX G/COLON TUBE W/DEVICE	982.86	69.59
49465	Other professional services	FLUORO EXAM OF G/COLON TUBE	186.60	41.97
49491	Major surgery	RPR HERN PREEMIE REDUC	1430.48	1430.48
49492	Major surgery	RPR ING HERN PREMIE BLOCKED	1717.27	1717.27
49495	Major surgery	RPR ING HERNIA BABY REDUC	734.78	734.78
49496	Major surgery	RPR ING HERNIA BABY BLOCKED	1105.71	1105.71
49500	Major surgery	RPR ING HERNIA INIT REDUCE	749.78	749.78
49501	Major surgery	RPR ING HERNIA INIT BLOCKED	1089.19	1089.19
49505	Major surgery	PRP I/HERN INIT REDUC >5 YR	939.49	939.49
49507	Major surgery	PRP I/HERN INIT BLOCK >5 YR	1055.63	1055.63
49520	Major surgery	REREPAIR ING HERNIA REDUCE	1136.71	1136.71
49521	Major surgery	REREPAIR ING HERNIA BLOCKED	1284.56	1284.56
49525	Major surgery	REPAIR ING HERNIA SLIDING	1030.11	1030.11
49540	Major surgery	REPAIR LUMBAR HERNIA	1204.98	1204.98
49550	Major surgery	RPR REM HERNIA INIT REDUCE	1037.75	1037.75
49553	Major surgery	RPR FEM HERNIA INIT BLOCKED	1134.86	1134.86
49555	Major surgery	REREPAIR FEM HERNIA REDUCE	1085.04	1085.04
49557	Major surgery	REREPAIR FEM HERNIA BLOCKED	1295.37	1295.37
49591	Other professional services	RPR AA HRN 1ST < 3 CM RDC	468.75	468.75
49592	Major surgery	RPR AA HRN 1ST < 3 NCR/STRN	846.44	846.44
49593	Major surgery	RPR AA HRN 1ST 3-10 RDC	1019.83	1019.83
49594	Major surgery	RPR AA HRN 1ST 3-10 NCR/STRN	1326.98	1326.98
49595	Major surgery	RPR AA HRN 1ST > 10 RDC	1372.41	1372.41
49596	Major surgery	RPR AA HRN 1ST > 10 NCR/STRN	1821.65	1821.65
49600	Major surgery	REPAIR UMBILICAL LESION	1316.66	1316.66
49605	Major surgery	REPAIR UMBILICAL LESION	8708.49	8708.49
49606	Major surgery	REPAIR UMBILICAL LESION	2024.65	2024.65
49610	Major surgery	REPAIR UMBILICAL LESION	1244.33	1244.33
49611	Major surgery	REPAIR UMBILICAL LESION	1097.54	1097.54
49613	Major surgery	RPR AA HRN RCR < 3 RDC	751.49	751.49
49614	Major surgery	RPR AA HRN RCR < 3 NCR/STRN	1017.16	1017.16
49615	Major surgery	RPR AA HRN RCR 3-10 RDC	1137.47	1137.47
49616	Major surgery	RPR AA HRN RCR 3-10 NCR/STRN	1527.77	1527.77
49617	Major surgery	RPR AA HRN RCR > 10 RDC	1575.99	1575.99
49618	Major surgery	RPR AA HRN RCR > 10 NCR/STRN	2207.19	2207.19
49621	Major surgery	RPR PARASTOMAL HERNIA RDC	1326.08	1326.08
49622	Major surgery	RPR PARASTOMAL HRNA NCR/STRN	1636.30	1636.30
49623	Major surgery	RMVL NINFCT MESH HERNIA RPR	352.21	352.21
49650	Major surgery	LAP ING HERNIA REPAIR INIT	778.95	778.95
49651	Major surgery	LAP ING HERNIA REPAIR RECUR	1016.34	1016.34
49659	Major surgery	UNLSTD LAPS PX HRNAP HRNRPHY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
49900	Major surgery	REPAIR OF ABDOMINAL WALL	1478.76	1478.76
49904	Major surgery	OMENTAL FLAP EXTRA-ABDOM	2488.34	2488.34
49905	Major surgery	OMENTAL FLAP INTRA-ABDOM	624.78	624.78
49906	Major surgery	FREE OMENTAL FLAP MICROVASC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
49999	Major surgery	UNLISTED PX ABD PERTM&OMN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
50010	Major surgery	EXPLORATION OF KIDNEY	1281.01	1281.01
50020	Major surgery	RENAL ABSCESS OPEN DRAIN	1839.53	1839.53
50040	Major surgery	NFROS NFROT W/DRG	1676.28	1676.28
50045	Major surgery	NEPHROTOMY W/EXPLORATION	1688.43	1688.43
50060	Major surgery	NL REMOVAL CALCULUS	2059.51	2059.51
50065	Major surgery	NL SEC SURG OPERJ CALCULUS	2182.17	2182.17
50070	Major surgery	NL COMP CGEN KDN ABNORMALITY	2140.57	2140.57
50075	Major surgery	NL RMVL LG STAGHORN CALCULUS	2630.04	2630.04
50080	Major surgery	PERQ NL/PL LITHOTRP SMPL<2CM	1262.55	1262.55
50081	Major surgery	PERQ NL/PL LITHOTRP CPLX>2CM	2033.48	2033.48
50100	Major surgery	TRNSXJ/REPOS ABRRNT RNL VSLS	1931.75	1931.75
50120	Major surgery	PYELOTOMY W/EXPLORATION	1719.00	1719.00
50125	Major surgery	PYELOTOMY W/DRG PYELOSTOMY	1778.65	1778.65
50130	Major surgery	PYELOTOMY W/REMOVAL CALCULUS	1867.71	1867.71
50135	Major surgery	PYELOTOMY COMPLICATED	2026.30	2026.30
50200	Other professional services	RENAL BIOPSY PERQ	696.90	174.77
50205	Major surgery	RENAL BX SURG EXPOSURE KDN	1351.99	1351.99
50220	Major surgery	REMOVE KIDNEY OPEN	1897.10	1897.10
50225	Major surgery	REMOVAL KIDNEY OPEN COMPLEX	2182.50	2182.50
50230	Major surgery	REMOVAL KIDNEY OPEN RADICAL	2307.14	2307.14
50234	Major surgery	REMOVAL OF KIDNEY & URETER	2347.70	2347.70
50236	Major surgery	REMOVAL OF KIDNEY & URETER	2642.68	2642.68
50240	Major surgery	PARTIAL REMOVAL OF KIDNEY	2399.98	2399.98
50250	Major surgery	CRYOABLATE RENAL MASS OPEN	2199.02	2199.02
50280	Major surgery	REMOVAL OF KIDNEY LESION	1712.86	1712.86
50290	Major surgery	REMOVAL OF KIDNEY LESION	1629.07	1629.07
50300	Other professional services	REMOVE CADAVER DONOR KIDNEY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
50320	Major surgery	REMOVE KIDNEY LIVING DONOR	2726.67	2726.67
50323	Other professional services	PREP CADAVER RENAL ALLOGRAFT	276.48	228.80
50325	Other professional services	PREP DONOR RENAL GRAFT	276.48	228.80
50327	Other professional services	PREP RENAL GRAFT/VENOUS	294.09	294.09
50328	Other professional services	PREP RENAL GRAFT/ARTERIAL	257.88	257.88
50329	Other professional services	PREP RENAL GRAFT/URETERAL	244.43	244.43
50340	Major surgery	REMOVAL OF KIDNEY	1721.42	1721.42
50360	Major surgery	TRANSPLANTATION OF KIDNEY	4346.67	4346.67
50365	Major surgery	TRANSPLANTATION OF KIDNEY	5190.94	5190.94
50370	Major surgery	REMOVE TRANSPLANTED KIDNEY	2180.94	2180.94
50380	Major surgery	REIMPLANTATION OF KIDNEY	3651.14	3651.14
50382	Other professional services	CHANGE URETER STENT PERCUT	1351.80	344.84
50384	Other professional services	REMOVE URETER STENT PERCUT	1159.59	311.36
50385	Other professional services	CHANGE STENT VIA TRANSURETH	1369.89	296.07
50386	Other professional services	REMOVE STENT VIA TRANSURETH	1022.40	224.21
50387	Other professional services	CHANGE NEPHROURETERAL CATH	743.13	114.12
50389	Other professional services	REMOVE RENAL TUBE W/FLUORO	558.24	73.41
50390	Other professional services	DRAINAGE OF KIDNEY LESION	130.10	130.10
50391	Other professional services	INSTLL RX AGNT INTO RNAL TUB	174.60	135.95
50396	Other professional services	MEASURE KIDNEY PRESSURE	160.26	160.26
50400	Major surgery	REVISION OF KIDNEY/URETER	2088.16	2088.16
50405	Major surgery	REVISION OF KIDNEY/URETER	2519.13	2519.13
50430	Other professional services	NJX PX NFROSGRM &/URTRGRM	858.44	211.23
50431	Other professional services	NJX PX NFROSGRM &/URTRGRM	435.90	91.16
50432	Other professional services	PLMT NEPHROSTOMY CATHETER	1225.14	280.49
50433	Other professional services	PLMT NEPHROURETERAL CATHETER	1525.32	348.26
50434	Other professional services	CONVERT NEPHROSTOMY CATHETER	1223.78	261.38
50435	Other professional services	EXCHANGE NEPHROSTOMY CATH	804.66	136.98
50436	Other professional services	DILAT XST TRC NDURLGC PX	205.59	205.59
50437	Other professional services	DILAT XST TRC NEW ACCESS RCS	341.34	341.34
50500	Major surgery	REPAIR OF KIDNEY WOUND	2296.69	2296.69
50520	Major surgery	CLOSE KIDNEY-SKIN FISTULA	2070.12	2070.12
50525	Major surgery	CLOSE NEPHROVISCERAL FISTULA	2621.60	2621.60
50526	Major surgery	CLOSE NEPHROVISCERAL FISTULA	2806.38	2806.38
50540	Major surgery	REVISION OF HORSESHOE KIDNEY	2072.91	2072.91
50541	Major surgery	LAPARO ABLATE RENAL CYST	1658.05	1658.05
50542	Major surgery	LAPARO ABLATE RENAL MASS	2098.14	2098.14
50543	Major surgery	LAPARO PARTIAL NEPHRECTOMY	2690.71	2690.71
50544	Major surgery	LAPAROSCOPY PYELOPLASTY	2239.36	2239.36
50545	Major surgery	LAPARO RADICAL NEPHRECTOMY	2408.56	2408.56
50546	Major surgery	LAPAROSCOPIC NEPHRECTOMY	2172.14	2172.14
50547	Major surgery	LAPARO REMOVAL DONOR KIDNEY	2902.42	2902.42
50548	Major surgery	LAPARO REMOVE W/URETER	2421.74	2421.74
50549	Major surgery	UNLISTED LAPS PX RENAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
50551	Other professional services	KIDNEY ENDOSCOPY	502.80	405.47
50553	Other professional services	KIDNEY ENDOSCOPY	539.51	433.53
50555	Other professional services	KIDNEY ENDOSCOPY & BIOPSY	575.27	470.66
50557	Other professional services	KIDNEY ENDOSCOPY & TREATMENT	585.02	476.78
50561	Other professional services	KIDNEY ENDOSCOPY & TREATMENT	664.53	544.46
50562	Major surgery	RENAL SCOPE W/TUMOR RESECT	1039.21	1039.21
50570	Other professional services	KIDNEY ENDOSCOPY	677.63	677.63
50572	Other professional services	KIDNEY ENDOSCOPY	732.27	732.27
50574	Other professional services	KIDNEY ENDOSCOPY & BIOPSY	778.26	778.26
50575	Other professional services	KIDNEY ENDOSCOPY	982.70	982.70
50576	Other professional services	KIDNEY ENDOSCOPY & TREATMENT	776.00	776.00
50580	Other professional services	KIDNEY ENDOSCOPY & TREATMENT	836.30	836.30
50590	Major surgery	FRAGMENTING OF KIDNEY STONE	1342.15	1040.01
50592	Other professional services	PERC RF ABLATE RENAL TUMOR	3769.73	471.86
50593	Other professional services	PERC CRYO ABLATE RENAL TUM	5041.20	629.48
50600	Major surgery	EXPLORATION OF URETER	1696.52	1696.52
50605	Major surgery	INSERT URETERAL SUPPORT	1801.62	1801.62
50606	Other professional services	ENDOLUMINAL BX URTR RNL PLVS	655.52	191.15
50610	Major surgery	REMOVAL OF URETER STONE	1708.55	1708.55
50620	Major surgery	REMOVAL OF URETER STONE	1634.80	1634.80
50630	Major surgery	REMOVAL OF URETER STONE	1615.59	1615.59
50650	Major surgery	REMOVAL OF URETER	1878.22	1878.22
50660	Major surgery	REMOVAL OF URETER	2066.18	2066.18
50684	Other professional services	INJECTION FOR URETER X-RAY	175.35	70.74
50686	Other professional services	MEASURE URETER PRESSURE	199.08	123.12
50688	Other professional services	CHANGE OF URETER TUBE/STENT	107.76	107.76
50690	Other professional services	INJECTION FOR URETER X-RAY	164.15	96.83
50693	Other professional services	PLMT URETERAL STENT PRQ	1340.52	278.97
50694	Other professional services	PLMT URETERAL STENT PRQ	1505.13	364.44
50695	Other professional services	PLMT URETERAL STENT PRQ	1808.76	467.51
50700	Major surgery	REVISION OF URETER	1677.33	1677.33
50705	Other professional services	URETERAL EMBOLIZATION/OCCL	2451.20	243.51
50706	Other professional services	BALLOON DILATE URTRL STRIX	1129.82	247.47
50715	Major surgery	RELEASE OF URETER	2173.53	2173.53
50722	Major surgery	RELEASE OF URETER	1845.36	1845.36
50725	Major surgery	RELEASE/REVISE URETER	1992.02	1992.02
50727	Major surgery	REVISE URETER	931.34	931.34
50728	Major surgery	REVISE URETER	1272.00	1272.00
50740	Major surgery	FUSION OF URETER & KIDNEY	2186.13	2186.13
50750	Major surgery	FUSION OF URETER & KIDNEY	2083.95	2083.95
50760	Major surgery	FUSION OF URETERS	2035.23	2035.23
50770	Major surgery	SPLICING OF URETERS	2083.95	2083.95
50780	Major surgery	REIMPLANT URETER IN BLADDER	2007.08	2007.08
50782	Major surgery	REIMPLANT URETER IN BLADDER	1943.33	1943.33
50783	Major surgery	REIMPLANT URETER IN BLADDER	2036.97	2036.97
50785	Major surgery	REIMPLANT URETER IN BLADDER	2189.13	2189.13
50800	Major surgery	IMPLANT URETER IN BOWEL	1670.76	1670.76
50810	Major surgery	FUSION OF URETER & BOWEL	2509.69	2509.69
50815	Major surgery	URINE SHUNT TO INTESTINE	2214.58	2214.58
50820	Major surgery	CONSTRUCT BOWEL BLADDER	2369.93	2369.93
50825	Major surgery	CONSTRUCT BOWEL BLADDER	2970.94	2970.94
50830	Major surgery	REVISE URINE FLOW	3248.23	3248.23
50840	Major surgery	REPLACE URETER BY BOWEL	2226.26	2226.26
50845	Major surgery	APPENDICO-VESICOSTOMY	2270.17	2270.17
50860	Major surgery	TRANSPLANT URETER TO SKIN	1712.22	1712.22
50900	Major surgery	REPAIR OF URETER	1528.35	1528.35
50920	Major surgery	CLOSURE URETER/SKIN FISTULA	1597.73	1597.73
50930	Major surgery	CLOSURE URETER/BOWEL FISTULA	1990.37	1990.37
50940	Major surgery	RELEASE OF URETER	1608.18	1608.18
50945	Major surgery	LAPAROSCOPY URETEROLITHOTOMY	1754.20	1754.20
50947	Major surgery	LAPARO NEW URETER/BLADDER	2498.57	2498.57
50948	Major surgery	LAPARO NEW URETER/BLADDER	2292.85	2292.85
50949	Major surgery	UNLISTED LAPS PX URETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
50951	Other professional services	ENDOSCOPY OF URETER	527.72	423.57
50953	Other professional services	ENDOSCOPY OF URETER	557.90	450.57
50955	Other professional services	URETER ENDOSCOPY & BIOPSY	595.25	486.09
50957	Other professional services	URETER ENDOSCOPY & TREATMENT	600.84	488.51
50961	Other professional services	URETER ENDOSCOPY & TREATMENT	542.33	437.72
50970	Other professional services	URETER ENDOSCOPY	510.96	510.96
50972	Other professional services	URETER ENDOSCOPY & CATHETER	493.29	493.29
50974	Other professional services	URETER ENDOSCOPY & BIOPSY	651.92	651.92
50976	Other professional services	URETER ENDOSCOPY & TREATMENT	642.93	642.93
50980	Other professional services	URETER ENDOSCOPY & TREATMENT	490.88	490.88
51020	Major surgery	INCISE & TREAT BLADDER	857.90	857.90
51030	Major surgery	INCISE & TREAT BLADDER	864.05	864.05
51040	Major surgery	INCISE & DRAIN BLADDER	532.37	532.37
51045	Major surgery	INCISE BLADDER/DRAIN URETER	901.11	901.11
51050	Major surgery	REMOVAL OF BLADDER STONE	859.74	859.74
51060	Major surgery	REMOVAL OF URETER STONE	1060.80	1060.80
51065	Major surgery	REMOVE URETER CALCULUS	1056.06	1056.06
51080	Major surgery	DRAINAGE OF BLADDER ABSCESS	746.05	746.05
51100	Other professional services	DRAIN BLADDER BY NEEDLE	102.53	54.32
51101	Other professional services	DRAIN BLADDER BY TROCAR/CATH	212.16	70.73
51102	Other professional services	DRAIN BL W/CATH INSERTION	331.49	197.78
51500	Major surgery	REMOVAL OF BLADDER CYST	1158.59	1158.59
51520	Major surgery	REMOVAL OF BLADDER LESION	1083.58	1083.58
51525	Major surgery	REMOVAL OF BLADDER LESION	1553.47	1553.47
51530	Major surgery	REMOVAL OF BLADDER LESION	1396.84	1396.84
51535	Major surgery	REPAIR OF URETER LESION	1413.96	1413.96
51550	Major surgery	PARTIAL REMOVAL OF BLADDER	1741.29	1741.29
51555	Major surgery	PARTIAL REMOVAL OF BLADDER	2276.86	2276.86
51565	Major surgery	REVISE BLADDER & URETER(S)	2328.01	2328.01
51570	Major surgery	REMOVAL OF BLADDER	2656.76	2656.76
51575	Major surgery	REMOVAL OF BLADDER & NODES	3274.19	3274.19
51580	Major surgery	REMOVE BLADDER/REVISE TRACT	3419.21	3419.21
51585	Major surgery	REMOVAL OF BLADDER & NODES	3801.60	3801.60
51590	Major surgery	REMOVE BLADDER/REVISE TRACT	3476.34	3476.34
51595	Major surgery	REMOVE BLADDER/REVISE TRACT	3936.64	3936.64
51596	Major surgery	REMOVE BLADDER/CREATE POUCH	4241.29	4241.29
51597	Major surgery	REMOVAL OF PELVIC STRUCTURES	4138.80	4138.80
51600	Other professional services	INJECTION FOR BLADDER X-RAY	288.12	60.26
51605	Other professional services	PREPARATION FOR BLADDER XRAY	53.61	53.61
51610	Other professional services	INJECTION FOR BLADDER X-RAY	177.84	89.15
51700	Other professional services	IRRIGATION OF BLADDER	105.77	41.64
51701	Other professional services	INSERT BLADDER CATHETER	61.86	35.49
51702	Other professional services	INSERT TEMP BLADDER CATH	86.10	35.16
51703	Other professional services	INSERT BLADDER CATH COMPLEX	207.26	105.83
51705	Other professional services	CHANGE OF BLADDER TUBE	135.12	71.91
51710	Other professional services	CHANGE OF BLADDER TUBE	188.75	111.44
51715	Other professional services	ENDOSCOPIC INJECTION/IMPLANT	511.86	276.27
51720	Other professional services	TREATMENT OF BLADDER LESION	122.73	60.42
51725	Other professional services	SIMPLE CYSTOMETROGRAM	313.82	313.82
51725-26	Other professional services	SIMPLE CYSTOMETROGRAM	105.32	105.32
51725-TC	Other professional services	SIMPLE CYSTOMETROGRAM	208.50	208.50
51726	Other professional services	COMPLEX CYSTOMETROGRAM	413.82	413.82
51726-26	Other professional services	COMPLEX CYSTOMETROGRAM	117.09	117.09
51726-TC	Other professional services	COMPLEX CYSTOMETROGRAM	296.75	296.75
51727	Other professional services	CYSTOMETROGRAM W/UP	503.85	503.85
51727-26	Other professional services	CYSTOMETROGRAM W/UP	147.08	147.08
51727-TC	Other professional services	CYSTOMETROGRAM W/UP	356.78	356.78
51728	Other professional services	CYSTOMETROGRAM W/VP	501.18	501.18
51728-26	Other professional services	CYSTOMETROGRAM W/VP	143.96	143.96
51728-TC	Other professional services	CYSTOMETROGRAM W/VP	357.23	357.23
51729	Other professional services	CYSTOMETROGRAM W/VP&UP	528.90	528.90
51729-26	Other professional services	CYSTOMETROGRAM W/VP&UP	174.08	174.08
51729-TC	Other professional services	CYSTOMETROGRAM W/VP&UP	354.83	354.83
51736	Other professional services	URINE FLOW MEASUREMENT	19.01	19.01
51736-26	Other professional services	URINE FLOW MEASUREMENT	11.40	11.40
51736-TC	Other professional services	URINE FLOW MEASUREMENT	7.61	7.61
51741	Other professional services	ELECTRO-UROFLOWMETRY FIRST	19.79	19.79
51741-26	Other professional services	ELECTRO-UROFLOWMETRY FIRST	11.73	11.73
51741-TC	Other professional services	ELECTRO-UROFLOWMETRY FIRST	8.06	8.06
51784	Other professional services	ANAL/URINARY MUSCLE STUDY	89.48	89.48
51784-26	Other professional services	ANAL/URINARY MUSCLE STUDY	51.41	51.41
51784-TC	Other professional services	ANAL/URINARY MUSCLE STUDY	38.07	38.07
51785	Other professional services	ANAL/URINARY MUSCLE STUDY	595.74	595.74
51785-26	Other professional services	ANAL/URINARY MUSCLE STUDY	124.49	124.49
51785-TC	Other professional services	ANAL/URINARY MUSCLE STUDY	471.26	471.26
51792	Other professional services	URINARY REFLEX STUDY	375.68	375.68
51792-26	Other professional services	URINARY REFLEX STUDY	76.80	76.80
51792-TC	Other professional services	URINARY REFLEX STUDY	298.89	298.89
51797	Major surgery	INTRAABDOMINAL PRESSURE TEST	337.70	337.70
51797-26	Major surgery	INTRAABDOMINAL PRESSURE TEST	71.62	71.62
51797-TC	Major surgery	INTRAABDOMINAL PRESSURE TEST	266.08	266.08
51798	Other professional services	US URINE CAPACITY MEASURE	15.33	15.33
51800	Major surgery	REVISION OF BLADDER/URETHRA	1877.93	1877.93
51820	Major surgery	REVISION OF URINARY TRACT	1963.26	1963.26
51840	Major surgery	ATTACH BLADDER/URETHRA	1261.98	1261.98
51841	Major surgery	ATTACH BLADDER/URETHRA	1461.15	1461.15
51845	Major surgery	REPAIR BLADDER NECK	1059.22	1059.22
51860	Major surgery	REPAIR OF BLADDER WOUND	1348.43	1348.43
51865	Major surgery	REPAIR OF BLADDER WOUND	1620.12	1620.12
51880	Major surgery	REPAIR OF BLADDER OPENING	847.12	847.12
51900	Major surgery	REPAIR BLADDER/VAGINA LESION	1494.73	1494.73
51920	Major surgery	CLOSE BLADDER-UTERUS FISTULA	1385.46	1385.46
51925	Major surgery	HYSTERECTOMY/BLADDER REPAIR	1950.55	1950.55
51940	Major surgery	CORRECTION OF BLADDER DEFECT	2959.61	2959.61
51960	Major surgery	REVISION OF BLADDER & BOWEL	2501.40	2501.40
51980	Major surgery	CONSTRUCT BLADDER OPENING	1295.66	1295.66
51990	Major surgery	LAPARO URETHRAL SUSPENSION	1348.91	1348.91
51992	Major surgery	LAPARO SLING OPERATION	1512.97	1512.97
51999	Major surgery	UNLISTED LAPS PX BLADDER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
52000	Other professional services	CYSTOSCOPY	330.14	111.38
52001	Other professional services	CYSTOSCOPY REMOVAL OF CLOTS	609.27	396.42
52005	Other professional services	CYSTOSCOPY & URETER CATHETER	418.79	184.55
52007	Other professional services	CYSTOSCOPY AND BIOPSY	618.62	229.74
52010	Other professional services	CYSTOSCOPY & DUCT CATHETER	527.00	228.65
52204	Other professional services	CYSTOSCOPY W/BIOPSY(S)	519.71	195.89
52214	Other professional services	CYSTOSCOPY AND TREATMENT	1022.04	241.58
52224	Other professional services	CYSTOSCOPY AND TREATMENT	1068.62	279.51
52234	Other professional services	CYSTOSCOPY AND TREATMENT	339.36	339.36
52235	Other professional services	CYSTOSCOPY AND TREATMENT	398.24	398.24
52240	Other professional services	CYSTOSCOPY AND TREATMENT	540.78	540.78
52250	Other professional services	CYSTOSCOPY AND RADIOTRACER	330.05	330.05
52260	Other professional services	CYSTOSCOPY AND TREATMENT	290.70	290.70
52265	Other professional services	CYSTOSCOPY AND TREATMENT	513.59	224.33
52270	Other professional services	CYSTOSCOPY & REVISE URETHRA	579.24	250.86
52275	Other professional services	CYSTOSCOPY & REVISE URETHRA	743.94	342.80
52276	Other professional services	CYSTOSCOPY AND TREATMENT	364.74	364.74
52277	Other professional services	CYSTOSCOPY AND TREATMENT	445.76	445.76
52281	Other professional services	CYSTOSCOPY AND TREATMENT	450.90	210.30
52282	Other professional services	CYSTOSCOPY IMPLANT STENT	464.93	464.93
52283	Other professional services	CYSTOSCOPY AND TREATMENT	490.22	278.28
52284	Other professional services	CYSTO RX BALO CATH URTL STRX	3657.21	227.43
52285	Other professional services	CYSTOSCOPY AND TREATMENT	485.07	270.86
52287	Other professional services	CYSTOSCOPY CHEMODENERVATION	534.87	233.33
52290	Other professional services	CYSTOSCOPY AND TREATMENT	336.15	336.15
52300	Other professional services	CYSTOSCOPY AND TREATMENT	386.28	386.28
52301	Other professional services	CYSTOSCOPY AND TREATMENT	400.28	400.28
52305	Other professional services	CYSTOSCOPY AND TREATMENT	383.55	383.55
52310	Other professional services	CYSTOSCOPY AND TREATMENT	441.44	209.49
52315	Other professional services	CYSTOSCOPY AND TREATMENT	651.08	378.65
52317	Other professional services	REMOVE BLADDER STONE	1216.08	477.92
52318	Other professional services	REMOVE BLADDER STONE	652.77	652.77
52320	Other professional services	CYSTOSCOPY AND TREATMENT	339.62	339.62
52325	Other professional services	CYSTOSCOPY STONE REMOVAL	441.30	441.30
52327	Other professional services	CYSTOSCOPY INJECT MATERIAL	357.45	357.45
52330	Other professional services	CYSTOSCOPY AND TREATMENT	830.96	363.41
52332	Other professional services	CYSTOSCOPY AND TREATMENT	551.09	214.98
52334	Other professional services	CREATE PASSAGE TO KIDNEY	252.27	252.27
52341	Other professional services	CYSTO W/URETER STRICTURE TX	392.12	392.12
52342	Other professional services	CYSTO W/UP STRICTURE TX	426.83	426.83
52343	Other professional services	CYSTO W/RENAL STRICTURE TX	474.41	474.41
52344	Other professional services	CYSTO/URETERO STRICTURE TX	509.76	509.76
52345	Other professional services	CYSTO/URETERO W/UP STRICTURE	544.02	544.02
52346	Other professional services	CYSTOURETERO W/RENAL STRICT	615.23	615.23
52351	Other professional services	CYSTOURETERO & OR PYELOSCOPE	417.95	417.95
52352	Other professional services	CYSTOURETERO W/STONE REMOVE	488.40	488.40
52353	Other professional services	CYSTOURETERO W/LITHOTRIPSY	540.33	540.33
52354	Other professional services	CYSTOURETERO W/BIOPSY	575.03	575.03
52355	Other professional services	CYSTOURETERO W/EXCISE TUMOR	644.31	644.31
52356	Other professional services	CYSTO/URETERO W/LITHOTRIPSY	573.21	573.21
52400	Major surgery	CYSTOURETERO W/CONGEN REPR	864.44	864.44
52402	Other professional services	CYSTOURETHRO CUT EJACUL DUCT	366.17	366.17
52441	Other professional services	CYSTOURETHRO W/IMPLANT	1723.50	289.46
52442	Major surgery	CYSTOURETHRO W/ADDL IMPLANT	1518.78	90.87
52450	Major surgery	INCISION OF PROSTATE	865.25	865.25
52500	Major surgery	REVISION OF BLADDER NECK	897.88	897.88
52601	Major surgery	PROSTATECTOMY (TURP)	1320.17	1320.17
52630	Major surgery	REMOVE PROSTATE REGROWTH	739.13	739.13
52640	Major surgery	RELIEVE BLADDER CONTRACTURE	588.86	588.86
52647	Major surgery	LASER SURGERY OF PROSTATE	2794.55	1180.39
52648	Major surgery	LASER SURGERY OF PROSTATE	2883.06	1257.67
52649	Major surgery	PROSTATE LASER ENUCLEATION	1496.18	1496.18
52700	Major surgery	DRAINAGE OF PROSTATE ABSCESS	805.84	805.84
53000	Other professional services	INCISION OF URETHRA	208.05	208.05
53010	Major surgery	INCISION OF URETHRA	542.98	542.98
53020	Other professional services	INCISION OF URETHRA	134.15	134.15
53025	Other professional services	INCISION OF URETHRA	95.55	95.55
53040	Major surgery	DRAINAGE OF URETHRA ABSCESS	714.89	714.89
53060	Other professional services	DRAINAGE OF URETHRA ABSCESS	264.12	231.38
53080	Major surgery	DRAINAGE OF URINARY LEAKAGE	767.07	767.07
53085	Major surgery	DRAINAGE OF URINARY LEAKAGE	1177.80	1177.80
53200	Other professional services	BIOPSY OF URETHRA	222.33	197.31
53210	Major surgery	REMOVAL OF URETHRA	1407.72	1407.72
53215	Major surgery	REMOVAL OF URETHRA	1677.33	1677.33
53220	Major surgery	TREATMENT OF URETHRA LESION	823.33	823.33
53230	Major surgery	REMOVAL OF URETHRA LESION	1107.50	1107.50
53235	Major surgery	REMOVAL OF URETHRA LESION	1153.00	1153.00
53240	Major surgery	SURGERY FOR URETHRA POUCH	774.58	774.58
53250	Major surgery	REMOVAL OF URETHRA GLAND	722.42	722.42
53260	Other professional services	TREATMENT OF URETHRA LESION	290.03	253.64
53265	Other professional services	TREATMENT OF URETHRA LESION	320.49	263.64
53270	Other professional services	REMOVAL OF URETHRA GLAND	297.17	258.96
53275	Other professional services	REPAIR OF URETHRA DEFECT	366.74	366.74
53400	Major surgery	REVISE URETHRA STAGE 1	1450.88	1450.88
53405	Major surgery	REVISE URETHRA STAGE 2	1582.56	1582.56
53410	Major surgery	RECONSTRUCTION OF URETHRA	1773.70	1773.70
53415	Major surgery	RECONSTRUCTION OF URETHRA	2042.29	2042.29
53420	Major surgery	RECONSTRUCT URETHRA STAGE 1	1523.30	1523.30
53425	Major surgery	RECONSTRUCT URETHRA STAGE 2	1694.43	1694.43
53430	Major surgery	RECONSTRUCTION OF URETHRA	1761.42	1761.42
53431	Major surgery	RECONSTRUCT URETHRA/BLADDER	2083.75	2083.75
53440	Major surgery	MALE SLING PROCEDURE	1366.31	1366.31
53442	Major surgery	REMOVE/REVISE MALE SLING	1427.65	1427.65
53444	Major surgery	INSERT TANDEM CUFF	1439.08	1439.08
53445	Major surgery	INSERT URO/VES NCK SPHINCTER	1374.73	1374.73
53446	Major surgery	REMOVE URO SPHINCTER	1168.34	1168.34
53447	Major surgery	REMOVE/REPLACE UR SPHINCTER	1462.40	1462.40
53448	Major surgery	REMOV/REPLC UR SPHINCTR COMP	2306.09	2306.09
53449	Major surgery	REPAIR URO SPHINCTER	1114.11	1114.11
53450	Major surgery	REVISION OF URETHRA	745.58	745.58
53451	Major surgery	TPRNL BALO CNTNC DEV BI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
53452	Major surgery	TPRNL BALO CNTNC DEV UNI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
53453	Major surgery	TPRNL BALO CNTNC DEV RMVL EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
53454	Major surgery	TPRNL BALO CNTNC DEV ADJMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
53460	Major surgery	REVISION OF URETHRA	834.37	834.37
53500	Major surgery	URETHRLYS TRANSVAG W/ SCOPE	1355.54	1355.54
53502	Major surgery	REPAIR OF URETHRA INJURY	885.87	885.87
53505	Major surgery	REPAIR OF URETHRA INJURY	885.28	885.28
53510	Major surgery	REPAIR OF URETHRA INJURY	1150.07	1150.07
53515	Major surgery	REPAIR OF URETHRA INJURY	1442.18	1442.18
53520	Major surgery	REPAIR OF URETHRA DEFECT	1018.02	1018.02
53600	Other professional services	DILATE URETHRA STRICTURE	123.45	87.98
53601	Other professional services	DILATE URETHRA STRICTURE	119.37	73.89
53605	Other professional services	DILATE URETHRA STRICTURE	88.56	88.56
53620	Other professional services	DILATE URETHRA STRICTURE	235.28	120.66
53621	Other professional services	DILATE URETHRA STRICTURE	224.69	99.60
53660	Other professional services	DILATION OF URETHRA	105.59	57.83
53661	Other professional services	DILATION OF URETHRA	103.80	56.04
53665	Other professional services	DILATION OF URETHRA	52.55	52.55
53850	Major surgery	PROSTATIC MICROWAVE THERMOTX	2508.56	648.45
53852	Major surgery	PROSTATIC RF THERMOTX	2450.66	694.63
53854	Major surgery	TRURL DSTRJ PRST8 TISS RF WV	2953.84	694.63
53855	Other professional services	INSERT PROST URETHRAL STENT	885.74	113.46
53860	Major surgery	TRANSURETHRAL RF TREATMENT	4202.21	404.55
53899	Major surgery	UNLISTED PX URINARY SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
54000	Other professional services	SLITTING OF PREPUCE	228.03	155.70
54001	Other professional services	SLITTING OF PREPUCE	277.58	197.07
54015	Other professional services	DRAIN PENIS LESION	425.82	425.82
54050	Other professional services	DESTRUCTION PENIS LESION(S)	201.53	149.67
54055	Other professional services	DESTRUCTION PENIS LESION(S)	192.29	134.52
54056	Other professional services	CRYOSURGERY PENIS LESION(S)	202.11	156.62
54057	Other professional services	LASER SURG PENIS LESION(S)	198.66	137.27
54060	Other professional services	EXCISION OF PENIS LESION(S)	273.83	184.68
54065	Other professional services	DESTRUCTION PENIS LESION(S)	311.28	240.78
54100	Other professional services	BIOPSY OF PENIS	281.66	169.31
54105	Other professional services	BIOPSY OF PENIS	386.67	297.98
54110	Major surgery	TREATMENT OF PENIS LESION	1135.10	1135.10
54111	Major surgery	TREAT PENIS LESION GRAFT	1449.12	1449.12
54112	Major surgery	TREAT PENIS LESION GRAFT	1698.31	1698.31
54115	Major surgery	TREATMENT OF PENIS LESION	835.20	778.44
54120	Major surgery	PARTIAL REMOVAL OF PENIS	1150.56	1150.56
54125	Major surgery	REMOVAL OF PENIS	1490.95	1490.95
54130	Major surgery	REMOVE PENIS & NODES	2158.86	2158.86
54135	Major surgery	REMOVE PENIS & NODES	2727.00	2727.00
54150	Other professional services	CIRCUMCISION W/REGIONL BLOCK	206.67	133.46
54160	Other professional services	CIRCUMCISION NEONATE	308.13	203.52
54161	Other professional services	CIRCUM 28 DAYS OR OLDER	276.20	276.20
54162	Other professional services	LYSIS PENIL CIRCUMIC LESION	358.97	280.74
54163	Other professional services	REPAIR OF CIRCUMCISION	307.58	307.58
54164	Other professional services	FRENULOTOMY OF PENIS	272.75	272.75
54200	Other professional services	TREATMENT OF PENIS LESION	162.80	122.31
54205	Major surgery	TREATMENT OF PENIS LESION	969.31	969.31
54220	Other professional services	TREATMENT OF PENIS LESION	308.85	186.51
54230	Other professional services	PREPARE PENIS STUDY	148.82	111.06
54231	Other professional services	DYNAMIC CAVERNOSOMETRY	200.82	161.25
54235	Other professional services	PENILE INJECTION	126.11	102.92
54240	Other professional services	PENIS STUDY	149.30	149.30
54240-26	Other professional services	PENIS STUDY	89.51	89.51
54240-TC	Other professional services	PENIS STUDY	59.78	59.78
54250	Other professional services	PENIS STUDY	170.61	170.61
54250-26	Other professional services	PENIS STUDY	150.72	150.72
54250-TC	Other professional services	PENIS STUDY	19.89	19.89
54300	Major surgery	REVISION OF PENIS	1172.40	1172.40
54304	Major surgery	REVISION OF PENIS	1356.63	1356.63
54308	Major surgery	RECONSTRUCTION OF URETHRA	1300.46	1300.46
54312	Major surgery	RECONSTRUCTION OF URETHRA	1484.87	1484.87
54316	Major surgery	RECONSTRUCTION OF URETHRA	1800.53	1800.53
54318	Major surgery	RECONSTRUCTION OF URETHRA	1293.38	1293.38
54322	Major surgery	RECONSTRUCTION OF URETHRA	1416.54	1416.54
54324	Major surgery	RECONSTRUCTION OF URETHRA	1753.64	1753.64
54326	Major surgery	RECONSTRUCTION OF URETHRA	1707.21	1707.21
54328	Major surgery	REVISE PENIS/URETHRA	1696.29	1696.29
54332	Major surgery	REVISE PENIS/URETHRA	1828.75	1828.75
54336	Major surgery	REVISE PENIS/URETHRA	2149.45	2149.45
54340	Major surgery	RPR HYPSPAD COMP SIMPLE	1036.35	1036.35
54344	Major surgery	RRP HYPSPAD COMP MOBLJ&URTP	1710.93	1710.93
54348	Major surgery	RPR HYPSPAD COMP DSJ & URTP	1829.10	1829.10
54352	Major surgery	REVJ PRIOR HYPSPAD REPAIR	2554.19	2554.19
54360	Major surgery	PENIS PLASTIC SURGERY	1309.15	1309.15
54380	Major surgery	REPAIR PENIS	1450.27	1450.27
54385	Major surgery	REPAIR PENIS	1687.71	1687.71
54390	Major surgery	REPAIR PENIS AND BLADDER	2244.96	2244.96
54400	Major surgery	INSERT SEMI-RIGID PROSTHESIS	968.16	968.16
54401	Major surgery	INSERT SELF-CONTD PROSTHESIS	1211.28	1211.28
54405	Major surgery	INSERT MULTI-COMP PENIS PROS	1465.41	1465.41
54406	Major surgery	REMOVE MUTI-COMP PENIS PROS	1328.26	1328.26
54408	Major surgery	REPAIR MULTI-COMP PENIS PROS	1436.31	1436.31
54410	Major surgery	REMOVE/REPLACE PENIS PROSTH	1566.94	1566.94
54411	Major surgery	REMOV/REPLC PENIS PROS COMP	1864.71	1864.71
54415	Major surgery	REMOVE SELF-CONTD PENIS PROS	969.48	969.48
54416	Major surgery	REMV/REPL PENIS CONTAIN PROS	1304.32	1304.32
54417	Major surgery	REMV/REPLC PENIS PROS COMPL	1630.36	1630.36
54420	Major surgery	REVISION OF PENIS	1276.04	1276.04
54430	Major surgery	REVISION OF PENIS	1161.44	1161.44
54435	Major surgery	REVISION OF PENIS	755.82	755.82
54437	Major surgery	REPAIR CORPOREAL TEAR	1234.82	1234.82
54438	Major surgery	REPLANTATION OF PENIS	2416.54	2416.54
54440	Major surgery	REPAIR OF PENIS	2675.97	2021.31
54450	Other professional services	PREPUTIAL STRETCHING	96.42	79.14
54500	Other professional services	BIOPSY OF TESTIS	103.68	103.68
54505	Other professional services	BIOPSY OF TESTIS	292.97	292.97
54512	Major surgery	EXCISE LESION TESTIS	978.12	978.12
54520	Major surgery	REMOVAL OF TESTIS	597.79	597.79
54522	Major surgery	ORCHIECTOMY PARTIAL	1068.23	1068.23
54530	Major surgery	REMOVAL OF TESTIS	926.60	926.60
54535	Major surgery	EXTENSIVE TESTIS SURGERY	1351.64	1351.64
54550	Major surgery	EXPLORATION FOR TESTIS	895.69	895.69
54560	Major surgery	EXPLORATION FOR TESTIS	1248.74	1248.74
54600	Major surgery	REDUCE TESTIS TORSION	825.73	825.73
54620	Other professional services	SUSPENSION OF TESTIS	417.02	417.02
54640	Major surgery	ORCHIOPEXY INGUN/SCROT APPR	783.43	783.43
54650	Major surgery	ORCHIOPEXY (FOWLER-STEPHENS)	1294.96	1294.96
54660	Major surgery	REVISION OF TESTIS	654.62	654.62
54670	Major surgery	REPAIR TESTIS INJURY	746.36	746.36
54680	Major surgery	RELOCATION OF TESTIS(ES)	1428.49	1428.49
54690	Major surgery	LAPAROSCOPY ORCHIECTOMY	1190.32	1190.32
54692	Major surgery	LAPAROSCOPY ORCHIOPEXY	1369.80	1369.80
54699	Major surgery	UNLISTED LAPS PX TESTIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
54700	Other professional services	DRAINAGE OF SCROTUM	298.13	298.13
54800	Other professional services	BIOPSY OF EPIDIDYMIS	174.41	174.41
54830	Major surgery	REMOVE EPIDIDYMIS LESION	680.04	680.04
54840	Major surgery	REMOVE EPIDIDYMIS LESION	587.75	587.75
54860	Major surgery	REMOVAL OF EPIDIDYMIS	764.26	764.26
54861	Major surgery	REMOVAL OF EPIDIDYMIS	1035.12	1035.12
54865	Major surgery	EXPLORE EPIDIDYMIS	657.54	657.54
54900	Major surgery	FUSION OF SPERMATIC DUCTS	1452.15	1452.15
54901	Major surgery	FUSION OF SPERMATIC DUCTS	1915.84	1915.84
55000	Other professional services	DRAINAGE OF HYDROCELE	167.54	117.96
55040	Major surgery	REMOVAL OF HYDROCELE	617.76	617.76
55041	Major surgery	REMOVAL OF HYDROCELES	932.31	932.31
55060	Major surgery	REPAIR OF HYDROCELE	692.80	692.80
55100	Other professional services	DRAINAGE OF SCROTUM ABSCESS	321.75	234.89
55110	Major surgery	EXPLORE SCROTUM	707.60	707.60
55120	Major surgery	REMOVAL OF SCROTUM LESION	649.19	649.19
55150	Major surgery	REMOVAL OF SCROTUM	897.64	897.64
55175	Major surgery	REVISION OF SCROTUM	665.79	665.79
55180	Major surgery	REVISION OF SCROTUM	1251.02	1251.02
55200	Major surgery	INCISION OF SPERM DUCT	694.06	506.63
55250	Major surgery	REMOVAL OF SPERM DUCT(S)	605.85	419.00
55300	Other professional services	PREPARE SPERM DUCT X-RAY	257.94	257.94
55400	Major surgery	REPAIR OF SPERM DUCT	910.34	910.34
55500	Major surgery	REMOVAL OF HYDROCELE	712.34	712.34
55520	Major surgery	REMOVAL OF SPERM CORD LESION	825.14	825.14
55530	Major surgery	REVISE SPERMATIC CORD VEINS	642.33	642.33
55535	Major surgery	REVISE SPERMATIC CORD VEINS	784.99	784.99
55540	Major surgery	REVISE HERNIA & SPERM VEINS	996.27	996.27
55550	Major surgery	LAPARO LIGATE SPERMATIC VEIN	783.86	783.86
55559	Major surgery	UNLSTD LAPS PX SPRMATIC CORD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
55600	Major surgery	INCISE SPERM DUCT POUCH	769.68	769.68
55605	Major surgery	INCISE SPERM DUCT POUCH	955.23	955.23
55650	Major surgery	REMOVE SPERM DUCT POUCH	1304.57	1304.57
55680	Major surgery	REMOVE SPERM POUCH LESION	633.75	633.75
55700	Other professional services	BIOPSY OF PROSTATE	333.95	180.68
55705	Other professional services	BIOPSY OF PROSTATE	369.80	369.80
55706	Other professional services	PROSTATE SATURATION SAMPLING	525.33	525.33
55720	Major surgery	DRAINAGE OF PROSTATE ABSCESS	823.62	823.62
55725	Major surgery	DRAINAGE OF PROSTATE ABSCESS	1084.75	1084.75
55801	Major surgery	REMOVAL OF PROSTATE	1982.10	1982.10
55810	Major surgery	EXTENSIVE PROSTATE SURGERY	2360.88	2360.88
55812	Major surgery	EXTENSIVE PROSTATE SURGERY	2902.07	2902.07
55815	Major surgery	EXTENSIVE PROSTATE SURGERY	3176.26	3176.26
55821	Major surgery	REMOVAL OF PROSTATE	1520.24	1520.24
55831	Major surgery	REMOVAL OF PROSTATE	1558.30	1558.30
55840	Major surgery	EXTENSIVE PROSTATE SURGERY	2116.12	2116.12
55842	Major surgery	EXTENSIVE PROSTATE SURGERY	2115.11	2115.11
55845	Major surgery	EXTENSIVE PROSTATE SURGERY	2459.81	2459.81
55860	Major surgery	SURGICAL EXPOSURE PROSTATE	1584.26	1584.26
55862	Major surgery	EXTENSIVE PROSTATE SURGERY	1980.95	1980.95
55865	Major surgery	EXTENSIVE PROSTATE SURGERY	2411.37	2411.37
55866	Major surgery	LAPS SURG PRST8ECT RPBIC RAD	2161.22	2161.22
55867	Major surgery	LAPS SURG PRST8ECT SMPL STOT	1897.94	1897.94
55870	Other professional services	ELECTROEJACULATION	249.06	197.21
55873	Major surgery	CRYOABLATE PROSTATE	10098.86	1387.21
55874	Other professional services	TPRNL PLMT BIODEGRDABL MATRL	3882.86	228.41
55875	Major surgery	TRANSPERI NEEDLE PLACE PROS	1417.83	1417.83
55876	Other professional services	PLACE RT DEVICE/MARKER PROS	210.80	142.58
55880	Major surgery	ABLTJ MAL PRST8 TISS HIFU	1774.85	1774.85
55899	Major surgery	UNLISTED PX MALE GENITAL SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
55920	Other professional services	PLACE NEEDLES PELVIC FOR RT	645.24	645.24
55970	Major surgery	SEX TRANSFORMATION M TO F	UCR or Pay Per Agreement	UCR or Pay Per Agreement
55980	Major surgery	SEX TRANSFORMATION F TO M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
56405	Other professional services	I & D OF VULVA/PERINEUM	204.15	177.32
56420	Other professional services	DRAINAGE OF GLAND ABSCESS	258.23	154.52
56440	Other professional services	SURGERY FOR VULVA LESION	254.04	254.04
56441	Other professional services	LYSIS OF LABIAL LESION(S)	256.13	217.46
56442	Other professional services	HYMENOTOMY	65.97	65.97
56501	Other professional services	DESTROY VULVA LESIONS SIM	267.38	186.87
56515	Other professional services	DESTROY VULVA LESION/S COMPL	386.37	297.23
56605	Other professional services	BIOPSY OF VULVA/PERINEUM	134.04	82.20
56606	Major surgery	BIOPSY OF VULVA/PERINEUM	68.50	52.53
56620	Major surgery	PARTIAL REMOVAL OF VULVA	1067.45	1067.45
56625	Major surgery	COMPLETE REMOVAL OF VULVA	1216.64	1216.64
56630	Major surgery	EXTENSIVE VULVA SURGERY	1747.06	1747.06
56631	Major surgery	EXTENSIVE VULVA SURGERY	2157.85	2157.85
56632	Major surgery	EXTENSIVE VULVA SURGERY	2606.96	2606.96
56633	Major surgery	EXTENSIVE VULVA SURGERY	2251.92	2251.92
56634	Major surgery	EXTENSIVE VULVA SURGERY	2355.85	2355.85
56637	Major surgery	EXTENSIVE VULVA SURGERY	2759.23	2759.23
56640	Major surgery	EXTENSIVE VULVA SURGERY	2773.56	2773.56
56700	Other professional services	PARTIAL REMOVAL OF HYMEN	284.01	284.01
56740	Other professional services	REMOVE VAGINA GLAND LESION	440.09	440.09
56800	Other professional services	REPAIR OF VAGINA	354.47	354.47
56805	Major surgery	REPAIR CLITORIS	2113.68	2113.68
56810	Other professional services	REPAIR OF PERINEUM	382.17	382.17
56820	Other professional services	EXAM OF VULVA W/SCOPE	174.75	116.99
56821	Other professional services	EXAM/BIOPSY OF VULVA W/SCOPE	234.02	157.61
57000	Other professional services	EXPLORATION OF VAGINA	282.47	282.47
57010	Major surgery	DRAINAGE OF PELVIC ABSCESS	832.90	832.90
57020	Other professional services	DRAINAGE OF PELVIC FLUID	173.72	110.04
57022	Other professional services	I & D VAGINAL HEMATOMA PP	253.40	253.40
57023	Other professional services	I & D VAG HEMATOMA NON-OB	447.36	447.36
57061	Other professional services	DESTROY VAG LESIONS SIMPLE	232.50	161.09
57065	Other professional services	DESTROY VAG LESIONS COMPLEX	343.91	260.22
57100	Other professional services	BIOPSY OF VAGINA	144.15	90.95
57105	Other professional services	BIOPSY OF VAGINA	246.84	205.01
57106	Major surgery	REMOVE VAGINA WALL PARTIAL	977.52	977.52
57107	Major surgery	REMOVE VAGINA TISSUE PART	2648.08	2648.08
57109	Major surgery	VAGINECTOMY PARTIAL W/NODES	3143.54	3143.54
57110	Major surgery	REMOVE VAGINA WALL COMPLETE	1640.40	1640.40
57111	Major surgery	REMOVE VAGINA TISSUE COMPL	3143.54	3143.54
57120	Major surgery	CLOSURE OF VAGINA	965.93	965.93
57130	Other professional services	REMOVE VAGINA LESION	320.70	242.01
57135	Other professional services	REMOVE VAGINA LESION	344.84	262.97
57150	Other professional services	TREAT VAGINA INFECTION	79.94	35.82
57155	Other professional services	INSERT UTERI TANDEM/OVOIDS	557.37	398.64
57156	Other professional services	INS VAG BRACHYTX DEVICE	320.33	212.54
57160	Other professional services	INSERT PESSARY/OTHER DEVICE	103.32	63.75
57170	Other professional services	FITTING OF DIAPHRAGM/CAP	107.81	65.52
57180	Other professional services	TREAT VAGINAL BLEEDING	275.03	169.05
57200	Major surgery	REPAIR OF VAGINA	605.14	605.14
57210	Major surgery	REPAIR VAGINA/PERINEUM	715.92	715.92
57220	Major surgery	REVISION OF URETHRA	630.14	630.14
57230	Major surgery	REPAIR OF URETHRAL LESION	762.66	762.66
57240	Major surgery	ANTERIOR COLPORRHAPHY	1115.89	1115.89
57250	Major surgery	REPAIR RECTUM & VAGINA	1119.61	1119.61
57260	Major surgery	CMBN ANT PST COLPRHY	1414.47	1414.47
57265	Major surgery	CMBN AP COLPRHY W/NTRCL RPR	1581.51	1581.51
57267	Major surgery	INSERT MESH/PELVIC FLR ADDON	451.64	451.64
57268	Major surgery	REPAIR OF BOWEL BULGE	922.00	922.00
57270	Major surgery	REPAIR OF BOWEL POUCH	1477.36	1477.36
57280	Major surgery	SUSPENSION OF VAGINA	1752.19	1752.19
57282	Major surgery	COLPOPEXY EXTRAPERITONEAL	1261.38	1261.38
57283	Major surgery	COLPOPEXY INTRAPERITONEAL	1269.22	1269.22
57284	Major surgery	REPAIR PARAVAG DEFECT OPEN	1512.91	1512.91
57285	Major surgery	REPAIR PARAVAG DEFECT VAG	1258.45	1258.45
57287	Major surgery	REVISE/REMOVE SLING REPAIR	1349.71	1349.71
57288	Major surgery	REPAIR BLADDER DEFECT	1352.09	1352.09
57289	Major surgery	REPAIR BLADDER & VAGINA	1441.58	1441.58
57291	Major surgery	CONSTRUCTION OF VAGINA	1000.19	1000.19
57292	Major surgery	CONSTRUCT VAGINA WITH GRAFT	1503.26	1503.26
57295	Major surgery	REVISE VAG GRAFT VIA VAGINA	912.97	912.97
57296	Major surgery	REVISE VAG GRAFT OPEN ABD	1738.13	1738.13
57300	Major surgery	REPAIR RECTUM-VAGINA FISTULA	1112.61	1112.61
57305	Major surgery	REPAIR RECTUM-VAGINA FISTULA	1766.06	1766.06
57307	Major surgery	FISTULA REPAIR & COLOSTOMY	1961.12	1961.12
57308	Major surgery	FISTULA REPAIR TRANSPERINE	1208.98	1208.98
57310	Major surgery	REPAIR URETHROVAGINAL LESION	900.28	900.28
57311	Major surgery	REPAIR URETHROVAGINAL LESION	1014.14	1014.14
57320	Major surgery	REPAIR BLADDER-VAGINA LESION	1027.26	1027.26
57330	Major surgery	REPAIR BLADDER-VAGINA LESION	1396.08	1396.08
57335	Major surgery	REPAIR VAGINA	2135.31	2135.31
57400	Other professional services	DILATION OF VAGINA	181.08	181.08
57410	Other professional services	PELVIC EXAMINATION	147.74	147.74
57415	Other professional services	REMOVE VAGINAL FOREIGN BODY	245.88	245.88
57420	Other professional services	EXAM OF VAGINA W/SCOPE	185.33	124.83
57421	Other professional services	EXAM/BIOPSY OF VAG W/SCOPE	247.82	169.14
57423	Major surgery	REPAIR PARAVAG DEFECT LAP	1684.22	1684.22
57425	Major surgery	LAPAROSCOPY SURG COLPOPEXY	1766.00	1766.00
57426	Major surgery	REVISE PROSTH VAG GRAFT LAP	1586.87	1586.87
57452	Other professional services	EXAM OF CERVIX W/SCOPE	176.57	126.54
57454	Other professional services	BX/CURETT OF CERVIX W/SCOPE	235.43	185.85
57455	Other professional services	BIOPSY OF CERVIX W/SCOPE	225.41	150.83
57456	Other professional services	ENDOCERV CURETTAGE W/SCOPE	212.42	140.57
57460	Other professional services	BX OF CERVIX W/SCOPE LEEP	434.07	221.67
57461	Other professional services	CONZ OF CERVIX W/SCOPE LEEP	484.08	253.95
57465	Other professional services	CAM CERVIX UTERI DRG COLP	76.20	58.91
57500	Other professional services	BIOPSY OF CERVIX	212.39	104.58
57505	Other professional services	ENDOCERVICAL CURETTAGE	215.07	152.76
57510	Other professional services	CAUTERIZATION OF CERVIX	232.94	157.89
57511	Other professional services	CRYOCAUTERY OF CERVIX	277.56	206.16
57513	Other professional services	LASER SURGERY OF CERVIX	286.22	205.25
57520	Major surgery	CONIZATION OF CERVIX	641.59	539.90
57522	Major surgery	CONIZATION OF CERVIX	550.54	464.82
57530	Major surgery	REMOVAL OF CERVIX	682.07	682.07
57531	Major surgery	REMOVAL OF CERVIX RADICAL	3253.73	3253.73
57540	Major surgery	REMOVAL OF RESIDUAL CERVIX	1436.80	1436.80
57545	Major surgery	REMOVE CERVIX/REPAIR PELVIS	1513.40	1513.40
57550	Major surgery	REMOVAL OF RESIDUAL CERVIX	786.34	786.34
57555	Major surgery	REMOVE CERVIX/REPAIR VAGINA	1125.23	1125.23
57556	Major surgery	REMOVE CERVIX REPAIR BOWEL	1068.56	1068.56
57558	Other professional services	D&C OF CERVICAL STUMP	220.85	180.36
57700	Major surgery	REVISION OF CERVIX	649.16	649.16
57720	Major surgery	REVISION OF CERVIX	608.50	608.50
57800	Other professional services	DILATION OF CERVICAL CANAL	108.02	67.08
58100	Other professional services	BIOPSY OF UTERUS LINING	141.02	87.80
58110	Major surgery	BX DONE W/COLPOSCOPY ADD-ON	90.75	72.42
58120	Other professional services	DILATION AND CURETTAGE	415.61	326.46
58140	Major surgery	MYOMECTOMY ABDOM METHOD	1672.48	1672.48
58145	Major surgery	MYOMECTOMY VAG METHOD	1034.92	1034.92
58146	Major surgery	MYOMECTOMY ABDOM COMPLEX	2093.25	2093.25
58150	Major surgery	TOTAL HYSTERECTOMY	1843.74	1843.74
58152	Major surgery	TOTAL HYSTERECTOMY	2243.49	2243.49
58180	Major surgery	PARTIAL HYSTERECTOMY	1743.73	1743.73
58200	Major surgery	EXTENSIVE HYSTERECTOMY	2444.85	2444.85
58210	Major surgery	EXTENSIVE HYSTERECTOMY	3300.45	3300.45
58240	Major surgery	REMOVAL OF PELVIS CONTENTS	5287.17	5287.17
58260	Major surgery	VAGINAL HYSTERECTOMY	1523.85	1523.85
58262	Major surgery	VAG HYST INCLUDING T/O	1684.31	1684.31
58263	Major surgery	VAG HYST W/T/O & VAG REPAIR	1805.17	1805.17
58267	Major surgery	VAG HYST W/URINARY REPAIR	1940.56	1940.56
58270	Major surgery	VAG HYST W/ENTEROCELE REPAIR	1623.24	1623.24
58275	Major surgery	HYSTERECTOMY/REVISE VAGINA	1799.48	1799.48
58280	Major surgery	HYSTERECTOMY/REVISE VAGINA	1923.27	1923.27
58285	Major surgery	EXTENSIVE HYSTERECTOMY	2581.74	2581.74
58290	Major surgery	VAG HYST COMPLEX	2086.58	2086.58
58291	Major surgery	VAG HYST INCL T/O COMPLEX	2253.99	2253.99
58292	Major surgery	VAG HYST T/O & REPAIR COMPL	2375.26	2375.26
58294	Major surgery	VAG HYST W/ENTEROCELE COMPL	2205.78	2205.78
58300	Other professional services	INSERT INTRAUTERINE DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
58301	Other professional services	REMOVE INTRAUTERINE DEVICE	153.38	91.98
58321	Other professional services	ARTIFICIAL INSEMINATION	114.09	66.78
58322	Other professional services	ARTIFICIAL INSEMINATION	127.10	79.79
58323	Other professional services	SPERM WASHING	20.79	16.70
58340	Other professional services	CATHETER FOR HYSTEROGRAPHY	331.61	80.09
58345	Other professional services	REOPEN FALLOPIAN TUBE	404.01	404.01
58346	Major surgery	INSERT HEYMAN UTERI CAPSULE	909.07	909.07
58350	Other professional services	REOPEN FALLOPIAN TUBE	213.03	132.53
58353	Other professional services	ENDOMETR ABLATE THERMAL	1262.51	322.40
58356	Other professional services	ENDOMETRIAL CRYOABLATION	2278.28	492.66
58400	Major surgery	SUSPENSION OF UTERUS	844.60	844.60
58410	Major surgery	SUSPENSION OF UTERUS	1480.89	1480.89
58520	Major surgery	REPAIR OF RUPTURED UTERUS	1450.22	1450.22
58540	Major surgery	REVISION OF UTERUS	1664.73	1664.73
58541	Major surgery	LSH UTERUS 250 G OR LESS	1328.55	1328.55
58542	Major surgery	LSH W/T/O UT 250 G OR LESS	1507.74	1507.74
58543	Major surgery	LSH UTERUS ABOVE 250 G	1529.89	1529.89
58544	Major surgery	LSH W/T/O UTERUS ABOVE 250 G	1643.85	1643.85
58545	Major surgery	LAPAROSCOPIC MYOMECTOMY	1636.13	1636.13
58546	Major surgery	LAPARO-MYOMECTOMY COMPLEX	2018.62	2018.62
58548	Major surgery	LAP RADICAL HYST	3413.77	3413.77
58550	Major surgery	LAPARO-ASST VAG HYSTERECTOMY	1601.77	1601.77
58552	Major surgery	LAPARO-VAG HYST INCL T/O	1779.32	1779.32
58553	Major surgery	LAPARO-VAG HYST COMPLEX	2030.09	2030.09
58554	Major surgery	LAPARO-VAG HYST W/T/O COMPL	2365.66	2365.66
58555	Other professional services	HYSTEROSCOPY DX SEP PROC	497.01	210.03
58558	Other professional services	HYSTEROSCOPY BIOPSY	1804.86	320.79
58559	Other professional services	HYSTEROSCOPY LYSIS	393.77	393.77
58560	Other professional services	HYSTEROSCOPY RESECT SEPTUM	433.59	433.59
58561	Other professional services	HYSTEROSCOPY REMOVE MYOMA	496.16	496.16
58562	Other professional services	HYSTEROSCOPY REMOVE FB	595.26	307.37
58563	Other professional services	HYSTEROSCOPY ABLATION	2856.51	340.92
58565	Major surgery	HYSTEROSCOPY STERILIZATION	2952.63	831.79
58570	Major surgery	TLH UTERUS 250 G OR LESS	1466.11	1466.11
58571	Major surgery	TLH W/T/O 250 G OR LESS	1650.38	1650.38
58572	Major surgery	TLH UTERUS OVER 250 G	1840.92	1840.92
58573	Major surgery	TLH W/T/O UTERUS OVER 250 G	2210.52	2210.52
58575	Major surgery	LAPS TOT HYST RESJ MAL	3503.60	3503.60
58578	Major surgery	UNLISTED LAPS PX UTERUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
58579	Major surgery	UNLISTED HYSTSC PX UTERUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
58580	Major surgery	TRANSCRV ABLTJ UTRN FIBRD RF	5525.79	728.89
58600	Major surgery	DIVISION OF FALLOPIAN TUBE	675.07	675.07
58605	Major surgery	DIVISION OF FALLOPIAN TUBE	613.63	613.63
58611	Major surgery	LIGATE OVIDUCT(S) ADD-ON	135.88	135.88
58615	Other professional services	OCCLUDE FALLOPIAN TUBE(S)	354.57	354.57
58660	Major surgery	LAPAROSCOPY LYSIS	1238.23	1238.23
58661	Other professional services	LAPAROSCOPY REMOVE ADNEXA	910.35	910.35
58662	Major surgery	LAPAROSCOPY EXCISE LESIONS	1294.39	1294.39
58670	Major surgery	LAPAROSCOPY TUBAL CAUTERY	676.26	676.26
58671	Major surgery	LAPAROSCOPY TUBAL BLOCK	676.26	676.26
58672	Major surgery	LAPAROSCOPY FIMBRIOPLASTY	1325.28	1325.28
58673	Major surgery	LAPAROSCOPY SALPINGOSTOMY	1438.18	1438.18
58674	Major surgery	LAPS ABLTJ UTERINE FIBROIDS	1475.04	1475.04
58679	Major surgery	UNLISTED LAPS PX OVIDCT OVRY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
58700	Major surgery	REMOVAL OF FALLOPIAN TUBE	1450.70	1450.70
58720	Major surgery	REMOVAL OF OVARY/TUBE(S)	1379.16	1379.16
58740	Major surgery	ADHESIOLYSIS TUBE OVARY	1632.81	1632.81
58750	Major surgery	REPAIR OVIDUCT	1650.97	1650.97
58752	Major surgery	REVISE OVARIAN TUBE(S)	1646.83	1646.83
58760	Major surgery	FIMBRIOPLASTY	1490.03	1490.03
58770	Major surgery	CREATE NEW TUBAL OPENING	1564.39	1564.39
58800	Major surgery	DRAINAGE OF OVARIAN CYST(S)	658.03	574.67
58805	Major surgery	DRAINAGE OF OVARIAN CYST(S)	779.45	779.45
58820	Major surgery	DRAIN OVARY ABSCESS OPEN	617.45	617.45
58822	Major surgery	DRAIN OVARY ABSCESS PERCUT	1298.41	1298.41
58825	Major surgery	TRANSPOSITION OVARY(S)	1288.81	1288.81
58900	Major surgery	BIOPSY OF OVARY(S)	795.74	795.74
58920	Major surgery	PARTIAL REMOVAL OF OVARY(S)	1297.57	1297.57
58925	Major surgery	REMOVAL OF OVARIAN CYST(S)	1389.26	1389.26
58940	Major surgery	REMOVAL OF OVARY(S)	1006.16	1006.16
58943	Major surgery	REMOVAL OF OVARY(S)	2179.20	2179.20
58950	Major surgery	RESECT OVARIAN MALIGNANCY	2087.75	2087.75
58951	Major surgery	RESECT OVARIAN MALIGNANCY	2616.51	2616.51
58952	Major surgery	RESECT OVARIAN MALIGNANCY	2988.26	2988.26
58953	Major surgery	TAH RAD DISSECT FOR DEBULK	3628.89	3628.89
58954	Major surgery	TAH RAD DEBULK/LYMPH REMOVE	3926.25	3926.25
58956	Major surgery	BSO OMENTECTOMY W/TAH	2469.19	2469.19
58957	Major surgery	RESECT RECURRENT GYN MAL	2883.00	2883.00
58958	Major surgery	RESECT RECUR GYN MAL W/LYM	3000.82	3000.82
58960	Major surgery	EXPLORATION OF ABDOMEN	1810.98	1810.98
58970	Other professional services	RETRIEVAL OF OOCYTE	334.98	272.21
58974	Other professional services	TRANSFER OF EMBRYO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
58976	Other professional services	TRANSFER OF EMBRYO	359.52	293.58
58999	Major surgery	UNLISTED PX FML GENITAL SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
59000	Other professional services	AMNIOCENTESIS DIAGNOSTIC	161.97	110.12
59001	Other professional services	AMNIOCENTESIS THERAPEUTIC	242.43	242.43
59012	Other professional services	FETAL CORD PUNCTURE PRENATAL	273.95	273.95
59015	Other professional services	CHORION BIOPSY	216.68	178.94
59020	Other professional services	FETAL CONTRACT STRESS TEST	97.76	97.76
59020-26	Other professional services	FETAL CONTRACT STRESS TEST	50.12	50.12
59020-TC	Other professional services	FETAL CONTRACT STRESS TEST	47.63	47.63
59025	Other professional services	FETAL NON-STRESS TEST	67.44	67.44
59025-26	Other professional services	FETAL NON-STRESS TEST	39.83	39.83
59025-TC	Other professional services	FETAL NON-STRESS TEST	27.62	27.62
59030	Other professional services	FETAL SCALP BLOOD SAMPLE	152.36	152.36
59050	Other professional services	FETAL MONITOR W/REPORT	67.67	67.67
59051	Other professional services	FETAL MONITOR/INTERPRET ONLY	57.05	57.05
59070	Other professional services	TRANSABDOM AMNIOINFUS W/US	545.69	419.70
59072	Other professional services	UMBILICAL CORD OCCLUD W/US	707.39	707.39
59074	Other professional services	FETAL FLUID DRAINAGE W/US	524.76	419.70
59076	Other professional services	FETAL SHUNT PLACEMENT W/US	707.39	707.39
59100	Major surgery	REMOVE UTERUS LESION	1529.17	1529.17
59120	Major surgery	TREAT ECTOPIC PREGNANCY	1459.17	1459.17
59121	Major surgery	TREAT ECTOPIC PREGNANCY	1459.75	1459.75
59130	Major surgery	TREAT ECTOPIC PREGNANCY	1693.13	1693.13
59136	Major surgery	TREAT ECTOPIC PREGNANCY	1606.29	1606.29
59140	Major surgery	TREAT ECTOPIC PREGNANCY	748.22	748.22
59150	Major surgery	TREAT ECTOPIC PREGNANCY	1415.62	1415.62
59151	Major surgery	TREAT ECTOPIC PREGNANCY	1384.85	1384.85
59160	Other professional services	D & C AFTER DELIVERY	375.72	259.29
59200	Other professional services	INSERT CERVICAL DILATOR	143.64	60.42
59300	Other professional services	EPISIOTOMY OR VAGINAL REPAIR	315.83	201.66
59320	Other professional services	REVISION OF CERVIX	206.79	206.79
59325	Other professional services	REVISION OF CERVIX	327.69	327.69
59350	Other professional services	REPAIR OF UTERUS	378.69	378.69
59400	Major surgery	OBSTETRICAL CARE	4321.04	4321.04
59409	Major surgery	OBSTETRICAL CARE	1422.35	1422.35
59410	Major surgery	OBSTETRICAL CARE	1925.00	1925.00
59412	Major surgery	ANTEPARTUM MANIPULATION	182.11	182.11
59414	Major surgery	DELIVER PLACENTA	160.27	160.27
59425	Major surgery	ANTEPARTUM CARE ONLY	1006.16	770.85
59426	Major surgery	ANTEPARTUM CARE ONLY	1840.06	1414.94
59430	Major surgery	CARE AFTER DELIVERY	472.64	318.90
59510	Major surgery	CESAREAN DELIVERY	4785.09	4785.09
59514	Major surgery	CESAREAN DELIVERY ONLY	1606.57	1606.57
59515	Major surgery	CESAREAN DELIVERY	2379.78	2379.78
59525	Major surgery	REMOVE UTERUS AFTER CESAREAN	850.41	850.41
59610	Major surgery	VBAC DELIVERY	4509.51	4509.51
59612	Major surgery	VBAC DELIVERY ONLY	1602.86	1602.86
59614	Major surgery	VBAC CARE AFTER DELIVERY	2070.57	2070.57
59618	Major surgery	ATTEMPTED VBAC DELIVERY	4834.15	4834.15
59620	Major surgery	ATTEMPTED VBAC DELIVERY ONLY	1660.33	1660.33
59622	Major surgery	ATTEMPTED VBAC AFTER CARE	2465.13	2465.13
59812	Major surgery	TREATMENT OF MISCARRIAGE	650.05	551.30
59820	Major surgery	CARE OF MISCARRIAGE	788.89	694.28
59821	Major surgery	TREATMENT OF MISCARRIAGE	776.74	678.00
59830	Major surgery	TREAT UTERUS INFECTION	831.75	831.75
59840	Other professional services	ABORTION	345.14	306.48
59841	Other professional services	ABORTION	587.93	512.88
59850	Major surgery	ABORTION	701.47	701.47
59851	Major surgery	ABORTION	768.40	768.40
59852	Major surgery	ABORTION	1055.42	1055.42
59855	Major surgery	ABORTION	761.30	761.30
59856	Major surgery	ABORTION	889.94	889.94
59857	Major surgery	ABORTION	1035.61	1035.61
59866	Other professional services	ABORTION (MPR)	324.39	324.39
59870	Major surgery	EVACUATE MOLE OF UTERUS	962.48	962.48
59871	Other professional services	REMOVE CERCLAGE SUTURE	182.12	182.12
59897	Major surgery	UNLISTED FETAL INVAS PX W/US	UCR or Pay Per Agreement	UCR or Pay Per Agreement
59898	Major surgery	UNLSTD LAPS PX MAT CARE&DLVR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
59899	Major surgery	UNLISTED PX MAT CARE&DLVR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
60000	Neurology	DRAIN THYROID/TONGUE CYST	265.42	226.00
60100	Neurology	BIOPSY OF THYROID	156.18	108.40
60200	Major surgery	REMOVE THYROID LESION	1207.95	1207.95
60210	Major surgery	PARTIAL THYROID EXCISION	1276.24	1276.24
60212	Major surgery	PARTIAL THYROID EXCISION	1832.36	1832.36
60220	Major surgery	PARTIAL REMOVAL OF THYROID	1277.19	1277.19
60225	Major surgery	PARTIAL REMOVAL OF THYROID	1693.46	1693.46
60240	Major surgery	REMOVAL OF THYROID	1651.53	1651.53
60252	Major surgery	REMOVAL OF THYROID	2375.10	2375.10
60254	Major surgery	EXTENSIVE THYROID SURGERY	3000.04	3000.04
60260	Major surgery	REPEAT THYROID SURGERY	1961.29	1961.29
60270	Major surgery	REMOVAL OF THYROID	2448.71	2448.71
60271	Major surgery	REMOVAL OF THYROID	1899.48	1899.48
60280	Major surgery	REMOVE THYROID DUCT LESION	828.03	828.03
60281	Major surgery	REMOVE THYROID DUCT LESION	1086.38	1086.38
60300	Neurology	ASPIR/INJ THYROID CYST	151.21	68.62
60500	Major surgery	EXPLORE PARATHYROID GLANDS	1743.36	1743.36
60502	Major surgery	RE-EXPLORE PARATHYROIDS	2337.02	2337.02
60505	Major surgery	EXPLORE PARATHYROID GLANDS	2522.17	2522.17
60512	Major surgery	AUTOTRANSPLANT PARATHYROID	430.60	430.60
60520	Major surgery	REMOVAL OF THYMUS GLAND	1875.92	1875.92
60521	Major surgery	REMOVAL OF THYMUS GLAND	1990.38	1990.38
60522	Major surgery	REMOVAL OF THYMUS GLAND	2407.53	2407.53
60540	Major surgery	EXPLORE ADRENAL GLAND	1934.91	1934.91
60545	Major surgery	EXPLORE ADRENAL GLAND	2237.90	2237.90
60600	Major surgery	REMOVE CAROTID BODY LESION	2424.71	2424.71
60605	Major surgery	REMOVE CAROTID BODY LESION	2875.33	2875.33
60650	Major surgery	LAPAROSCOPY ADRENALECTOMY	2133.09	2133.09
60659	Major surgery	UNLISTED LAPS PX ENDOC SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
60699	Major surgery	UNLISTED PX ENDOCRINE SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
61000	Neurology	REMOVE CRANIAL CAVITY FLUID	157.28	157.28
61001	Neurology	REMOVE CRANIAL CAVITY FLUID	149.25	149.25
61020	Neurology	REMOVE BRAIN CAVITY FLUID	148.58	148.58
61026	Neurology	INJECTION INTO BRAIN CANAL	153.81	153.81
61050	Neurology	REMOVE BRAIN CANAL FLUID	113.85	113.85
61055	Neurology	INJECTION INTO BRAIN CANAL	165.12	165.12
61070	Neurology	BRAIN CANAL SHUNT PROCEDURE	79.15	79.15
61105	Major surgery	TWIST DRILL HOLE	833.18	833.18
61107	Neurology	DRILL SKULL FOR IMPLANTATION	428.37	428.37
61108	Major surgery	DRILL SKULL FOR DRAINAGE	1617.99	1617.99
61120	Major surgery	BURR HOLE FOR PUNCTURE	1340.55	1340.55
61140	Major surgery	PIERCE SKULL FOR BIOPSY	2263.29	2263.29
61150	Major surgery	PIERCE SKULL FOR DRAINAGE	2396.08	2396.08
61151	Major surgery	PIERCE SKULL FOR DRAINAGE	1768.28	1768.28
61154	Major surgery	PIERCE SKULL & REMOVE CLOT	2275.26	2275.26
61156	Major surgery	PIERCE SKULL FOR DRAINAGE	2199.89	2199.89
61210	Neurology	PIERCE SKULL IMPLANT DEVICE	501.93	501.93
61215	Major surgery	INSERT BRAIN-FLUID DEVICE	927.42	927.42
61250	Major surgery	PIERCE SKULL & EXPLORE	1547.56	1547.56
61253	Major surgery	PIERCE SKULL & EXPLORE	1768.28	1768.28
61304	Major surgery	OPEN SKULL FOR EXPLORATION	2907.35	2907.35
61305	Major surgery	OPEN SKULL FOR EXPLORATION	3548.53	3548.53
61312	Major surgery	OPEN SKULL FOR DRAINAGE	3658.77	3658.77
61313	Major surgery	OPEN SKULL FOR DRAINAGE	3516.90	3516.90
61314	Major surgery	OPEN SKULL FOR DRAINAGE	3234.08	3234.08
61315	Major surgery	OPEN SKULL FOR DRAINAGE	3660.68	3660.68
61316	Major surgery	IMPLT CRAN BONE FLAP TO ABDO	152.57	152.57
61320	Major surgery	OPEN SKULL FOR DRAINAGE	3349.44	3349.44
61321	Major surgery	OPEN SKULL FOR DRAINAGE	3756.56	3756.56
61322	Major surgery	DECOMPRESSIVE CRANIOTOMY	4213.33	4213.33
61323	Major surgery	DECOMPRESSIVE LOBECTOMY	4221.65	4221.65
61330	Major surgery	DECOMPRESS EYE SOCKET	3178.95	3178.95
61333	Major surgery	EXPLORE ORBIT/REMOVE LESION	3563.57	3563.57
61340	Major surgery	SUBTEMPORAL DECOMPRESSION	2555.48	2555.48
61343	Major surgery	INCISE SKULL (PRESS RELIEF)	3878.02	3878.02
61345	Major surgery	RELIEVE CRANIAL PRESSURE	3613.95	3613.95
61450	Major surgery	INCISE SKULL FOR SURGERY	3395.30	3395.30
61458	Major surgery	INCISE SKULL FOR BRAIN WOUND	3558.52	3558.52
61460	Major surgery	INCISE SKULL FOR SURGERY	3725.26	3725.26
61500	Major surgery	REMOVAL OF SKULL LESION	2325.57	2325.57
61501	Major surgery	REMOVE INFECTED SKULL BONE	2027.81	2027.81
61510	Major surgery	REMOVAL OF BRAIN LESION	3900.49	3900.49
61512	Major surgery	REMOVE BRAIN LINING LESION	4507.70	4507.70
61514	Major surgery	REMOVAL OF BRAIN ABSCESS	3389.59	3389.59
61516	Major surgery	REMOVAL OF BRAIN LESION	3320.07	3320.07
61517	Major surgery	IMPLT BRAIN CHEMOTX ADD-ON	151.92	151.92
61518	Major surgery	REMOVAL OF BRAIN LESION	4895.57	4895.57
61519	Major surgery	REMOVE BRAIN LINING LESION	5188.62	5188.62
61520	Major surgery	REMOVAL OF BRAIN LESION	6576.47	6576.47
61521	Major surgery	REMOVAL OF BRAIN LESION	5599.80	5599.80
61522	Major surgery	REMOVAL OF BRAIN ABSCESS	3867.84	3867.84
61524	Major surgery	REMOVAL OF BRAIN LESION	3686.90	3686.90
61526	Major surgery	REMOVAL OF BRAIN LESION	5948.67	5948.67
61530	Major surgery	REMOVAL OF BRAIN LESION	5409.53	5409.53
61531	Major surgery	IMPLANT BRAIN ELECTRODES	2184.23	2184.23
61533	Major surgery	IMPLANT BRAIN ELECTRODES	2708.88	2708.88
61534	Major surgery	REMOVAL OF BRAIN LESION	2930.05	2930.05
61535	Major surgery	REMOVE BRAIN ELECTRODES	1795.62	1795.62
61536	Major surgery	REMOVAL OF BRAIN LESION	4547.19	4547.19
61537	Major surgery	REMOVAL OF BRAIN TISSUE	4330.07	4330.07
61538	Major surgery	REMOVAL OF BRAIN TISSUE	4686.86	4686.86
61539	Major surgery	REMOVAL OF BRAIN TISSUE	4168.24	4168.24
61540	Major surgery	REMOVAL OF BRAIN TISSUE	3847.14	3847.14
61541	Major surgery	INCISION OF BRAIN TISSUE	3801.78	3801.78
61543	Major surgery	REMOVAL OF BRAIN TISSUE	3842.85	3842.85
61544	Major surgery	REMOVE & TREAT BRAIN LESION	3358.39	3358.39
61545	Major surgery	EXCISION OF BRAIN TUMOR	5621.09	5621.09
61546	Major surgery	REMOVAL OF PITUITARY GLAND	4077.53	4077.53
61548	Major surgery	REMOVAL OF PITUITARY GLAND	2789.61	2789.61
61550	Major surgery	RELEASE OF SKULL SEAMS	2136.62	2136.62
61552	Major surgery	RELEASE OF SKULL SEAMS	2642.35	2642.35
61556	Major surgery	INCISE SKULL/SUTURES	3028.76	3028.76
61557	Major surgery	INCISE SKULL/SUTURES	2995.69	2995.69
61558	Major surgery	EXCISION OF SKULL/SUTURES	3337.11	3337.11
61559	Major surgery	EXCISION OF SKULL/SUTURES	4245.72	4245.72
61563	Major surgery	EXCISION OF SKULL TUMOR	3507.52	3507.52
61564	Major surgery	EXCISION OF SKULL TUMOR	4252.23	4252.23
61566	Major surgery	REMOVAL OF BRAIN TISSUE	3958.64	3958.64
61567	Major surgery	INCISION OF BRAIN TISSUE	4508.58	4508.58
61570	Major surgery	REMOVE FOREIGN BODY BRAIN	3315.86	3315.86
61571	Major surgery	INCISE SKULL FOR BRAIN WOUND	3525.35	3525.35
61575	Major surgery	SKULL BASE/BRAINSTEM SURGERY	4419.62	4419.62
61576	Major surgery	SKULL BASE/BRAINSTEM SURGERY	7358.34	7358.34
61580	Major surgery	CRANIOFACIAL APPROACH SKULL	4460.98	4460.98
61581	Major surgery	CRANIOFACIAL APPROACH SKULL	4906.75	4906.75
61582	Major surgery	CRANIOFACIAL APPROACH SKULL	5326.07	5326.07
61583	Major surgery	CRANIOFACIAL APPROACH SKULL	5163.66	5163.66
61584	Major surgery	ORBITOCRANIAL APPROACH/SKULL	5091.90	5091.90
61585	Major surgery	ORBITOCRANIAL APPROACH/SKULL	5783.23	5783.23
61586	Major surgery	RESECT NASOPHARYNX SKULL	4479.17	4479.17
61590	Major surgery	INFRATEMPORAL APPROACH/SKULL	5434.63	5434.63
61591	Major surgery	INFRATEMPORAL APPROACH/SKULL	5509.18	5509.18
61592	Major surgery	ORBITOCRANIAL APPROACH/SKULL	5605.16	5605.16
61595	Major surgery	TRANSTEMPORAL APPROACH/SKULL	4281.99	4281.99
61596	Major surgery	TRANSCOCHLEAR APPROACH/SKULL	4412.62	4412.62
61597	Major surgery	TRANSCONDYLAR APPROACH/SKULL	5239.34	5239.34
61598	Major surgery	TRANSPETROSAL APPROACH/SKULL	5037.51	5037.51
61600	Major surgery	RESECT/EXCISE CRANIAL LESION	3811.90	3811.90
61601	Major surgery	RESECT/EXCISE CRANIAL LESION	4307.90	4307.90
61605	Major surgery	RESECT/EXCISE CRANIAL LESION	3912.99	3912.99
61606	Major surgery	RESECT/EXCISE CRANIAL LESION	5155.94	5155.94
61607	Major surgery	RESECT/EXCISE CRANIAL LESION	5356.71	5356.71
61608	Major surgery	RESECT/EXCISE CRANIAL LESION	5785.61	5785.61
61611	Major surgery	TRANSECT ARTERY SINUS	813.99	813.99
61613	Major surgery	REMOVE ANEURYSM SINUS	5789.43	5789.43
61615	Major surgery	RESECT/EXCISE LESION SKULL	4971.00	4971.00
61616	Major surgery	RESECT/EXCISE LESION SKULL	5914.66	5914.66
61618	Major surgery	REPAIR DURA	2295.21	2295.21
61619	Major surgery	REPAIR DURA	2563.80	2563.80
61623	Neurology	ENDOVASC TEMPORY VESSEL OCCL	796.93	796.93
61624	Neurology	TRANSCATH OCCLUSION CNS	1605.37	1605.37
61626	Neurology	TRANSCATH OCCLUSION NON-CNS	1258.70	1258.70
61630	Neurology	INTRACRANIAL ANGIOPLASTY	1893.93	1893.93
61635	Neurology	INTRACRAN ANGIOPLSTY W/STENT	2058.22	2058.22
61640	Neurology	DILATE IC VASOSPASM INIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
61641	Major surgery	DILAT IC VSPSM EA VSL SM TER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
61642	Major surgery	DILAT IC VSPSM EA DIFF TER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
61645	Neurology	PERQ ART M-THROMBECT &/NFS	1168.49	1168.49
61650	Neurology	EVASC PRLNG ADMN RX AGNT 1ST	803.49	803.49
61651	Other professional services	EVASC PRLNG ADMN RX AGNT ADD	336.14	336.14
61680	Major surgery	INTRACRANIAL VESSEL SURGERY	4012.09	4012.09
61682	Major surgery	INTRACRANIAL VESSEL SURGERY	7320.61	7320.61
61684	Major surgery	INTRACRANIAL VESSEL SURGERY	5010.95	5010.95
61686	Major surgery	INTRACRANIAL VESSEL SURGERY	7884.38	7884.38
61690	Major surgery	INTRACRANIAL VESSEL SURGERY	3858.02	3858.02
61692	Major surgery	INTRACRANIAL VESSEL SURGERY	6412.58	6412.58
61697	Major surgery	BRAIN ANEURYSM REPR COMPLX	7422.15	7422.15
61698	Major surgery	BRAIN ANEURYSM REPR COMPLX	8118.22	8118.22
61700	Major surgery	BRAIN ANEURYSM REPR SIMPLE	6007.56	6007.56
61702	Major surgery	INNER SKULL VESSEL SURGERY	7063.64	7063.64
61703	Major surgery	CLAMP NECK ARTERY	2416.38	2416.38
61705	Major surgery	REVISE CIRCULATION TO HEAD	4588.88	4588.88
61708	Major surgery	REVISE CIRCULATION TO HEAD	4491.12	4491.12
61710	Major surgery	REVISE CIRCULATION TO HEAD	3789.71	3789.71
61711	Major surgery	FUSION OF SKULL ARTERIES	4599.11	4599.11
61720	Major surgery	INCISE SKULL/BRAIN SURGERY	2260.34	2260.34
61735	Major surgery	INCISE SKULL/BRAIN SURGERY	2831.50	2831.50
61736	Major surgery	LITT ICR 1 TRAJ 1 SMPL LES	2123.24	2123.24
61737	Major surgery	LITT ICR MLT TRJ MLT/CPLX LS	2547.64	2547.64
61750	Major surgery	INCISE SKULL/BRAIN BIOPSY	2497.27	2497.27
61751	Major surgery	BRAIN BIOPSY W/CT/MR GUIDE	2468.27	2468.27
61760	Major surgery	IMPLANT BRAIN ELECTRODES	2796.44	2796.44
61770	Major surgery	INCISE SKULL FOR TREATMENT	2872.37	2872.37
61781	Major surgery	SCAN PROC CRANIAL INTRA	410.67	410.67
61782	Major surgery	SCAN PROC CRANIAL EXTRA	310.52	310.52
61783	Major surgery	SCAN PROC SPINAL	404.96	404.96
61790	Major surgery	TREAT TRIGEMINAL NERVE	1573.47	1573.47
61791	Major surgery	TREAT TRIGEMINAL TRACT	2005.42	2005.42
61796	Major surgery	SRS CRANIAL LESION SIMPLE	1811.94	1811.94
61797	Major surgery	SRS CRAN LES SIMPLE ADDL	382.51	382.51
61798	Major surgery	SRS CRANIAL LESION COMPLEX	2448.67	2448.67
61799	Major surgery	SRS CRAN LES COMPLEX ADDL	528.63	528.63
61800	Major surgery	APPLY SRS HEADFRAME ADD-ON	263.56	263.56
61850	Major surgery	IMPLANT NEUROELECTRODES	1756.74	1756.74
61860	Major surgery	IMPLANT NEUROELECTRODES	2769.99	2769.99
61863	Major surgery	IMPLANT NEUROELECTRODE	2674.60	2674.60
61864	Major surgery	IMPLANT NEUROELECTRDE ADDL	492.38	492.38
61867	Major surgery	IMPLANT NEUROELECTRODE	4029.52	4029.52
61868	Major surgery	IMPLANT NEUROELECTRDE ADDL	869.45	869.45
61880	Major surgery	REVISE/REMOVE NEUROELECTRODE	1051.81	1051.81
61885	Major surgery	INSRT/REDO NEUROSTIM 1 ARRAY	946.61	946.61
61886	Major surgery	IMPLANT NEUROSTIM ARRAYS	1576.77	1576.77
61888	Neurology	REVISE/REMOVE NEURORECEIVER	556.77	556.77
61889	Major surgery	INS SK-MNT CRNL NSTM PG/RCVR	2314.24	2314.24
61891	Major surgery	REV/RPLCMT SK-MNT CRNL NSTM	1094.16	1094.16
61892	Major surgery	RMV SK-MNT CRNL NSTM PG/RCVR	1512.73	1512.73
62000	Major surgery	TREAT SKULL FRACTURE	1843.20	1843.20
62005	Major surgery	TREAT SKULL FRACTURE	2262.00	2262.00
62010	Major surgery	TREATMENT OF HEAD INJURY	2729.77	2729.77
62100	Major surgery	REPAIR BRAIN FLUID LEAKAGE	2805.68	2805.68
62115	Major surgery	REDUCTION OF SKULL DEFECT	2998.24	2998.24
62117	Major surgery	REDUCTION OF SKULL DEFECT	3474.06	3474.06
62120	Major surgery	REPAIR SKULL CAVITY LESION	3682.73	3682.73
62121	Major surgery	INCISE SKULL REPAIR	2796.01	2796.01
62140	Major surgery	CRNOP SKULL DEFECT<5 CM DIAM	1826.19	1826.19
62141	Major surgery	CRNOP SKULL DEFECT>5 CM DIAM	2037.26	2037.26
62142	Major surgery	RMVL B1 FLP/PROSTC PLATE SKL	1594.07	1594.07
62143	Major surgery	RPL B1 FLP/PROSTC PLATE SKL	1859.50	1859.50
62145	Major surgery	REPAIR OF SKULL & BRAIN	2520.82	2520.82
62146	Major surgery	CRNOP W/AUTOGRAFT<5 CM DIAM	2222.81	2222.81
62147	Major surgery	CRNOP W/AUTOGRAFT>5 CM DIAM	2520.38	2520.38
62148	Major surgery	RETR BONE FLAP TO FIX SKULL	219.28	219.28
62160	Major surgery	NEUROENDOSCOPY ADD-ON	327.74	327.74
62161	Major surgery	DISSECT BRAIN W/SCOPE	2707.67	2707.67
62162	Major surgery	REMOVE COLLOID CYST W/SCOPE	3347.16	3347.16
62164	Major surgery	REMOVE BRAIN TUMOR W/SCOPE	3711.73	3711.73
62165	Major surgery	REMOVE PITUIT TUMOR W/SCOPE	2713.80	2713.80
62180	Major surgery	ESTABLISH BRAIN CAVITY SHUNT	2837.00	2837.00
62190	Major surgery	ESTABLISH BRAIN CAVITY SHUNT	1660.64	1660.64
62192	Major surgery	ESTABLISH BRAIN CAVITY SHUNT	1772.98	1772.98
62194	Neurology	REPLACE/IRRIGATE CATHETER	695.78	695.78
62200	Major surgery	ESTABLISH BRAIN CAVITY SHUNT	2443.74	2443.74
62201	Major surgery	BRAIN CAVITY SHUNT W/SCOPE	2164.79	2164.79
62220	Major surgery	ESTABLISH BRAIN CAVITY SHUNT	1736.88	1736.88
62223	Major surgery	ESTABLISH BRAIN CAVITY SHUNT	1845.42	1845.42
62225	Major surgery	REPLACE/IRRIGATE CATHETER	962.68	962.68
62230	Major surgery	REPLACE/REVISE BRAIN SHUNT	1500.41	1500.41
62252	Neurology	CSF SHUNT REPROGRAM	119.23	119.23
62252-26	Neurology	CSF SHUNT REPROGRAM	62.78	62.78
62252-TC	Neurology	CSF SHUNT REPROGRAM	56.47	56.47
62256	Major surgery	REMOVE BRAIN CAVITY SHUNT	1097.13	1097.13
62258	Major surgery	REPLACE BRAIN CAVITY SHUNT	1984.14	1984.14
62263	Pain management	EPIDURAL LYSIS MULT SESSIONS	972.59	493.17
62264	Pain management	EPIDURAL LYSIS ON SINGLE DAY	662.24	371.62
62267	Pain management	INTERDISCAL PERQ ASPIR DX	397.62	232.55
62268	Pain management	DRAIN SPINAL CORD CYST	483.64	483.64
62269	Pain management	NEEDLE BIOPSY SPINAL CORD	391.75	391.75
62270	Pain management	DX LMBR SPI PNXR	218.03	94.96
62272	Pain management	THER SPI PNXR DRG CSF	274.62	135.75
62273	Pain management	INJECT EPIDURAL PATCH	254.52	171.98
62280	Pain management	TREAT SPINAL CORD LESION	493.94	242.87
62281	Pain management	TREAT SPINAL CORD LESION	363.65	236.63
62282	Pain management	TREAT SPINAL CANAL LESION	467.26	215.70
62284	Pain management	INJECTION FOR MYELOGRAM	280.49	125.30
62287	Major surgery	DCMPRN PX PERQ 1/MLT LUMBAR	1096.27	1096.27
62290	Pain management	NJX PX DISCOGRAPHY LUMBAR	516.16	236.92
62291	Pain management	NJX PX DISCOGRAPHY CRV/THRC	465.32	216.72
62292	Major surgery	NJX CHEMONUCLEOLYSIS LMBR	1059.67	1059.67
62294	Major surgery	INJECTION INTO SPINAL ARTERY	1698.72	1698.72
62302	Pain management	MYELOGRAPHY LUMBAR INJECTION	381.11	179.46
62303	Pain management	MYELOGRAPHY LUMBAR INJECTION	387.66	179.59
62304	Pain management	MYELOGRAPHY LUMBAR INJECTION	378.98	177.33
62305	Pain management	MYELOGRAPHY LUMBAR INJECTION	412.47	184.14
62320	Pain management	NJX INTERLAMINAR CRV/THRC	246.78	150.91
62321	Pain management	NJX INTERLAMINAR CRV/THRC	395.00	163.21
62322	Pain management	NJX INTERLAMINAR LMBR/SAC	204.42	120.39
62323	Pain management	NJX INTERLAMINAR LMBR/SAC	388.14	150.89
62324	Pain management	NJX INTERLAMINAR CRV/THRC	208.36	135.71
62325	Pain management	NJX INTERLAMINAR CRV/THRC	376.58	168.00
62326	Pain management	NJX INTERLAMINAR LMBR/SAC	208.43	129.85
62327	Pain management	NJX INTERLAMINAR LMBR/SAC	409.49	162.87
62328	Pain management	DX LMBR SPI PNXR W/FLUOR/CT	332.63	129.01
62329	Pain management	THER SPI PNXR CSF FLUOR/CT	390.83	156.56
62350	Pain management	IMPLANT SPINAL CANAL CATH	602.11	602.11
62351	Major surgery	IMPLANT SPINAL CANAL CATH	1630.61	1630.61
62355	Pain management	REMOVE SPINAL CANAL CATHETER	416.35	416.35
62360	Pain management	INSERT SPINE INFUSION DEVICE	468.53	468.53
62361	Pain management	IMPLANT SPINE INFUSION PUMP	651.07	651.07
62362	Pain management	IMPLANT SPINE INFUSION PUMP	581.00	581.00
62365	Pain management	REMOVE SPINE INFUSION DEVICE	449.23	449.23
62367	Pain management	ANALYZE SPINE INFUS PUMP	48.51	37.64
62368	Pain management	ANALYZE SP INF PUMP W/REPROG	67.27	51.95
62369	Pain management	ANAL SP INF PMP W/REPRG&FILL	138.44	52.93
62370	Pain management	ANL SP INF PMP W/MDREPRG&FIL	139.07	69.37
62380	Major surgery	NDSC DCMPRN 1 NTRSPC LUMBAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
63001	Major surgery	REMOVE SPINE LAMINA 1/2 CRVL	2190.06	2190.06
63003	Major surgery	REMOVE SPINE LAMINA 1/2 THRC	2199.29	2199.29
63005	Major surgery	REMOVE SPINE LAMINA 1/2 LMBR	2140.83	2140.83
63011	Major surgery	REMOVE SPINE LAMINA 1/2 SCRL	1956.61	1956.61
63012	Major surgery	REMOVE LAMINA/FACETS LUMBAR	2131.16	2131.16
63015	Major surgery	REMOVE SPINE LAMINA >2 CRVCL	2635.39	2635.39
63016	Major surgery	REMOVE SPINE LAMINA >2 THRC	2713.56	2713.56
63017	Major surgery	REMOVE SPINE LAMINA >2 LMBR	2253.58	2253.58
63020	Major surgery	NECK SPINE DISK SURGERY	1963.77	1963.77
63030	Major surgery	LOW BACK DISK SURGERY	1638.37	1638.37
63035	Major surgery	SPINAL DISK SURGERY ADD-ON	410.77	410.77
63040	Major surgery	LAMINOTOMY SINGLE CERVICAL	2460.90	2460.90
63042	Major surgery	LAMINOTOMY SINGLE LUMBAR	2317.89	2317.89
63043	Major surgery	LAMINOTOMY ADDL CERVICAL	573.11	573.11
63044	Major surgery	LAMINOTOMY ADDL LUMBAR	540.40	540.40
63045	Major surgery	LAM FACETEC & FORAMOT CRV	2295.58	2295.58
63046	Major surgery	LAM FACETEC & FORAMOT THRC	2196.17	2196.17
63047	Major surgery	LAM FACETEC & FORAMOT LUMBAR	1977.87	1977.87
63048	Major surgery	LAM FACETEC &FORAMOT EA ADDL	370.38	370.38
63050	Major surgery	CERVICAL LAMINOPLSTY 2/> SEG	2623.86	2623.86
63051	Major surgery	C-LAMINOPLASTY W/GRAFT/PLATE	3018.60	3018.60
63052	Major surgery	LAM FACETC/FRMT ARTHRD LUM 1	453.86	453.86
63053	Major surgery	LAM FACTC/FRMT ARTHRD LUM EA	403.30	403.30
63055	Major surgery	DECOMPRESS SPINAL CORD THRC	2886.10	2886.10
63056	Major surgery	DECOMPRESS SPINAL CORD LMBR	2653.46	2653.46
63057	Major surgery	DECOMPRESS SPINE CORD ADD-ON	563.76	563.76
63064	Major surgery	DECOMPRESS SPINAL CORD THRC	3155.06	3155.06
63066	Major surgery	DECOMPRESS SPINE CORD ADD-ON	357.71	357.71
63075	Major surgery	NECK SPINE DISK SURGERY	2413.32	2413.32
63076	Major surgery	NECK SPINE DISK SURGERY	426.31	426.31
63077	Major surgery	SPINE DISK SURGERY THORAX	2625.85	2625.85
63078	Major surgery	SPINE DISK SURGERY THORAX	360.01	360.01
63081	Major surgery	REMOVE VERT BODY DCMPRN CRVL	3135.42	3135.42
63082	Major surgery	REMOVE VERTEBRAL BODY ADD-ON	467.24	467.24
63085	Major surgery	REMOVE VERT BODY DCMPRN THRC	3450.88	3450.88
63086	Major surgery	REMOVE VERTEBRAL BODY ADD-ON	336.38	336.38
63087	Major surgery	REMOV VERTBR DCMPRN THRCLMBR	4297.57	4297.57
63088	Major surgery	REMOVE VERTEBRAL BODY ADD-ON	454.64	454.64
63090	Major surgery	REMOVE VERT BODY DCMPRN LMBR	3473.83	3473.83
63091	Major surgery	REMOVE VERTEBRAL BODY ADD-ON	310.21	310.21
63101	Major surgery	REMOVE VERT BODY DCMPRN THRC	4126.80	4126.80
63102	Major surgery	REMOVE VERT BODY DCMPRN LMBR	4064.56	4064.56
63103	Major surgery	REMOVE VERTEBRAL BODY ADD-ON	515.74	515.74
63170	Major surgery	INCISE SPINAL CORD TRACT(S)	2830.41	2830.41
63172	Major surgery	DRAINAGE OF SPINAL CYST	2509.46	2509.46
63173	Major surgery	DRAINAGE OF SPINAL CYST	3062.26	3062.26
63185	Major surgery	INCISE SPINE NRV HALF SEGMNT	2190.03	2190.03
63190	Major surgery	INCISE SPINE NRV >2 SEGMNTS	2233.22	2233.22
63191	Major surgery	INCISE SPINE ACCESSORY NERVE	2457.51	2457.51
63197	Major surgery	LAM W/CORDOTOMY 1STG THRC	3036.40	3036.40
63200	Major surgery	RELEASE SPINAL CORD LUMBAR	2723.49	2723.49
63250	Major surgery	REVISE SPINAL CORD VSLS CRVL	5221.92	5221.92
63251	Major surgery	REVISE SPINAL CORD VSLS THRC	5339.70	5339.70
63252	Major surgery	REVISE SPINE CORD VSL THRLMB	5339.08	5339.08
63265	Major surgery	EXCISE INTRASPINL LESION CRV	2967.22	2967.22
63266	Major surgery	EXCISE INTRSPINL LESION THRC	3047.85	3047.85
63267	Major surgery	EXCISE INTRSPINL LESION LMBR	2447.00	2447.00
63268	Major surgery	EXCISE INTRSPINL LESION SCRL	2601.09	2601.09
63270	Major surgery	EXCISE INTRSPINL LESION CRVL	3676.51	3676.51
63271	Major surgery	EXCISE INTRSPINL LESION THRC	3669.35	3669.35
63272	Major surgery	EXCISE INTRSPINL LESION LMBR	3330.66	3330.66
63273	Major surgery	EXCISE INTRSPINL LESION SCRL	3311.28	3311.28
63275	Major surgery	BX/EXC XDRL SPINE LESN CRVL	3195.47	3195.47
63276	Major surgery	BX/EXC XDRL SPINE LESN THRC	3175.07	3175.07
63277	Major surgery	BX/EXC XDRL SPINE LESN LMBR	2778.95	2778.95
63278	Major surgery	BX/EXC XDRL SPINE LESN SCRL	2832.26	2832.26
63280	Major surgery	BX/EXC IDRL SPINE LESN CRVL	3752.42	3752.42
63281	Major surgery	BX/EXC IDRL SPINE LESN THRC	3722.16	3722.16
63282	Major surgery	BX/EXC IDRL SPINE LESN LMBR	3510.72	3510.72
63283	Major surgery	BX/EXC IDRL SPINE LESN SCRL	3375.68	3375.68
63285	Major surgery	BX/EXC IDRL IMED LESN CERVL	4616.76	4616.76
63286	Major surgery	BX/EXC IDRL IMED LESN THRC	4546.70	4546.70
63287	Major surgery	BX/EXC IDRL IMED LESN THRLMB	4839.24	4839.24
63290	Major surgery	BX/EXC XDRL/IDRL LSN ANY LVL	4920.51	4920.51
63295	Major surgery	REPAIR LAMINECTOMY DEFECT	573.98	573.98
63300	Major surgery	REMOVE VERT XDRL BODY CRVCL	3223.47	3223.47
63301	Major surgery	REMOVE VERT XDRL BODY THRC	3904.31	3904.31
63302	Major surgery	REMOVE VERT XDRL BODY THRLMB	3858.04	3858.04
63303	Major surgery	REMOV VERT XDRL BDY LMBR/SAC	4089.21	4089.21
63304	Major surgery	REMOVE VERT IDRL BODY CRVCL	4153.83	4153.83
63305	Major surgery	REMOVE VERT IDRL BODY THRC	4417.32	4417.32
63306	Major surgery	REMOV VERT IDRL BDY THRCLMBR	4341.01	4341.01
63307	Major surgery	REMOV VERT IDRL BDY LMBR/SAC	4249.40	4249.40
63308	Major surgery	REMOVE VERTEBRAL BODY ADD-ON	562.13	562.13
63600	Major surgery	REMOVE SPINAL CORD LESION	1945.73	1945.73
63610	Pain management	STIMULATION OF SPINAL CORD	849.91	849.91
63620	Major surgery	SRS SPINAL LESION	2000.68	2000.68
63621	Major surgery	SRS SPINAL LESION ADDL	439.41	439.41
63650	Pain management	IMPLANT NEUROELECTRODES	3392.44	630.66
63655	Major surgery	IMPLANT NEUROELECTRODES	1501.56	1501.56
63661	Pain management	REMOVE SPINE ELTRD PERQ ARAY	1024.96	497.62
63662	Major surgery	REMOVE SPINE ELTRD PLATE	1523.16	1523.16
63663	Pain management	REVISE SPINE ELTRD PERQ ARAY	1356.57	684.91
63664	Major surgery	REVISE SPINE ELTRD PLATE	1584.96	1584.96
63685	Pain management	INS/RPLC SPI NPG/RCVR POCKET	513.11	513.11
63688	Pain management	REV/RMV IMP SP NPG/R DTCH CN	452.37	452.37
63700	Major surgery	REPAIR OF SPINAL HERNIATION	2338.69	2338.69
63702	Major surgery	REPAIR OF SPINAL HERNIATION	2551.67	2551.67
63704	Major surgery	REPAIR OF SPINAL HERNIATION	2967.96	2967.96
63706	Major surgery	REPAIR OF SPINAL HERNIATION	3289.42	3289.42
63707	Major surgery	REPAIR SPINAL FLUID LEAKAGE	1678.52	1678.52
63709	Major surgery	REPAIR SPINAL FLUID LEAKAGE	1993.17	1993.17
63710	Major surgery	GRAFT REPAIR OF SPINE DEFECT	1942.61	1942.61
63740	Major surgery	INSTALL SPINAL SHUNT	1761.51	1761.51
63741	Major surgery	INSTALL SPINAL SHUNT	1222.49	1222.49
63744	Major surgery	REVISION OF SPINAL SHUNT	1224.95	1224.95
63746	Major surgery	REMOVAL OF SPINAL SHUNT	1096.13	1096.13
64400	Pain management	NJX AA&/STRD TRIGEMINAL NRV	169.06	76.64
64405	Pain management	NJX AA&/STRD GR OCPL NRV	112.84	78.73
64408	Pain management	NJX AA&/STRD VAGUS NRV	122.51	67.66
64415	Pain management	NJX AA&/STRD BRCH PLXS IMG	202.79	105.93
64416	Pain management	NJX AA&/STRD BRCH PL NFS IMG	117.70	117.70
64417	Pain management	NJX AA&/STRD AX NERVE IMG	241.09	97.26
64418	Pain management	NJX AA&/STRD SPRSCAP NRV	130.68	84.22
64420	Pain management	NJX AA&/STRD NTRCOST NRV 1	148.18	88.38
64421	Pain management	NJX AA&/STRD NTRCOST NRV EA	50.71	37.85
64425	Pain management	NJX AA&/STRD II IH NERVES	166.63	82.62
64430	Pain management	NJX AA&/STRD PUDENDAL NERVE	148.07	82.84
64435	Pain management	NJX AA&/STRD PARACRV NRV	120.75	65.90
64445	Pain management	NJX AA&/STRD SCIATIC NRV IMG	238.80	109.31
64446	Pain management	NJX AA&/STRD SC NRV NFS IMG	115.03	115.03
64447	Pain management	NJX AA&/STRD FEMORAL NRV IMG	175.75	96.19
64448	Pain management	NJX AA&/STRD FEM NRV NFS IMG	109.96	109.96
64449	Pain management	NJX AA&/STRD LMBR PLEX NFS	96.48	96.48
64450	Pain management	NJX AA&/STRD OTHER PN/BRANCH	113.40	63.49
64451	Pain management	NJX AA&/STRD NRV NRVTG SI JT	342.10	124.16
64454	Pain management	NJX AA&/STRD GNCLR NRV BRNCH	333.22	125.14
64455	Pain management	NJX AA&/STRD PLTR COM DG NRV	76.27	51.05
64461	Pain management	PVB THORACIC SINGLE INJ SITE	203.36	118.84
64462	Other professional services	PVB THORACIC 2ND+ INJ SITE	99.72	67.89
64463	Pain management	PVB THORACIC CONT INFUSION	342.84	124.39
64479	Pain management	NJX AA&/STRD TFRM EPI C/T 1	400.52	198.37
64480	Major surgery	NJX AA&/STRD TFRM EPI C/T EA	242.70	110.86
64483	Pain management	NJX AA&/STRD TFRM EPI L/S 1	370.73	169.08
64484	Major surgery	NJX AA&/STRD TFRM EPI L/S EA	200.54	93.52
64486	Pain management	TAP BLOCK UNIL BY INJECTION	168.56	84.04
64487	Pain management	TAP BLOCK UNI BY INFUSION	319.99	96.59
64488	Pain management	TAP BLOCK BI INJECTION	208.13	104.84
64489	Pain management	TAP BLOCK BI BY INFUSION	517.05	117.70
64490	Pain management	INJ PARAVERT F JNT C/T 1 LEV	290.84	159.87
64491	Major surgery	INJ PARAVERT F JNT C/T 2 LEV	176.12	107.54
64492	Major surgery	INJ PARAVERT F JNT C/T 3 LEV	176.73	109.32
64493	Pain management	INJ PARAVERT F JNT L/S 1 LEV	267.34	137.36
64494	Major surgery	INJ PARAVERT F JNT L/S 2 LEV	164.48	92.33
64495	Major surgery	INJ PARAVERT F JNT L/S 3 LEV	164.48	94.11
64505	Pain management	N BLOCK SPENOPALATINE GANGL	216.20	156.89
64510	Pain management	N BLOCK STELLATE GANGLION	220.60	116.82
64517	Pain management	N BLOCK INJ HYPOGAS PLXS	294.67	191.87
64520	Pain management	N BLOCK LUMBAR/THORACIC	345.53	129.06
64530	Pain management	N BLOCK INJ CELIAC PELUS	343.20	143.52
64553	Pain management	IMPLANT NEUROELECTRODES	5724.28	667.76
64555	Pain management	IMPLANT NEUROELECTRODES	3160.41	492.54
64561	Pain management	IMPLANT NEUROELECTRODES	1098.49	458.96
64566	Pain management	NEUROELTRD STIM POST TIBIAL	174.23	45.74
64568	Major surgery	OPN IMPLTJ CRNL NRV NEA&PG	1088.39	1088.39
64569	Major surgery	REVISE/REPL VAGUS N ELTRD	1376.93	1376.93
64570	Major surgery	REMOVE VAGUS N ELTRD	1316.25	1316.25
64575	Major surgery	OPN IMPLTJ NEA PERPH NERVE	568.74	568.74
64580	Major surgery	OPN IMPLTJ NEA NEUROMUSCULAR	565.70	565.70
64581	Major surgery	OPN IMPLTJ NEA SACRAL NERVE	1189.70	1189.70
64582	Major surgery	OPN MPLTJ HPGLSL NSTM ARY PG	1518.00	1518.00
64583	Major surgery	REV/RPLCT HPGLSL NSTM ARY PG	1566.92	1566.92
64584	Major surgery	RMVL HPGLSL NSTIM ARY PG	1321.98	1321.98
64585	Pain management	REV/RMV PERPH NSTIM ELTRD RA	363.96	218.16
64590	Pain management	INS/RPL PRPH SAC/GSTR NPG/R	665.82	446.38
64595	Pain management	REV/RMV PRPH SAC/GSTR NPG/R	547.86	347.70
64596	Pain management	INS/RPLCMT PRQ ELTRD RA PN 1	UCR or Pay Per Agreement	UCR or Pay Per Agreement
64597	Pain management	INS/RPLCM PRQ ELTRD RA PN EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
64598	Pain management	REVJ/RMVL NEA PN W/INT NSTIM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
64600	Pain management	INJECTION TREATMENT OF NERVE	713.21	355.88
64605	Pain management	INJECTION TREATMENT OF NERVE	1338.98	628.27
64610	Pain management	INJECTION TREATMENT OF NERVE	1147.05	714.10
64611	Pain management	CHEMODENERV SALIV GLANDS	196.68	168.02
64612	Pain management	DESTROY NERVE FACE MUSCLE	206.99	179.32
64615	Pain management	CHEMODENERV MUSC MIGRAINE	227.86	181.40
64616	Pain management	CHEMODENERV MUSC NECK DYSTON	205.89	162.40
64617	Pain management	CHEMODENER MUSCLE LARYNX EMG	244.43	163.88
64620	Pain management	INJECTION TREATMENT OF NERVE	319.04	269.62
64624	Pain management	DSTRJ NULYT AGT GNCLR NRV	582.95	222.15
64625	Pain management	RF ABLTJ NRV NRVTG SI JT	710.26	297.56
64628	Pain management	TRML DSTRJ IOS BVN 1ST 2 L/S	627.08	627.08
64629	Pain management	TRML DSTRJ IOS BVN EA ADDL	297.05	297.05
64630	Pain management	INJECTION TREATMENT OF NERVE	386.13	288.77
64632	Pain management	N BLOCK INJ COMMON DIGIT	138.39	102.80
64633	Pain management	DESTROY CERV/THOR FACET JNT	658.57	292.34
64634	Major surgery	DESTROY C/TH FACET JNT ADDL	457.57	121.74
64635	Pain management	DESTROY LUMB/SAC FACET JNT	664.01	292.85
64636	Major surgery	DESTROY L/S FACET JNT ADDL	429.35	106.53
64640	Pain management	INJECTION TREATMENT OF NERVE	373.60	180.85
64642	Pain management	CHEMODENERV 1 EXTREMITY 1-4	229.28	160.08
64643	Major surgery	CHEMODENERV 1 EXTREM 1-4 EA	167.91	125.35
64644	Pain management	CHEMODENERV 1 EXTREM 5/> MUS	266.52	173.61
64645	Major surgery	CHEMODENERV 1 EXTREM 5/> EA	215.69	144.75
64646	Pain management	CHEMODENERV TRUNK MUSC 1-5	240.98	172.76
64647	Pain management	CHEMODENERV TRUNK MUSC 6/>	274.41	198.79
64650	Pain management	CHEMODENERV ECCRINE GLANDS	133.06	61.39
64653	Pain management	CHEMODENERV ECCRINE GLANDS	156.02	77.44
64680	Pain management	INJECTION TREATMENT OF NERVE	512.52	243.67
64681	Pain management	INJECTION TREATMENT OF NERVE	679.74	332.29
64702	Major surgery	REVISE FINGER/TOE NERVE	937.09	937.09
64704	Major surgery	REVISE HAND/FOOT NERVE	594.79	594.79
64708	Major surgery	REVISE ARM/LEG NERVE	927.58	927.58
64712	Major surgery	REVISION OF SCIATIC NERVE	1077.45	1077.45
64713	Major surgery	REVISION OF ARM NERVE(S)	1444.72	1444.72
64714	Major surgery	REVISE LOW BACK NERVE(S)	1381.59	1381.59
64716	Major surgery	REVISION OF CRANIAL NERVE	929.23	929.23
64718	Major surgery	REVISE ULNAR NERVE AT ELBOW	1098.16	1098.16
64719	Major surgery	REVISE ULNAR NERVE AT WRIST	744.02	744.02
64721	Major surgery	CARPAL TUNNEL SURGERY	810.77	797.16
64722	Major surgery	RELIEVE PRESSURE ON NERVE(S)	673.24	673.24
64726	Major surgery	RELEASE FOOT/TOE NERVE	494.21	494.21
64727	Major surgery	INTERNAL NERVE REVISION	323.70	323.70
64732	Major surgery	INCISION OF BROW NERVE	817.05	817.05
64734	Major surgery	INCISION OF CHEEK NERVE	922.10	922.10
64736	Major surgery	INCISION OF CHIN NERVE	605.87	605.87
64738	Major surgery	INCISION OF JAW NERVE	817.26	817.26
64740	Major surgery	INCISION OF TONGUE NERVE	833.64	833.64
64742	Major surgery	INCISION OF FACIAL NERVE	900.37	900.37
64744	Major surgery	INCISE NERVE BACK OF HEAD	908.13	908.13
64746	Major surgery	INCISE DIAPHRAGM NERVE	771.46	771.46
64755	Major surgery	INCISION OF STOMACH NERVES	1645.00	1645.00
64760	Major surgery	INCISION OF VAGUS NERVE	935.79	935.79
64763	Major surgery	INCISE HIP/THIGH NERVE	925.92	925.92
64766	Major surgery	INCISE HIP/THIGH NERVE	1141.84	1141.84
64771	Major surgery	SEVER CRANIAL NERVE	1047.97	1047.97
64772	Major surgery	INCISION OF SPINAL NERVE	1012.71	1012.71
64774	Major surgery	REMOVE SKIN NERVE LESION	777.31	777.31
64776	Major surgery	REMOVE DIGIT NERVE LESION	738.64	738.64
64778	Major surgery	DIGIT NERVE SURGERY ADD-ON	320.35	320.35
64782	Major surgery	REMOVE LIMB NERVE LESION	831.60	831.60
64783	Major surgery	LIMB NERVE SURGERY ADD-ON	382.08	382.08
64784	Major surgery	REMOVE NERVE LESION	1309.80	1309.80
64786	Major surgery	REMOVE SCIATIC NERVE LESION	1795.70	1795.70
64787	Major surgery	IMPLANT NERVE END	418.28	418.28
64788	Major surgery	REMOVE SKIN NERVE LESION	742.46	742.46
64790	Major surgery	REMOVAL OF NERVE LESION	1527.77	1527.77
64792	Major surgery	REMOVAL OF NERVE LESION	1930.48	1930.48
64795	Pain management	BIOPSY OF NERVE	289.39	289.39
64802	Major surgery	SYMPATHECTOMY CERVICAL	1513.86	1513.86
64804	Major surgery	REMOVE SYMPATHETIC NERVES	2122.97	2122.97
64809	Major surgery	REMOVE SYMPATHETIC NERVES	1939.96	1939.96
64818	Major surgery	REMOVE SYMPATHETIC NERVES	1405.40	1405.40
64820	Major surgery	SYMPATHECTOMY DIGITAL ARTERY	1390.92	1390.92
64821	Major surgery	REMOVE SYMPATHETIC NERVES	1267.93	1267.93
64822	Major surgery	REMOVE SYMPATHETIC NERVES	1267.93	1267.93
64823	Major surgery	SYMPATHECTOMY SUPFC PALMAR	1434.40	1434.40
64831	Major surgery	REPAIR OF DIGIT NERVE	1259.39	1259.39
64832	Major surgery	REPAIR NERVE ADD-ON	592.27	592.27
64834	Major surgery	REPAIR OF HAND OR FOOT NERVE	1351.17	1351.17
64835	Major surgery	REPAIR OF HAND OR FOOT NERVE	1475.08	1475.08
64836	Major surgery	REPAIR OF HAND OR FOOT NERVE	1475.08	1475.08
64837	Major surgery	REPAIR NERVE ADD-ON	644.83	644.83
64840	Major surgery	REPAIR OF LEG NERVE	1735.27	1735.27
64856	Major surgery	REPAIR/TRANSPOSE NERVE	1810.73	1810.73
64857	Major surgery	REPAIR ARM/LEG NERVE	1894.29	1894.29
64858	Major surgery	REPAIR SCIATIC NERVE	2112.22	2112.22
64859	Major surgery	NERVE SURGERY	438.22	438.22
64861	Major surgery	REPAIR OF ARM NERVES	2702.66	2702.66
64862	Major surgery	REPAIR OF LOW BACK NERVES	2464.33	2464.33
64864	Major surgery	REPAIR OF FACIAL NERVE	1551.73	1551.73
64865	Major surgery	REPAIR OF FACIAL NERVE	1963.94	1963.94
64866	Major surgery	FUSION OF FACIAL/OTHER NERVE	2231.15	2231.15
64868	Major surgery	FUSION OF FACIAL/OTHER NERVE	1802.11	1802.11
64872	Major surgery	SUBSEQUENT REPAIR OF NERVE	204.95	204.95
64874	Major surgery	REPAIR & REVISE NERVE ADD-ON	307.22	307.22
64876	Major surgery	REPAIR NERVE/SHORTEN BONE	347.78	347.78
64885	Major surgery	NERVE GRAFT HEAD/NECK <4 CM	1947.15	1947.15
64886	Major surgery	NERVE GRAFT HEAD/NECK >4 CM	2327.15	2327.15
64890	Major surgery	NRV GRF 1STRND HND/FOOT <4CM	1940.56	1940.56
64891	Major surgery	NRV GRF 1STRND HND/FOOT >4CM	2063.18	2063.18
64892	Major surgery	NRV GRF 1STRND ARM/LEG <4CM	1889.02	1889.02
64893	Major surgery	NRV GRF 1STRND ARM/LEG >4 CM	2013.51	2013.51
64895	Major surgery	NRV GRF MLTST HND/FOOT <4 CM	2376.02	2376.02
64896	Major surgery	NRV GRF MLTST HND/FOOT >4 CM	2562.85	2562.85
64897	Major surgery	NRV GRF MLTST ARM/LEG <4 CM	2272.30	2272.30
64898	Major surgery	NRV GRF MLTST ARM/LEG >4 CM	2460.55	2460.55
64901	Major surgery	NERVE GRAFT ADD-ON	1052.47	1052.47
64902	Major surgery	NERVE GRAFT ADD-ON	1217.93	1217.93
64905	Major surgery	NERVE PEDICLE TRANSFER	1802.35	1802.35
64907	Major surgery	NERVE PEDICLE TRANSFER	2331.73	2331.73
64910	Major surgery	NERVE REPAIR W/ALLOGRAFT	1378.10	1378.10
64911	Major surgery	NEURORRAPHY W/VEIN AUTOGRAFT	1841.19	1841.19
64912	Major surgery	NRV RPR W/NRV ALGRFT 1ST	1612.08	1612.08
64913	Other professional services	NRV RPR W/NRV ALGRFT EA ADDL	236.97	236.97
64999	Major surgery	UNLISTED PX NERVOUS SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
65091	Major surgery	REVISE EYE	1339.34	1339.34
65093	Major surgery	REVISE EYE WITH IMPLANT	1327.66	1327.66
65101	Major surgery	REMOVAL OF EYE	1532.97	1532.97
65103	Major surgery	REMOVE EYE/INSERT IMPLANT	1583.19	1583.19
65105	Major surgery	REMOVE EYE/ATTACH IMPLANT	1722.57	1722.57
65110	Major surgery	REMOVAL OF EYE	2381.48	2381.48
65112	Major surgery	REMOVE EYE/REVISE SOCKET	2729.12	2729.12
65114	Major surgery	REMOVE EYE/REVISE SOCKET	2848.48	2848.48
65125	Major surgery	REVISE OCULAR IMPLANT	816.00	531.00
65130	Major surgery	INSERT OCULAR IMPLANT	1538.71	1538.71
65135	Major surgery	INSERT OCULAR IMPLANT	1557.72	1557.72
65140	Major surgery	ATTACH OCULAR IMPLANT	1673.70	1673.70
65150	Major surgery	REVISE OCULAR IMPLANT	1263.11	1263.11
65155	Major surgery	REINSERT OCULAR IMPLANT	1740.94	1740.94
65175	Major surgery	REMOVAL OF OCULAR IMPLANT	1404.29	1404.29
65205	Other professional services	REMOVE FOREIGN BODY FROM EYE	40.05	40.52
65210	Other professional services	REMOVE FOREIGN BODY FROM EYE	53.69	50.04
65220	Other professional services	REMOVE FOREIGN BODY FROM EYE	84.21	57.38
65222	Other professional services	REMOVE FOREIGN BODY FROM EYE	94.74	70.19
65235	Major surgery	REMOVE FOREIGN BODY FROM EYE	1320.11	1320.11
65260	Major surgery	REMOVE FOREIGN BODY FROM EYE	1767.46	1767.46
65265	Major surgery	REMOVE FOREIGN BODY FROM EYE	1989.88	1989.88
65270	Other professional services	REPAIR OF EYE WOUND	391.76	194.82
65272	Major surgery	REPAIR OF EYE WOUND	948.85	636.07
65273	Major surgery	REPAIR OF EYE WOUND	684.06	684.06
65275	Major surgery	REPAIR OF EYE WOUND	1062.18	829.80
65280	Major surgery	REPAIR OF EYE WOUND	1207.62	1207.62
65285	Major surgery	REPAIR OF EYE WOUND	1990.40	1990.40
65286	Major surgery	REPAIR OF EYE WOUND	1253.67	892.40
65290	Major surgery	REPAIR OF EYE SOCKET WOUND	882.65	882.65
65400	Major surgery	REMOVAL OF EYE LESION	1249.52	1086.33
65410	Other professional services	BIOPSY OF CORNEA	198.47	142.07
65420	Major surgery	REMOVAL OF EYE LESION	968.06	686.01
65426	Major surgery	REMOVAL OF EYE LESION	1203.29	862.72
65430	Other professional services	CORNEAL SMEAR	159.93	140.39
65435	Other professional services	CURETTE/TREAT CORNEA	114.33	96.60
65436	Major surgery	CURETTE/TREAT CORNEA	700.54	666.82
65450	Major surgery	TREATMENT OF CORNEAL LESION	595.65	583.23
65600	Major surgery	REVISION OF CORNEA	787.88	615.23
65710	Major surgery	CORNEAL TRANSPLANT	2051.03	2051.03
65730	Major surgery	CORNEAL TRANSPLANT	2254.82	2254.82
65750	Major surgery	CORNEAL TRANSPLANT	2269.33	2269.33
65755	Major surgery	CORNEAL TRANSPLANT	2262.16	2262.16
65756	Major surgery	CORNEAL TRNSPL ENDOTHELIAL	2127.59	2127.59
65757	Major surgery	PREP CORNEAL ENDO ALLOGRAFT	179.38	179.38
65760	Other professional services	REVISION OF CORNEA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
65765	Other professional services	REVISION OF CORNEA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
65767	Other professional services	CORNEAL TISSUE TRANSPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
65770	Major surgery	REVISE CORNEA WITH IMPLANT	2534.18	2534.18
65771	Other professional services	RADIAL KERATOTOMY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
65772	Major surgery	CORRECTION OF ASTIGMATISM	823.27	731.04
65775	Major surgery	CORRECTION OF ASTIGMATISM	1034.71	1034.71
65778	Other professional services	COVER EYE W/MEMBRANE	1487.07	61.67
65779	Other professional services	COVER EYE W/MEMBRANE SUTURE	1581.42	163.29
65780	Major surgery	OCULAR RECONST TRANSPLANT	1065.42	1065.42
65781	Major surgery	OCULAR RECONST TRANSPLANT	2387.31	2387.31
65782	Major surgery	OCULAR RECONST TRANSPLANT	2061.68	2061.68
65785	Major surgery	IMPLTJ NTRSTRML CRNL RNG SEG	3775.94	799.52
65800	Other professional services	DRAINAGE OF EYE	165.93	123.65
65810	Major surgery	DRAINAGE OF EYE	837.12	837.12
65815	Major surgery	DRAINAGE OF EYE	1154.13	859.09
65820	Major surgery	RELIEVE INNER EYE PRESSURE	1481.40	1481.40
65850	Major surgery	INCISION OF EYE	1519.34	1519.34
65855	Other professional services	TRABECULOPLASTY LASER SURG	340.31	284.81
65860	Major surgery	INCISE INNER EYE ADHESIONS	554.91	448.48
65865	Major surgery	INCISE INNER EYE ADHESIONS	862.31	862.31
65870	Major surgery	INCISE INNER EYE ADHESIONS	1071.37	1071.37
65875	Major surgery	INCISE INNER EYE ADHESIONS	1143.64	1143.64
65880	Major surgery	INCISE INNER EYE ADHESIONS	1201.57	1201.57
65900	Major surgery	REMOVE EYE LESION	1784.46	1784.46
65920	Major surgery	REMOVE IMPLANT OF EYE	1426.62	1426.62
65930	Major surgery	REMOVE BLOOD CLOT FROM EYE	1157.36	1157.36
66020	Other professional services	INJECTION TREATMENT OF EYE	272.64	182.13
66030	Other professional services	INJECTION TREATMENT OF EYE	245.40	154.44
66130	Major surgery	REMOVE EYE LESION	1269.66	1017.78
66150	Major surgery	GLAUCOMA SURGERY	1581.06	1581.06
66155	Major surgery	GLAUCOMA SURGERY	1580.42	1580.42
66160	Major surgery	GLAUCOMA SURGERY	1776.98	1776.98
66170	Major surgery	GLAUCOMA SURGERY	1971.33	1971.33
66172	Major surgery	INCISION OF EYE	2151.81	2151.81
66174	Major surgery	TRLUML DIL AQ O/F CAN W/O ST	1124.14	1124.14
66175	Major surgery	TRLUML DIL AQ O/F CAN W/ST	1306.56	1306.56
66179	Major surgery	AQUEOUS SHUNT EYE W/O GRAFT	1947.21	1947.21
66180	Major surgery	AQUEOUS SHUNT EYE W/GRAFT	2051.87	2051.87
66183	Major surgery	INSERT ANT DRAINAGE DEVICE	1855.31	1855.31
66184	Major surgery	REVISION OF AQUEOUS SHUNT	1426.97	1426.97
66185	Major surgery	REVISE AQUEOUS SHUNT EYE	1532.64	1532.64
66225	Major surgery	REPAIR/GRAFT EYE LESION	1685.97	1685.97
66250	Major surgery	FOLLOW-UP SURGERY OF EYE	1350.41	1002.75
66500	Major surgery	INCISION OF IRIS	710.19	710.19
66505	Major surgery	INCISION OF IRIS	772.43	772.43
66600	Major surgery	REMOVE IRIS AND LESION	1628.70	1628.70
66605	Major surgery	REMOVAL OF IRIS	1961.10	1961.10
66625	Major surgery	REMOVAL OF IRIS	773.25	773.25
66630	Major surgery	REMOVAL OF IRIS	1022.37	1022.37
66635	Major surgery	REMOVAL OF IRIS	1031.65	1031.65
66680	Major surgery	REPAIR IRIS & CILIARY BODY	939.67	939.67
66682	Major surgery	REPAIR IRIS & CILIARY BODY	1280.97	1280.97
66700	Major surgery	DESTRUCTION CILIARY BODY	817.01	706.45
66710	Major surgery	CILIARY TRANSSLERAL THERAPY	798.68	705.84
66711	Major surgery	ECP CILIARY BODY DESTRUCTION	912.19	912.19
66720	Major surgery	DESTRUCTION CILIARY BODY	844.47	741.59
66740	Major surgery	DESTRUCTION CILIARY BODY	793.94	706.45
66761	Other professional services	REVISION OF IRIS	413.99	327.57
66762	Major surgery	REVISION OF IRIS	861.14	765.36
66770	Major surgery	REMOVAL OF INNER EYE LESION	955.91	867.83
66820	Major surgery	INCISION SECONDARY CATARACT	842.15	842.15
66821	Major surgery	AFTER CATARACT LASER SURGERY	602.08	561.27
66825	Major surgery	REPOSITION INTRAOCULAR LENS	1498.24	1498.24
66830	Major surgery	REMOVAL OF LENS LESION	1278.79	1278.79
66840	Major surgery	REMOVAL OF LENS MATERIAL	1248.20	1248.20
66850	Major surgery	REMOVAL OF LENS MATERIAL	1419.74	1419.74
66852	Major surgery	REMOVAL OF LENS MATERIAL	1510.57	1510.57
66920	Major surgery	EXTRACTION OF LENS	1348.48	1348.48
66930	Major surgery	EXTRACTION OF LENS	1543.70	1543.70
66940	Major surgery	EXTRACTION OF LENS	1413.15	1413.15
66982	Major surgery	XCAPSL CTRC RMVL CPLX WO ECP	1342.56	1342.56
66983	Major surgery	CATARACT SURG W/IOL 1 STAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
66984	Major surgery	XCAPSL CTRC RMVL W/O ECP	979.86	979.86
66985	Major surgery	INSERT LENS PROSTHESIS	1385.36	1385.36
66986	Major surgery	EXCHANGE LENS PROSTHESIS	1624.74	1624.74
66987	Major surgery	XCAPSL CTRC RMVL CPLX W/ECP	1616.88	1616.88
66988	Major surgery	XCAPSL CTRC RMVL W/ECP	1313.73	1313.73
66989	Major surgery	XCPSL CTRC RMVL CPLX INSJ 1+	1541.51	1541.51
66990	Major surgery	OPHTHALMIC ENDOSCOPE ADD-ON	158.87	158.87
66991	Major surgery	XCAPSL CTRC RMVL INSJ 1+	1231.04	1231.04
66999	Major surgery	UNLISTED PX ANT SEGMENT EYE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
67005	Major surgery	PARTIAL REMOVAL OF EYE FLUID	860.52	860.52
67010	Major surgery	PARTIAL REMOVAL OF EYE FLUID	984.40	984.40
67015	Major surgery	RELEASE OF EYE FLUID	1088.84	1088.84
67025	Major surgery	REPLACE EYE FLUID	1333.33	1135.84
67027	Major surgery	IMPLANT EYE DRUG SYSTEM	1525.41	1525.41
67028	Other professional services	INJECTION EYE DRUG	157.10	127.08
67030	Major surgery	INCISE INNER EYE STRANDS	1004.31	1004.31
67031	Major surgery	LASER SURGERY EYE STRANDS	700.13	636.87
67036	Major surgery	REMOVAL OF INNER EYE FLUID	1613.49	1613.49
67039	Major surgery	LASER TREATMENT OF RETINA	1726.41	1726.41
67040	Major surgery	LASER TREATMENT OF RETINA	1863.17	1863.17
67041	Major surgery	VIT FOR MACULAR PUCKER	2054.89	2054.89
67042	Major surgery	VIT FOR MACULAR HOLE	2054.89	2054.89
67043	Major surgery	VIT FOR MEMBRANE DISSECT	2167.41	2167.41
67101	Other professional services	REPAIR DETACHED RETINA CRTX	464.07	394.49
67105	Other professional services	REPAIR DETACHED RETINA PC	411.05	380.58
67107	Major surgery	REPAIR DETACHED RETINA	2020.12	2020.12
67108	Major surgery	REPAIR DETACHED RETINA	2138.66	2138.66
67110	Major surgery	REPAIR DETACHED RETINA	1602.53	1464.18
67113	Major surgery	REPAIR RETINAL DETACH CPLX	2390.21	2390.21
67115	Major surgery	RELEASE ENCIRCLING MATERIAL	899.07	899.07
67120	Major surgery	REMOVE EYE IMPLANT MATERIAL	1206.31	999.96
67121	Major surgery	REMOVE EYE IMPLANT MATERIAL	1626.30	1626.30
67141	Major surgery	PROPH RTA DTCHMNT CRTX DTHRM	485.18	389.98
67145	Major surgery	PROPH RTA DTCHMNT PC	437.87	389.98
67208	Major surgery	TREATMENT OF RETINAL LESION	1085.86	1039.16
67210	Major surgery	TREATMENT OF RETINAL LESION	928.71	897.37
67218	Major surgery	TREATMENT OF RETINAL LESION	2501.99	2501.99
67220	Major surgery	TREATMENT OF CHOROID LESION	955.48	897.55
67221	Other professional services	OCULAR PHOTODYNAMIC THER	376.70	288.47
67225	Major surgery	EYE PHOTODYNAMIC THER ADD-ON	52.40	49.45
67227	Other professional services	DSTRJ EXTENSIVE RETINOPATHY	409.50	352.65
67228	Other professional services	TREATMENT X10SV RETINOPATHY	471.29	419.90
67229	Major surgery	TR RETINAL LES PRETERM INF	2082.54	2082.54
67250	Major surgery	REINFORCE EYE WALL	1628.13	1628.13
67255	Major surgery	REINFORCE/GRAFT EYE WALL	1241.27	1241.27
67299	Major surgery	UNLISTED PX POSTERIOR SEGMNT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
67311	Major surgery	REVISE EYE MUSCLE	821.52	821.52
67312	Major surgery	REVISE TWO EYE MUSCLES	1197.92	1197.92
67314	Major surgery	REVISE EYE MUSCLE	821.52	821.52
67316	Major surgery	REVISE TWO EYE MUSCLES	1284.72	1284.72
67318	Major surgery	REVISE EYE MUSCLE(S)	1242.17	1242.17
67320	Major surgery	REVISE EYE MUSCLE(S) ADD-ON	314.67	314.67
67331	Major surgery	EYE SURGERY FOLLOW-UP ADD-ON	279.36	279.36
67332	Major surgery	REREVISE EYE MUSCLES ADD-ON	366.21	366.21
67334	Major surgery	REVISE EYE MUSCLE W/SUTURE	275.50	275.50
67335	Major surgery	EYE SUTURE DURING SURGERY	336.45	336.45
67340	Major surgery	REVISE EYE MUSCLE ADD-ON	525.60	525.60
67343	Major surgery	RELEASE EYE TISSUE	1213.25	1213.25
67345	Other professional services	DESTROY NERVE OF EYE MUSCLE	335.49	298.20
67346	Other professional services	BIOPSY EYE MUSCLE	266.73	266.73
67399	Major surgery	UNLISTED PX EXTRAOCULAR MUSC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
67400	Major surgery	EXPLORE/BIOPSY EYE SOCKET	1867.13	1867.13
67405	Major surgery	EXPLORE/DRAIN EYE SOCKET	1630.67	1630.67
67412	Major surgery	EXPLORE/TREAT EYE SOCKET	1779.75	1779.75
67413	Major surgery	EXPLORE/TREAT EYE SOCKET	1735.01	1735.01
67414	Major surgery	EXPLR/DECOMPRESS EYE SOCKET	2615.67	2615.67
67415	Other professional services	ASPIRATION ORBITAL CONTENTS	142.41	142.41
67420	Major surgery	EXPLORE/TREAT EYE SOCKET	3125.75	3125.75
67430	Major surgery	EXPLORE/TREAT EYE SOCKET	2496.35	2496.35
67440	Major surgery	EXPLORE/DRAIN EYE SOCKET	2421.41	2421.41
67445	Major surgery	EXPLR/DECOMPRESS EYE SOCKET	2752.76	2752.76
67450	Major surgery	EXPLORE/BIOPSY EYE SOCKET	2508.58	2508.58
67500	Other professional services	INJECT/TREAT EYE SOCKET	108.08	89.88
67505	Other professional services	INJECT/TREAT EYE SOCKET	119.57	100.01
67515	Other professional services	INJECT/TREAT EYE SOCKET	71.55	65.18
67516	Other professional services	SPRCHOROIDAL SPC NJX RX AGT	166.85	134.55
67550	Major surgery	INSERT EYE SOCKET IMPLANT	1952.77	1952.77
67560	Major surgery	REVISE EYE SOCKET IMPLANT	1996.70	1996.70
67570	Major surgery	DECOMPRESS OPTIC NERVE	2292.71	2292.71
67599	Major surgery	UNLISTED PROCEDURE ORBIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
67700	Other professional services	DRAINAGE OF EYELID ABSCESS	389.37	161.51
67710	Other professional services	INCISION OF EYELID	332.48	135.99
67715	Other professional services	INCISION OF EYELID FOLD	357.32	148.56
67800	Other professional services	REMOVE EYELID LESION	179.28	141.98
67801	Other professional services	REMOVE EYELID LESIONS	226.97	182.40
67805	Other professional services	REMOVE EYELID LESIONS	283.38	226.53
67808	Major surgery	REMOVE EYELID LESION(S)	663.43	663.43
67810	Other professional services	BIOPSY EYELID & LID MARGIN	253.04	94.29
67820	Other professional services	REVISE EYELASHES	26.37	30.93
67825	Other professional services	REVISE EYELASHES	187.08	169.34
67830	Other professional services	REVISE EYELASHES	371.15	190.59
67835	Major surgery	REVISE EYELASHES	795.33	795.33
67840	Other professional services	REMOVE EYELID LESION	386.10	217.82
67850	Other professional services	DSTRJ LESION LID MARGIN <1CM	298.55	182.10
67875	Other professional services	CLOSURE OF EYELID BY SUTURE	250.79	132.54
67880	Major surgery	REVISION OF EYELID	842.58	663.43
67882	Major surgery	REVISION OF EYELID	1030.32	848.21
67900	Major surgery	REPAIR BROW DEFECT	1173.08	909.97
67901	Major surgery	REPAIR EYELID DEFECT	1429.60	1061.25
67902	Major surgery	REPAIR EYELID DEFECT	1307.14	1307.14
67903	Major surgery	REPAIR EYELID DEFECT	1088.14	865.23
67904	Major surgery	REPAIR EYELID DEFECT	1334.19	1072.27
67906	Major surgery	REPAIR EYELID DEFECT	909.46	909.46
67908	Major surgery	REPAIR EYELID DEFECT	976.05	778.58
67909	Major surgery	REVISE EYELID DEFECT	988.32	787.88
67911	Major surgery	REVISE EYELID DEFECT	1007.78	1007.78
67912	Major surgery	CORRECTION EYELID W/IMPLANT	1607.27	873.52
67914	Major surgery	REPAIR EYELID DEFECT	877.07	593.27
67915	Major surgery	REPAIR EYELID DEFECT	566.85	360.50
67916	Major surgery	REPAIR EYELID DEFECT	1095.67	774.03
67917	Major surgery	REPAIR EYELID DEFECT	1121.97	821.61
67921	Major surgery	REPAIR EYELID DEFECT	857.40	563.55
67922	Major surgery	REPAIR EYELID DEFECT	550.89	360.50
67923	Major surgery	REPAIR EYELID DEFECT	1096.43	774.79
67924	Major surgery	REPAIR EYELID DEFECT	1167.08	821.77
67930	Other professional services	REPAIR EYELID WOUND	514.01	327.08
67935	Major surgery	REPAIR EYELID WOUND	1079.93	789.03
67938	Other professional services	REMOVE EYELID FOREIGN BODY	371.36	163.50
67950	Major surgery	REVISION OF EYELID	1053.76	832.03
67961	Major surgery	REVISION OF EYELID	1060.31	817.89
67966	Major surgery	REVISION OF EYELID	1402.21	1176.94
67971	Major surgery	RECONSTRUCTION OF EYELID	1293.61	1293.61
67973	Major surgery	RECONSTRUCTION OF EYELID	1664.19	1664.19
67974	Major surgery	RECONSTRUCTION OF EYELID	1660.74	1660.74
67975	Major surgery	RECONSTRUCTION OF EYELID	1224.93	1224.93
67999	Major surgery	UNLISTED PROCEDURE EYELIDS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
68020	Other professional services	INCISE/DRAIN EYELID LINING	168.98	153.06
68040	Other professional services	TREATMENT OF EYELID LESIONS	87.18	66.71
68100	Other professional services	BIOPSY OF EYELID LINING	247.74	132.21
68110	Other professional services	REMOVE EYELID LINING LESION	326.37	205.85
68115	Other professional services	REMOVE EYELID LINING LESION	457.95	253.74
68130	Major surgery	REMOVE EYELID LINING LESION	994.19	744.69
68135	Other professional services	REMOVE EYELID LINING LESION	219.17	207.35
68200	Other professional services	TREAT EYELID BY INJECTION	57.66	47.21
68320	Major surgery	REVISE/GRAFT EYELID LINING	1335.73	972.70
68325	Major surgery	REVISE/GRAFT EYELID LINING	1181.23	1181.23
68326	Major surgery	REVISE/GRAFT EYELID LINING	1159.96	1159.96
68328	Major surgery	REVISE/GRAFT EYELID LINING	1267.46	1267.46
68330	Major surgery	REVISE EYELID LINING	1120.74	829.26
68335	Major surgery	REVISE/GRAFT EYELID LINING	1163.27	1163.27
68340	Major surgery	SEPARATE EYELID ADHESIONS	1081.28	715.86
68360	Major surgery	REVISE EYELID LINING	976.79	739.69
68362	Major surgery	REVISE EYELID LINING	1179.36	1179.36
68371	Other professional services	HARVEST EYE TISSUE ALOGRAFT	571.44	571.44
68399	Major surgery	UNLISTED PX CONJUNCTIVA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
68400	Other professional services	INCISE/DRAIN TEAR GLAND	408.41	182.37
68420	Other professional services	INCISE/DRAIN TEAR SAC	456.71	231.11
68440	Other professional services	INCISE TEAR DUCT OPENING	145.38	139.02
68500	Major surgery	REMOVAL OF TEAR GLAND	1914.69	1914.69
68505	Major surgery	PARTIAL REMOVAL TEAR GLAND	1906.20	1906.20
68510	Other professional services	BIOPSY OF TEAR GLAND	623.84	397.79
68520	Major surgery	REMOVAL OF TEAR SAC	1331.01	1331.01
68525	Other professional services	BIOPSY OF TEAR SAC	356.60	356.60
68530	Other professional services	CLEARANCE OF TEAR DUCT	599.04	352.08
68540	Major surgery	REMOVE TEAR GLAND LESION	1773.35	1773.35
68550	Major surgery	REMOVE TEAR GLAND LESION	2207.21	2207.21
68700	Major surgery	REPAIR TEAR DUCTS	1085.21	1085.21
68705	Other professional services	REVISE TEAR DUCT OPENING	360.71	229.71
68720	Major surgery	CREATE TEAR SAC DRAIN	1460.71	1460.71
68745	Major surgery	CREATE TEAR DUCT DRAIN	1468.94	1468.94
68750	Major surgery	CREATE TEAR DUCT DRAIN	1549.98	1549.98
68760	Other professional services	CLOSE TEAR DUCT OPENING	303.03	202.52
68761	Other professional services	CLOSE TEAR DUCT OPENING	202.40	162.83
68770	Major surgery	CLOSE TEAR SYSTEM FISTULA	1128.84	1128.84
68801	Other professional services	DILATE TEAR DUCT OPENING	133.79	110.58
68810	Other professional services	PROBE NASOLACRIMAL DUCT	223.28	177.35
68811	Other professional services	PROBE NASOLACRIMAL DUCT	187.25	187.25
68815	Other professional services	PROBE NASOLACRIMAL DUCT	516.84	308.09
68816	Other professional services	PROBE NL DUCT W/BALLOON	1156.14	217.86
68840	Other professional services	EXPLORE/IRRIGATE TEAR DUCTS	184.92	162.63
68841	Other professional services	INSJ RX ELUT IMPLT LAC CANAL	53.12	44.93
68850	Other professional services	INJECTION FOR TEAR SAC X-RAY	81.15	71.60
68899	Major surgery	UNLISTED PX LACRIMAL SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
69000	Other professional services	DRAIN EXTERNAL EAR LESION	258.11	175.34
69005	Other professional services	DRAIN EXTERNAL EAR LESION	305.16	226.02
69020	Other professional services	DRAIN OUTER EAR CANAL LESION	321.57	201.05
69090	Other professional services	PIERCE EARLOBES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
69100	Other professional services	BIOPSY OF EXTERNAL EAR	132.33	64.56
69105	Other professional services	BIOPSY OF EXTERNAL EAR CANAL	199.40	88.88
69110	Major surgery	REMOVE EXTERNAL EAR PARTIAL	845.83	593.95
69120	Major surgery	REMOVAL OF EXTERNAL EAR	702.27	702.27
69140	Major surgery	REMOVE EAR CANAL LESION(S)	1627.12	1627.12
69145	Major surgery	REMOVE EAR CANAL LESION(S)	739.85	467.86
69150	Major surgery	EXTENSIVE EAR CANAL SURGERY	1822.68	1822.68
69155	Major surgery	EXTENSIVE EAR/NECK SURGERY	2950.10	2950.10
69200	Other professional services	CLEAR OUTER EAR CANAL	111.45	65.97
69205	Other professional services	CLEAR OUTER EAR CANAL	133.20	133.20
69209	Other professional services	REMOVE IMPACTED EAR WAX UNI	21.71	21.71
69210	Other professional services	REMOVE IMPACTED EAR WAX UNI	66.69	45.32
69220	Other professional services	CLEAN OUT MASTOID CAVITY	108.81	71.52
69222	Other professional services	CLEAN OUT MASTOID CAVITY	299.58	190.88
69300	Major surgery	REVISE EXTERNAL EAR	1177.18	855.54
69310	Major surgery	REBUILD OUTER EAR CANAL	2013.00	2013.00
69320	Major surgery	REBUILD OUTER EAR CANAL	2814.30	2814.30
69399	Major surgery	UNLISTED PX EXTERNAL EAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
69420	Other professional services	INCISION OF EARDRUM	264.89	168.92
69421	Other professional services	INCISION OF EARDRUM	212.03	212.03
69424	Other professional services	REMOVE VENTILATING TUBE	176.46	84.59
69433	Other professional services	CREATE EARDRUM OPENING	280.65	185.60
69436	Other professional services	CREATE EARDRUM OPENING	223.73	223.73
69440	Major surgery	EXPLORATION OF MIDDLE EAR	1255.37	1255.37
69450	Major surgery	EARDRUM REVISION	993.62	993.62
69501	Major surgery	MASTOIDECTOMY	1290.04	1290.04
69502	Major surgery	MASTOIDECTOMY	1713.35	1713.35
69505	Major surgery	REMOVE MASTOID STRUCTURES	2217.48	2217.48
69511	Major surgery	EXTENSIVE MASTOID SURGERY	2269.92	2269.92
69530	Major surgery	EXTENSIVE MASTOID SURGERY	3025.15	3025.15
69535	Major surgery	REMOVE PART OF TEMPORAL BONE	4813.20	4813.20
69540	Other professional services	REMOVE EAR LESION	292.28	181.76
69550	Major surgery	REMOVE EAR LESION	1918.90	1918.90
69552	Major surgery	REMOVE EAR LESION	2865.51	2865.51
69554	Major surgery	REMOVE EAR LESION	4576.81	4576.81
69601	Major surgery	MASTOID SURGERY REVISION	1846.07	1846.07
69602	Major surgery	MASTOID SURGERY REVISION	1973.81	1973.81
69603	Major surgery	MASTOID SURGERY REVISION	2318.41	2318.41
69604	Major surgery	MASTOID SURGERY REVISION	2016.28	2016.28
69610	Other professional services	REPAIR OF EARDRUM	534.47	402.11
69620	Major surgery	REPAIR OF EARDRUM	1337.51	898.77
69631	Major surgery	REPAIR EARDRUM STRUCTURES	1612.55	1612.55
69632	Major surgery	REBUILD EARDRUM STRUCTURES	1958.50	1958.50
69633	Major surgery	REBUILD EARDRUM STRUCTURES	1905.44	1905.44
69635	Major surgery	REPAIR EARDRUM STRUCTURES	2303.50	2303.50
69636	Major surgery	REBUILD EARDRUM STRUCTURES	2541.34	2541.34
69637	Major surgery	REBUILD EARDRUM STRUCTURES	2530.94	2530.94
69641	Major surgery	REVISE MIDDLE EAR & MASTOID	1888.09	1888.09
69642	Major surgery	REVISE MIDDLE EAR & MASTOID	2424.44	2424.44
69643	Major surgery	REVISE MIDDLE EAR & MASTOID	2215.40	2215.40
69644	Major surgery	REVISE MIDDLE EAR & MASTOID	2718.16	2718.16
69645	Major surgery	REVISE MIDDLE EAR & MASTOID	2666.45	2666.45
69646	Major surgery	REVISE MIDDLE EAR & MASTOID	2836.88	2836.88
69650	Major surgery	RELEASE MIDDLE EAR BONE	1457.29	1457.29
69660	Major surgery	REVISE MIDDLE EAR BONE	1675.95	1675.95
69661	Major surgery	REVISE MIDDLE EAR BONE	2183.59	2183.59
69662	Major surgery	REVISE MIDDLE EAR BONE	2096.54	2096.54
69666	Major surgery	REPAIR MIDDLE EAR STRUCTURES	1466.42	1466.42
69667	Major surgery	REPAIR MIDDLE EAR STRUCTURES	1470.53	1470.53
69670	Major surgery	REMOVE MASTOID AIR CELLS	1710.83	1710.83
69676	Major surgery	REMOVE MIDDLE EAR NERVE	1512.11	1512.11
69700	Major surgery	CLOSE MASTOID FISTULA	1208.67	1208.67
69705	Other professional services	NPS SURG DILAT EUST TUBE UNI	3668.94	241.44
69706	Other professional services	NPS SURG DILAT EUST TUBE BI	3792.11	337.32
69710	Other professional services	IMPLANT/REPLACE HEARING AID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
69711	Major surgery	REMOVE/REPAIR HEARING AID	1520.82	1520.82
69714	Major surgery	IMPL OI IMPLT SKULL PERQ ESP	897.82	897.82
69716	Major surgery	IMPL OI IMPLT SK TC ESP<100	1125.31	1125.31
69717	Major surgery	RPLCMT OI IMPLT SKL PRQ ESP	1017.71	1017.71
69719	Major surgery	RPLCM OI IMPLT SK TC ESP<100	1168.75	1168.75
69720	Major surgery	RELEASE FACIAL NERVE	2131.47	2131.47
69725	Major surgery	RELEASE FACIAL NERVE	3383.97	3383.97
69726	Major surgery	RMV NTR OI IMPLT SKL PRQ ESP	865.37	865.37
69727	Major surgery	RMV NTR OI IMP SK TC ESP<100	965.68	965.68
69728	Major surgery	RMV NTR OI IMP SK TC>=100	1090.15	1090.15
69729	Major surgery	IMPL OI IMPLT SK TC ESP>=100	1220.17	1220.17
69730	Major surgery	RPLC OI IMPLT SK TC ESP>=100	1262.68	1262.68
69740	Major surgery	REPAIR FACIAL NERVE	2103.41	2103.41
69745	Major surgery	REPAIR FACIAL NERVE	2241.12	2241.12
69799	Major surgery	UNLISTED PX MIDDLE EAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
69801	Other professional services	INCISE INNER EAR	316.10	173.30
69805	Major surgery	EXPLORE INNER EAR	1866.58	1866.58
69806	Major surgery	EXPLORE INNER EAR	1671.11	1671.11
69905	Major surgery	REMOVE INNER EAR	1664.85	1664.85
69910	Major surgery	REMOVE INNER EAR & MASTOID	1796.81	1796.81
69915	Major surgery	INCISE INNER EAR NERVE	2722.82	2722.82
69930	Major surgery	IMPLANT COCHLEAR DEVICE	2202.10	2202.10
69949	Major surgery	UNLISTED PX INNER EAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
69950	Major surgery	INCISE INNER EAR NERVE	3161.61	3161.61
69955	Major surgery	RELEASE FACIAL NERVE	3559.51	3559.51
69960	Major surgery	RELEASE INNER EAR CANAL	3412.29	3412.29
69970	Major surgery	REMOVE INNER EAR LESION	3849.26	3849.26
69979	Major surgery	UNLISTED PX TEMPORAL BONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
69990	Major surgery	MICROSURGERY ADD-ON	378.51	378.51
70010	Radiology	CONTRAST X-RAY OF BRAIN	105.50	105.50
70015	Radiology	CONTRAST X-RAY OF BRAIN	298.90	298.90
70015-26	Radiology	CONTRAST X-RAY OF BRAIN	103.37	103.37
70015-TC	Radiology	CONTRAST X-RAY OF BRAIN	195.55	195.55
70030	Radiology	X-RAY EYE FOR FOREIGN BODY	58.46	58.46
70030-26	Radiology	X-RAY EYE FOR FOREIGN BODY	15.46	15.46
70030-TC	Radiology	X-RAY EYE FOR FOREIGN BODY	43.00	43.00
70100	Radiology	X-RAY EXAM OF JAW <4VIEWS	69.69	69.69
70100-26	Radiology	X-RAY EXAM OF JAW <4VIEWS	16.05	16.05
70100-TC	Radiology	X-RAY EXAM OF JAW <4VIEWS	53.64	53.64
70110	Radiology	X-RAY EXAM OF JAW 4/> VIEWS	78.31	78.31
70110-26	Radiology	X-RAY EXAM OF JAW 4/> VIEWS	21.70	21.70
70110-TC	Radiology	X-RAY EXAM OF JAW 4/> VIEWS	56.59	56.59
70120	Radiology	X-RAY EXAM OF MASTOIDS	68.50	68.50
70120-26	Radiology	X-RAY EXAM OF MASTOIDS	16.05	16.05
70120-TC	Radiology	X-RAY EXAM OF MASTOIDS	52.46	52.46
70130	Radiology	X-RAY EXAM OF MASTOIDS	111.07	111.07
70130-26	Radiology	X-RAY EXAM OF MASTOIDS	29.66	29.66
70130-TC	Radiology	X-RAY EXAM OF MASTOIDS	81.43	81.43
70134	Radiology	X-RAY EXAM OF MIDDLE EAR	111.25	111.25
70134-26	Radiology	X-RAY EXAM OF MIDDLE EAR	31.59	31.59
70134-TC	Radiology	X-RAY EXAM OF MIDDLE EAR	79.66	79.66
70140	Radiology	X-RAY EXAM OF FACIAL BONES	57.33	57.33
70140-26	Radiology	X-RAY EXAM OF FACIAL BONES	17.28	17.28
70140-TC	Radiology	X-RAY EXAM OF FACIAL BONES	40.03	40.03
70150	Radiology	X-RAY EXAM OF FACIAL BONES	84.86	84.86
70150-26	Radiology	X-RAY EXAM OF FACIAL BONES	22.93	22.93
70150-TC	Radiology	X-RAY EXAM OF FACIAL BONES	61.91	61.91
70160	Radiology	X-RAY EXAM OF NASAL BONES	67.28	67.28
70160-26	Radiology	X-RAY EXAM OF NASAL BONES	14.82	14.82
70160-TC	Radiology	X-RAY EXAM OF NASAL BONES	52.46	52.46
70170	Radiology	X-RAY EXAM OF TEAR DUCT	101.13	101.13
70170-26	Radiology	X-RAY EXAM OF TEAR DUCT	26.50	26.50
70170-TC	Radiology	X-RAY EXAM OF TEAR DUCT	74.63	74.63
70190	Radiology	X-RAY EXAM OF EYE SOCKETS	67.47	67.47
70190-26	Radiology	X-RAY EXAM OF EYE SOCKETS	19.75	19.75
70190-TC	Radiology	X-RAY EXAM OF EYE SOCKETS	47.72	47.72
70200	Radiology	X-RAY EXAM OF EYE SOCKETS	86.13	86.13
70200-26	Radiology	X-RAY EXAM OF EYE SOCKETS	24.80	24.80
70200-TC	Radiology	X-RAY EXAM OF EYE SOCKETS	61.33	61.33
70210	Radiology	X-RAY EXAM OF SINUSES	57.82	57.82
70210-26	Radiology	X-RAY EXAM OF SINUSES	15.42	15.42
70210-TC	Radiology	X-RAY EXAM OF SINUSES	42.41	42.41
70220	Radiology	X-RAY EXAM OF SINUSES	67.53	67.53
70220-26	Radiology	X-RAY EXAM OF SINUSES	19.21	19.21
70220-TC	Radiology	X-RAY EXAM OF SINUSES	48.32	48.32
70240	Radiology	X-RAY EXAM PITUITARY SADDLE	59.10	59.10
70240-26	Radiology	X-RAY EXAM PITUITARY SADDLE	16.69	16.69
70240-TC	Radiology	X-RAY EXAM PITUITARY SADDLE	42.41	42.41
70250	Radiology	X-RAY EXAM OF SKULL	64.37	64.37
70250-26	Radiology	X-RAY EXAM OF SKULL	16.05	16.05
70250-TC	Radiology	X-RAY EXAM OF SKULL	48.32	48.32
70260	Radiology	X-RAY EXAM OF SKULL	80.22	80.22
70260-26	Radiology	X-RAY EXAM OF SKULL	24.80	24.80
70260-TC	Radiology	X-RAY EXAM OF SKULL	55.42	55.42
70300	Radiology	X-RAY EXAM OF TEETH	23.21	23.21
70300-26	Radiology	X-RAY EXAM OF TEETH	9.18	9.18
70300-TC	Radiology	X-RAY EXAM OF TEETH	14.02	14.02
70310	Radiology	X-RAY EXAM OF TEETH	72.56	72.56
70310-26	Radiology	X-RAY EXAM OF TEETH	14.78	14.78
70310-TC	Radiology	X-RAY EXAM OF TEETH	57.78	57.78
70320	Radiology	FULL MOUTH X-RAY OF TEETH	95.32	95.32
70320-26	Radiology	FULL MOUTH X-RAY OF TEETH	19.79	19.79
70320-TC	Radiology	FULL MOUTH X-RAY OF TEETH	75.52	75.52
70328	Radiology	X-RAY EXAM OF JAW JOINT	62.01	62.01
70328-26	Radiology	X-RAY EXAM OF JAW JOINT	16.05	16.05
70328-TC	Radiology	X-RAY EXAM OF JAW JOINT	45.96	45.96
70330	Radiology	X-RAY EXAM OF JAW JOINTS	94.81	94.81
70330-26	Radiology	X-RAY EXAM OF JAW JOINTS	21.08	21.08
70330-TC	Radiology	X-RAY EXAM OF JAW JOINTS	73.75	73.75
70332	Radiology	X-RAY EXAM OF JAW JOINT	148.51	148.51
70332-26	Radiology	X-RAY EXAM OF JAW JOINT	47.00	47.00
70332-TC	Radiology	X-RAY EXAM OF JAW JOINT	101.54	101.54
70336	Radiology	MAGNETIC IMAGE JAW JOINT	487.21	487.21
70336-26	Radiology	MAGNETIC IMAGE JAW JOINT	128.06	128.06
70336-TC	Radiology	MAGNETIC IMAGE JAW JOINT	359.15	359.15
70350	Radiology	X-RAY HEAD FOR ORTHODONTIA	30.03	30.03
70350-26	Radiology	X-RAY HEAD FOR ORTHODONTIA	15.42	15.42
70350-TC	Radiology	X-RAY HEAD FOR ORTHODONTIA	14.61	14.61
70355	Radiology	PANORAMIC X-RAY OF JAWS	33.13	33.13
70355-26	Radiology	PANORAMIC X-RAY OF JAWS	17.92	17.92
70355-TC	Radiology	PANORAMIC X-RAY OF JAWS	15.21	15.21
70360	Radiology	X-RAY EXAM OF NECK	56.10	56.10
70360-26	Radiology	X-RAY EXAM OF NECK	16.05	16.05
70360-TC	Radiology	X-RAY EXAM OF NECK	40.03	40.03
70370	Radiology	THROAT X-RAY & FLUOROSCOPY	187.26	187.26
70370-26	Radiology	THROAT X-RAY & FLUOROSCOPY	27.79	27.79
70370-TC	Radiology	THROAT X-RAY & FLUOROSCOPY	159.47	159.47
70371	Radiology	SPEECH EVALUATION COMPLEX	197.07	197.07
70371-26	Radiology	SPEECH EVALUATION COMPLEX	76.03	76.03
70371-TC	Radiology	SPEECH EVALUATION COMPLEX	121.04	121.04
70380	Radiology	X-RAY EXAM OF SALIVARY GLAND	67.28	67.28
70380-26	Radiology	X-RAY EXAM OF SALIVARY GLAND	14.82	14.82
70380-TC	Radiology	X-RAY EXAM OF SALIVARY GLAND	52.46	52.46
70390	Radiology	X-RAY EXAM OF SALIVARY DUCT	206.47	206.47
70390-26	Radiology	X-RAY EXAM OF SALIVARY DUCT	32.80	32.80
70390-TC	Radiology	X-RAY EXAM OF SALIVARY DUCT	173.67	173.67
70450	Radiology	CT HEAD/BRAIN W/O DYE	195.94	195.94
70450-26	Radiology	CT HEAD/BRAIN W/O DYE	73.71	73.71
70450-TC	Radiology	CT HEAD/BRAIN W/O DYE	122.23	122.23
70460	Radiology	CT HEAD/BRAIN W/DYE	273.78	273.78
70460-26	Radiology	CT HEAD/BRAIN W/DYE	98.36	98.36
70460-TC	Radiology	CT HEAD/BRAIN W/DYE	175.44	175.44
70470	Radiology	CT HEAD/BRAIN W/O & W/DYE	320.23	320.23
70470-26	Radiology	CT HEAD/BRAIN W/O & W/DYE	110.66	110.66
70470-TC	Radiology	CT HEAD/BRAIN W/O & W/DYE	209.57	209.57
70480	Radiology	CT ORBIT/EAR/FOSSA W/O DYE	293.67	293.67
70480-26	Radiology	CT ORBIT/EAR/FOSSA W/O DYE	111.89	111.89
70480-TC	Radiology	CT ORBIT/EAR/FOSSA W/O DYE	181.78	181.78
70481	Radiology	CT ORBIT/EAR/FOSSA W/DYE	332.75	332.75
70481-26	Radiology	CT ORBIT/EAR/FOSSA W/DYE	98.36	98.36
70481-TC	Radiology	CT ORBIT/EAR/FOSSA W/DYE	234.39	234.39
70482	Radiology	CT ORBIT/EAR/FOSSA W/O&W/DYE	388.23	388.23
70482-26	Radiology	CT ORBIT/EAR/FOSSA W/O&W/DYE	110.08	110.08
70482-TC	Radiology	CT ORBIT/EAR/FOSSA W/O&W/DYE	278.15	278.15
70486	Radiology	CT MAXILLOFACIAL W/O DYE	236.15	236.15
70486-26	Radiology	CT MAXILLOFACIAL W/O DYE	74.30	74.30
70486-TC	Radiology	CT MAXILLOFACIAL W/O DYE	161.83	161.83
70487	Radiology	CT MAXILLOFACIAL W/DYE	280.72	280.72
70487-26	Radiology	CT MAXILLOFACIAL W/DYE	97.75	97.75
70487-TC	Radiology	CT MAXILLOFACIAL W/DYE	182.95	182.95
70488	Radiology	CT MAXILLOFACIAL W/O & W/DYE	339.75	339.75
70488-26	Radiology	CT MAXILLOFACIAL W/O & W/DYE	110.08	110.08
70488-TC	Radiology	CT MAXILLOFACIAL W/O & W/DYE	229.67	229.67
70490	Radiology	CT SOFT TISSUE NECK W/O DYE	277.29	277.29
70490-26	Radiology	CT SOFT TISSUE NECK W/O DYE	111.31	111.31
70490-TC	Radiology	CT SOFT TISSUE NECK W/O DYE	165.98	165.98
70491	Radiology	CT SOFT TISSUE NECK W/DYE	340.28	340.28
70491-26	Radiology	CT SOFT TISSUE NECK W/DYE	120.06	120.06
70491-TC	Radiology	CT SOFT TISSUE NECK W/DYE	220.21	220.21
70492	Radiology	CT SFT TSUE NCK W/O & W/DYE	408.04	408.04
70492-26	Radiology	CT SFT TSUE NCK W/O & W/DYE	139.95	139.95
70492-TC	Radiology	CT SFT TSUE NCK W/O & W/DYE	268.11	268.11
70496	Radiology	CT ANGIOGRAPHY HEAD	508.25	508.25
70496-26	Radiology	CT ANGIOGRAPHY HEAD	151.63	151.63
70496-TC	Radiology	CT ANGIOGRAPHY HEAD	356.62	356.62
70498	Radiology	CT ANGIOGRAPHY NECK	507.66	507.66
70498-26	Radiology	CT ANGIOGRAPHY NECK	151.63	151.63
70498-TC	Radiology	CT ANGIOGRAPHY NECK	356.03	356.03
70540	Radiology	MRI ORBIT/FACE/NECK W/O DYE	417.57	417.57
70540-26	Radiology	MRI ORBIT/FACE/NECK W/O DYE	116.96	116.96
70540-TC	Radiology	MRI ORBIT/FACE/NECK W/O DYE	300.61	300.61
70542	Radiology	MRI ORBIT/FACE/NECK W/DYE	495.38	495.38
70542-26	Radiology	MRI ORBIT/FACE/NECK W/DYE	140.54	140.54
70542-TC	Radiology	MRI ORBIT/FACE/NECK W/DYE	354.84	354.84
70543	Radiology	MRI ORBT/FAC/NCK W/O &W/DYE	625.70	625.70
70543-26	Radiology	MRI ORBT/FAC/NCK W/O &W/DYE	186.30	186.30
70543-TC	Radiology	MRI ORBT/FAC/NCK W/O &W/DYE	439.39	439.39
70544	Radiology	MR ANGIOGRAPHY HEAD W/O DYE	397.35	397.35
70544-26	Radiology	MR ANGIOGRAPHY HEAD W/O DYE	103.99	103.99
70544-TC	Radiology	MR ANGIOGRAPHY HEAD W/O DYE	293.36	293.36
70545	Radiology	MR ANGIOGRAPHY HEAD W/DYE	418.65	418.65
70545-26	Radiology	MR ANGIOGRAPHY HEAD W/DYE	103.99	103.99
70545-TC	Radiology	MR ANGIOGRAPHY HEAD W/DYE	314.65	314.65
70546	Radiology	MR ANGIOGRAPH HEAD W/O&W/DYE	606.90	606.90
70546-26	Radiology	MR ANGIOGRAPH HEAD W/O&W/DYE	128.64	128.64
70546-TC	Radiology	MR ANGIOGRAPH HEAD W/O&W/DYE	478.26	478.26
70547	Radiology	MR ANGIOGRAPHY NECK W/O DYE	397.96	397.96
70547-26	Radiology	MR ANGIOGRAPHY NECK W/O DYE	103.99	103.99
70547-TC	Radiology	MR ANGIOGRAPHY NECK W/O DYE	293.94	293.94
70548	Radiology	MR ANGIOGRAPHY NECK W/DYE	454.02	454.02
70548-26	Radiology	MR ANGIOGRAPHY NECK W/DYE	130.51	130.51
70548-TC	Radiology	MR ANGIOGRAPHY NECK W/DYE	323.51	323.51
70549	Radiology	MR ANGIOGRAPH NECK W/O&W/DYE	636.62	636.62
70549-26	Radiology	MR ANGIOGRAPH NECK W/O&W/DYE	156.00	156.00
70549-TC	Radiology	MR ANGIOGRAPH NECK W/O&W/DYE	480.62	480.62
70551	Radiology	MRI BRAIN STEM W/O DYE	363.03	363.03
70551-26	Radiology	MRI BRAIN STEM W/O DYE	128.64	128.64
70551-TC	Radiology	MRI BRAIN STEM W/O DYE	234.39	234.39
70552	Radiology	MRI BRAIN STEM W/DYE	499.53	499.53
70552-26	Radiology	MRI BRAIN STEM W/DYE	154.73	154.73
70552-TC	Radiology	MRI BRAIN STEM W/DYE	344.80	344.80
70553	Radiology	MRI BRAIN STEM W/O & W/DYE	588.94	588.94
70553-26	Radiology	MRI BRAIN STEM W/O & W/DYE	198.61	198.61
70553-TC	Radiology	MRI BRAIN STEM W/O & W/DYE	390.33	390.33
70554	Radiology	FMRI BRAIN BY TECH	700.85	700.85
70554-26	Radiology	FMRI BRAIN BY TECH	184.16	184.16
70554-TC	Radiology	FMRI BRAIN BY TECH	516.69	516.69
70555	Radiology	FMRI BRAIN BY PHYS/PSYCH	1200.93	1200.93
70555-26	Radiology	FMRI BRAIN BY PHYS/PSYCH	216.94	216.94
70555-TC	Radiology	FMRI BRAIN BY PHYS/PSYCH	983.99	983.99
70557	Radiology	MRI BRAIN W/O DYE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
70557-26	Radiology	MRI BRAIN W/O DYE	277.60	277.60
70557-TC	Radiology	MRI BRAIN W/O DYE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
70558	Radiology	MRI BRAIN W/DYE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
70558-26	Radiology	MRI BRAIN W/DYE	306.05	306.05
70558-TC	Radiology	MRI BRAIN W/DYE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
70559	Radiology	MRI BRAIN W/O & W/DYE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
70559-26	Radiology	MRI BRAIN W/O & W/DYE	286.32	286.32
70559-TC	Radiology	MRI BRAIN W/O & W/DYE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
71045	Radiology	X-RAY EXAM CHEST 1 VIEW	46.04	46.04
71045-26	Radiology	X-RAY EXAM CHEST 1 VIEW	15.46	15.46
71045-TC	Radiology	X-RAY EXAM CHEST 1 VIEW	30.58	30.58
71046	Radiology	X-RAY EXAM CHEST 2 VIEWS	60.43	60.43
71046-26	Radiology	X-RAY EXAM CHEST 2 VIEWS	19.21	19.21
71046-TC	Radiology	X-RAY EXAM CHEST 2 VIEWS	41.22	41.22
71047	Radiology	X-RAY EXAM CHEST 3 VIEWS	76.03	76.03
71047-26	Radiology	X-RAY EXAM CHEST 3 VIEWS	24.16	24.16
71047-TC	Radiology	X-RAY EXAM CHEST 3 VIEWS	51.87	51.87
71048	Radiology	X-RAY EXAM CHEST 4+ VIEWS	82.13	82.13
71048-26	Radiology	X-RAY EXAM CHEST 4+ VIEWS	26.72	26.72
71048-TC	Radiology	X-RAY EXAM CHEST 4+ VIEWS	55.42	55.42
71100	Radiology	X-RAY EXAM RIBS UNI 2 VIEWS	65.75	65.75
71100-26	Radiology	X-RAY EXAM RIBS UNI 2 VIEWS	19.21	19.21
71100-TC	Radiology	X-RAY EXAM RIBS UNI 2 VIEWS	46.55	46.55
71101	Radiology	X-RAY EXAM UNILAT RIBS/CHEST	76.03	76.03
71101-26	Radiology	X-RAY EXAM UNILAT RIBS/CHEST	23.58	23.58
71101-TC	Radiology	X-RAY EXAM UNILAT RIBS/CHEST	52.46	52.46
71110	Radiology	X-RAY EXAM RIBS BIL 3 VIEWS	79.09	79.09
71110-26	Radiology	X-RAY EXAM RIBS BIL 3 VIEWS	25.45	25.45
71110-TC	Radiology	X-RAY EXAM RIBS BIL 3 VIEWS	53.64	53.64
71111	Radiology	X-RAY EXAM RIBS/CHEST4/> VWS	94.44	94.44
71111-26	Radiology	X-RAY EXAM RIBS/CHEST4/> VWS	28.37	28.37
71111-TC	Radiology	X-RAY EXAM RIBS/CHEST4/> VWS	66.05	66.05
71120	Radiology	X-RAY EXAM BREASTBONE 2/>VWS	60.33	60.33
71120-26	Radiology	X-RAY EXAM BREASTBONE 2/>VWS	17.34	17.34
71120-TC	Radiology	X-RAY EXAM BREASTBONE 2/>VWS	43.00	43.00
71130	Radiology	X-RAY STRENOCLAVIC JT 3/>VWS	74.02	74.02
71130-26	Radiology	X-RAY STRENOCLAVIC JT 3/>VWS	19.21	19.21
71130-TC	Radiology	X-RAY STRENOCLAVIC JT 3/>VWS	54.81	54.81
71250	Radiology	CT THORAX DX C-	245.76	245.76
71250-26	Radiology	CT THORAX DX C-	93.97	93.97
71250-TC	Radiology	CT THORAX DX C-	151.79	151.79
71260	Radiology	CT THORAX DX C+	308.06	308.06
71260-26	Radiology	CT THORAX DX C+	101.44	101.44
71260-TC	Radiology	CT THORAX DX C+	206.60	206.60
71270	Radiology	CT THORAX DX C-/C+	361.69	361.69
71270-26	Radiology	CT THORAX DX C-/C+	108.38	108.38
71270-TC	Radiology	CT THORAX DX C-/C+	253.32	253.32
71271	Radiology	CT THORAX LUNG CANCER SCR C-	253.87	253.87
71271-26	Radiology	CT THORAX LUNG CANCER SCR C-	93.97	93.97
71271-TC	Radiology	CT THORAX LUNG CANCER SCR C-	159.90	159.90
71275	Radiology	CT ANGIOGRAPHY CHEST	518.47	518.47
71275-26	Radiology	CT ANGIOGRAPHY CHEST	157.70	157.70
71275-TC	Radiology	CT ANGIOGRAPHY CHEST	360.77	360.77
71550	Radiology	MRI CHEST W/O DYE	621.76	621.76
71550-26	Radiology	MRI CHEST W/O DYE	126.77	126.77
71550-TC	Radiology	MRI CHEST W/O DYE	494.97	494.97
71551	Radiology	MRI CHEST W/DYE	687.90	687.90
71551-26	Radiology	MRI CHEST W/DYE	150.35	150.35
71551-TC	Radiology	MRI CHEST W/DYE	537.56	537.56
71552	Radiology	MRI CHEST W/O & W/DYE	868.30	868.30
71552-26	Radiology	MRI CHEST W/O & W/DYE	196.11	196.11
71552-TC	Radiology	MRI CHEST W/O & W/DYE	672.18	672.18
71555	Radiology	MRI ANGIO CHEST W OR W/O DYE	615.38	615.38
71555-26	Radiology	MRI ANGIO CHEST W OR W/O DYE	155.45	155.45
71555-TC	Radiology	MRI ANGIO CHEST W OR W/O DYE	459.93	459.93
72020	Radiology	X-RAY EXAM OF SPINE 1 VIEW	43.58	43.58
72020-26	Radiology	X-RAY EXAM OF SPINE 1 VIEW	14.20	14.20
72020-TC	Radiology	X-RAY EXAM OF SPINE 1 VIEW	29.41	29.41
72040	Radiology	X-RAY EXAM NECK SPINE 2-3 VW	71.06	71.06
72040-26	Radiology	X-RAY EXAM NECK SPINE 2-3 VW	19.79	19.79
72040-TC	Radiology	X-RAY EXAM NECK SPINE 2-3 VW	51.27	51.27
72050	Radiology	X-RAY EXAM NECK SPINE 4/5VWS	96.14	96.14
72050-26	Radiology	X-RAY EXAM NECK SPINE 4/5VWS	23.58	23.58
72050-TC	Radiology	X-RAY EXAM NECK SPINE 4/5VWS	72.56	72.56
72052	Radiology	X-RAY EXAM NECK SPINE 6/>VWS	112.07	112.07
72052-26	Radiology	X-RAY EXAM NECK SPINE 6/>VWS	26.50	26.50
72052-TC	Radiology	X-RAY EXAM NECK SPINE 6/>VWS	85.57	85.57
72070	Radiology	X-RAY EXAM THORAC SPINE 2VWS	59.14	59.14
72070-26	Radiology	X-RAY EXAM THORAC SPINE 2VWS	17.92	17.92
72070-TC	Radiology	X-RAY EXAM THORAC SPINE 2VWS	41.22	41.22
72072	Radiology	X-RAY EXAM THORAC SPINE 3VWS	71.12	71.12
72072-26	Radiology	X-RAY EXAM THORAC SPINE 3VWS	19.83	19.83
72072-TC	Radiology	X-RAY EXAM THORAC SPINE 3VWS	51.27	51.27
72074	Radiology	X-RAY EXAM THORAC SPINE4/>VW	80.09	80.09
72074-26	Radiology	X-RAY EXAM THORAC SPINE4/>VW	21.70	21.70
72074-TC	Radiology	X-RAY EXAM THORAC SPINE4/>VW	58.36	58.36
72080	Radiology	X-RAY EXAM THORACOLMB 2/> VW	62.15	62.15
72080-26	Radiology	X-RAY EXAM THORACOLMB 2/> VW	18.56	18.56
72080-TC	Radiology	X-RAY EXAM THORACOLMB 2/> VW	43.58	43.58
72081	Radiology	X-RAY EXAM ENTIRE SPI 1 VW	76.58	76.58
72081-26	Radiology	X-RAY EXAM ENTIRE SPI 1 VW	22.93	22.93
72081-TC	Radiology	X-RAY EXAM ENTIRE SPI 1 VW	53.64	53.64
72082	Radiology	X-RAY EXAM ENTIRE SPI 2/3 VW	125.72	125.72
72082-26	Radiology	X-RAY EXAM ENTIRE SPI 2/3 VW	27.73	27.73
72082-TC	Radiology	X-RAY EXAM ENTIRE SPI 2/3 VW	97.99	97.99
72083	Radiology	X-RAY EXAM ENTIRE SPI 4/5 VW	142.04	142.04
72083-26	Radiology	X-RAY EXAM ENTIRE SPI 4/5 VW	31.65	31.65
72083-TC	Radiology	X-RAY EXAM ENTIRE SPI 4/5 VW	110.41	110.41
72084	Radiology	X-RAY EXAM ENTIRE SPI 6/> VW	176.28	176.28
72084-26	Radiology	X-RAY EXAM ENTIRE SPI 6/> VW	36.48	36.48
72084-TC	Radiology	X-RAY EXAM ENTIRE SPI 6/> VW	139.80	139.80
72100	Radiology	X-RAY EXAM L-S SPINE 2/3 VWS	71.66	71.66
72100-26	Radiology	X-RAY EXAM L-S SPINE 2/3 VWS	19.79	19.79
72100-TC	Radiology	X-RAY EXAM L-S SPINE 2/3 VWS	51.87	51.87
72110	Radiology	X-RAY EXAM L-2 SPINE 4/>VWS	93.13	93.13
72110-26	Radiology	X-RAY EXAM L-2 SPINE 4/>VWS	22.93	22.93
72110-TC	Radiology	X-RAY EXAM L-2 SPINE 4/>VWS	70.20	70.20
72114	Radiology	X-RAY EXAM L-S SPINE BENDING	109.71	109.71
72114-26	Radiology	X-RAY EXAM L-S SPINE BENDING	26.50	26.50
72114-TC	Radiology	X-RAY EXAM L-S SPINE BENDING	83.21	83.21
72120	Radiology	X-RAY BEND ONLY L-S SPINE	72.83	72.83
72120-26	Radiology	X-RAY BEND ONLY L-S SPINE	19.79	19.79
72120-TC	Radiology	X-RAY BEND ONLY L-S SPINE	53.04	53.04
72125	Radiology	CT NECK SPINE W/O DYE	240.22	240.22
72125-26	Radiology	CT NECK SPINE W/O DYE	86.68	86.68
72125-TC	Radiology	CT NECK SPINE W/O DYE	153.56	153.56
72126	Radiology	CT NECK SPINE W/DYE	311.30	311.30
72126-26	Radiology	CT NECK SPINE W/DYE	105.87	105.87
72126-TC	Radiology	CT NECK SPINE W/DYE	205.43	205.43
72127	Radiology	CT NECK SPINE W/O & W/DYE	363.99	363.99
72127-26	Radiology	CT NECK SPINE W/O & W/DYE	110.08	110.08
72127-TC	Radiology	CT NECK SPINE W/O & W/DYE	253.91	253.91
72128	Radiology	CT CHEST SPINE W/O DYE	239.64	239.64
72128-26	Radiology	CT CHEST SPINE W/O DYE	86.68	86.68
72128-TC	Radiology	CT CHEST SPINE W/O DYE	152.98	152.98
72129	Radiology	CT CHEST SPINE W/DYE	313.50	313.50
72129-26	Radiology	CT CHEST SPINE W/DYE	106.29	106.29
72129-TC	Radiology	CT CHEST SPINE W/DYE	207.21	207.21
72130	Radiology	CT CHEST SPINE W/O & W/DYE	366.35	366.35
72130-26	Radiology	CT CHEST SPINE W/O & W/DYE	110.66	110.66
72130-TC	Radiology	CT CHEST SPINE W/O & W/DYE	255.68	255.68
72131	Radiology	CT LUMBAR SPINE W/O DYE	238.47	238.47
72131-26	Radiology	CT LUMBAR SPINE W/O DYE	86.68	86.68
72131-TC	Radiology	CT LUMBAR SPINE W/O DYE	151.79	151.79
72132	Radiology	CT LUMBAR SPINE W/DYE	311.88	311.88
72132-26	Radiology	CT LUMBAR SPINE W/DYE	105.87	105.87
72132-TC	Radiology	CT LUMBAR SPINE W/DYE	206.02	206.02
72133	Radiology	CT LUMBAR SPINE W/O & W/DYE	364.57	364.57
72133-26	Radiology	CT LUMBAR SPINE W/O & W/DYE	110.08	110.08
72133-TC	Radiology	CT LUMBAR SPINE W/O & W/DYE	254.49	254.49
72141	Radiology	MRI NECK SPINE W/O DYE	352.99	352.99
72141-26	Radiology	MRI NECK SPINE W/O DYE	128.64	128.64
72141-TC	Radiology	MRI NECK SPINE W/O DYE	224.35	224.35
72142	Radiology	MRI NECK SPINE W/DYE	508.81	508.81
72142-26	Radiology	MRI NECK SPINE W/DYE	155.75	155.75
72142-TC	Radiology	MRI NECK SPINE W/DYE	353.07	353.07
72146	Radiology	MRI CHEST SPINE W/O DYE	352.40	352.40
72146-26	Radiology	MRI CHEST SPINE W/O DYE	128.64	128.64
72146-TC	Radiology	MRI CHEST SPINE W/O DYE	223.76	223.76
72147	Radiology	MRI CHEST SPINE W/DYE	504.25	504.25
72147-26	Radiology	MRI CHEST SPINE W/DYE	154.73	154.73
72147-TC	Radiology	MRI CHEST SPINE W/DYE	349.52	349.52
72148	Radiology	MRI LUMBAR SPINE W/O DYE	354.18	354.18
72148-26	Radiology	MRI LUMBAR SPINE W/O DYE	129.23	129.23
72148-TC	Radiology	MRI LUMBAR SPINE W/O DYE	224.93	224.93
72149	Radiology	MRI LUMBAR SPINE W/DYE	499.94	499.94
72149-26	Radiology	MRI LUMBAR SPINE W/DYE	155.14	155.14
72149-TC	Radiology	MRI LUMBAR SPINE W/DYE	344.80	344.80
72156	Radiology	MRI NECK SPINE W/O & W/DYE	591.90	591.90
72156-26	Radiology	MRI NECK SPINE W/O & W/DYE	199.21	199.21
72156-TC	Radiology	MRI NECK SPINE W/O & W/DYE	392.69	392.69
72157	Radiology	MRI CHEST SPINE W/O & W/DYE	593.07	593.07
72157-26	Radiology	MRI CHEST SPINE W/O & W/DYE	199.21	199.21
72157-TC	Radiology	MRI CHEST SPINE W/O & W/DYE	393.88	393.88
72158	Radiology	MRI LUMBAR SPINE W/O & W/DYE	590.71	590.71
72158-26	Radiology	MRI LUMBAR SPINE W/O & W/DYE	199.21	199.21
72158-TC	Radiology	MRI LUMBAR SPINE W/O & W/DYE	391.50	391.50
72159	Radiology	MR ANGIO SPINE W/O&W/DYE	636.62	636.62
72159-26	Radiology	MR ANGIO SPINE W/O&W/DYE	156.59	156.59
72159-TC	Radiology	MR ANGIO SPINE W/O&W/DYE	480.03	480.03
72170	Radiology	X-RAY EXAM OF PELVIS	50.13	50.13
72170-26	Radiology	X-RAY EXAM OF PELVIS	15.42	15.42
72170-TC	Radiology	X-RAY EXAM OF PELVIS	34.71	34.71
72190	Radiology	X-RAY EXAM OF PELVIS	75.93	75.93
72190-26	Radiology	X-RAY EXAM OF PELVIS	22.31	22.31
72190-TC	Radiology	X-RAY EXAM OF PELVIS	53.64	53.64
72191	Radiology	CT ANGIOGRAPH PELV W/O&W/DYE	560.39	560.39
72191-26	Radiology	CT ANGIOGRAPH PELV W/O&W/DYE	155.30	155.30
72191-TC	Radiology	CT ANGIOGRAPH PELV W/O&W/DYE	405.11	405.11
72192	Radiology	CT PELVIS W/O DYE	245.82	245.82
72192-26	Radiology	CT PELVIS W/O DYE	94.61	94.61
72192-TC	Radiology	CT PELVIS W/O DYE	151.20	151.20
72193	Radiology	CT PELVIS W/DYE	420.99	420.99
72193-26	Radiology	CT PELVIS W/DYE	100.85	100.85
72193-TC	Radiology	CT PELVIS W/DYE	320.13	320.13
72194	Radiology	CT PELVIS W/O & W/DYE	464.43	464.43
72194-26	Radiology	CT PELVIS W/O & W/DYE	105.28	105.28
72194-TC	Radiology	CT PELVIS W/O & W/DYE	359.15	359.15
72195	Radiology	MRI PELVIS W/O DYE	423.25	423.25
72195-26	Radiology	MRI PELVIS W/O DYE	127.37	127.37
72195-TC	Radiology	MRI PELVIS W/O DYE	295.89	295.89
72196	Radiology	MRI PELVIS W/DYE	495.75	495.75
72196-26	Radiology	MRI PELVIS W/DYE	149.76	149.76
72196-TC	Radiology	MRI PELVIS W/DYE	345.99	345.99
72197	Radiology	MRI PELVIS W/O & W/DYE	622.38	622.38
72197-26	Radiology	MRI PELVIS W/O & W/DYE	190.67	190.67
72197-TC	Radiology	MRI PELVIS W/O & W/DYE	431.71	431.71
72198	Radiology	MR ANGIO PELVIS W/O & W/DYE	623.03	623.03
72198-26	Radiology	MR ANGIO PELVIS W/O & W/DYE	154.83	154.83
72198-TC	Radiology	MR ANGIO PELVIS W/O & W/DYE	468.20	468.20
72200	Radiology	X-RAY EXAM SI JOINTS	59.59	59.59
72200-26	Radiology	X-RAY EXAM SI JOINTS	14.82	14.82
72200-TC	Radiology	X-RAY EXAM SI JOINTS	44.77	44.77
72202	Radiology	X-RAY EXAM SI JOINTS 3/> VWS	70.53	70.53
72202-26	Radiology	X-RAY EXAM SI JOINTS 3/> VWS	19.83	19.83
72202-TC	Radiology	X-RAY EXAM SI JOINTS 3/> VWS	50.68	50.68
72220	Radiology	X-RAY EXAM SACRUM TAILBONE	58.42	58.42
72220-26	Radiology	X-RAY EXAM SACRUM TAILBONE	15.42	15.42
72220-TC	Radiology	X-RAY EXAM SACRUM TAILBONE	43.00	43.00
72240	Radiology	MYELOGRAPHY NECK SPINE	201.81	201.81
72240-26	Radiology	MYELOGRAPHY NECK SPINE	79.58	79.58
72240-TC	Radiology	MYELOGRAPHY NECK SPINE	122.23	122.23
72255	Radiology	MYELOGRAPHY THORACIC SPINE	194.28	194.28
72255-26	Radiology	MYELOGRAPHY THORACIC SPINE	79.15	79.15
72255-TC	Radiology	MYELOGRAPHY THORACIC SPINE	115.13	115.13
72265	Radiology	MYELOGRAPHY L-S SPINE	196.42	196.42
72265-26	Radiology	MYELOGRAPHY L-S SPINE	73.03	73.03
72265-TC	Radiology	MYELOGRAPHY L-S SPINE	123.42	123.42
72270	Radiology	MYELOGPHY 2/> SPINE REGIONS	275.57	275.57
72270-26	Radiology	MYELOGPHY 2/> SPINE REGIONS	119.07	119.07
72270-TC	Radiology	MYELOGPHY 2/> SPINE REGIONS	156.53	156.53
72285	Radiology	DISCOGRAPHY CERV/THOR SPINE	238.80	238.80
72285-26	Radiology	DISCOGRAPHY CERV/THOR SPINE	102.38	102.38
72285-TC	Radiology	DISCOGRAPHY CERV/THOR SPINE	136.42	136.42
72295	Radiology	X-RAY OF LOWER SPINE DISK	200.58	200.58
72295-26	Radiology	X-RAY OF LOWER SPINE DISK	72.44	72.44
72295-TC	Radiology	X-RAY OF LOWER SPINE DISK	128.13	128.13
73000	Radiology	X-RAY EXAM OF COLLAR BONE	58.36	58.36
73000-26	Radiology	X-RAY EXAM OF COLLAR BONE	14.78	14.78
73000-TC	Radiology	X-RAY EXAM OF COLLAR BONE	43.58	43.58
73010	Radiology	X-RAY EXAM OF SHOULDER BLADE	43.04	43.04
73010-26	Radiology	X-RAY EXAM OF SHOULDER BLADE	16.01	16.01
73010-TC	Radiology	X-RAY EXAM OF SHOULDER BLADE	27.03	27.03
73020	Radiology	X-RAY EXAM OF SHOULDER	38.81	38.81
73020-26	Radiology	X-RAY EXAM OF SHOULDER	13.55	13.55
73020-TC	Radiology	X-RAY EXAM OF SHOULDER	25.25	25.25
73030	Radiology	X-RAY EXAM OF SHOULDER	62.60	62.60
73030-26	Radiology	X-RAY EXAM OF SHOULDER	16.65	16.65
73030-TC	Radiology	X-RAY EXAM OF SHOULDER	45.96	45.96
73040	Radiology	CONTRAST X-RAY OF SHOULDER	235.44	235.44
73040-26	Radiology	CONTRAST X-RAY OF SHOULDER	48.77	48.77
73040-TC	Radiology	CONTRAST X-RAY OF SHOULDER	186.67	186.67
73050	Radiology	X-RAY EXAM OF SHOULDERS	51.95	51.95
73050-26	Radiology	X-RAY EXAM OF SHOULDERS	16.65	16.65
73050-TC	Radiology	X-RAY EXAM OF SHOULDERS	35.31	35.31
73060	Radiology	X-RAY EXAM OF HUMERUS	57.19	57.19
73060-26	Radiology	X-RAY EXAM OF HUMERUS	14.20	14.20
73060-TC	Radiology	X-RAY EXAM OF HUMERUS	43.00	43.00
73070	Radiology	X-RAY EXAM OF ELBOW	52.46	52.46
73070-26	Radiology	X-RAY EXAM OF ELBOW	14.78	14.78
73070-TC	Radiology	X-RAY EXAM OF ELBOW	37.67	37.67
73080	Radiology	X-RAY EXAM OF ELBOW	59.01	59.01
73080-26	Radiology	X-RAY EXAM OF ELBOW	15.42	15.42
73080-TC	Radiology	X-RAY EXAM OF ELBOW	43.58	43.58
73085	Radiology	CONTRAST X-RAY OF ELBOW	179.26	179.26
73085-26	Radiology	CONTRAST X-RAY OF ELBOW	47.00	47.00
73085-TC	Radiology	CONTRAST X-RAY OF ELBOW	132.27	132.27
73090	Radiology	X-RAY EXAM OF FOREARM	52.46	52.46
73090-26	Radiology	X-RAY EXAM OF FOREARM	14.20	14.20
73090-TC	Radiology	X-RAY EXAM OF FOREARM	38.26	38.26
73092	Radiology	X-RAY EXAM OF ARM INFANT	56.59	56.59
73092-26	Radiology	X-RAY EXAM OF ARM INFANT	14.20	14.20
73092-TC	Radiology	X-RAY EXAM OF ARM INFANT	42.41	42.41
73100	Radiology	X-RAY EXAM OF WRIST	60.72	60.72
73100-26	Radiology	X-RAY EXAM OF WRIST	14.78	14.78
73100-TC	Radiology	X-RAY EXAM OF WRIST	45.96	45.96
73110	Radiology	X-RAY EXAM OF WRIST	73.79	73.79
73110-26	Radiology	X-RAY EXAM OF WRIST	15.42	15.42
73110-TC	Radiology	X-RAY EXAM OF WRIST	58.36	58.36
73115	Radiology	CONTRAST X-RAY OF WRIST	241.35	241.35
73115-26	Radiology	CONTRAST X-RAY OF WRIST	49.35	49.35
73115-TC	Radiology	CONTRAST X-RAY OF WRIST	192.00	192.00
73120	Radiology	X-RAY EXAM OF HAND	56.59	56.59
73120-26	Radiology	X-RAY EXAM OF HAND	14.78	14.78
73120-TC	Radiology	X-RAY EXAM OF HAND	41.81	41.81
73130	Radiology	X-RAY EXAM OF HAND	66.69	66.69
73130-26	Radiology	X-RAY EXAM OF HAND	15.42	15.42
73130-TC	Radiology	X-RAY EXAM OF HAND	51.27	51.27
73140	Radiology	X-RAY EXAM OF FINGER(S)	68.27	68.27
73140-26	Radiology	X-RAY EXAM OF FINGER(S)	12.27	12.27
73140-TC	Radiology	X-RAY EXAM OF FINGER(S)	56.00	56.00
73200	Radiology	CT UPPER EXTREMITY W/O DYE	296.99	296.99
73200-26	Radiology	CT UPPER EXTREMITY W/O DYE	86.68	86.68
73200-TC	Radiology	CT UPPER EXTREMITY W/O DYE	210.33	210.33
73201	Radiology	CT UPPER EXTREMITY W/DYE	369.54	369.54
73201-26	Radiology	CT UPPER EXTREMITY W/DYE	100.85	100.85
73201-TC	Radiology	CT UPPER EXTREMITY W/DYE	268.69	268.69
73202	Radiology	CT UPPR EXTREMITY W/O&W/DYE	457.33	457.33
73202-26	Radiology	CT UPPR EXTREMITY W/O&W/DYE	105.28	105.28
73202-TC	Radiology	CT UPPR EXTREMITY W/O&W/DYE	352.05	352.05
73206	Radiology	CT ANGIO UPR EXTRM W/O&W/DYE	546.80	546.80
73206-26	Radiology	CT ANGIO UPR EXTRM W/O&W/DYE	155.30	155.30
73206-TC	Radiology	CT ANGIO UPR EXTRM W/O&W/DYE	391.50	391.50
73218	Radiology	MRI UPPER EXTREMITY W/O DYE	558.73	558.73
73218-26	Radiology	MRI UPPER EXTREMITY W/O DYE	118.15	118.15
73218-TC	Radiology	MRI UPPER EXTREMITY W/O DYE	440.58	440.58
73219	Radiology	MRI UPPER EXTREMITY W/DYE	610.68	610.68
73219-26	Radiology	MRI UPPER EXTREMITY W/DYE	141.12	141.12
73219-TC	Radiology	MRI UPPER EXTREMITY W/DYE	469.56	469.56
73220	Radiology	MRI UPPR EXTREMITY W/O&W/DYE	755.78	755.78
73220-26	Radiology	MRI UPPR EXTREMITY W/O&W/DYE	186.89	186.89
73220-TC	Radiology	MRI UPPR EXTREMITY W/O&W/DYE	568.89	568.89
73221	Radiology	MRI JOINT UPR EXTREM W/O DYE	375.00	375.00
73221-26	Radiology	MRI JOINT UPR EXTREM W/O DYE	118.15	118.15
73221-TC	Radiology	MRI JOINT UPR EXTREM W/O DYE	256.87	256.87
73222	Radiology	MRI JOINT UPR EXTREM W/DYE	577.57	577.57
73222-26	Radiology	MRI JOINT UPR EXTREM W/DYE	141.73	141.73
73222-TC	Radiology	MRI JOINT UPR EXTREM W/DYE	435.84	435.84
73223	Radiology	MRI JOINT UPR EXTR W/O&W/DYE	714.38	714.38
73223-26	Radiology	MRI JOINT UPR EXTR W/O&W/DYE	187.47	187.47
73223-TC	Radiology	MRI JOINT UPR EXTR W/O&W/DYE	526.91	526.91
73225	Radiology	MR ANGIO UPR EXTR W/O&W/DYE	630.38	630.38
73225-26	Radiology	MR ANGIO UPR EXTR W/O&W/DYE	150.35	150.35
73225-TC	Radiology	MR ANGIO UPR EXTR W/O&W/DYE	480.03	480.03
73501	Radiology	X-RAY EXAM HIP UNI 1 VIEW	59.05	59.05
73501-26	Radiology	X-RAY EXAM HIP UNI 1 VIEW	16.65	16.65
73501-TC	Radiology	X-RAY EXAM HIP UNI 1 VIEW	42.41	42.41
73502	Radiology	X-RAY EXAM HIP UNI 2-3 VIEWS	85.25	85.25
73502-26	Radiology	X-RAY EXAM HIP UNI 2-3 VIEWS	19.79	19.79
73502-TC	Radiology	X-RAY EXAM HIP UNI 2-3 VIEWS	65.46	65.46
73503	Radiology	X-RAY EXAM HIP UNI 4/> VIEWS	107.37	107.37
73503-26	Radiology	X-RAY EXAM HIP UNI 4/> VIEWS	24.16	24.16
73503-TC	Radiology	X-RAY EXAM HIP UNI 4/> VIEWS	83.21	83.21
73521	Radiology	X-RAY EXAM HIPS BI 2 VIEWS	74.02	74.02
73521-26	Radiology	X-RAY EXAM HIPS BI 2 VIEWS	19.79	19.79
73521-TC	Radiology	X-RAY EXAM HIPS BI 2 VIEWS	54.23	54.23
73522	Radiology	X-RAY EXAM HIPS BI 3-4 VIEWS	96.82	96.82
73522-26	Radiology	X-RAY EXAM HIPS BI 3-4 VIEWS	26.03	26.03
73522-TC	Radiology	X-RAY EXAM HIPS BI 3-4 VIEWS	70.79	70.79
73523	Radiology	X-RAY EXAM HIPS BI 5/> VIEWS	110.94	110.94
73523-26	Radiology	X-RAY EXAM HIPS BI 5/> VIEWS	27.73	27.73
73523-TC	Radiology	X-RAY EXAM HIPS BI 5/> VIEWS	83.21	83.21
73525	Radiology	CONTRAST X-RAY OF HIP	230.37	230.37
73525-26	Radiology	CONTRAST X-RAY OF HIP	51.38	51.38
73525-TC	Radiology	CONTRAST X-RAY OF HIP	178.99	178.99
73551	Radiology	X-RAY EXAM OF FEMUR 1	52.46	52.46
73551-26	Radiology	X-RAY EXAM OF FEMUR 1	14.78	14.78
73551-TC	Radiology	X-RAY EXAM OF FEMUR 1	37.67	37.67
73552	Radiology	X-RAY EXAM OF FEMUR 2/>	63.78	63.78
73552-26	Radiology	X-RAY EXAM OF FEMUR 2/>	16.05	16.05
73552-TC	Radiology	X-RAY EXAM OF FEMUR 2/>	47.72	47.72
73560	Radiology	X-RAY EXAM OF KNEE 1 OR 2	61.33	61.33
73560-26	Radiology	X-RAY EXAM OF KNEE 1 OR 2	14.78	14.78
73560-TC	Radiology	X-RAY EXAM OF KNEE 1 OR 2	46.55	46.55
73562	Radiology	X-RAY EXAM OF KNEE 3	73.24	73.24
73562-26	Radiology	X-RAY EXAM OF KNEE 3	16.65	16.65
73562-TC	Radiology	X-RAY EXAM OF KNEE 3	56.59	56.59
73564	Radiology	X-RAY EXAM KNEE 4 OR MORE	84.67	84.67
73564-26	Radiology	X-RAY EXAM KNEE 4 OR MORE	20.38	20.38
73564-TC	Radiology	X-RAY EXAM KNEE 4 OR MORE	64.27	64.27
73565	Radiology	X-RAY EXAM OF KNEES	71.37	71.37
73565-26	Radiology	X-RAY EXAM OF KNEES	14.78	14.78
73565-TC	Radiology	X-RAY EXAM OF KNEES	56.59	56.59
73580	Radiology	CONTRAST X-RAY OF KNEE JOINT	197.93	197.93
73580-26	Radiology	CONTRAST X-RAY OF KNEE JOINT	55.59	55.59
73580-TC	Radiology	CONTRAST X-RAY OF KNEE JOINT	142.33	142.33
73590	Radiology	X-RAY EXAM OF LOWER LEG	56.59	56.59
73590-26	Radiology	X-RAY EXAM OF LOWER LEG	14.20	14.20
73590-TC	Radiology	X-RAY EXAM OF LOWER LEG	42.41	42.41
73592	Radiology	X-RAY EXAM OF LEG INFANT	56.59	56.59
73592-26	Radiology	X-RAY EXAM OF LEG INFANT	14.20	14.20
73592-TC	Radiology	X-RAY EXAM OF LEG INFANT	42.41	42.41
73600	Radiology	X-RAY EXAM OF ANKLE	57.78	57.78
73600-26	Radiology	X-RAY EXAM OF ANKLE	14.20	14.20
73600-TC	Radiology	X-RAY EXAM OF ANKLE	43.58	43.58
73610	Radiology	X-RAY EXAM OF ANKLE	65.50	65.50
73610-26	Radiology	X-RAY EXAM OF ANKLE	15.42	15.42
73610-TC	Radiology	X-RAY EXAM OF ANKLE	50.10	50.10
73615	Radiology	CONTRAST X-RAY OF ANKLE	228.93	228.93
73615-26	Radiology	CONTRAST X-RAY OF ANKLE	49.94	49.94
73615-TC	Radiology	CONTRAST X-RAY OF ANKLE	178.99	178.99
73620	Radiology	X-RAY EXAM OF FOOT	51.27	51.27
73620-26	Radiology	X-RAY EXAM OF FOOT	13.59	13.59
73620-TC	Radiology	X-RAY EXAM OF FOOT	37.67	37.67
73630	Radiology	X-RAY EXAM OF FOOT	61.37	61.37
73630-26	Radiology	X-RAY EXAM OF FOOT	14.82	14.82
73630-TC	Radiology	X-RAY EXAM OF FOOT	46.55	46.55
73650	Radiology	X-RAY EXAM OF HEEL	51.27	51.27
73650-26	Radiology	X-RAY EXAM OF HEEL	14.20	14.20
73650-TC	Radiology	X-RAY EXAM OF HEEL	37.09	37.09
73660	Radiology	X-RAY EXAM OF TOE(S)	52.32	52.32
73660-26	Radiology	X-RAY EXAM OF TOE(S)	11.68	11.68
73660-TC	Radiology	X-RAY EXAM OF TOE(S)	40.64	40.64
73700	Radiology	CT LOWER EXTREMITY W/O DYE	239.05	239.05
73700-26	Radiology	CT LOWER EXTREMITY W/O DYE	86.68	86.68
73700-TC	Radiology	CT LOWER EXTREMITY W/O DYE	152.37	152.37
73701	Radiology	CT LOWER EXTREMITY W/DYE	307.46	307.46
73701-26	Radiology	CT LOWER EXTREMITY W/DYE	100.85	100.85
73701-TC	Radiology	CT LOWER EXTREMITY W/DYE	206.60	206.60
73702	Radiology	CT LWR EXTREMITY W/O&W/DYE	359.78	359.78
73702-26	Radiology	CT LWR EXTREMITY W/O&W/DYE	105.28	105.28
73702-TC	Radiology	CT LWR EXTREMITY W/O&W/DYE	254.49	254.49
73706	Radiology	CT ANGIO LWR EXTR W/O&W/DYE	594.36	594.36
73706-26	Radiology	CT ANGIO LWR EXTR W/O&W/DYE	163.41	163.41
73706-TC	Radiology	CT ANGIO LWR EXTR W/O&W/DYE	430.95	430.95
73718	Radiology	MRI LOWER EXTREMITY W/O DYE	412.25	412.25
73718-26	Radiology	MRI LOWER EXTREMITY W/O DYE	116.96	116.96
73718-TC	Radiology	MRI LOWER EXTREMITY W/O DYE	295.29	295.29
73719	Radiology	MRI LOWER EXTREMITY W/DYE	485.92	485.92
73719-26	Radiology	MRI LOWER EXTREMITY W/DYE	140.54	140.54
73719-TC	Radiology	MRI LOWER EXTREMITY W/DYE	345.38	345.38
73720	Radiology	MRI LWR EXTREMITY W/O&W/DYE	622.73	622.73
73720-26	Radiology	MRI LWR EXTREMITY W/O&W/DYE	186.30	186.30
73720-TC	Radiology	MRI LWR EXTREMITY W/O&W/DYE	436.45	436.45
73721	Radiology	MRI JNT OF LWR EXTRE W/O DYE	374.42	374.42
73721-26	Radiology	MRI JNT OF LWR EXTRE W/O DYE	118.15	118.15
73721-TC	Radiology	MRI JNT OF LWR EXTRE W/O DYE	256.27	256.27
73722	Radiology	MRI JOINT OF LWR EXTR W/DYE	578.16	578.16
73722-26	Radiology	MRI JOINT OF LWR EXTR W/DYE	141.12	141.12
73722-TC	Radiology	MRI JOINT OF LWR EXTR W/DYE	437.03	437.03
73723	Radiology	MRI JOINT LWR EXTR W/O&W/DYE	711.42	711.42
73723-26	Radiology	MRI JOINT LWR EXTR W/O&W/DYE	186.89	186.89
73723-TC	Radiology	MRI JOINT LWR EXTR W/O&W/DYE	524.55	524.55
73725	Radiology	MR ANG LWR EXT W OR W/O DYE	618.81	618.81
73725-26	Radiology	MR ANG LWR EXT W OR W/O DYE	155.92	155.92
73725-TC	Radiology	MR ANG LWR EXT W OR W/O DYE	462.89	462.89
74018	Radiology	X-RAY EXAM ABDOMEN 1 VIEW	54.33	54.33
74018-26	Radiology	X-RAY EXAM ABDOMEN 1 VIEW	16.05	16.05
74018-TC	Radiology	X-RAY EXAM ABDOMEN 1 VIEW	38.26	38.26
74019	Radiology	X-RAY EXAM ABDOMEN 2 VIEWS	65.79	65.79
74019-26	Radiology	X-RAY EXAM ABDOMEN 2 VIEWS	19.83	19.83
74019-TC	Radiology	X-RAY EXAM ABDOMEN 2 VIEWS	45.96	45.96
74021	Radiology	X-RAY EXAM ABDOMEN 3+ VIEWS	77.22	77.22
74021-26	Radiology	X-RAY EXAM ABDOMEN 3+ VIEWS	23.58	23.58
74021-TC	Radiology	X-RAY EXAM ABDOMEN 3+ VIEWS	53.64	53.64
74022	Radiology	X-RAY EXAM COMPLETE ABDOMEN	89.70	89.70
74022-26	Radiology	X-RAY EXAM COMPLETE ABDOMEN	27.79	27.79
74022-TC	Radiology	X-RAY EXAM COMPLETE ABDOMEN	61.91	61.91
74150	Radiology	CT ABDOMEN W/O DYE	252.78	252.78
74150-26	Radiology	CT ABDOMEN W/O DYE	103.37	103.37
74150-TC	Radiology	CT ABDOMEN W/O DYE	149.43	149.43
74160	Radiology	CT ABDOMEN W/DYE	429.02	429.02
74160-26	Radiology	CT ABDOMEN W/DYE	110.66	110.66
74160-TC	Radiology	CT ABDOMEN W/DYE	318.36	318.36
74170	Radiology	CT ABDOMEN W/O & W/DYE	482.25	482.25
74170-26	Radiology	CT ABDOMEN W/O & W/DYE	121.33	121.33
74170-TC	Radiology	CT ABDOMEN W/O & W/DYE	360.93	360.93
74174	Radiology	CT ANGIO ABD&PELV W/O&W/DYE	700.09	700.09
74174-26	Radiology	CT ANGIO ABD&PELV W/O&W/DYE	189.91	189.91
74174-TC	Radiology	CT ANGIO ABD&PELV W/O&W/DYE	510.18	510.18
74175	Radiology	CT ANGIO ABDOM W/O & W/DYE	562.81	562.81
74175-26	Radiology	CT ANGIO ABDOM W/O & W/DYE	157.11	157.11
74175-TC	Radiology	CT ANGIO ABDOM W/O & W/DYE	405.70	405.70
74176	Radiology	CT ABD & PELVIS W/O CONTRAST	339.26	339.26
74176-26	Radiology	CT ABD & PELVIS W/O CONTRAST	150.99	150.99
74176-TC	Radiology	CT ABD & PELVIS W/O CONTRAST	188.27	188.27
74177	Radiology	CT ABD & PELV W/CONTRAST	559.01	559.01
74177-26	Radiology	CT ABD & PELV W/CONTRAST	157.87	157.87
74177-TC	Radiology	CT ABD & PELV W/CONTRAST	401.13	401.13
74178	Radiology	CT ABD & PELV 1/> REGNS	626.96	626.96
74178-26	Radiology	CT ABD & PELV 1/> REGNS	173.98	173.98
74178-TC	Radiology	CT ABD & PELV 1/> REGNS	453.00	453.00
74181	Radiology	MRI ABDOMEN W/O DYE	362.35	362.35
74181-26	Radiology	MRI ABDOMEN W/O DYE	126.77	126.77
74181-TC	Radiology	MRI ABDOMEN W/O DYE	235.58	235.58
74182	Radiology	MRI ABDOMEN W/DYE	557.82	557.82
74182-26	Radiology	MRI ABDOMEN W/DYE	149.76	149.76
74182-TC	Radiology	MRI ABDOMEN W/DYE	408.06	408.06
74183	Radiology	MRI ABDOMEN W/O & W/DYE	624.74	624.74
74183-26	Radiology	MRI ABDOMEN W/O & W/DYE	190.67	190.67
74183-TC	Radiology	MRI ABDOMEN W/O & W/DYE	434.07	434.07
74185	Radiology	MRI ANGIO ABDOM W ORW/O DYE	620.67	620.67
74185-26	Radiology	MRI ANGIO ABDOM W ORW/O DYE	154.83	154.83
74185-TC	Radiology	MRI ANGIO ABDOM W ORW/O DYE	465.84	465.84
74190	Radiology	X-RAY EXAM OF PERITONEUM	142.58	142.58
74190-26	Radiology	X-RAY EXAM OF PERITONEUM	40.21	40.21
74190-TC	Radiology	X-RAY EXAM OF PERITONEUM	102.38	102.38
74210	Radiology	X-RAY XM PHRNX&/CRV ESOPH C+	170.04	170.04
74210-26	Radiology	X-RAY XM PHRNX&/CRV ESOPH C+	50.78	50.78
74210-TC	Radiology	X-RAY XM PHRNX&/CRV ESOPH C+	119.26	119.26
74220	Radiology	X-RAY XM ESOPHAGUS 1CNTRST	174.82	174.82
74220-26	Radiology	X-RAY XM ESOPHAGUS 1CNTRST	52.01	52.01
74220-TC	Radiology	X-RAY XM ESOPHAGUS 1CNTRST	122.81	122.81
74221	Radiology	X-RAY XM ESOPHAGUS 2CNTRST	197.01	197.01
74221-26	Radiology	X-RAY XM ESOPHAGUS 2CNTRST	60.59	60.59
74221-TC	Radiology	X-RAY XM ESOPHAGUS 2CNTRST	136.42	136.42
74230	Radiology	X-RAY XM SWLNG FUNCJ C+	222.96	222.96
74230-26	Radiology	X-RAY XM SWLNG FUNCJ C+	46.35	46.35
74230-TC	Radiology	X-RAY XM SWLNG FUNCJ C+	176.61	176.61
74235	Radiology	REMOVE ESOPHAGUS OBSTRUCTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74235-26	Radiology	REMOVE ESOPHAGUS OBSTRUCTION	103.37	103.37
74235-TC	Radiology	REMOVE ESOPHAGUS OBSTRUCTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74240	Radiology	X-RAY XM UPR GI TRC 1CNTRST	220.53	220.53
74240-26	Radiology	X-RAY XM UPR GI TRC 1CNTRST	69.93	69.93
74240-TC	Radiology	X-RAY XM UPR GI TRC 1CNTRST	150.60	150.60
74246	Radiology	X-RAY XM UPR GI TRC 2CNTRST	249.81	249.81
74246-26	Radiology	X-RAY XM UPR GI TRC 2CNTRST	77.92	77.92
74246-TC	Radiology	X-RAY XM UPR GI TRC 2CNTRST	171.89	171.89
74248	Major surgery	X-RAY SM INT F-THRU STD	148.51	148.51
74248-26	Radiology	X-RAY SM INT F-THRU STD	60.59	60.59
74248-TC	Radiology	X-RAY SM INT F-THRU STD	87.93	87.93
74250	Radiology	X-RAY XM SM INT 1CNTRST STD	218.81	218.81
74250-26	Radiology	X-RAY XM SM INT 1CNTRST STD	69.97	69.97
74250-TC	Radiology	X-RAY XM SM INT 1CNTRST STD	148.82	148.82
74251	Radiology	X-RAY XM SM INT 2CNTRST STD	647.07	647.07
74251-26	Radiology	X-RAY XM SM INT 2CNTRST STD	101.50	101.50
74251-TC	Radiology	X-RAY XM SM INT 2CNTRST STD	545.57	545.57
74261	Radiology	CT COLONOGRAPHY DX	763.29	763.29
74261-26	Radiology	CT COLONOGRAPHY DX	208.01	208.01
74261-TC	Radiology	CT COLONOGRAPHY DX	555.28	555.28
74262	Radiology	CT COLONOGRAPHY DX W/DYE	858.20	858.20
74262-26	Radiology	CT COLONOGRAPHY DX W/DYE	217.17	217.17
74262-TC	Radiology	CT COLONOGRAPHY DX W/DYE	641.02	641.02
74263	Radiology	CT COLONOGRAPHY SCREENING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74263-26	Radiology	CT COLONOGRAPHY SCREENING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74263-TC	Radiology	CT COLONOGRAPHY SCREENING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74270	Radiology	X-RAY XM COLON 1CNTRST STD	275.89	275.89
74270-26	Radiology	X-RAY XM COLON 1CNTRST STD	89.82	89.82
74270-TC	Radiology	X-RAY XM COLON 1CNTRST STD	186.09	186.09
74280	Radiology	X-RAY XM COLON 2CNTRST STD	394.10	394.10
74280-26	Radiology	X-RAY XM COLON 2CNTRST STD	109.43	109.43
74280-TC	Radiology	X-RAY XM COLON 2CNTRST STD	284.66	284.66
74283	Radiology	THER NMA RDCTJ INTUS/OBSTRCJ	459.44	459.44
74283-26	Radiology	THER NMA RDCTJ INTUS/OBSTRCJ	182.31	182.31
74283-TC	Radiology	THER NMA RDCTJ INTUS/OBSTRCJ	277.13	277.13
74290	Radiology	CONTRAST X-RAY GALLBLADDER	151.79	151.79
74290-26	Radiology	CONTRAST X-RAY GALLBLADDER	27.79	27.79
74290-TC	Radiology	CONTRAST X-RAY GALLBLADDER	124.00	124.00
74300	Radiology	X-RAY BILE DUCTS/PANCREAS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74300-26	Radiology	X-RAY BILE DUCTS/PANCREAS	24.00	24.00
74300-TC	Radiology	X-RAY BILE DUCTS/PANCREAS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74301	Radiology	X-RAYS AT SURGERY ADD-ON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74301-26	Radiology	X-RAYS AT SURGERY ADD-ON	17.98	17.98
74301-TC	Radiology	X-RAYS AT SURGERY ADD-ON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74328	Radiology	X-RAY BILE DUCT ENDOSCOPY	289.01	289.01
74328-26	Radiology	X-RAY BILE DUCT ENDOSCOPY	42.10	42.10
74328-TC	Radiology	X-RAY BILE DUCT ENDOSCOPY	246.91	246.91
74329	Radiology	X-RAY FOR PANCREAS ENDOSCOPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74329-26	Radiology	X-RAY FOR PANCREAS ENDOSCOPY	42.69	42.69
74329-TC	Radiology	X-RAY FOR PANCREAS ENDOSCOPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74330	Radiology	X-RAY BILE/PANC ENDOSCOPY	296.36	296.36
74330-26	Radiology	X-RAY BILE/PANC ENDOSCOPY	49.45	49.45
74330-TC	Radiology	X-RAY BILE/PANC ENDOSCOPY	246.91	246.91
74340	Radiology	X-RAY GUIDE FOR GI TUBE	251.80	251.80
74340-26	Radiology	X-RAY GUIDE FOR GI TUBE	46.39	46.39
74340-TC	Radiology	X-RAY GUIDE FOR GI TUBE	205.41	205.41
74355	Radiology	X-RAY GUIDE INTESTINAL TUBE	272.40	272.40
74355-26	Radiology	X-RAY GUIDE INTESTINAL TUBE	66.18	66.18
74355-TC	Radiology	X-RAY GUIDE INTESTINAL TUBE	206.21	206.21
74360	Radiology	X-RAY GUIDE GI DILATION	295.17	295.17
74360-26	Radiology	X-RAY GUIDE GI DILATION	49.02	49.02
74360-TC	Radiology	X-RAY GUIDE GI DILATION	246.15	246.15
74363	Radiology	X-RAY BILE DUCT DILATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74363-26	Radiology	X-RAY BILE DUCT DILATION	75.47	75.47
74363-TC	Radiology	X-RAY BILE DUCT DILATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74400	Radiology	UROGRAPHY IV +-KUB TOMOG	240.94	240.94
74400-26	Radiology	UROGRAPHY IV +-KUB TOMOG	42.61	42.61
74400-TC	Radiology	UROGRAPHY IV +-KUB TOMOG	198.33	198.33
74410	Radiology	UROGRAPHY NFS DRIP&/BOLUS	252.93	252.93
74410-26	Radiology	UROGRAPHY NFS DRIP&/BOLUS	42.18	42.18
74410-TC	Radiology	UROGRAPHY NFS DRIP&/BOLUS	210.76	210.76
74415	Radiology	UROGRAPHY NFS DRIP&/BLS W/NF	269.49	269.49
74415-26	Radiology	UROGRAPHY NFS DRIP&/BLS W/NF	42.18	42.18
74415-TC	Radiology	UROGRAPHY NFS DRIP&/BLS W/NF	227.31	227.31
74420	Radiology	UROGRAPHY RTRGR +-KUB	140.32	140.32
74420-26	Radiology	UROGRAPHY RTRGR +-KUB	44.69	44.69
74420-TC	Radiology	UROGRAPHY RTRGR +-KUB	95.61	95.61
74425	Radiology	UROGRAPHY ANTEGRADE RS&I	242.56	242.56
74425-26	Radiology	UROGRAPHY ANTEGRADE RS&I	43.47	43.47
74425-TC	Radiology	UROGRAPHY ANTEGRADE RS&I	199.10	199.10
74430	Radiology	CONTRAST X-RAY BLADDER	74.33	74.33
74430-26	Radiology	CONTRAST X-RAY BLADDER	27.79	27.79
74430-TC	Radiology	CONTRAST X-RAY BLADDER	46.55	46.55
74440	Radiology	X-RAY MALE GENITAL TRACT	174.12	174.12
74440-26	Radiology	X-RAY MALE GENITAL TRACT	32.37	32.37
74440-TC	Radiology	X-RAY MALE GENITAL TRACT	141.75	141.75
74445	Radiology	X-RAY EXAM OF PENIS	184.90	184.90
74445-26	Radiology	X-RAY EXAM OF PENIS	98.14	98.14
74445-TC	Radiology	X-RAY EXAM OF PENIS	86.76	86.76
74450	Radiology	X-RAY URETHRA/BLADDER	142.72	142.72
74450-26	Radiology	X-RAY URETHRA/BLADDER	28.59	28.59
74450-TC	Radiology	X-RAY URETHRA/BLADDER	114.13	114.13
74455	Radiology	X-RAY URETHRA/BLADDER	185.70	185.70
74455-26	Radiology	X-RAY URETHRA/BLADDER	28.59	28.59
74455-TC	Radiology	X-RAY URETHRA/BLADDER	157.11	157.11
74470	Radiology	X-RAY EXAM OF KIDNEY LESION	143.79	143.79
74470-26	Radiology	X-RAY EXAM OF KIDNEY LESION	45.22	45.22
74470-TC	Radiology	X-RAY EXAM OF KIDNEY LESION	98.57	98.57
74485	Radiology	DILATION URTR/URT RS&I	214.93	214.93
74485-26	Radiology	DILATION URTR/URT RS&I	71.41	71.41
74485-TC	Radiology	DILATION URTR/URT RS&I	143.50	143.50
74712	Radiology	MRI FETAL SNGL/1ST GESTATION	756.17	756.17
74712-26	Radiology	MRI FETAL SNGL/1ST GESTATION	261.18	261.18
74712-TC	Radiology	MRI FETAL SNGL/1ST GESTATION	494.97	494.97
74713	Radiology	MRI FETAL EA ADDL GESTATION	368.92	368.92
74713-26	Radiology	MRI FETAL EA ADDL GESTATION	160.97	160.97
74713-TC	Radiology	MRI FETAL EA ADDL GESTATION	207.95	207.95
74740	Radiology	X-RAY FEMALE GENITAL TRACT	167.45	167.45
74740-26	Radiology	X-RAY FEMALE GENITAL TRACT	33.38	33.38
74740-TC	Radiology	X-RAY FEMALE GENITAL TRACT	134.04	134.04
74742	Radiology	X-RAY FALLOPIAN TUBE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74742-26	Radiology	X-RAY FALLOPIAN TUBE	53.24	53.24
74742-TC	Radiology	X-RAY FALLOPIAN TUBE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
74775	Radiology	X-RAY EXAM OF PERINEUM	168.79	168.79
74775-26	Radiology	X-RAY EXAM OF PERINEUM	53.88	53.88
74775-TC	Radiology	X-RAY EXAM OF PERINEUM	114.91	114.91
75557	Radiology	CARDIAC MRI FOR MORPH	516.40	516.40
75557-26	Radiology	CARDIAC MRI FOR MORPH	202.20	202.20
75557-TC	Radiology	CARDIAC MRI FOR MORPH	314.22	314.22
75559	Radiology	CARDIAC MRI W/STRESS IMG	694.41	694.41
75559-26	Radiology	CARDIAC MRI W/STRESS IMG	251.90	251.90
75559-TC	Radiology	CARDIAC MRI W/STRESS IMG	442.51	442.51
75561	Radiology	CARDIAC MRI FOR MORPH W/DYE	672.75	672.75
75561-26	Radiology	CARDIAC MRI FOR MORPH W/DYE	223.90	223.90
75561-TC	Radiology	CARDIAC MRI FOR MORPH W/DYE	448.85	448.85
75563	Radiology	CARD MRI W/STRESS IMG & DYE	784.62	784.62
75563-26	Radiology	CARD MRI W/STRESS IMG & DYE	256.54	256.54
75563-TC	Radiology	CARD MRI W/STRESS IMG & DYE	528.08	528.08
75565	Radiology	CARD MRI VELOC FLOW MAPPING	83.79	83.79
75565-26	Radiology	CARD MRI VELOC FLOW MAPPING	21.70	21.70
75565-TC	Radiology	CARD MRI VELOC FLOW MAPPING	62.09	62.09
75571	Radiology	CT HRT W/O DYE W/CA TEST	183.42	183.42
75571-26	Radiology	CT HRT W/O DYE W/CA TEST	50.13	50.13
75571-TC	Radiology	CT HRT W/O DYE W/CA TEST	133.28	133.28
75572	Radiology	CT HRT W/3D IMAGE	420.32	420.32
75572-26	Radiology	CT HRT W/3D IMAGE	150.62	150.62
75572-TC	Radiology	CT HRT W/3D IMAGE	269.70	269.70
75573	Radiology	CT HRT C+ STRUX CGEN HRT DS	561.62	561.62
75573-26	Radiology	CT HRT C+ STRUX CGEN HRT DS	219.94	219.94
75573-TC	Radiology	CT HRT C+ STRUX CGEN HRT DS	341.68	341.68
75574	Radiology	CT ANGIO HRT W/3D IMAGE	594.18	594.18
75574-26	Radiology	CT ANGIO HRT W/3D IMAGE	206.99	206.99
75574-TC	Radiology	CT ANGIO HRT W/3D IMAGE	387.19	387.19
75580	Radiology	N-INVAS EST C FFR SW ALY CTA	1605.55	1605.55
75580-26	Radiology	N-INVAS EST C FFR SW ALY CTA	64.53	64.53
75580-TC	Radiology	N-INVAS EST C FFR SW ALY CTA	1541.01	1541.01
75600	Radiology	CONTRAST EXAM THORACIC AORTA	324.23	324.23
75600-26	Radiology	CONTRAST EXAM THORACIC AORTA	41.94	41.94
75600-TC	Radiology	CONTRAST EXAM THORACIC AORTA	282.28	282.28
75605	Radiology	CONTRAST EXAM THORACIC AORTA	217.25	217.25
75605-26	Radiology	CONTRAST EXAM THORACIC AORTA	96.39	96.39
75605-TC	Radiology	CONTRAST EXAM THORACIC AORTA	120.88	120.88
75625	Radiology	CONTRAST EXAM ABDOMINL AORTA	227.23	227.23
75625-26	Radiology	CONTRAST EXAM ABDOMINL AORTA	120.96	120.96
75625-TC	Radiology	CONTRAST EXAM ABDOMINL AORTA	106.26	106.26
75630	Radiology	X-RAY AORTA LEG ARTERIES	283.51	283.51
75630-26	Radiology	X-RAY AORTA LEG ARTERIES	169.14	169.14
75630-TC	Radiology	X-RAY AORTA LEG ARTERIES	114.37	114.37
75635	Radiology	CT ANGIO ABDOMINAL ARTERIES	755.70	755.70
75635-26	Radiology	CT ANGIO ABDOMINAL ARTERIES	205.47	205.47
75635-TC	Radiology	CT ANGIO ABDOMINAL ARTERIES	550.23	550.23
75705	Radiology	ARTERY X-RAYS SPINE	446.51	446.51
75705-26	Radiology	ARTERY X-RAYS SPINE	206.37	206.37
75705-TC	Radiology	ARTERY X-RAYS SPINE	240.14	240.14
75710	Radiology	ARTERY X-RAYS ARM/LEG	270.17	270.17
75710-26	Radiology	ARTERY X-RAYS ARM/LEG	148.12	148.12
75710-TC	Radiology	ARTERY X-RAYS ARM/LEG	122.05	122.05
75716	Radiology	ARTERY X-RAYS ARMS/LEGS	294.00	294.00
75716-26	Radiology	ARTERY X-RAYS ARMS/LEGS	166.63	166.63
75716-TC	Radiology	ARTERY X-RAYS ARMS/LEGS	127.37	127.37
75726	Radiology	ARTERY X-RAYS ABDOMEN	307.81	307.81
75726-26	Radiology	ARTERY X-RAYS ABDOMEN	170.37	170.37
75726-TC	Radiology	ARTERY X-RAYS ABDOMEN	137.44	137.44
75731	Radiology	ARTERY X-RAYS ADRENAL GLAND	275.87	275.87
75731-26	Radiology	ARTERY X-RAYS ADRENAL GLAND	98.98	98.98
75731-TC	Radiology	ARTERY X-RAYS ADRENAL GLAND	176.88	176.88
75733	Radiology	ARTERY X-RAYS ADRENALS	310.54	310.54
75733-26	Radiology	ARTERY X-RAYS ADRENALS	111.95	111.95
75733-TC	Radiology	ARTERY X-RAYS ADRENALS	198.59	198.59
75736	Radiology	ARTERY X-RAYS PELVIS	257.63	257.63
75736-26	Radiology	ARTERY X-RAYS PELVIS	94.34	94.34
75736-TC	Radiology	ARTERY X-RAYS PELVIS	163.27	163.27
75741	Radiology	ARTERY X-RAYS LUNG	234.35	234.35
75741-26	Radiology	ARTERY X-RAYS LUNG	109.34	109.34
75741-TC	Radiology	ARTERY X-RAYS LUNG	125.01	125.01
75743	Radiology	ARTERY X-RAYS LUNGS	266.86	266.86
75743-26	Radiology	ARTERY X-RAYS LUNGS	139.46	139.46
75743-TC	Radiology	ARTERY X-RAYS LUNGS	127.37	127.37
75746	Radiology	ARTERY X-RAYS LUNG	242.76	242.76
75746-26	Radiology	ARTERY X-RAYS LUNG	95.86	95.86
75746-TC	Radiology	ARTERY X-RAYS LUNG	146.89	146.89
75756	Radiology	ARTERY X-RAYS CHEST	295.74	295.74
75756-26	Radiology	ARTERY X-RAYS CHEST	98.75	98.75
75756-TC	Radiology	ARTERY X-RAYS CHEST	196.99	196.99
75774	Radiology	ARTERY X-RAY EACH VESSEL	174.15	174.15
75774-26	Radiology	ARTERY X-RAY EACH VESSEL	83.85	83.85
75774-TC	Radiology	ARTERY X-RAY EACH VESSEL	90.30	90.30
75801	Radiology	LYMPH VESSEL X-RAY ARM/LEG	501.11	501.11
75801-26	Radiology	LYMPH VESSEL X-RAY ARM/LEG	76.17	76.17
75801-TC	Radiology	LYMPH VESSEL X-RAY ARM/LEG	424.94	424.94
75803	Radiology	LYMPH VESSEL X-RAY ARMS/LEGS	527.79	527.79
75803-26	Radiology	LYMPH VESSEL X-RAY ARMS/LEGS	102.08	102.08
75803-TC	Radiology	LYMPH VESSEL X-RAY ARMS/LEGS	425.70	425.70
75805	Radiology	LYMPH VESSEL X-RAY TRUNK	549.57	549.57
75805-26	Radiology	LYMPH VESSEL X-RAY TRUNK	70.57	70.57
75805-TC	Radiology	LYMPH VESSEL X-RAY TRUNK	479.00	479.00
75807	Radiology	LYMPH VESSEL X-RAY TRUNK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
75807-26	Radiology	LYMPH VESSEL X-RAY TRUNK	95.84	95.84
75807-TC	Radiology	LYMPH VESSEL X-RAY TRUNK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
75809	Radiology	NONVASCULAR SHUNT X-RAY	146.41	146.41
75809-26	Radiology	NONVASCULAR SHUNT X-RAY	41.34	41.34
75809-TC	Radiology	NONVASCULAR SHUNT X-RAY	105.09	105.09
75810	Radiology	VEIN X-RAY SPLEEN/LIVER	1074.63	1074.63
75810-26	Radiology	VEIN X-RAY SPLEEN/LIVER	87.67	87.67
75810-TC	Radiology	VEIN X-RAY SPLEEN/LIVER	986.95	986.95
75820	Radiology	VEIN X-RAY ARM/LEG	194.43	194.43
75820-26	Radiology	VEIN X-RAY ARM/LEG	89.37	89.37
75820-TC	Radiology	VEIN X-RAY ARM/LEG	105.09	105.09
75822	Radiology	VEIN X-RAY ARMS/LEGS	241.16	241.16
75822-26	Radiology	VEIN X-RAY ARMS/LEGS	124.86	124.86
75822-TC	Radiology	VEIN X-RAY ARMS/LEGS	116.32	116.32
75825	Radiology	VEIN X-RAY TRUNK	205.10	205.10
75825-26	Radiology	VEIN X-RAY TRUNK	95.88	95.88
75825-TC	Radiology	VEIN X-RAY TRUNK	109.22	109.22
75827	Radiology	VEIN X-RAY CHEST	213.54	213.54
75827-26	Radiology	VEIN X-RAY CHEST	96.64	96.64
75827-TC	Radiology	VEIN X-RAY CHEST	116.90	116.90
75831	Radiology	VEIN X-RAY KIDNEY	215.22	215.22
75831-26	Radiology	VEIN X-RAY KIDNEY	93.76	93.76
75831-TC	Radiology	VEIN X-RAY KIDNEY	121.47	121.47
75833	Radiology	VEIN X-RAY KIDNEYS	266.06	266.06
75833-26	Radiology	VEIN X-RAY KIDNEYS	125.68	125.68
75833-TC	Radiology	VEIN X-RAY KIDNEYS	140.38	140.38
75840	Radiology	VEIN X-RAY ADRENAL GLAND	231.68	231.68
75840-26	Radiology	VEIN X-RAY ADRENAL GLAND	98.98	98.98
75840-TC	Radiology	VEIN X-RAY ADRENAL GLAND	132.70	132.70
75842	Radiology	VEIN X-RAY ADRENAL GLANDS	286.81	286.81
75842-26	Radiology	VEIN X-RAY ADRENAL GLANDS	129.87	129.87
75842-TC	Radiology	VEIN X-RAY ADRENAL GLANDS	156.94	156.94
75860	Radiology	VEIN X-RAY NECK	225.87	225.87
75860-26	Radiology	VEIN X-RAY NECK	96.72	96.72
75860-TC	Radiology	VEIN X-RAY NECK	129.15	129.15
75870	Radiology	VEIN X-RAY SKULL	277.74	277.74
75870-26	Radiology	VEIN X-RAY SKULL	104.25	104.25
75870-TC	Radiology	VEIN X-RAY SKULL	173.49	173.49
75872	Radiology	VEIN X-RAY SKULL EPIDURAL	231.68	231.68
75872-26	Radiology	VEIN X-RAY SKULL EPIDURAL	98.98	98.98
75872-TC	Radiology	VEIN X-RAY SKULL EPIDURAL	132.70	132.70
75880	Radiology	VEIN X-RAY EYE SOCKET	193.28	193.28
75880-26	Radiology	VEIN X-RAY EYE SOCKET	61.17	61.17
75880-TC	Radiology	VEIN X-RAY EYE SOCKET	132.11	132.11
75885	Radiology	VEIN X-RAY LIVER W/HEMODYNAM	246.64	246.64
75885-26	Radiology	VEIN X-RAY LIVER W/HEMODYNAM	118.66	118.66
75885-TC	Radiology	VEIN X-RAY LIVER W/HEMODYNAM	127.98	127.98
75887	Radiology	VEIN X-RAY LIVER W/O HEMODYN	248.41	248.41
75887-26	Radiology	VEIN X-RAY LIVER W/O HEMODYN	119.24	119.24
75887-TC	Radiology	VEIN X-RAY LIVER W/O HEMODYN	129.15	129.15
75889	Radiology	VEIN X-RAY LIVER W/HEMODYNAM	222.50	222.50
75889-26	Radiology	VEIN X-RAY LIVER W/HEMODYNAM	94.52	94.52
75889-TC	Radiology	VEIN X-RAY LIVER W/HEMODYNAM	127.98	127.98
75891	Radiology	VEIN X-RAY LIVER	223.84	223.84
75891-26	Radiology	VEIN X-RAY LIVER	94.69	94.69
75891-TC	Radiology	VEIN X-RAY LIVER	129.15	129.15
75893	Radiology	VENOUS SAMPLING BY CATHETER	187.63	187.63
75893-26	Radiology	VENOUS SAMPLING BY CATHETER	46.06	46.06
75893-TC	Radiology	VENOUS SAMPLING BY CATHETER	141.57	141.57
75894	Radiology	X-RAYS TRANSCATH THERAPY	2016.63	2016.63
75894-26	Radiology	X-RAYS TRANSCATH THERAPY	126.44	126.44
75894-TC	Radiology	X-RAYS TRANSCATH THERAPY	1890.19	1890.19
75898	Radiology	FOLLOW-UP ANGIOGRAPHY	243.09	243.09
75898-26	Radiology	FOLLOW-UP ANGIOGRAPHY	160.86	160.86
75898-TC	Radiology	FOLLOW-UP ANGIOGRAPHY	82.23	82.23
75901	Radiology	REMOVE CVA DEVICE OBSTRUCT	404.72	404.72
75901-26	Radiology	REMOVE CVA DEVICE OBSTRUCT	40.83	40.83
75901-TC	Radiology	REMOVE CVA DEVICE OBSTRUCT	363.89	363.89
75902	Radiology	REMOVE CVA LUMEN OBSTRUCT	156.68	156.68
75902-26	Radiology	REMOVE CVA LUMEN OBSTRUCT	32.68	32.68
75902-TC	Radiology	REMOVE CVA LUMEN OBSTRUCT	124.00	124.00
75956	Radiology	XRAY ENDOVASC THOR AO REPR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
75956-26	Radiology	XRAY ENDOVASC THOR AO REPR	588.49	588.49
75956-TC	Radiology	XRAY ENDOVASC THOR AO REPR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
75957	Radiology	XRAY ENDOVASC THOR AO REPR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
75957-26	Radiology	XRAY ENDOVASC THOR AO REPR	505.34	505.34
75957-TC	Radiology	XRAY ENDOVASC THOR AO REPR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
75958	Radiology	XRAY PLACE PROX EXT THOR AO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
75958-26	Radiology	XRAY PLACE PROX EXT THOR AO	332.18	332.18
75958-TC	Radiology	XRAY PLACE PROX EXT THOR AO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
75959	Radiology	XRAY PLACE DIST EXT THOR AO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
75959-26	Radiology	XRAY PLACE DIST EXT THOR AO	294.16	294.16
75959-TC	Radiology	XRAY PLACE DIST EXT THOR AO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
75970	Radiology	VASCULAR BIOPSY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
75970-26	Radiology	VASCULAR BIOPSY	68.54	68.54
75970-TC	Radiology	VASCULAR BIOPSY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
75984	Radiology	XRAY CONTROL CATHETER CHANGE	171.85	171.85
75984-26	Radiology	XRAY CONTROL CATHETER CHANGE	69.15	69.15
75984-TC	Radiology	XRAY CONTROL CATHETER CHANGE	102.71	102.71
75989	Radiology	ABSCESS DRAINAGE UNDER X-RAY	201.61	201.61
75989-26	Radiology	ABSCESS DRAINAGE UNDER X-RAY	100.66	100.66
75989-TC	Radiology	ABSCESS DRAINAGE UNDER X-RAY	100.93	100.93
76000	Radiology	FLUOROSCOPY <1 HR PHYS/QHP	76.44	76.44
76000-26	Radiology	FLUOROSCOPY <1 HR PHYS/QHP	26.93	26.93
76000-TC	Radiology	FLUOROSCOPY <1 HR PHYS/QHP	49.49	49.49
76010	Radiology	X-RAY NOSE TO RECTUM	52.55	52.55
76010-26	Radiology	X-RAY NOSE TO RECTUM	15.46	15.46
76010-TC	Radiology	X-RAY NOSE TO RECTUM	37.09	37.09
76080	Radiology	X-RAY EXAM OF FISTULA	107.56	107.56
76080-26	Radiology	X-RAY EXAM OF FISTULA	45.05	45.05
76080-TC	Radiology	X-RAY EXAM OF FISTULA	62.50	62.50
76098	Radiology	X-RAY EXAM SURGICAL SPECIMEN	76.65	76.65
76098-26	Radiology	X-RAY EXAM SURGICAL SPECIMEN	27.73	27.73
76098-TC	Radiology	X-RAY EXAM SURGICAL SPECIMEN	48.91	48.91
76100	Radiology	X-RAY EXAM OF BODY SECTION	160.52	160.52
76100-26	Radiology	X-RAY EXAM OF BODY SECTION	50.72	50.72
76100-TC	Radiology	X-RAY EXAM OF BODY SECTION	109.80	109.80
76120	Radiology	CINE/VIDEO X-RAYS	210.44	210.44
76120-26	Radiology	CINE/VIDEO X-RAYS	35.00	35.00
76120-TC	Radiology	CINE/VIDEO X-RAYS	175.44	175.44
76125	Radiology	CINE/VIDEO X-RAYS ADD-ON	110.92	110.92
76125-26	Radiology	CINE/VIDEO X-RAYS ADD-ON	24.00	24.00
76125-TC	Radiology	CINE/VIDEO X-RAYS ADD-ON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76140	Radiology	X-RAY CONSULTATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76145	Radiology	MED PHYSIC DOS EVAL RAD EXPS	1594.07	1594.07
76376	Radiology	3D RENDER W/INTRP POSTPROCES	44.95	44.95
76376-26	Radiology	3D RENDER W/INTRP POSTPROCES	17.34	17.34
76376-TC	Radiology	3D RENDER W/INTRP POSTPROCES	27.63	27.63
76377	Radiology	3D RENDER W/INTRP POSTPROCES	140.93	140.93
76377-26	Radiology	3D RENDER W/INTRP POSTPROCES	69.13	69.13
76377-TC	Radiology	3D RENDER W/INTRP POSTPROCES	71.80	71.80
76380	Radiology	CAT SCAN FOLLOW-UP STUDY	241.16	241.16
76380-26	Radiology	CAT SCAN FOLLOW-UP STUDY	82.86	82.86
76380-TC	Radiology	CAT SCAN FOLLOW-UP STUDY	158.30	158.30
76390	Radiology	MR SPECTROSCOPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76390-26	Radiology	MR SPECTROSCOPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76390-TC	Radiology	MR SPECTROSCOPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76391	Radiology	MR ELASTOGRAPHY	370.44	370.44
76391-26	Radiology	MR ELASTOGRAPHY	95.84	95.84
76391-TC	Radiology	MR ELASTOGRAPHY	274.60	274.60
76496	Radiology	UNLISTED FLUOROSCOPIC PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76496-26	Radiology	UNLISTED FLUOROSCOPIC PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76496-TC	Radiology	UNLISTED FLUOROSCOPIC PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76497	Radiology	UNLISTED CT PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76497-26	Radiology	UNLISTED CT PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76497-TC	Radiology	UNLISTED CT PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76498	Radiology	UNLISTED MR PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76498-26	Radiology	UNLISTED MR PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76498-TC	Radiology	UNLISTED MR PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76499	Radiology	UNLISTED DX RADIOGRAPHIC PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76499-26	Radiology	UNLISTED DX RADIOGRAPHIC PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76499-TC	Radiology	UNLISTED DX RADIOGRAPHIC PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76506	Radiology	ECHO EXAM OF HEAD	202.25	202.25
76506-26	Radiology	ECHO EXAM OF HEAD	56.37	56.37
76506-TC	Radiology	ECHO EXAM OF HEAD	145.88	145.88
76510	Radiology	OPH US DX B-SCAN&QUAN A-SCAN	124.78	124.78
76510-26	Radiology	OPH US DX B-SCAN&QUAN A-SCAN	71.14	71.14
76510-TC	Radiology	OPH US DX B-SCAN&QUAN A-SCAN	53.64	53.64
76511	Radiology	OPH US DX QUAN A-SCAN ONLY	103.80	103.80
76511-26	Radiology	OPH US DX QUAN A-SCAN ONLY	64.94	64.94
76511-TC	Radiology	OPH US DX QUAN A-SCAN ONLY	38.86	38.86
76512	Radiology	OPH US DX B-SCAN	87.46	87.46
76512-26	Radiology	OPH US DX B-SCAN	55.69	55.69
76512-TC	Radiology	OPH US DX B-SCAN	31.77	31.77
76513	Radiology	OPH US DX ANT SGM US UNI/BI	135.54	135.54
76513-26	Radiology	OPH US DX ANT SGM US UNI/BI	58.83	58.83
76513-TC	Radiology	OPH US DX ANT SGM US UNI/BI	76.69	76.69
76514	Radiology	ECHO EXAM OF EYE THICKNESS	20.44	20.44
76514-26	Radiology	ECHO EXAM OF EYE THICKNESS	14.10	14.10
76514-TC	Radiology	ECHO EXAM OF EYE THICKNESS	6.34	6.34
76516	Radiology	ECHO EXAM OF EYE	84.34	84.34
76516-26	Radiology	ECHO EXAM OF EYE	40.76	40.76
76516-TC	Radiology	ECHO EXAM OF EYE	43.58	43.58
76519	Radiology	ECHO EXAM OF EYE	122.83	122.83
76519-26	Radiology	ECHO EXAM OF EYE	55.01	55.01
76519-TC	Radiology	ECHO EXAM OF EYE	67.82	67.82
76529	Radiology	ECHO EXAM OF EYE	154.32	154.32
76529-26	Radiology	ECHO EXAM OF EYE	58.70	58.70
76529-TC	Radiology	ECHO EXAM OF EYE	95.61	95.61
76536	Radiology	US EXAM OF HEAD AND NECK	197.69	197.69
76536-26	Radiology	US EXAM OF HEAD AND NECK	48.85	48.85
76536-TC	Radiology	US EXAM OF HEAD AND NECK	148.82	148.82
76604	Radiology	US EXAM CHEST	103.23	103.23
76604-26	Radiology	US EXAM CHEST	49.59	49.59
76604-TC	Radiology	US EXAM CHEST	53.64	53.64
76641	Radiology	ULTRASOUND BREAST COMPLETE	184.72	184.72
76641-26	Radiology	ULTRASOUND BREAST COMPLETE	63.69	63.69
76641-TC	Radiology	ULTRASOUND BREAST COMPLETE	121.04	121.04
76642	Radiology	ULTRASOUND BREAST LIMITED	153.15	153.15
76642-26	Radiology	ULTRASOUND BREAST LIMITED	59.30	59.30
76642-TC	Radiology	ULTRASOUND BREAST LIMITED	93.85	93.85
76700	Radiology	US EXAM ABDOM COMPLETE	209.18	209.18
76700-26	Radiology	US EXAM ABDOM COMPLETE	69.97	69.97
76700-TC	Radiology	US EXAM ABDOM COMPLETE	139.21	139.21
76705	Radiology	ECHO EXAM OF ABDOMEN	156.45	156.45
76705-26	Radiology	ECHO EXAM OF ABDOMEN	50.78	50.78
76705-TC	Radiology	ECHO EXAM OF ABDOMEN	105.67	105.67
76706	Radiology	US ABDL AORTA SCREEN AAA	191.14	191.14
76706-26	Radiology	US ABDL AORTA SCREEN AAA	47.62	47.62
76706-TC	Radiology	US ABDL AORTA SCREEN AAA	143.50	143.50
76770	Radiology	US EXAM ABDO BACK WALL COMP	194.82	194.82
76770-26	Radiology	US EXAM ABDO BACK WALL COMP	64.33	64.33
76770-TC	Radiology	US EXAM ABDO BACK WALL COMP	130.49	130.49
76775	Radiology	US EXAM ABDO BACK WALL LIM	107.91	107.91
76775-26	Radiology	US EXAM ABDO BACK WALL LIM	50.13	50.13
76775-TC	Radiology	US EXAM ABDO BACK WALL LIM	57.78	57.78
76776	Radiology	US EXAM K TRANSPL W/DOPPLER	263.93	263.93
76776-26	Radiology	US EXAM K TRANSPL W/DOPPLER	65.60	65.60
76776-TC	Radiology	US EXAM K TRANSPL W/DOPPLER	198.33	198.33
76800	Radiology	US EXAM SPINAL CANAL	308.88	308.88
76800-26	Radiology	US EXAM SPINAL CANAL	110.97	110.97
76800-TC	Radiology	US EXAM SPINAL CANAL	197.91	197.91
76801	Radiology	OB US < 14 WKS SINGLE FETUS	211.97	211.97
76801-26	Radiology	OB US < 14 WKS SINGLE FETUS	86.19	86.19
76801-TC	Radiology	OB US < 14 WKS SINGLE FETUS	125.78	125.78
76802	Radiology	OB US < 14 WKS ADDL FETUS	109.84	109.84
76802-26	Radiology	OB US < 14 WKS ADDL FETUS	72.60	72.60
76802-TC	Radiology	OB US < 14 WKS ADDL FETUS	37.25	37.25
76805	Radiology	OB US >= 14 WKS SNGL FETUS	244.32	244.32
76805-26	Radiology	OB US >= 14 WKS SNGL FETUS	86.79	86.79
76805-TC	Radiology	OB US >= 14 WKS SNGL FETUS	157.54	157.54
76810	Radiology	OB US >= 14 WKS ADDL FETUS	159.04	159.04
76810-26	Radiology	OB US >= 14 WKS ADDL FETUS	85.90	85.90
76810-TC	Radiology	OB US >= 14 WKS ADDL FETUS	73.14	73.14
76811	Radiology	OB US DETAILED SNGL FETUS	322.35	322.35
76811-26	Radiology	OB US DETAILED SNGL FETUS	166.18	166.18
76811-TC	Radiology	OB US DETAILED SNGL FETUS	156.18	156.18
76812	Radiology	OB US DETAILED ADDL FETUS	347.39	347.39
76812-26	Radiology	OB US DETAILED ADDL FETUS	156.16	156.16
76812-TC	Radiology	OB US DETAILED ADDL FETUS	191.24	191.24
76813	Radiology	OB US NUCHAL MEAS 1 GEST	210.07	210.07
76813-26	Radiology	OB US NUCHAL MEAS 1 GEST	103.23	103.23
76813-TC	Radiology	OB US NUCHAL MEAS 1 GEST	106.86	106.86
76814	Radiology	OB US NUCHAL MEAS ADD-ON	136.03	136.03
76814-26	Radiology	OB US NUCHAL MEAS ADD-ON	86.52	86.52
76814-TC	Radiology	OB US NUCHAL MEAS ADD-ON	49.49	49.49
76815	Radiology	OB US LIMITED FETUS(S)	146.07	146.07
76815-26	Radiology	OB US LIMITED FETUS(S)	56.37	56.37
76815-TC	Radiology	OB US LIMITED FETUS(S)	89.70	89.70
76816	Radiology	OB US FOLLOW-UP PER FETUS	198.63	198.63
76816-26	Radiology	OB US FOLLOW-UP PER FETUS	74.63	74.63
76816-TC	Radiology	OB US FOLLOW-UP PER FETUS	124.00	124.00
76817	Radiology	TRANSVAGINAL US OBSTETRIC	167.25	167.25
76817-26	Radiology	TRANSVAGINAL US OBSTETRIC	65.72	65.72
76817-TC	Radiology	TRANSVAGINAL US OBSTETRIC	101.54	101.54
76818	Radiology	FETAL BIOPHYS PROFILE W/NST	214.62	214.62
76818-26	Radiology	FETAL BIOPHYS PROFILE W/NST	92.14	92.14
76818-TC	Radiology	FETAL BIOPHYS PROFILE W/NST	122.48	122.48
76819	Radiology	FETAL BIOPHYS PROFIL W/O NST	154.93	154.93
76819-26	Radiology	FETAL BIOPHYS PROFIL W/O NST	67.16	67.16
76819-TC	Radiology	FETAL BIOPHYS PROFIL W/O NST	87.77	87.77
76820	Radiology	UMBILICAL ARTERY ECHO	81.26	81.26
76820-26	Radiology	UMBILICAL ARTERY ECHO	43.58	43.58
76820-TC	Radiology	UMBILICAL ARTERY ECHO	37.67	37.67
76821	Radiology	MIDDLE CEREBRAL ARTERY ECHO	160.68	160.68
76821-26	Radiology	MIDDLE CEREBRAL ARTERY ECHO	61.50	61.50
76821-TC	Radiology	MIDDLE CEREBRAL ARTERY ECHO	99.16	99.16
76825	Radiology	ECHO EXAM OF FETAL HEART	470.87	470.87
76825-26	Radiology	ECHO EXAM OF FETAL HEART	145.59	145.59
76825-TC	Radiology	ECHO EXAM OF FETAL HEART	325.28	325.28
76826	Radiology	ECHO EXAM OF FETAL HEART	281.15	281.15
76826-26	Radiology	ECHO EXAM OF FETAL HEART	72.17	72.17
76826-TC	Radiology	ECHO EXAM OF FETAL HEART	208.98	208.98
76827	Radiology	ECHO EXAM OF FETAL HEART	126.40	126.40
76827-26	Radiology	ECHO EXAM OF FETAL HEART	50.90	50.90
76827-TC	Radiology	ECHO EXAM OF FETAL HEART	75.52	75.52
76828	Radiology	ECHO EXAM OF FETAL HEART	88.63	88.63
76828-26	Radiology	ECHO EXAM OF FETAL HEART	48.59	48.59
76828-TC	Radiology	ECHO EXAM OF FETAL HEART	40.03	40.03
76830	Radiology	TRANSVAGINAL US NON-OB	214.09	214.09
76830-26	Radiology	TRANSVAGINAL US NON-OB	60.12	60.12
76830-TC	Radiology	TRANSVAGINAL US NON-OB	153.99	153.99
76831	Radiology	ECHO EXAM UTERUS	209.25	209.25
76831-26	Radiology	ECHO EXAM UTERUS	63.38	63.38
76831-TC	Radiology	ECHO EXAM UTERUS	145.88	145.88
76856	Radiology	US EXAM PELVIC COMPLETE	189.42	189.42
76856-26	Radiology	US EXAM PELVIC COMPLETE	59.51	59.51
76856-TC	Radiology	US EXAM PELVIC COMPLETE	129.91	129.91
76857	Radiology	US EXAM PELVIC LIMITED	89.37	89.37
76857-26	Radiology	US EXAM PELVIC LIMITED	42.82	42.82
76857-TC	Radiology	US EXAM PELVIC LIMITED	46.55	46.55
76870	Radiology	US EXAM SCROTUM	179.73	179.73
76870-26	Radiology	US EXAM SCROTUM	55.15	55.15
76870-TC	Radiology	US EXAM SCROTUM	124.59	124.59
76872	Radiology	US TRANSRECTAL	359.72	359.72
76872-26	Radiology	US TRANSRECTAL	59.69	59.69
76872-TC	Radiology	US TRANSRECTAL	300.03	300.03
76873	Radiology	ECHOGRAP TRANS R PROS STUDY	317.58	317.58
76873-26	Radiology	ECHOGRAP TRANS R PROS STUDY	139.95	139.95
76873-TC	Radiology	ECHOGRAP TRANS R PROS STUDY	177.65	177.65
76881	Radiology	US COMPL JOINT R-T W/IMG	98.61	98.61
76881-26	Radiology	US COMPL JOINT R-T W/IMG	79.27	79.27
76881-TC	Radiology	US COMPL JOINT R-T W/IMG	19.34	19.34
76882	Radiology	US LMTD JT/FCL EVL NVASC XTR	114.76	114.76
76882-26	Radiology	US LMTD JT/FCL EVL NVASC XTR	59.94	59.94
76882-TC	Radiology	US LMTD JT/FCL EVL NVASC XTR	54.81	54.81
76883	Radiology	US NRV&ACC STRUX 1XTR COMPRE	131.08	131.08
76883-26	Radiology	US NRV&ACC STRUX 1XTR COMPRE	105.83	105.83
76883-TC	Radiology	US NRV&ACC STRUX 1XTR COMPRE	25.25	25.25
76885	Radiology	US EXAM INFANT HIPS DYNAMIC	243.15	243.15
76885-26	Radiology	US EXAM INFANT HIPS DYNAMIC	64.33	64.33
76885-TC	Radiology	US EXAM INFANT HIPS DYNAMIC	178.82	178.82
76886	Radiology	US EXAM INFANT HIPS STATIC	179.05	179.05
76886-26	Radiology	US EXAM INFANT HIPS STATIC	53.88	53.88
76886-TC	Radiology	US EXAM INFANT HIPS STATIC	125.19	125.19
76932	Radiology	ECHO GUIDE FOR HEART BIOPSY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76932-26	Radiology	ECHO GUIDE FOR HEART BIOPSY	64.33	64.33
76932-TC	Radiology	ECHO GUIDE FOR HEART BIOPSY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76936	Radiology	ECHO GUIDE FOR ARTERY REPAIR	467.18	467.18
76936-26	Radiology	ECHO GUIDE FOR ARTERY REPAIR	169.08	169.08
76936-TC	Radiology	ECHO GUIDE FOR ARTERY REPAIR	298.10	298.10
76937	Radiology	US GUIDE VASCULAR ACCESS	68.74	68.74
76937-26	Radiology	US GUIDE VASCULAR ACCESS	25.16	25.16
76937-TC	Radiology	US GUIDE VASCULAR ACCESS	43.58	43.58
76940	Radiology	US GUIDE TISSUE ABLATION	310.97	310.97
76940-26	Radiology	US GUIDE TISSUE ABLATION	179.97	179.97
76940-TC	Radiology	US GUIDE TISSUE ABLATION	131.00	131.00
76941	Radiology	ECHO GUIDE FOR TRANSFUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76941-26	Radiology	ECHO GUIDE FOR TRANSFUSION	117.59	117.59
76941-TC	Radiology	ECHO GUIDE FOR TRANSFUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76942	Radiology	ECHO GUIDE FOR BIOPSY	105.38	105.38
76942-26	Radiology	ECHO GUIDE FOR BIOPSY	55.28	55.28
76942-TC	Radiology	ECHO GUIDE FOR BIOPSY	50.10	50.10
76945	Radiology	ECHO GUIDE VILLUS SAMPLING	66.32	66.32
76945-26	Radiology	ECHO GUIDE VILLUS SAMPLING	58.58	58.58
76945-TC	Radiology	ECHO GUIDE VILLUS SAMPLING	7.74	7.74
76946	Radiology	ECHO GUIDE FOR AMNIOCENTESIS	60.59	60.59
76946-26	Radiology	ECHO GUIDE FOR AMNIOCENTESIS	33.56	33.56
76946-TC	Radiology	ECHO GUIDE FOR AMNIOCENTESIS	27.03	27.03
76948	Radiology	ECHO GUIDE OVA ASPIRATION	145.92	145.92
76948-26	Radiology	ECHO GUIDE OVA ASPIRATION	58.58	58.58
76948-TC	Radiology	ECHO GUIDE OVA ASPIRATION	87.34	87.34
76965	Radiology	ECHO GUIDANCE RADIOTHERAPY	172.65	172.65
76965-26	Radiology	ECHO GUIDANCE RADIOTHERAPY	123.75	123.75
76965-TC	Radiology	ECHO GUIDANCE RADIOTHERAPY	48.91	48.91
76975	Radiology	GI ENDOSCOPIC ULTRASOUND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76975-26	Radiology	GI ENDOSCOPIC ULTRASOUND	74.28	74.28
76975-TC	Radiology	GI ENDOSCOPIC ULTRASOUND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76977	Radiology	US BONE DENSITY MEASURE	12.91	12.91
76977-26	Radiology	US BONE DENSITY MEASURE	4.80	4.80
76977-TC	Radiology	US BONE DENSITY MEASURE	8.11	8.11
76978	Radiology	US TRGT DYN MBUBB 1ST LES	399.18	399.18
76978-26	Radiology	US TRGT DYN MBUBB 1ST LES	141.12	141.12
76978-TC	Radiology	US TRGT DYN MBUBB 1ST LES	258.04	258.04
76979	Radiology	US TRGT DYN MBUBB EA ADDL	256.25	256.25
76979-26	Radiology	US TRGT DYN MBUBB EA ADDL	73.71	73.71
76979-TC	Radiology	US TRGT DYN MBUBB EA ADDL	182.54	182.54
76981	Radiology	USE PARENCHYMA	187.18	187.18
76981-26	Radiology	USE PARENCHYMA	51.95	51.95
76981-TC	Radiology	USE PARENCHYMA	135.23	135.23
76982	Radiology	USE 1ST TARGET LESION	167.68	167.68
76982-26	Radiology	USE 1ST TARGET LESION	51.95	51.95
76982-TC	Radiology	USE 1ST TARGET LESION	115.71	115.71
76983	Radiology	USE EA ADDL TARGET LESION	111.07	111.07
76983-26	Radiology	USE EA ADDL TARGET LESION	45.61	45.61
76983-TC	Radiology	USE EA ADDL TARGET LESION	65.46	65.46
76984	Radiology	DX INTRAOP THORACIC AORTA US	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76984-26	Radiology	DX INTRAOP THORACIC AORTA US	55.40	55.40
76984-TC	Radiology	DX INTRAOP THORACIC AORTA US	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76987	Radiology	DX INTRAOP EPICAR CAR US CHD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76987-26	Radiology	DX INTRAOP EPICAR CAR US CHD	170.78	170.78
76987-TC	Radiology	DX INTRAOP EPICAR CAR US CHD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76988	Radiology	DX NTROP EPCR US CHD IMG ACQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76988-26	Radiology	DX NTROP EPCR US CHD IMG ACQ	108.50	108.50
76988-TC	Radiology	DX NTROP EPCR US CHD IMG ACQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76989	Radiology	DX INTRAOP EPCAR US CHD I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76989-26	Radiology	DX INTRAOP EPCAR US CHD I&R	63.55	63.55
76989-TC	Radiology	DX INTRAOP EPCAR US CHD I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76998	Radiology	US GUIDE INTRAOP	289.44	289.44
76998-26	Radiology	US GUIDE INTRAOP	83.23	83.23
76998-TC	Radiology	US GUIDE INTRAOP	206.21	206.21
76999	Radiology	ECHO EXAMINATION PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76999-26	Radiology	ECHO EXAMINATION PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
76999-TC	Radiology	ECHO EXAMINATION PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77001	Radiology	FLUOROGUIDE FOR VEIN DEVICE	175.97	175.97
77001-26	Radiology	FLUOROGUIDE FOR VEIN DEVICE	32.47	32.47
77001-TC	Radiology	FLUOROGUIDE FOR VEIN DEVICE	143.50	143.50
77002	Radiology	NEEDLE LOCALIZATION BY XRAY	207.64	207.64
77002-26	Radiology	NEEDLE LOCALIZATION BY XRAY	48.77	48.77
77002-TC	Radiology	NEEDLE LOCALIZATION BY XRAY	158.89	158.89
77003	Radiology	FLUOROGUIDE FOR SPINE INJECT	188.84	188.84
77003-26	Radiology	FLUOROGUIDE FOR SPINE INJECT	52.42	52.42
77003-TC	Radiology	FLUOROGUIDE FOR SPINE INJECT	136.42	136.42
77011	Radiology	CT SCAN FOR LOCALIZATION	396.83	396.83
77011-26	Radiology	CT SCAN FOR LOCALIZATION	111.99	111.99
77011-TC	Radiology	CT SCAN FOR LOCALIZATION	284.82	284.82
77012	Radiology	CT SCAN FOR NEEDLE BIOPSY	251.98	251.98
77012-26	Radiology	CT SCAN FOR NEEDLE BIOPSY	126.79	126.79
77012-TC	Radiology	CT SCAN FOR NEEDLE BIOPSY	125.19	125.19
77013	Radiology	CT GUIDE FOR TISSUE ABLATION	1115.87	1115.87
77013-26	Radiology	CT GUIDE FOR TISSUE ABLATION	332.20	332.20
77013-TC	Radiology	CT GUIDE FOR TISSUE ABLATION	783.67	783.67
77014	Radiology	CT SCAN FOR THERAPY GUIDE	215.46	215.46
77014-26	Radiology	CT SCAN FOR THERAPY GUIDE	81.98	81.98
77014-TC	Radiology	CT SCAN FOR THERAPY GUIDE	133.46	133.46
77021	Radiology	MRI GUIDANCE NDL PLMT RS&I	760.21	760.21
77021-26	Radiology	MRI GUIDANCE NDL PLMT RS&I	129.66	129.66
77021-TC	Radiology	MRI GUIDANCE NDL PLMT RS&I	630.55	630.55
77022	Radiology	MRI GDN PARNCHYMA TISS ABLTJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77022-26	Radiology	MRI GDN PARNCHYMA TISS ABLTJ	362.86	362.86
77022-TC	Radiology	MRI GDN PARNCHYMA TISS ABLTJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77046	Radiology	MRI BREAST C- UNILATERAL	393.22	393.22
77046-26	Radiology	MRI BREAST C- UNILATERAL	125.72	125.72
77046-TC	Radiology	MRI BREAST C- UNILATERAL	267.50	267.50
77047	Radiology	MRI BREAST C- BILATERAL	405.00	405.00
77047-26	Radiology	MRI BREAST C- BILATERAL	138.66	138.66
77047-TC	Radiology	MRI BREAST C- BILATERAL	266.33	266.33
77048	Radiology	MRI BREAST C-+ W/CAD UNI	620.14	620.14
77048-26	Radiology	MRI BREAST C-+ W/CAD UNI	182.52	182.52
77048-TC	Radiology	MRI BREAST C-+ W/CAD UNI	437.62	437.62
77049	Radiology	MRI BREAST C-+ W/CAD BI	633.34	633.34
77049-26	Radiology	MRI BREAST C-+ W/CAD BI	199.84	199.84
77049-TC	Radiology	MRI BREAST C-+ W/CAD BI	433.49	433.49
77053	Radiology	X-RAY OF MAMMARY DUCT	96.99	96.99
77053-26	Radiology	X-RAY OF MAMMARY DUCT	31.53	31.53
77053-TC	Radiology	X-RAY OF MAMMARY DUCT	65.46	65.46
77054	Radiology	X-RAY OF MAMMARY DUCTS	124.61	124.61
77054-26	Radiology	X-RAY OF MAMMARY DUCTS	39.04	39.04
77054-TC	Radiology	X-RAY OF MAMMARY DUCTS	85.57	85.57
77061	Radiology	BREAST TOMOSYNTHESIS UNI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77061-26	Radiology	BREAST TOMOSYNTHESIS UNI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77061-TC	Radiology	BREAST TOMOSYNTHESIS UNI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77062	Radiology	BREAST TOMOSYNTHESIS BI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77062-26	Radiology	BREAST TOMOSYNTHESIS BI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77062-TC	Radiology	BREAST TOMOSYNTHESIS BI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77063	Radiology	BREAST TOMOSYNTHESIS BI	94.58	94.58
77063-26	Radiology	BREAST TOMOSYNTHESIS BI	52.01	52.01
77063-TC	Radiology	BREAST TOMOSYNTHESIS BI	42.57	42.57
77065	Radiology	DX MAMMO INCL CAD UNI	225.30	225.30
77065-26	Radiology	DX MAMMO INCL CAD UNI	70.57	70.57
77065-TC	Radiology	DX MAMMO INCL CAD UNI	154.75	154.75
77066	Radiology	DX MAMMO INCL CAD BI	284.99	284.99
77066-26	Radiology	DX MAMMO INCL CAD BI	86.68	86.68
77066-TC	Radiology	DX MAMMO INCL CAD BI	198.33	198.33
77067	Radiology	SCR MAMMO BI INCL CAD	229.81	229.81
77067-26	Radiology	SCR MAMMO BI INCL CAD	66.18	66.18
77067-TC	Radiology	SCR MAMMO BI INCL CAD	163.61	163.61
77071	Radiology	X-RAY STRESS VIEW	98.34	98.34
77072	Radiology	X-RAYS FOR BONE AGE	46.68	46.68
77072-26	Radiology	X-RAYS FOR BONE AGE	16.69	16.69
77072-TC	Radiology	X-RAYS FOR BONE AGE	29.99	29.99
77073	Radiology	X-RAYS BONE LENGTH STUDIES	81.14	81.14
77073-26	Radiology	X-RAYS BONE LENGTH STUDIES	23.95	23.95
77073-TC	Radiology	X-RAYS BONE LENGTH STUDIES	57.19	57.19
77074	Radiology	X-RAYS BONE SURVEY LIMITED	117.47	117.47
77074-26	Radiology	X-RAYS BONE SURVEY LIMITED	38.40	38.40
77074-TC	Radiology	X-RAYS BONE SURVEY LIMITED	79.05	79.05
77075	Radiology	X-RAYS BONE SURVEY COMPLETE	178.56	178.56
77075-26	Radiology	X-RAYS BONE SURVEY COMPLETE	48.22	48.22
77075-TC	Radiology	X-RAYS BONE SURVEY COMPLETE	130.34	130.34
77076	Radiology	X-RAYS BONE SURVEY INFANT	192.70	192.70
77076-26	Radiology	X-RAYS BONE SURVEY INFANT	61.17	61.17
77076-TC	Radiology	X-RAYS BONE SURVEY INFANT	131.53	131.53
77077	Radiology	JOINT SURVEY SINGLE VIEW	84.44	84.44
77077-26	Radiology	JOINT SURVEY SINGLE VIEW	30.21	30.21
77077-TC	Radiology	JOINT SURVEY SINGLE VIEW	54.23	54.23
77078	Radiology	CT BONE DENSITY AXIAL	184.14	184.14
77078-26	Radiology	CT BONE DENSITY AXIAL	21.70	21.70
77078-TC	Radiology	CT BONE DENSITY AXIAL	162.44	162.44
77080	Radiology	DXA BONE DENSITY AXIAL	69.79	69.79
77080-26	Radiology	DXA BONE DENSITY AXIAL	17.34	17.34
77080-TC	Radiology	DXA BONE DENSITY AXIAL	52.46	52.46
77081	Radiology	DXA BONE DENSITY/PERIPHERAL	56.78	56.78
77081-26	Radiology	DXA BONE DENSITY/PERIPHERAL	17.34	17.34
77081-TC	Radiology	DXA BONE DENSITY/PERIPHERAL	39.45	39.45
77084	Radiology	MAGNETIC IMAGE BONE MARROW	583.99	583.99
77084-26	Radiology	MAGNETIC IMAGE BONE MARROW	139.27	139.27
77084-TC	Radiology	MAGNETIC IMAGE BONE MARROW	444.72	444.72
77085	Radiology	DXA BONE DENSITY STUDY	95.51	95.51
77085-26	Radiology	DXA BONE DENSITY STUDY	26.09	26.09
77085-TC	Radiology	DXA BONE DENSITY STUDY	69.44	69.44
77086	Radiology	FRACTURE ASSESSMENT VIA DXA	60.20	60.20
77086-26	Radiology	FRACTURE ASSESSMENT VIA DXA	14.82	14.82
77086-TC	Radiology	FRACTURE ASSESSMENT VIA DXA	45.36	45.36
77089	Radiology	TBS DXA CAL W/I&R FX RISK	71.99	71.99
77090	Radiology	TBS TECHL PREP&TRANSMIS DATA	4.56	4.56
77091	Radiology	TBS TECHL CALCULATION ONLY	49.49	49.49
77092	Radiology	TBS I&R FX RSK QHP	17.92	17.92
77261	Radiology	RADIATION THERAPY PLANNING	129.56	129.56
77262	Radiology	RADIATION THERAPY PLANNING	198.26	198.26
77263	Radiology	RADIATION THERAPY PLANNING	307.07	307.07
77280	Radiology	SET RADIATION THERAPY FIELD	480.38	480.38
77280-26	Radiology	SET RADIATION THERAPY FIELD	69.03	69.03
77280-TC	Radiology	SET RADIATION THERAPY FIELD	411.35	411.35
77285	Radiology	SET RADIATION THERAPY FIELD	786.20	786.20
77285-26	Radiology	SET RADIATION THERAPY FIELD	104.23	104.23
77285-TC	Radiology	SET RADIATION THERAPY FIELD	681.97	681.97
77290	Radiology	SET RADIATION THERAPY FIELD	799.77	799.77
77290-26	Radiology	SET RADIATION THERAPY FIELD	151.07	151.07
77290-TC	Radiology	SET RADIATION THERAPY FIELD	648.71	648.71
77293	Radiology	RESPIRATOR MOTION MGMT SIMUL	731.91	731.91
77293-26	Radiology	RESPIRATOR MOTION MGMT SIMUL	193.19	193.19
77293-TC	Radiology	RESPIRATOR MOTION MGMT SIMUL	538.73	538.73
77295	Radiology	3-D RADIOTHERAPY PLAN	868.71	868.71
77295-26	Radiology	3-D RADIOTHERAPY PLAN	413.42	413.42
77295-TC	Radiology	3-D RADIOTHERAPY PLAN	455.29	455.29
77299	Radiology	UNLISTED PX THER RAD TX PLNG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77299-26	Radiology	UNLISTED PX THER RAD TX PLNG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77299-TC	Radiology	UNLISTED PX THER RAD TX PLNG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77300	Radiology	RADIATION THERAPY DOSE PLAN	119.34	119.34
77300-26	Radiology	RADIATION THERAPY DOSE PLAN	59.79	59.79
77300-TC	Radiology	RADIATION THERAPY DOSE PLAN	59.55	59.55
77301	Radiology	RADIOTHERAPY DOSE PLAN IMRT	3299.48	3299.48
77301-26	Radiology	RADIOTHERAPY DOSE PLAN IMRT	770.58	770.58
77301-TC	Radiology	RADIOTHERAPY DOSE PLAN IMRT	2528.92	2528.92
77306	Radiology	TELETHX ISODOSE PLAN SIMPLE	268.40	268.40
77306-26	Radiology	TELETHX ISODOSE PLAN SIMPLE	135.10	135.10
77306-TC	Radiology	TELETHX ISODOSE PLAN SIMPLE	133.28	133.28
77307	Radiology	TELETHX ISODOSE PLAN CPLX	520.71	520.71
77307-26	Radiology	TELETHX ISODOSE PLAN CPLX	279.55	279.55
77307-TC	Radiology	TELETHX ISODOSE PLAN CPLX	241.16	241.16
77316	Radiology	BRACHYTX ISODOSE PLAN SIMPLE	441.73	441.73
77316-26	Radiology	BRACHYTX ISODOSE PLAN SIMPLE	135.10	135.10
77316-TC	Radiology	BRACHYTX ISODOSE PLAN SIMPLE	306.62	306.62
77317	Radiology	BRACHYTX ISODOSE INTERMED	581.02	581.02
77317-26	Radiology	BRACHYTX ISODOSE INTERMED	177.00	177.00
77317-TC	Radiology	BRACHYTX ISODOSE INTERMED	404.02	404.02
77318	Radiology	BRACHYTX ISODOSE COMPLEX	824.97	824.97
77318-26	Radiology	BRACHYTX ISODOSE COMPLEX	278.95	278.95
77318-TC	Radiology	BRACHYTX ISODOSE COMPLEX	546.00	546.00
77321	Radiology	SPECIAL TELETX PORT PLAN	170.98	170.98
77321-26	Radiology	SPECIAL TELETX PORT PLAN	91.92	91.92
77321-TC	Radiology	SPECIAL TELETX PORT PLAN	79.05	79.05
77331	Radiology	SPECIAL RADIATION DOSIMETRY	118.58	118.58
77331-26	Radiology	SPECIAL RADIATION DOSIMETRY	84.45	84.45
77331-TC	Radiology	SPECIAL RADIATION DOSIMETRY	34.13	34.13
77332	Radiology	RADIATION TREATMENT AID(S)	71.39	71.39
77332-26	Radiology	RADIATION TREATMENT AID(S)	43.78	43.78
77332-TC	Radiology	RADIATION TREATMENT AID(S)	27.63	27.63
77333	Radiology	RADIATION TREATMENT AID(S)	245.90	245.90
77333-26	Radiology	RADIATION TREATMENT AID(S)	72.23	72.23
77333-TC	Radiology	RADIATION TREATMENT AID(S)	173.67	173.67
77334	Radiology	RADIATION TREATMENT AID(S)	227.33	227.33
77334-26	Radiology	RADIATION TREATMENT AID(S)	111.03	111.03
77334-TC	Radiology	RADIATION TREATMENT AID(S)	116.32	116.32
77336	Radiology	RADIATION PHYSICS CONSULT	156.53	156.53
77338	Radiology	DESIGN MLC DEVICE FOR IMRT	847.08	847.08
77338-26	Radiology	DESIGN MLC DEVICE FOR IMRT	414.00	414.00
77338-TC	Radiology	DESIGN MLC DEVICE FOR IMRT	433.08	433.08
77370	Radiology	RADIATION PHYSICS CONSULT	254.10	254.10
77371	Radiology	SRS MULTISOURCE	4730.86	4730.86
77372	Radiology	SRS LINEAR BASED	1687.08	1687.08
77373	Radiology	SBRT DELIVERY	1760.75	1760.75
77385	Radiology	NTSTY MODUL RAD TX DLVR SMPL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77386	Radiology	NTSTY MODUL RAD TX DLVR CPLX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77387	Radiology	GUIDANCE FOR RADJ TX DLVR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77399	Radiology	UNLISTED PX MED RADJ PHYSICS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77399-26	Radiology	UNLISTED PX MED RADJ PHYSICS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77399-TC	Radiology	UNLISTED PX MED RADJ PHYSICS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77401	Radiology	RADIATION TREATMENT DELIVERY	73.75	73.75
77402	Radiology	RADIATION TREATMENT DELIVERY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77407	Radiology	RADIATION TREATMENT DELIVERY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77412	Radiology	RADIATION TREATMENT DELIVERY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77417	Radiology	RADIOLOGY PORT IMAGES(S)	26.44	26.44
77423	Radiology	NEUTRON BEAM TX COMPLEX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77424	Radiology	IO RAD TX DELIVERY BY X-RAY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77425	Radiology	IO RAD TX DELIVER BY ELCTRNS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77427	Radiology	RADIATION TX MANAGEMENT X5	348.60	348.60
77431	Radiology	RADIATION THERAPY MANAGEMENT	196.44	196.44
77432	Radiology	STEREOTACTIC RADIATION TRMT	776.06	776.06
77435	Radiology	SBRT MANAGEMENT	1173.12	1173.12
77469	Radiology	IO RADIATION TX MANAGEMENT	583.15	583.15
77470	Radiology	SPECIAL RADIATION TREATMENT	259.64	259.64
77470-26	Radiology	SPECIAL RADIATION TREATMENT	196.11	196.11
77470-TC	Radiology	SPECIAL RADIATION TREATMENT	63.53	63.53
77499	Radiology	UNLISTED PX THER RAD TX MGMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77499-26	Radiology	UNLISTED PX THER RAD TX MGMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77499-TC	Radiology	UNLISTED PX THER RAD TX MGMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77520	Radiology	PROTON TRMT SIMPLE W/O COMP	1605.12	1605.12
77522	Radiology	PROTON TRMT SIMPLE W/COMP	1661.40	1661.40
77523	Radiology	PROTON TRMT INTERMEDIATE	1726.45	1726.45
77525	Radiology	PROTON TREATMENT COMPLEX	1927.67	1927.67
77600	Radiology	HYPERTHERMIA TREATMENT	970.91	970.91
77600-26	Radiology	HYPERTHERMIA TREATMENT	130.53	130.53
77600-TC	Radiology	HYPERTHERMIA TREATMENT	840.37	840.37
77605	Radiology	HYPERTHERMIA TREATMENT	1678.09	1678.09
77605-26	Radiology	HYPERTHERMIA TREATMENT	179.81	179.81
77605-TC	Radiology	HYPERTHERMIA TREATMENT	1498.28	1498.28
77610	Radiology	HYPERTHERMIA TREATMENT	1218.48	1218.48
77610-26	Radiology	HYPERTHERMIA TREATMENT	126.98	126.98
77610-TC	Radiology	HYPERTHERMIA TREATMENT	1091.49	1091.49
77615	Radiology	HYPERTHERMIA TREATMENT	1911.25	1911.25
77615-26	Radiology	HYPERTHERMIA TREATMENT	178.23	178.23
77615-TC	Radiology	HYPERTHERMIA TREATMENT	1733.02	1733.02
77620	Radiology	HYPERTHERMIA TREATMENT	1131.04	1131.04
77620-26	Radiology	HYPERTHERMIA TREATMENT	147.75	147.75
77620-TC	Radiology	HYPERTHERMIA TREATMENT	983.29	983.29
77750	Radiology	INFUSE RADIOACTIVE MATERIALS	716.98	716.98
77750-26	Radiology	INFUSE RADIOACTIVE MATERIALS	482.49	482.49
77750-TC	Radiology	INFUSE RADIOACTIVE MATERIALS	234.49	234.49
77761	Radiology	APPLY INTRCAV RADIAT SIMPLE	762.31	762.31
77761-26	Radiology	APPLY INTRCAV RADIAT SIMPLE	371.46	371.46
77761-TC	Radiology	APPLY INTRCAV RADIAT SIMPLE	390.84	390.84
77762	Radiology	APPLY INTRCAV RADIAT INTERM	1004.39	1004.39
77762-26	Radiology	APPLY INTRCAV RADIAT INTERM	555.95	555.95
77762-TC	Radiology	APPLY INTRCAV RADIAT INTERM	448.44	448.44
77763	Radiology	APPLY INTRCAV RADIAT COMPL	1421.04	1421.04
77763-26	Radiology	APPLY INTRCAV RADIAT COMPL	835.50	835.50
77763-TC	Radiology	APPLY INTRCAV RADIAT COMPL	585.55	585.55
77767	Radiology	HDR RDNCL SKN SURF BRACHYTX	446.90	446.90
77767-26	Radiology	HDR RDNCL SKN SURF BRACHYTX	101.26	101.26
77767-TC	Radiology	HDR RDNCL SKN SURF BRACHYTX	345.64	345.64
77768	Radiology	HDR RDNCL SKN SURF BRACHYTX	654.24	654.24
77768-26	Radiology	HDR RDNCL SKN SURF BRACHYTX	135.10	135.10
77768-TC	Radiology	HDR RDNCL SKN SURF BRACHYTX	519.15	519.15
77770	Radiology	HDR RDNCL NTRSTL/ICAV BRCHTX	624.74	624.74
77770-26	Radiology	HDR RDNCL NTRSTL/ICAV BRCHTX	188.21	188.21
77770-TC	Radiology	HDR RDNCL NTRSTL/ICAV BRCHTX	436.53	436.53
77771	Radiology	HDR RDNCL NTRSTL/ICAV BRCHTX	1087.79	1087.79
77771-26	Radiology	HDR RDNCL NTRSTL/ICAV BRCHTX	366.50	366.50
77771-TC	Radiology	HDR RDNCL NTRSTL/ICAV BRCHTX	721.29	721.29
77772	Radiology	HDR RDNCL NTRSTL/ICAV BRCHTX	1622.77	1622.77
77772-26	Radiology	HDR RDNCL NTRSTL/ICAV BRCHTX	517.74	517.74
77772-TC	Radiology	HDR RDNCL NTRSTL/ICAV BRCHTX	1105.03	1105.03
77778	Radiology	APPLY INTERSTIT RADIAT COMPL	1666.31	1666.31
77778-26	Radiology	APPLY INTERSTIT RADIAT COMPL	845.34	845.34
77778-TC	Radiology	APPLY INTERSTIT RADIAT COMPL	820.97	820.97
77789	Radiology	APPLY SURF LDR RADIONUCLIDE	240.73	240.73
77789-26	Radiology	APPLY SURF LDR RADIONUCLIDE	110.39	110.39
77789-TC	Radiology	APPLY SURF LDR RADIONUCLIDE	130.34	130.34
77790	Radiology	RADIATION HANDLING	31.59	31.59
77790-26	Radiology	RADIATION HANDLING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77790-TC	Radiology	RADIATION HANDLING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77799	Radiology	UNLISTED PX CLIN BRACHYTX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77799-26	Radiology	UNLISTED PX CLIN BRACHYTX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
77799-TC	Radiology	UNLISTED PX CLIN BRACHYTX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78012	Radiology	THYROID UPTAKE MEASUREMENT	143.91	143.91
78012-26	Radiology	THYROID UPTAKE MEASUREMENT	16.11	16.11
78012-TC	Radiology	THYROID UPTAKE MEASUREMENT	127.80	127.80
78013	Radiology	THYROID IMAGING W/BLOOD FLOW	304.65	304.65
78013-26	Radiology	THYROID IMAGING W/BLOOD FLOW	31.57	31.57
78013-TC	Radiology	THYROID IMAGING W/BLOOD FLOW	273.08	273.08
78014	Radiology	THYROID IMAGING W/BLOOD FLOW	387.47	387.47
78014-26	Radiology	THYROID IMAGING W/BLOOD FLOW	42.24	42.24
78014-TC	Radiology	THYROID IMAGING W/BLOOD FLOW	345.23	345.23
78015	Radiology	THYROID MET IMAGING	378.05	378.05
78015-26	Radiology	THYROID MET IMAGING	58.25	58.25
78015-TC	Radiology	THYROID MET IMAGING	319.80	319.80
78016	Radiology	THYROID MET IMAGING/STUDIES	450.88	450.88
78016-26	Radiology	THYROID MET IMAGING/STUDIES	60.47	60.47
78016-TC	Radiology	THYROID MET IMAGING/STUDIES	390.41	390.41
78018	Radiology	THYROID MET IMAGING BODY	506.49	506.49
78018-26	Radiology	THYROID MET IMAGING BODY	70.96	70.96
78018-TC	Radiology	THYROID MET IMAGING BODY	435.51	435.51
78020	Radiology	THYROID MET UPTAKE	140.52	140.52
78020-26	Radiology	THYROID MET UPTAKE	48.03	48.03
78020-TC	Radiology	THYROID MET UPTAKE	92.49	92.49
78070	Radiology	PARATHYROID PLANAR IMAGING	480.01	480.01
78070-26	Radiology	PARATHYROID PLANAR IMAGING	68.74	68.74
78070-TC	Radiology	PARATHYROID PLANAR IMAGING	411.27	411.27
78071	Radiology	PARATHYRD PLANAR W/WO SUBTRJ	572.03	572.03
78071-26	Radiology	PARATHYRD PLANAR W/WO SUBTRJ	102.22	102.22
78071-TC	Radiology	PARATHYRD PLANAR W/WO SUBTRJ	469.81	469.81
78072	Radiology	PARATHYRD PLANAR W/SPECT&CT	710.17	710.17
78072-26	Radiology	PARATHYRD PLANAR W/SPECT&CT	134.10	134.10
78072-TC	Radiology	PARATHYRD PLANAR W/SPECT&CT	576.07	576.07
78075	Radiology	ADRENAL CORTEX & MEDULLA IMG	721.23	721.23
78075-26	Radiology	ADRENAL CORTEX & MEDULLA IMG	64.33	64.33
78075-TC	Radiology	ADRENAL CORTEX & MEDULLA IMG	656.92	656.92
78099	Radiology	UNLISTED ENDOCRINE PX DX NUC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78099-26	Radiology	UNLISTED ENDOCRINE PX DX NUC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78099-TC	Radiology	UNLISTED ENDOCRINE PX DX NUC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78102	Radiology	BONE MARROW IMAGING LTD	285.99	285.99
78102-26	Radiology	BONE MARROW IMAGING LTD	45.44	45.44
78102-TC	Radiology	BONE MARROW IMAGING LTD	240.57	240.57
78103	Radiology	BONE MARROW IMAGING MULT	306.03	306.03
78103-26	Radiology	BONE MARROW IMAGING MULT	55.40	55.40
78103-TC	Radiology	BONE MARROW IMAGING MULT	250.61	250.61
78104	Radiology	BONE MARROW IMAGING BODY	409.83	409.83
78104-26	Radiology	BONE MARROW IMAGING BODY	67.14	67.14
78104-TC	Radiology	BONE MARROW IMAGING BODY	342.69	342.69
78110	Radiology	PLASMA VOLUME SINGLE	122.46	122.46
78110-26	Radiology	PLASMA VOLUME SINGLE	14.33	14.33
78110-TC	Radiology	PLASMA VOLUME SINGLE	108.13	108.13
78111	Radiology	PLASMA VOLUME MULTIPLE	129.69	129.69
78111-26	Radiology	PLASMA VOLUME MULTIPLE	16.24	16.24
78111-TC	Radiology	PLASMA VOLUME MULTIPLE	113.45	113.45
78120	Radiology	RED CELL MASS SINGLE	125.60	125.60
78120-26	Radiology	RED CELL MASS SINGLE	17.47	17.47
78120-TC	Radiology	RED CELL MASS SINGLE	108.13	108.13
78121	Radiology	RED CELL MASS MULTIPLE	137.26	137.26
78121-26	Radiology	RED CELL MASS MULTIPLE	23.81	23.81
78121-TC	Radiology	RED CELL MASS MULTIPLE	113.45	113.45
78122	Radiology	BLOOD VOLUME	174.95	174.95
78122-26	Radiology	BLOOD VOLUME	37.26	37.26
78122-TC	Radiology	BLOOD VOLUME	137.69	137.69
78130	Radiology	RED CELL SURVIVAL STUDY	221.66	221.66
78130-26	Radiology	RED CELL SURVIVAL STUDY	45.28	45.28
78130-TC	Radiology	RED CELL SURVIVAL STUDY	176.38	176.38
78140	Radiology	RED CELL SEQUESTRATION	195.82	195.82
78140-26	Radiology	RED CELL SEQUESTRATION	45.28	45.28
78140-TC	Radiology	RED CELL SEQUESTRATION	150.52	150.52
78185	Radiology	SPLEEN IMAGING	275.40	275.40
78185-26	Radiology	SPLEEN IMAGING	29.50	29.50
78185-TC	Radiology	SPLEEN IMAGING	245.90	245.90
78191	Radiology	PLATELET SURVIVAL	221.66	221.66
78191-26	Radiology	PLATELET SURVIVAL	45.28	45.28
78191-TC	Radiology	PLATELET SURVIVAL	176.38	176.38
78195	Radiology	LYMPH SYSTEM IMAGING	577.79	577.79
78195-26	Radiology	LYMPH SYSTEM IMAGING	101.63	101.63
78195-TC	Radiology	LYMPH SYSTEM IMAGING	476.15	476.15
78199	Radiology	UNLSTD HEMATOP RET/ENDO LYMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78199-26	Radiology	UNLSTD HEMATOP RET/ENDO LYMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78199-TC	Radiology	UNLSTD HEMATOP RET/ENDO LYMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78201	Radiology	LIVER IMAGING	314.46	314.46
78201-26	Radiology	LIVER IMAGING	36.62	36.62
78201-TC	Radiology	LIVER IMAGING	277.82	277.82
78202	Radiology	LIVER IMAGING WITH FLOW	346.13	346.13
78202-26	Radiology	LIVER IMAGING WITH FLOW	42.88	42.88
78202-TC	Radiology	LIVER IMAGING WITH FLOW	303.24	303.24
78215	Radiology	LIVER AND SPLEEN IMAGING	324.15	324.15
78215-26	Radiology	LIVER AND SPLEEN IMAGING	41.59	41.59
78215-TC	Radiology	LIVER AND SPLEEN IMAGING	282.56	282.56
78216	Radiology	LIVER & SPLEEN IMAGE/FLOW	227.97	227.97
78216-26	Radiology	LIVER & SPLEEN IMAGE/FLOW	47.29	47.29
78216-TC	Radiology	LIVER & SPLEEN IMAGE/FLOW	180.69	180.69
78226	Radiology	HEPATOBILIARY SYSTEM IMAGING	528.22	528.22
78226-26	Radiology	HEPATOBILIARY SYSTEM IMAGING	63.73	63.73
78226-TC	Radiology	HEPATOBILIARY SYSTEM IMAGING	464.49	464.49
78227	Radiology	HEPATOBIL SYST IMAGE W/DRUG	708.38	708.38
78227-26	Radiology	HEPATOBIL SYST IMAGE W/DRUG	76.91	76.91
78227-TC	Radiology	HEPATOBIL SYST IMAGE W/DRUG	631.49	631.49
78230	Radiology	SALIVARY GLAND IMAGING	291.43	291.43
78230-26	Radiology	SALIVARY GLAND IMAGING	39.04	39.04
78230-TC	Radiology	SALIVARY GLAND IMAGING	252.39	252.39
78231	Radiology	SERIAL SALIVARY IMAGING	185.35	185.35
78231-26	Radiology	SERIAL SALIVARY IMAGING	38.36	38.36
78231-TC	Radiology	SERIAL SALIVARY IMAGING	146.99	146.99
78232	Radiology	SALIVARY GLAND FUNCTION EXAM	181.56	181.56
78232-26	Radiology	SALIVARY GLAND FUNCTION EXAM	34.57	34.57
78232-TC	Radiology	SALIVARY GLAND FUNCTION EXAM	146.99	146.99
78258	Radiology	ESOPHAGEAL MOTILITY STUDY	352.95	352.95
78258-26	Radiology	ESOPHAGEAL MOTILITY STUDY	60.94	60.94
78258-TC	Radiology	ESOPHAGEAL MOTILITY STUDY	292.01	292.01
78261	Radiology	GASTRIC MUCOSA IMAGING	329.82	329.82
78261-26	Radiology	GASTRIC MUCOSA IMAGING	50.99	50.99
78261-TC	Radiology	GASTRIC MUCOSA IMAGING	278.83	278.83
78262	Radiology	GASTROESOPHAGEAL REFLUX EXAM	403.34	403.34
78262-26	Radiology	GASTROESOPHAGEAL REFLUX EXAM	58.89	58.89
78262-TC	Radiology	GASTROESOPHAGEAL REFLUX EXAM	344.47	344.47
78264	Radiology	GASTRIC EMPTYING IMAG STUDY	537.75	537.75
78264-26	Radiology	GASTRIC EMPTYING IMAG STUDY	67.51	67.51
78264-TC	Radiology	GASTRIC EMPTYING IMAG STUDY	470.24	470.24
78265	Radiology	GASTRIC EMPTYING IMAG STUDY	639.76	639.76
78265-26	Radiology	GASTRIC EMPTYING IMAG STUDY	83.19	83.19
78265-TC	Radiology	GASTRIC EMPTYING IMAG STUDY	556.57	556.57
78266	Radiology	GASTRIC EMPTYING IMAG STUDY	727.56	727.56
78266-26	Radiology	GASTRIC EMPTYING IMAG STUDY	89.58	89.58
78266-TC	Radiology	GASTRIC EMPTYING IMAG STUDY	637.98	637.98
78267	Clinical Laboratory	BREATH TST ATTAIN/ANAL C-14	16.59	16.59
78268	Clinical Laboratory	BREATH TEST ANALYSIS C-14	141.62	141.62
78278	Radiology	ACUTE GI BLOOD LOSS IMAGING	568.09	568.09
78278-26	Radiology	ACUTE GI BLOOD LOSS IMAGING	84.84	84.84
78278-TC	Radiology	ACUTE GI BLOOD LOSS IMAGING	483.25	483.25
78282	Radiology	GI PROTEIN LOSS EXAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78282-26	Radiology	GI PROTEIN LOSS EXAM	28.24	28.24
78282-TC	Radiology	GI PROTEIN LOSS EXAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78290	Radiology	MECKELS DIVERT EXAM	534.44	534.44
78290-26	Radiology	MECKELS DIVERT EXAM	57.70	57.70
78290-TC	Radiology	MECKELS DIVERT EXAM	476.74	476.74
78291	Radiology	LEVEEN/SHUNT PATENCY EXAM	432.33	432.33
78291-26	Radiology	LEVEEN/SHUNT PATENCY EXAM	76.64	76.64
78291-TC	Radiology	LEVEEN/SHUNT PATENCY EXAM	355.70	355.70
78299	Radiology	UNLISTED GI PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78299-26	Radiology	UNLISTED GI PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78299-TC	Radiology	UNLISTED GI PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78300	Radiology	BONE IMAGING LIMITED AREA	368.51	368.51
78300-26	Radiology	BONE IMAGING LIMITED AREA	53.27	53.27
78300-TC	Radiology	BONE IMAGING LIMITED AREA	315.24	315.24
78305	Radiology	BONE IMAGING MULTIPLE AREAS	444.85	444.85
78305-26	Radiology	BONE IMAGING MULTIPLE AREAS	70.67	70.67
78305-TC	Radiology	BONE IMAGING MULTIPLE AREAS	374.19	374.19
78306	Radiology	BONE IMAGING WHOLE BODY	480.46	480.46
78306-26	Radiology	BONE IMAGING WHOLE BODY	73.16	73.16
78306-TC	Radiology	BONE IMAGING WHOLE BODY	407.30	407.30
78315	Radiology	BONE IMAGING 3 PHASE	564.68	564.68
78315-26	Radiology	BONE IMAGING 3 PHASE	87.36	87.36
78315-TC	Radiology	BONE IMAGING 3 PHASE	477.34	477.34
78350	Radiology	BONE MINERAL SINGLE PHOTON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78350-26	Radiology	BONE MINERAL SINGLE PHOTON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78350-TC	Radiology	BONE MINERAL SINGLE PHOTON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78351	Radiology	BONE MINERAL DUAL PHOTON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78399	Radiology	UNLISTED MUSCSKEL PX DX NUC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78399-26	Radiology	UNLISTED MUSCSKEL PX DX NUC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78399-TC	Radiology	UNLISTED MUSCSKEL PX DX NUC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78414	Radiology	NON-IMAGING HEART FUNCTION	166.37	166.37
78414-26	Radiology	NON-IMAGING HEART FUNCTION	38.61	38.61
78414-TC	Radiology	NON-IMAGING HEART FUNCTION	127.76	127.76
78428	Radiology	CARDIAC SHUNT IMAGING	310.56	310.56
78428-26	Radiology	CARDIAC SHUNT IMAGING	65.85	65.85
78428-TC	Radiology	CARDIAC SHUNT IMAGING	244.71	244.71
78429	Radiology	MYOCRD IMG PET 1 STD W/CT	173.69	173.69
78429-26	Radiology	MYOCRD IMG PET 1 STD W/CT	144.50	144.50
78429-TC	Radiology	MYOCRD IMG PET 1 STD W/CT	29.19	29.19
78430	Radiology	MYOCRD IMG PET RST/STRS W/CT	166.92	166.92
78430-26	Radiology	MYOCRD IMG PET RST/STRS W/CT	137.73	137.73
78430-TC	Radiology	MYOCRD IMG PET RST/STRS W/CT	29.19	29.19
78431	Radiology	MYOCRD IMG PET RST&STRS CT	4224.11	4224.11
78431-26	Radiology	MYOCRD IMG PET RST&STRS CT	160.52	160.52
78431-TC	Radiology	MYOCRD IMG PET RST&STRS CT	4063.59	4063.59
78432	Radiology	MYOCRD IMG PET 2RTRACER	3512.87	3512.87
78432-26	Radiology	MYOCRD IMG PET 2RTRACER	171.80	171.80
78432-TC	Radiology	MYOCRD IMG PET 2RTRACER	3341.05	3341.05
78433	Radiology	MYOCRD IMG PET 2RTRACER CT	3709.89	3709.89
78433-26	Radiology	MYOCRD IMG PET 2RTRACER CT	187.90	187.90
78433-TC	Radiology	MYOCRD IMG PET 2RTRACER CT	3521.97	3521.97
78434	Major surgery	AQMBF PET REST & RX STRESS	58.03	58.03
78434-26	Radiology	AQMBF PET REST & RX STRESS	52.90	52.90
78434-TC	Radiology	AQMBF PET REST & RX STRESS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78445	Radiology	VASCULAR FLOW IMAGING	335.48	335.48
78445-26	Radiology	VASCULAR FLOW IMAGING	44.05	44.05
78445-TC	Radiology	VASCULAR FLOW IMAGING	291.41	291.41
78451	Radiology	HT MUSCLE IMAGE SPECT SING	560.04	560.04
78451-26	Radiology	HT MUSCLE IMAGE SPECT SING	117.43	117.43
78451-TC	Radiology	HT MUSCLE IMAGE SPECT SING	442.61	442.61
78452	Radiology	HT MUSCLE IMAGE SPECT MULT	773.37	773.37
78452-26	Radiology	HT MUSCLE IMAGE SPECT MULT	138.51	138.51
78452-TC	Radiology	HT MUSCLE IMAGE SPECT MULT	634.86	634.86
78453	Radiology	HT MUSCLE IMAGE PLANAR SING	475.82	475.82
78453-26	Radiology	HT MUSCLE IMAGE PLANAR SING	83.46	83.46
78453-TC	Radiology	HT MUSCLE IMAGE PLANAR SING	392.36	392.36
78454	Radiology	HT MUSC IMAGE PLANAR MULT	709.96	709.96
78454-26	Radiology	HT MUSC IMAGE PLANAR MULT	115.73	115.73
78454-TC	Radiology	HT MUSC IMAGE PLANAR MULT	594.24	594.24
78456	Radiology	ACUTE VENOUS THROMBUS IMAGE	514.66	514.66
78456-26	Radiology	ACUTE VENOUS THROMBUS IMAGE	85.23	85.23
78456-TC	Radiology	ACUTE VENOUS THROMBUS IMAGE	429.45	429.45
78457	Radiology	VENOUS THROMBOSIS IMAGING	274.99	274.99
78457-26	Radiology	VENOUS THROMBOSIS IMAGING	63.98	63.98
78457-TC	Radiology	VENOUS THROMBOSIS IMAGING	211.01	211.01
78458	Radiology	VEN THROMBOSIS IMAGES BILAT	344.51	344.51
78458-26	Radiology	VEN THROMBOSIS IMAGES BILAT	78.51	78.51
78458-TC	Radiology	VEN THROMBOSIS IMAGES BILAT	266.00	266.00
78459	Radiology	MYOCRD IMG PET SINGLE STUDY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78459-26	Radiology	MYOCRD IMG PET SINGLE STUDY	133.73	133.73
78459-TC	Radiology	MYOCRD IMG PET SINGLE STUDY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78466	Radiology	HEART INFARCT IMAGE	297.88	297.88
78466-26	Radiology	HEART INFARCT IMAGE	58.50	58.50
78466-TC	Radiology	HEART INFARCT IMAGE	239.38	239.38
78468	Radiology	HEART INFARCT IMAGE (EF)	327.81	327.81
78468-26	Radiology	HEART INFARCT IMAGE (EF)	68.33	68.33
78468-TC	Radiology	HEART INFARCT IMAGE (EF)	259.49	259.49
78469	Radiology	HEART INFARCT IMAGE (3D)	367.40	367.40
78469-26	Radiology	HEART INFARCT IMAGE (3D)	78.35	78.35
78469-TC	Radiology	HEART INFARCT IMAGE (3D)	289.05	289.05
78472	Radiology	GATED HEART PLANAR SINGLE	376.39	376.39
78472-26	Radiology	GATED HEART PLANAR SINGLE	83.79	83.79
78472-TC	Radiology	GATED HEART PLANAR SINGLE	292.60	292.60
78473	Radiology	GATED HEART MULTIPLE	480.66	480.66
78473-26	Radiology	GATED HEART MULTIPLE	124.96	124.96
78473-TC	Radiology	GATED HEART MULTIPLE	355.70	355.70
78481	Radiology	HEART FIRST PASS SINGLE	296.73	296.73
78481-26	Radiology	HEART FIRST PASS SINGLE	83.79	83.79
78481-TC	Radiology	HEART FIRST PASS SINGLE	212.94	212.94
78483	Radiology	HEART FIRST PASS MULTIPLE	399.22	399.22
78483-26	Radiology	HEART FIRST PASS MULTIPLE	125.54	125.54
78483-TC	Radiology	HEART FIRST PASS MULTIPLE	273.68	273.68
78491	Radiology	MYOCRD IMG PET 1STD RST/STRS	2298.97	2298.97
78491-26	Radiology	MYOCRD IMG PET 1STD RST/STRS	131.29	131.29
78491-TC	Radiology	MYOCRD IMG PET 1STD RST/STRS	2167.68	2167.68
78492	Radiology	MYOCRD IMG PET MLT RST&STRS	2321.83	2321.83
78492-26	Radiology	MYOCRD IMG PET MLT RST&STRS	154.15	154.15
78492-TC	Radiology	MYOCRD IMG PET MLT RST&STRS	2167.68	2167.68
78494	Radiology	HEART IMAGE SPECT	380.33	380.33
78494-26	Radiology	HEART IMAGE SPECT	101.34	101.34
78494-TC	Radiology	HEART IMAGE SPECT	279.01	279.01
78496	Radiology	HEART FIRST PASS ADD-ON	76.36	76.36
78496-26	Radiology	HEART FIRST PASS ADD-ON	42.82	42.82
78496-TC	Radiology	HEART FIRST PASS ADD-ON	33.54	33.54
78499	Radiology	UNLISTED CV PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78499-26	Radiology	UNLISTED CV PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78499-TC	Radiology	UNLISTED CV PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78579	Radiology	LUNG VENTILATION IMAGING	307.16	307.16
78579-26	Radiology	LUNG VENTILATION IMAGING	41.59	41.59
78579-TC	Radiology	LUNG VENTILATION IMAGING	265.57	265.57
78580	Radiology	LUNG PERFUSION IMAGING	386.49	386.49
78580-26	Radiology	LUNG PERFUSION IMAGING	63.14	63.14
78580-TC	Radiology	LUNG PERFUSION IMAGING	323.35	323.35
78582	Radiology	LUNG VENTILAT&PERFUS IMAGING	541.44	541.44
78582-26	Radiology	LUNG VENTILAT&PERFUS IMAGING	91.14	91.14
78582-TC	Radiology	LUNG VENTILAT&PERFUS IMAGING	450.29	450.29
78597	Radiology	LUNG PERFUSION DIFFERENTIAL	328.32	328.32
78597-26	Radiology	LUNG PERFUSION DIFFERENTIAL	61.58	61.58
78597-TC	Radiology	LUNG PERFUSION DIFFERENTIAL	266.76	266.76
78598	Radiology	LUNG PERF&VENTILAT DIFERENTL	491.07	491.07
78598-26	Radiology	LUNG PERF&VENTILAT DIFERENTL	70.92	70.92
78598-TC	Radiology	LUNG PERF&VENTILAT DIFERENTL	420.15	420.15
78599	Radiology	UNLISTED RESP PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78599-26	Radiology	UNLISTED RESP PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78599-TC	Radiology	UNLISTED RESP PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78600	Radiology	BRAIN IMAGE < 4 VIEWS	299.68	299.68
78600-26	Radiology	BRAIN IMAGE < 4 VIEWS	37.81	37.81
78600-TC	Radiology	BRAIN IMAGE < 4 VIEWS	261.85	261.85
78601	Radiology	BRAIN IMAGE W/FLOW < 4 VIEWS	356.75	356.75
78601-26	Radiology	BRAIN IMAGE W/FLOW < 4 VIEWS	43.47	43.47
78601-TC	Radiology	BRAIN IMAGE W/FLOW < 4 VIEWS	313.29	313.29
78605	Radiology	BRAIN IMAGE 4+ VIEWS	331.27	331.27
78605-26	Radiology	BRAIN IMAGE 4+ VIEWS	46.35	46.35
78605-TC	Radiology	BRAIN IMAGE 4+ VIEWS	284.91	284.91
78606	Radiology	BRAIN IMAGE W/FLOW 4 + VIEWS	536.02	536.02
78606-26	Radiology	BRAIN IMAGE W/FLOW 4 + VIEWS	54.56	54.56
78606-TC	Radiology	BRAIN IMAGE W/FLOW 4 + VIEWS	481.47	481.47
78608	Radiology	BRAIN IMAGING (PET)	2293.79	2293.79
78608-26	Radiology	BRAIN IMAGING (PET)	126.11	126.11
78608-TC	Radiology	BRAIN IMAGING (PET)	2167.68	2167.68
78609	Radiology	BRAIN IMAGING (PET)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78609-26	Radiology	BRAIN IMAGING (PET)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78609-TC	Radiology	BRAIN IMAGING (PET)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78610	Radiology	BRAIN FLOW IMAGING ONLY	287.94	287.94
78610-26	Radiology	BRAIN FLOW IMAGING ONLY	25.49	25.49
78610-TC	Radiology	BRAIN FLOW IMAGING ONLY	262.45	262.45
78630	Radiology	CEREBROSPINAL FLUID SCAN	547.44	547.44
78630-26	Radiology	CEREBROSPINAL FLUID SCAN	57.70	57.70
78630-TC	Radiology	CEREBROSPINAL FLUID SCAN	489.74	489.74
78635	Radiology	CSF VENTRICULOGRAPHY	548.89	548.89
78635-26	Radiology	CSF VENTRICULOGRAPHY	53.24	53.24
78635-TC	Radiology	CSF VENTRICULOGRAPHY	495.65	495.65
78645	Radiology	CSF SHUNT EVALUATION	525.06	525.06
78645-26	Radiology	CSF SHUNT EVALUATION	48.32	48.32
78645-TC	Radiology	CSF SHUNT EVALUATION	476.74	476.74
78650	Radiology	CSF LEAKAGE IMAGING	441.03	441.03
78650-26	Radiology	CSF LEAKAGE IMAGING	45.28	45.28
78650-TC	Radiology	CSF LEAKAGE IMAGING	395.73	395.73
78660	Radiology	NUCLEAR EXAM OF TEAR FLOW	237.00	237.00
78660-26	Radiology	NUCLEAR EXAM OF TEAR FLOW	39.00	39.00
78660-TC	Radiology	NUCLEAR EXAM OF TEAR FLOW	198.00	198.00
78699	Radiology	UNLISTED NRVS SYS PX DX NUC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78699-26	Radiology	UNLISTED NRVS SYS PX DX NUC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78699-TC	Radiology	UNLISTED NRVS SYS PX DX NUC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78700	Radiology	KIDNEY IMAGING MORPHOL	281.97	281.97
78700-26	Radiology	KIDNEY IMAGING MORPHOL	37.87	37.87
78700-TC	Radiology	KIDNEY IMAGING MORPHOL	244.12	244.12
78701	Radiology	KIDNEY IMAGING WITH FLOW	370.27	370.27
78701-26	Radiology	KIDNEY IMAGING WITH FLOW	42.18	42.18
78701-TC	Radiology	KIDNEY IMAGING WITH FLOW	328.07	328.07
78707	Radiology	K FLOW/FUNCT IMAGE W/O DRUG	384.56	384.56
78707-26	Radiology	K FLOW/FUNCT IMAGE W/O DRUG	80.73	80.73
78707-TC	Radiology	K FLOW/FUNCT IMAGE W/O DRUG	303.83	303.83
78708	Radiology	K FLOW/FUNCT IMAGE W/DRUG	314.46	314.46
78708-26	Radiology	K FLOW/FUNCT IMAGE W/DRUG	102.43	102.43
78708-TC	Radiology	K FLOW/FUNCT IMAGE W/DRUG	212.02	212.02
78709	Radiology	K FLOW/FUNCT IMAGE MULTIPLE	603.60	603.60
78709-26	Radiology	K FLOW/FUNCT IMAGE MULTIPLE	119.18	119.18
78709-TC	Radiology	K FLOW/FUNCT IMAGE MULTIPLE	484.42	484.42
78725	Radiology	KIDNEY FUNCTION STUDY	172.42	172.42
78725-26	Radiology	KIDNEY FUNCTION STUDY	31.20	31.20
78725-TC	Radiology	KIDNEY FUNCTION STUDY	141.24	141.24
78730	Radiology	URINARY BLADDER RETENTION	121.76	121.76
78730-26	Radiology	URINARY BLADDER RETENTION	13.71	13.71
78730-TC	Radiology	URINARY BLADDER RETENTION	108.03	108.03
78740	Radiology	URETERAL REFLUX STUDY	374.77	374.77
78740-26	Radiology	URETERAL REFLUX STUDY	48.48	48.48
78740-TC	Radiology	URETERAL REFLUX STUDY	326.29	326.29
78761	Radiology	TESTICULAR IMAGING W/FLOW	351.45	351.45
78761-26	Radiology	TESTICULAR IMAGING W/FLOW	61.82	61.82
78761-TC	Radiology	TESTICULAR IMAGING W/FLOW	289.63	289.63
78799	Radiology	UNLISTED GU PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78799-26	Radiology	UNLISTED GU PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78799-TC	Radiology	UNLISTED GU PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78800	Radiology	RP LOCLZJ TUM 1 AREA 1 D IMG	413.46	413.46
78800-26	Radiology	RP LOCLZJ TUM 1 AREA 1 D IMG	55.83	55.83
78800-TC	Radiology	RP LOCLZJ TUM 1 AREA 1 D IMG	357.63	357.63
78801	Radiology	RP LOCLZJ TUM 2+AREA 1+D IMG	443.78	443.78
78801-26	Radiology	RP LOCLZJ TUM 2+AREA 1+D IMG	61.91	61.91
78801-TC	Radiology	RP LOCLZJ TUM 2+AREA 1+D IMG	381.89	381.89
78802	Radiology	RP LOCLZJ TUM WHBDY 1 D IMG	501.48	501.48
78802-26	Radiology	RP LOCLZJ TUM WHBDY 1 D IMG	67.57	67.57
78802-TC	Radiology	RP LOCLZJ TUM WHBDY 1 D IMG	433.91	433.91
78803	Radiology	RP LOCLZJ TUM SPECT 1 AREA	619.57	619.57
78803-26	Radiology	RP LOCLZJ TUM SPECT 1 AREA	91.83	91.83
78803-TC	Radiology	RP LOCLZJ TUM SPECT 1 AREA	527.75	527.75
78804	Radiology	RP LOCLZJ TUM WHBDY 2+D IMG	1041.89	1041.89
78804-26	Radiology	RP LOCLZJ TUM WHBDY 2+D IMG	85.53	85.53
78804-TC	Radiology	RP LOCLZJ TUM WHBDY 2+D IMG	956.34	956.34
78808	Radiology	IV INJ RA DRUG DX STUDY	70.88	70.88
78811	Radiology	PET IMAGE LTD AREA	2297.35	2297.35
78811-26	Radiology	PET IMAGE LTD AREA	129.68	129.68
78811-TC	Radiology	PET IMAGE LTD AREA	2167.68	2167.68
78812	Radiology	PET IMAGE SKULL-THIGH	2854.98	2854.98
78812-26	Radiology	PET IMAGE SKULL-THIGH	163.72	163.72
78812-TC	Radiology	PET IMAGE SKULL-THIGH	2691.25	2691.25
78813	Radiology	PET IMAGE FULL BODY	2858.86	2858.86
78813-26	Radiology	PET IMAGE FULL BODY	167.58	167.58
78813-TC	Radiology	PET IMAGE FULL BODY	2691.25	2691.25
78814	Radiology	PET IMAGE W/CT LMTD	2353.20	2353.20
78814-26	Radiology	PET IMAGE W/CT LMTD	185.52	185.52
78814-TC	Radiology	PET IMAGE W/CT LMTD	2167.68	2167.68
78815	Radiology	PET IMAGE W/CT SKULL-THIGH	2897.84	2897.84
78815-26	Radiology	PET IMAGE W/CT SKULL-THIGH	206.58	206.58
78815-TC	Radiology	PET IMAGE W/CT SKULL-THIGH	2691.25	2691.25
78816	Radiology	PET IMAGE W/CT FULL BODY	2900.06	2900.06
78816-26	Radiology	PET IMAGE W/CT FULL BODY	208.81	208.81
78816-TC	Radiology	PET IMAGE W/CT FULL BODY	2691.25	2691.25
78830	Radiology	RP LOCLZJ TUM SPECT W/CT 1	776.65	776.65
78830-26	Radiology	RP LOCLZJ TUM SPECT W/CT 1	123.10	123.10
78830-TC	Radiology	RP LOCLZJ TUM SPECT W/CT 1	653.52	653.52
78831	Radiology	RP LOCLZJ TUM SPECT 2 AREAS	1159.74	1159.74
78831-26	Radiology	RP LOCLZJ TUM SPECT 2 AREAS	154.91	154.91
78831-TC	Radiology	RP LOCLZJ TUM SPECT 2 AREAS	1004.84	1004.84
78832	Radiology	RP LOCLZJ TUM SPECT W/CT 2	1464.74	1464.74
78832-26	Radiology	RP LOCLZJ TUM SPECT W/CT 2	176.44	176.44
78832-TC	Radiology	RP LOCLZJ TUM SPECT W/CT 2	1288.31	1288.31
78835	Major surgery	RP QUAN MEAS SINGLE AREA	159.59	159.59
78835-26	Radiology	RP QUAN MEAS SINGLE AREA	38.55	38.55
78835-TC	Radiology	RP QUAN MEAS SINGLE AREA	121.04	121.04
78999	Radiology	UNLISTED MISC PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78999-26	Radiology	UNLISTED MISC PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
78999-TC	Radiology	UNLISTED MISC PX DX NUC MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
79005	Radiology	NUCLEAR RX ORAL ADMIN	244.10	244.10
79005-26	Radiology	NUCLEAR RX ORAL ADMIN	153.39	153.39
79005-TC	Radiology	NUCLEAR RX ORAL ADMIN	90.71	90.71
79101	Radiology	NUCLEAR RX IV ADMIN	265.55	265.55
79101-26	Radiology	NUCLEAR RX IV ADMIN	170.68	170.68
79101-TC	Radiology	NUCLEAR RX IV ADMIN	94.87	94.87
79200	Radiology	NUCLEAR RX INTRACAV ADMIN	239.17	239.17
79200-26	Radiology	NUCLEAR RX INTRACAV ADMIN	146.25	146.25
79200-TC	Radiology	NUCLEAR RX INTRACAV ADMIN	92.92	92.92
79300	Radiology	NUCLR RX INTERSTIT COLLOID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
79300-26	Radiology	NUCLR RX INTERSTIT COLLOID	117.80	117.80
79300-TC	Radiology	NUCLR RX INTERSTIT COLLOID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
79403	Radiology	HEMATOPOIETIC NUCLEAR TX	379.35	379.35
79403-26	Radiology	HEMATOPOIETIC NUCLEAR TX	200.87	200.87
79403-TC	Radiology	HEMATOPOIETIC NUCLEAR TX	178.48	178.48
79440	Radiology	NUCLEAR RX INTRA-ARTICULAR	216.27	216.27
79440-26	Radiology	NUCLEAR RX INTRA-ARTICULAR	146.25	146.25
79440-TC	Radiology	NUCLEAR RX INTRA-ARTICULAR	70.02	70.02
79445	Radiology	NUCLEAR RX INTRA-ARTERIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
79445-26	Radiology	NUCLEAR RX INTRA-ARTERIAL	198.80	198.80
79445-TC	Radiology	NUCLEAR RX INTRA-ARTERIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
79999	Radiology	RP THERAPY UNLISTED PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
79999-26	Radiology	RP THERAPY UNLISTED PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
79999-TC	Radiology	RP THERAPY UNLISTED PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80047	Clinical Laboratory	METABOLIC PANEL IONIZED CA	20.60	20.60
80048	Clinical Laboratory	METABOLIC PANEL TOTAL CA	12.69	12.69
80050	Other professional services	GENERAL HEALTH PANEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80051	Clinical Laboratory	ELECTROLYTE PANEL	10.52	10.52
80053	Clinical Laboratory	COMPREHEN METABOLIC PANEL	15.84	15.84
80055	Clinical Laboratory	OBSTETRIC PANEL	71.72	71.72
80061	Clinical Laboratory	LIPID PANEL	20.09	20.09
80069	Clinical Laboratory	RENAL FUNCTION PANEL	13.02	13.02
80074	Clinical Laboratory	ACUTE HEPATITIS PANEL	71.45	71.45
80076	Clinical Laboratory	HEPATIC FUNCTION PANEL	12.26	12.26
80081	Clinical Laboratory	OBSTETRIC PANEL	112.29	112.29
80143	Clinical Laboratory	DRUG ASSAY ACETAMINOPHEN	27.96	27.96
80145	Clinical Laboratory	DRUG ASSAY ADALIMUMAB	57.86	57.86
80150	Clinical Laboratory	ASSAY OF AMIKACIN	22.62	22.62
80151	Clinical Laboratory	DRUG ASSAY AMIODARONE	27.96	27.96
80155	Clinical Laboratory	DRUG ASSAY CAFFEINE	57.86	57.86
80156	Clinical Laboratory	ASSAY CARBAMAZEPINE TOTAL	21.86	21.86
80157	Clinical Laboratory	ASSAY CARBAMAZEPINE FREE	19.88	19.88
80158	Clinical Laboratory	DRUG ASSAY CYCLOSPORINE	27.08	27.08
80159	Clinical Laboratory	DRUG ASSAY CLOZAPINE	30.23	30.23
80161	Clinical Laboratory	ASY CARBAMAZEPIN 10,11-EPXID	27.96	27.96
80162	Clinical Laboratory	ASSAY OF DIGOXIN TOTAL	19.92	19.92
80163	Clinical Laboratory	ASSAY OF DIGOXIN FREE	19.92	19.92
80164	Clinical Laboratory	ASSAY DIPROPYLACETIC ACD TOT	20.31	20.31
80165	Clinical Laboratory	DIPROPYLACETIC ACID FREE	20.31	20.31
80167	Clinical Laboratory	DRUG ASSAY FELBAMATE	27.96	27.96
80168	Clinical Laboratory	ASSAY OF ETHOSUXIMIDE	24.51	24.51
80169	Clinical Laboratory	DRUG ASSAY EVEROLIMUS	20.60	20.60
80170	Clinical Laboratory	ASSAY OF GENTAMICIN	24.57	24.57
80171	Clinical Laboratory	DRUG SCREEN QUANT GABAPENTIN	32.51	32.51
80173	Clinical Laboratory	ASSAY OF HALOPERIDOL	23.67	23.67
80175	Clinical Laboratory	DRUG SCREEN QUAN LAMOTRIGINE	19.88	19.88
80176	Clinical Laboratory	ASSAY OF LIDOCAINE	22.04	22.04
80177	Clinical Laboratory	DRUG SCRN QUAN LEVETIRACETAM	19.88	19.88
80178	Clinical Laboratory	ASSAY OF LITHIUM	9.92	9.92
80179	Clinical Laboratory	DRUG ASSAY SALICYLATE	27.96	27.96
80180	Clinical Laboratory	DRUG SCRN QUAN MYCOPHENOLATE	27.08	27.08
80181	Clinical Laboratory	DRUG ASSAY FLECAINIDE	27.96	27.96
80183	Clinical Laboratory	DRUG SCRN QUANT OXCARBAZEPIN	19.88	19.88
80184	Clinical Laboratory	ASSAY OF PHENOBARBITAL	22.95	22.95
80185	Clinical Laboratory	ASSAY OF PHENYTOIN TOTAL	19.88	19.88
80186	Clinical Laboratory	ASSAY OF PHENYTOIN FREE	20.64	20.64
80187	Clinical Laboratory	DRUG ASSAY POSACONAZOLE	40.67	40.67
80188	Clinical Laboratory	ASSAY OF PRIMIDONE	24.89	24.89
80189	Clinical Laboratory	DRUG ASSAY ITRACONAZOLE	40.67	40.67
80190	Clinical Laboratory	ASSAY OF PROCAINAMIDE	90.00	90.00
80192	Clinical Laboratory	ASSAY OF PROCAINAMIDE	25.13	25.13
80193	Clinical Laboratory	DRUG ASSAY LEFLUNOMIDE	57.86	57.86
80194	Clinical Laboratory	ASSAY OF QUINIDINE	21.90	21.90
80195	Clinical Laboratory	ASSAY OF SIROLIMUS	20.60	20.60
80197	Clinical Laboratory	ASSAY OF TACROLIMUS	20.60	20.60
80198	Clinical Laboratory	ASSAY OF THEOPHYLLINE	21.21	21.21
80199	Clinical Laboratory	DRUG SCREEN QUANT TIAGABINE	40.67	40.67
80200	Clinical Laboratory	ASSAY OF TOBRAMYCIN	24.20	24.20
80201	Clinical Laboratory	ASSAY OF TOPIRAMATE	17.88	17.88
80202	Clinical Laboratory	ASSAY OF VANCOMYCIN	20.31	20.31
80203	Clinical Laboratory	DRUG SCREEN QUANT ZONISAMIDE	19.88	19.88
80204	Clinical Laboratory	DRUG ASSAY METHOTREXATE	57.86	57.86
80210	Clinical Laboratory	DRUG ASSAY RUFINAMIDE	40.67	40.67
80220	Clinical Laboratory	DRUG ASY HYDROXYCHLOROQUINE	27.96	27.96
80230	Clinical Laboratory	DRUG ASSAY INFLIXIMAB	57.86	57.86
80235	Clinical Laboratory	DRUG ASSAY LACOSAMIDE	40.67	40.67
80280	Clinical Laboratory	DRUG ASSAY VEDOLIZUMAB	57.86	57.86
80285	Clinical Laboratory	DRUG ASSAY VORICONAZOLE	40.67	40.67
80299	Clinical Laboratory	QUANTITATIVE ASSAY DRUG	27.96	27.96
80305	Clinical Laboratory	DRUG TEST PRSMV DIR OPT OBS	18.90	18.90
80306	Clinical Laboratory	DRUG TEST PRSMV INSTRMNT	25.71	25.71
80307	Clinical Laboratory	DRUG TEST PRSMV CHEM ANLYZR	93.21	93.21
80320	Other professional services	DRUG SCREEN QUANTALCOHOLS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80321	Other professional services	ALCOHOLS BIOMARKERS 1OR 2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80322	Other professional services	ALCOHOLS BIOMARKERS 3/MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80323	Other professional services	ALKALOIDS NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80324	Other professional services	DRUG SCREEN AMPHETAMINES 1/2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80325	Other professional services	AMPHETAMINES 3OR 4	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80326	Other professional services	AMPHETAMINES 5 OR MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80327	Other professional services	ANABOLIC STEROID 1 OR 2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80328	Other professional services	ANABOLIC STEROID 3 OR MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80329	Other professional services	ANALGESICS NON-OPIOID 1 OR 2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80330	Other professional services	ANALGESICS NON-OPIOID 3-5	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80331	Other professional services	ANALGESICS NON-OPIOID 6/MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80332	Other professional services	ANTIDEPRESSANTS CLASS 1 OR 2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80333	Other professional services	ANTIDEPRESSANTS CLASS 3-5	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80334	Other professional services	ANTIDEPRESSANTS CLASS 6/MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80335	Other professional services	ANTIDEPRESSANT TRICYCLIC 1/2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80336	Other professional services	ANTIDEPRESSANT TRICYCLIC 3-5	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80337	Other professional services	TRICYCLIC & CYCLICALS 6/MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80338	Other professional services	ANTIDEPRESSANT NOT SPECIFIED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80339	Other professional services	ANTIEPILEPTICS NOS 1-3	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80340	Other professional services	ANTIEPILEPTICS NOS 4-6	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80341	Other professional services	ANTIEPILEPTICS NOS 7/MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80342	Other professional services	ANTIPSYCHOTICS NOS 1-3	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80343	Other professional services	ANTIPSYCHOTICS NOS 4-6	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80344	Other professional services	ANTIPSYCHOTICS NOS 7/MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80345	Other professional services	DRUG SCREENING BARBITURATES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80346	Other professional services	BENZODIAZEPINES1-12	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80347	Other professional services	BENZODIAZEPINES 13 OR MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80348	Other professional services	DRUG SCREENING BUPRENORPHINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80349	Other professional services	CANNABINOIDS NATURAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80350	Other professional services	CANNABINOIDS SYNTHETIC 1-3	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80351	Other professional services	CANNABINOIDS SYNTHETIC 4-6	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80352	Other professional services	CANNABINOID SYNTHETIC 7/MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80353	Other professional services	DRUG SCREENING COCAINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80354	Other professional services	DRUG SCREENING FENTANYL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80355	Other professional services	GABAPENTIN NON-BLOOD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80356	Other professional services	HEROIN METABOLITE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80357	Other professional services	KETAMINE AND NORKETAMINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80358	Other professional services	DRUG SCREENING METHADONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80359	Other professional services	METHYLENEDIOXYAMPHETAMINES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80360	Other professional services	METHYLPHENIDATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80361	Other professional services	OPIATES 1 OR MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80362	Other professional services	OPIOIDS & OPIATE ANALOGS 1/2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80363	Other professional services	OPIOIDS & OPIATE ANALOGS 3/4	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80364	Other professional services	OPIOID &OPIATE ANALOG 5/MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80365	Other professional services	DRUG SCREENING OXYCODONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80366	Other professional services	DRUG SCREENING PREGABALIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80367	Other professional services	DRUG SCREENING PROPOXYPHENE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80368	Other professional services	SEDATIVE HYPNOTICS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80369	Other professional services	SKELETAL MUSCLE RELAXANT 1/2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80370	Other professional services	SKEL MUSC RELAXANT 3 OR MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80371	Other professional services	STIMULANTS SYNTHETIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80372	Other professional services	DRUG SCREENING TAPENTADOL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80373	Other professional services	DRUG SCREENING TRAMADOL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80374	Other professional services	STEREOISOMER ANALYSIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80375	Other professional services	DRUG/SUBSTANCE NOS 1-3	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80376	Other professional services	DRUG/SUBSTANCE NOS 4-6	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80377	Other professional services	DRUG/SUBSTANCE NOS 7/MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
80400	Clinical Laboratory	ACTH STIMULATION PANEL	48.93	48.93
80402	Clinical Laboratory	ACTH STIMULATION PANEL	130.44	130.44
80406	Clinical Laboratory	ACTH STIMULATION PANEL	117.39	117.39
80408	Clinical Laboratory	ALDOSTERONE SUPPRESSION EVAL	188.25	188.25
80410	Clinical Laboratory	CALCITONIN STIMUL PANEL	120.56	120.56
80412	Clinical Laboratory	CRH STIMULATION PANEL	1202.43	1202.43
80414	Clinical Laboratory	TESTOSTERONE RESPONSE PANEL	77.46	77.46
80415	Clinical Laboratory	TOT ESTRADIOL RESPONSE PANEL	83.84	83.84
80416	Clinical Laboratory	RENIN STIMULATION PANEL	313.98	313.98
80417	Clinical Laboratory	RENIN STIMULATION PANEL	65.99	65.99
80418	Clinical Laboratory	PITUITARY EVALUATION PANEL	869.22	869.22
80420	Clinical Laboratory	DEXAMETHASONE PANEL	242.82	242.82
80422	Clinical Laboratory	GLUCAGON TOLERANCE PANEL	69.11	69.11
80424	Clinical Laboratory	GLUCAGON TOLERANCE PANEL	75.75	75.75
80426	Clinical Laboratory	GONADOTROPIN HORMONE PANEL	222.62	222.62
80428	Clinical Laboratory	GROWTH HORMONE PANEL	100.05	100.05
80430	Clinical Laboratory	GROWTH HORMONE PANEL	194.00	194.00
80432	Clinical Laboratory	INSULIN SUPPRESSION PANEL	248.42	248.42
80434	Clinical Laboratory	INSULIN TOLERANCE PANEL	427.55	427.55
80435	Clinical Laboratory	INSULIN TOLERANCE PANEL	154.50	154.50
80436	Clinical Laboratory	METYRAPONE PANEL	136.74	136.74
80438	Clinical Laboratory	TRH STIMULATION PANEL	75.62	75.62
80439	Clinical Laboratory	TRH STIMULATION PANEL	100.82	100.82
80503	Clinical Laboratory	PATH CLIN CONSLTJ SF 5-20	37.70	30.87
80504	Clinical Laboratory	PATH CLIN CONSLTJ MOD 21-40	74.54	66.35
80505	Clinical Laboratory	PATH CLIN CONSLTJ HIGH 41-60	134.55	124.55
80506	Clinical Laboratory	PATH CLIN CONSLTJ PROLNG SVC	59.70	59.70
81000	Clinical Laboratory	URINALYSIS NONAUTO W/SCOPE	6.03	6.03
81001	Clinical Laboratory	URINALYSIS AUTO W/SCOPE	4.76	4.76
81002	Clinical Laboratory	URINALYSIS NONAUTO W/O SCOPE	5.22	5.22
81003	Clinical Laboratory	URINALYSIS AUTO W/O SCOPE	3.38	3.38
81005	Clinical Laboratory	URINALYSIS	3.26	3.26
81007	Clinical Laboratory	URINE SCREEN FOR BACTERIA	44.97	44.97
81015	Clinical Laboratory	MICROSCOPIC EXAM OF URINE	4.58	4.58
81020	Clinical Laboratory	URINALYSIS GLASS TEST	7.05	7.05
81025	Clinical Laboratory	URINE PREGNANCY TEST	12.92	12.92
81050	Clinical Laboratory	URINALYSIS VOLUME MEASURE	5.46	5.46
81099	Other professional services	UNLISTED URINALYSIS PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
81105	Clinical Laboratory	HPA-1 GENOTYPING	183.33	183.33
81106	Clinical Laboratory	HPA-2 GENOTYPING	183.33	183.33
81107	Clinical Laboratory	HPA-3 GENOTYPING	183.33	183.33
81108	Clinical Laboratory	HPA-4 GENOTYPING	183.33	183.33
81109	Clinical Laboratory	HPA-5 GENOTYPING	183.33	183.33
81110	Clinical Laboratory	HPA-6 GENOTYPING	183.33	183.33
81111	Clinical Laboratory	HPA-9 GENOTYPING	183.33	183.33
81112	Clinical Laboratory	HPA-15 GENOTYPING	183.33	183.33
81120	Clinical Laboratory	IDH1 COMMON VARIANTS	289.88	289.88
81121	Clinical Laboratory	IDH2 COMMON VARIANTS	443.69	443.69
81161	Clinical Laboratory	DMD DUP/DELET ANALYSIS	418.50	418.50
81162	Clinical Laboratory	BRCA1&2 GEN FULL SEQ DUP/DEL	2737.32	2737.32
81163	Clinical Laboratory	BRCA1&2 GENE FULL SEQ ALYS	702.00	702.00
81164	Clinical Laboratory	BRCA1&2 GEN FUL DUP/DEL ALYS	876.35	876.35
81165	Clinical Laboratory	BRCA1 GENE FULL SEQ ALYS	424.32	424.32
81166	Clinical Laboratory	BRCA1 GENE FULL DUP/DEL ALYS	452.03	452.03
81167	Clinical Laboratory	BRCA2 GENE FULL DUP/DEL ALYS	424.32	424.32
81168	Clinical Laboratory	CCND1/IGH TRANSLOCATION ALYS	310.97	310.97
81170	Clinical Laboratory	ABL1 GENE	450.00	450.00
81171	Clinical Laboratory	AFF2 GEN ALY DETC ABNL ALLEL	205.50	205.50
81172	Clinical Laboratory	AFF2 GEN ALYS CHARAC ALLELES	412.25	412.25
81173	Clinical Laboratory	AR GENE FULL GENE SEQUENCE	452.03	452.03
81174	Clinical Laboratory	AR GENE KNOWN FAMIL VARIANT	277.80	277.80
81175	Clinical Laboratory	ASXL1 FULL GENE SEQUENCE	1014.75	1014.75
81176	Clinical Laboratory	ASXL1 GENE TARGET SEQ ALYS	362.85	362.85
81177	Clinical Laboratory	ATN1 GENE DETC ABNOR ALLELES	205.50	205.50
81178	Clinical Laboratory	ATXN1 GENE DETC ABNOR ALLELE	205.50	205.50
81179	Clinical Laboratory	ATXN2 GENE DETC ABNOR ALLELE	205.50	205.50
81180	Clinical Laboratory	ATXN3 GENE DETC ABNOR ALLELE	205.50	205.50
81181	Clinical Laboratory	ATXN7 GENE DETC ABNOR ALLELE	205.50	205.50
81182	Clinical Laboratory	ATXN8OS GEN DETC ABNOR ALLEL	205.50	205.50
81183	Clinical Laboratory	ATXN10 GENE DETC ABNOR ALLEL	205.50	205.50
81184	Clinical Laboratory	CACNA1A GEN DETC ABNOR ALLEL	205.50	205.50
81185	Clinical Laboratory	CACNA1A GENE FULL GENE SEQ	1269.41	1269.41
81186	Clinical Laboratory	CACNA1A GEN KNOWN FAMIL VRNT	277.80	277.80
81187	Clinical Laboratory	CNBP GENE DETC ABNOR ALLELE	205.50	205.50
81188	Clinical Laboratory	CSTB GENE DETC ABNOR ALLELE	205.50	205.50
81189	Clinical Laboratory	CSTB GENE FULL GENE SEQUENCE	412.25	412.25
81190	Clinical Laboratory	CSTB GENE KNOWN FAMIL VRNT	277.80	277.80
81191	Clinical Laboratory	NTRK1 TRANSLOCATION ANALYSIS	310.97	310.97
81192	Clinical Laboratory	NTRK2 TRANSLOCATION ANALYSIS	310.97	310.97
81193	Clinical Laboratory	NTRK3 TRANSLOCATION ANALYSIS	310.97	310.97
81194	Clinical Laboratory	NTRK TRANSLOCATION ANALYSIS	777.42	777.42
81200	Clinical Laboratory	ASPA GENE	70.88	70.88
81201	Clinical Laboratory	APC GENE FULL SEQUENCE	1170.00	1170.00
81202	Clinical Laboratory	APC GENE KNOWN FAM VARIANTS	420.00	420.00
81203	Clinical Laboratory	APC GENE DUP/DELET VARIANTS	300.00	300.00
81204	Clinical Laboratory	AR GENE CHARAC ALLELES	205.50	205.50
81205	Clinical Laboratory	BCKDHB GENE	142.49	142.49
81206	Clinical Laboratory	BCR/ABL1 GENE MAJOR BP	245.94	245.94
81207	Clinical Laboratory	BCR/ABL1 GENE MINOR BP	217.26	217.26
81208	Clinical Laboratory	BCR/ABL1 GENE OTHER BP	321.93	321.93
81209	Clinical Laboratory	BLM GENE	58.97	58.97
81210	Clinical Laboratory	BRAF GENE	263.10	263.10
81212	Clinical Laboratory	BRCA1&2 185&5385&6174 VRNT	660.00	660.00
81215	Clinical Laboratory	BRCA1 GENE KNOWN FAMIL VRNT	562.88	562.88
81216	Clinical Laboratory	BRCA2 GENE FULL SEQ ALYS	277.68	277.68
81217	Clinical Laboratory	BRCA2 GENE KNOWN FAMIL VRNT	562.88	562.88
81218	Clinical Laboratory	CEBPA GENE FULL SEQUENCE	362.85	362.85
81219	Clinical Laboratory	CALR GENE COM VARIANTS	182.45	182.45
81220	Clinical Laboratory	CFTR GENE COM VARIANTS	834.90	834.90
81221	Clinical Laboratory	CFTR GENE KNOWN FAM VARIANTS	145.83	145.83
81222	Clinical Laboratory	CFTR GENE DUP/DELET VARIANTS	652.61	652.61
81223	Clinical Laboratory	CFTR GENE FULL SEQUENCE	748.50	748.50
81224	Clinical Laboratory	CFTR GENE INTRON POLY T	253.13	253.13
81225	Clinical Laboratory	CYP2C19 GENE COM VARIANTS	437.04	437.04
81226	Clinical Laboratory	CYP2D6 GENE COM VARIANTS	676.37	676.37
81227	Clinical Laboratory	CYP2C9 GENE COM VARIANTS	262.22	262.22
81228	Clinical Laboratory	CYTOG ALYS CHRML ABNR CGH	1350.00	1350.00
81229	Clinical Laboratory	CYTOG ALYS CHRML ABNR SNPCGH	1740.00	1740.00
81230	Clinical Laboratory	CYP3A4 GENE COMMON VARIANTS	262.22	262.22
81231	Clinical Laboratory	CYP3A5 GENE COMMON VARIANTS	262.22	262.22
81232	Clinical Laboratory	DPYD GENE COMMON VARIANTS	262.22	262.22
81233	Clinical Laboratory	BTK GENE COMMON VARIANTS	263.10	263.10
81234	Clinical Laboratory	DMPK GENE DETC ABNOR ALLELE	205.50	205.50
81235	Clinical Laboratory	EGFR GENE COM VARIANTS	486.87	486.87
81236	Clinical Laboratory	EZH2 GENE FULL GENE SEQUENCE	424.32	424.32
81237	Clinical Laboratory	EZH2 GENE COMMON VARIANTS	263.10	263.10
81238	Clinical Laboratory	F9 FULL GENE SEQUENCE	900.00	900.00
81239	Clinical Laboratory	DMPK GENE CHARAC ALLELES	412.25	412.25
81240	Clinical Laboratory	F2 GENE	98.54	98.54
81241	Clinical Laboratory	F5 GENE	110.06	110.06
81242	Clinical Laboratory	FANCC GENE	54.93	54.93
81243	Clinical Laboratory	FMR1 GEN ALY DETC ABNL ALLEL	85.56	85.56
81244	Clinical Laboratory	FMR1 GEN ALYS CHARAC ALLELES	67.34	67.34
81245	Clinical Laboratory	FLT3 GENE	248.27	248.27
81246	Clinical Laboratory	FLT3 GENE ANALYSIS	124.50	124.50
81247	Clinical Laboratory	G6PD GENE ALYS CMN VARIANT	262.22	262.22
81248	Clinical Laboratory	G6PD KNOWN FAMILIAL VARIANT	562.88	562.88
81249	Clinical Laboratory	G6PD FULL GENE SEQUENCE	900.00	900.00
81250	Clinical Laboratory	G6PC GENE	87.74	87.74
81251	Clinical Laboratory	GBA GENE	70.88	70.88
81252	Clinical Laboratory	GJB2 GENE FULL SEQUENCE	151.68	151.68
81253	Clinical Laboratory	GJB2 GENE KNOWN FAM VARIANTS	92.28	92.28
81254	Clinical Laboratory	GJB6 GENE COM VARIANTS	52.50	52.50
81255	Clinical Laboratory	HEXA GENE	77.18	77.18
81256	Clinical Laboratory	HFE GENE	98.04	98.04
81257	Clinical Laboratory	HBA1/HBA2 GENE	153.39	153.39
81258	Clinical Laboratory	HBA1/HBA2 GENE FAM VRNT	562.88	562.88
81259	Clinical Laboratory	HBA1/HBA2 FULL GENE SEQUENCE	900.00	900.00
81260	Clinical Laboratory	IKBKAP GENE	58.97	58.97
81261	Clinical Laboratory	IGH GENE REARRANGE AMP METH	296.99	296.99
81262	Clinical Laboratory	IGH GENE REARRANG DIR PROBE	102.83	102.83
81263	Clinical Laboratory	IGH VARI REGIONAL MUTATION	441.78	441.78
81264	Clinical Laboratory	IGK REARRANGEABN CLONAL POP	259.10	259.10
81265	Clinical Laboratory	STR MARKERS SPECIMEN ANAL	349.61	349.61
81266	Clinical Laboratory	STR MARKERS SPEC ANAL ADDL	457.22	457.22
81267	Clinical Laboratory	CHIMERISM ANAL NO CELL SELEC	311.19	311.19
81268	Clinical Laboratory	CHIMERISM ANAL W/CELL SELECT	391.19	391.19
81269	Clinical Laboratory	HBA1/HBA2 GENE DUP/DEL VRNTS	303.60	303.60
81270	Clinical Laboratory	JAK2 GENE	137.49	137.49
81271	Clinical Laboratory	HTT GENE DETC ABNOR ALLELES	205.50	205.50
81272	Clinical Laboratory	KIT GENE TARGETED SEQ ANALYS	494.27	494.27
81273	Clinical Laboratory	KIT GENE ANALYS D816 VARIANT	187.31	187.31
81274	Clinical Laboratory	HTT GENE CHARAC ALLELES	412.25	412.25
81275	Clinical Laboratory	KRAS GENE VARIANTS EXON 2	289.88	289.88
81276	Clinical Laboratory	KRAS GENE ADDL VARIANTS	289.88	289.88
81277	Clinical Laboratory	CYTOGENOMIC NEO MICRORA ALYS	1740.00	1740.00
81278	Clinical Laboratory	IGH@/BCL2 TRANSLOCATION ALYS	310.97	310.97
81279	Clinical Laboratory	JAK2 GENE TRGT SEQUENCE ALYS	277.80	277.80
81283	Clinical Laboratory	IFNL3 GENE	110.06	110.06
81284	Clinical Laboratory	FXN GENE DETC ABNOR ALLELES	205.50	205.50
81285	Clinical Laboratory	FXN GENE CHARAC ALLELES	412.25	412.25
81286	Clinical Laboratory	FXN GENE FULL GENE SEQUENCE	412.25	412.25
81287	Clinical Laboratory	MGMT GENE PRMTR MTHYLTN ALYS	186.96	186.96
81288	Clinical Laboratory	MLH1 GENE	288.48	288.48
81289	Clinical Laboratory	FXN GENE KNOWN FAMIL VARIANT	277.80	277.80
81290	Clinical Laboratory	MCOLN1 GENE	58.97	58.97
81291	Clinical Laboratory	MTHFR GENE	98.01	98.01
81292	Clinical Laboratory	MLH1 GENE FULL SEQ	1013.10	1013.10
81293	Clinical Laboratory	MLH1 GENE KNOWN VARIANTS	496.50	496.50
81294	Clinical Laboratory	MLH1 GENE DUP/DELETE VARIANT	303.60	303.60
81295	Clinical Laboratory	MSH2 GENE FULL SEQ	572.55	572.55
81296	Clinical Laboratory	MSH2 GENE KNOWN VARIANTS	506.60	506.60
81297	Clinical Laboratory	MSH2 GENE DUP/DELETE VARIANT	319.95	319.95
81298	Clinical Laboratory	MSH6 GENE FULL SEQ	962.78	962.78
81299	Clinical Laboratory	MSH6 GENE KNOWN VARIANTS	462.00	462.00
81300	Clinical Laboratory	MSH6 GENE DUP/DELETE VARIANT	357.00	357.00
81301	Clinical Laboratory	MICROSATELLITE INSTABILITY	522.84	522.84
81302	Clinical Laboratory	MECP2 GENE FULL SEQ	791.81	791.81
81303	Clinical Laboratory	MECP2 GENE KNOWN VARIANT	180.00	180.00
81304	Clinical Laboratory	MECP2 GENE DUP/DELET VARIANT	225.00	225.00
81305	Clinical Laboratory	MYD88 GENE P.LEU265PRO VRNT	263.10	263.10
81306	Clinical Laboratory	NUDT15 GENE COMMON VARIANTS	437.04	437.04
81307	Clinical Laboratory	PALB2 GENE FULL GENE SEQ	1014.75	1014.75
81308	Clinical Laboratory	PALB2 GENE KNOWN FAMIL VRNT	452.03	452.03
81309	Clinical Laboratory	PIK3CA GENE TRGT SEQ ALYS	412.25	412.25
81310	Clinical Laboratory	NPM1 GENE	369.78	369.78
81311	Clinical Laboratory	NRAS GENE VARIANTS EXON 2&3	443.69	443.69
81312	Clinical Laboratory	PABPN1 GENE DETC ABNOR ALLEL	205.50	205.50
81313	Clinical Laboratory	PCA3/KLK3 ANTIGEN	382.58	382.58
81314	Clinical Laboratory	PDGFRA GENE	494.27	494.27
81315	Clinical Laboratory	PML/RARALPHA COM BREAKPOINTS	310.97	310.97
81316	Clinical Laboratory	PML/RARALPHA 1 BREAKPOINT	310.97	310.97
81317	Clinical Laboratory	PMS2 GENE FULL SEQ ANALYSIS	1014.75	1014.75
81318	Clinical Laboratory	PMS2 KNOWN FAMILIAL VARIANTS	496.50	496.50
81319	Clinical Laboratory	PMS2 GENE DUP/DELET VARIANTS	305.25	305.25
81320	Clinical Laboratory	PLCG2 GENE COMMON VARIANTS	437.04	437.04
81321	Clinical Laboratory	PTEN GENE FULL SEQUENCE	900.00	900.00
81322	Clinical Laboratory	PTEN GENE KNOWN FAM VARIANT	69.90	69.90
81323	Clinical Laboratory	PTEN GENE DUP/DELET VARIANT	450.00	450.00
81324	Clinical Laboratory	PMP22 GENE DUP/DELET	1137.54	1137.54
81325	Clinical Laboratory	PMP22 GENE FULL SEQUENCE	1154.37	1154.37
81326	Clinical Laboratory	PMP22 GENE KNOWN FAM VARIANT	69.90	69.90
81327	Clinical Laboratory	SEPT9 GEN PRMTR MTHYLTN ALYS	288.00	288.00
81328	Clinical Laboratory	SLCO1B1 GENE COM VARIANTS	262.22	262.22
81329	Clinical Laboratory	SMN1 GENE DOS/DELETION ALYS	205.50	205.50
81330	Clinical Laboratory	SMPD1 GENE COMMON VARIANTS	70.50	70.50
81331	Clinical Laboratory	SNRPN/UBE3A GENE	76.61	76.61
81332	Clinical Laboratory	SERPINA1 GENE	65.48	65.48
81333	Clinical Laboratory	TGFBI GENE COMMON VARIANTS	205.50	205.50
81334	Clinical Laboratory	RUNX1 GENE TARGETED SEQ ALYS	494.27	494.27
81335	Clinical Laboratory	TPMT GENE COM VARIANTS	262.22	262.22
81336	Clinical Laboratory	SMN1 GENE FULL GENE SEQUENCE	452.03	452.03
81337	Clinical Laboratory	SMN1 GEN NOWN FAMIL SEQ VRNT	277.80	277.80
81338	Clinical Laboratory	MPL GENE COMMON VARIANTS	225.50	225.50
81339	Clinical Laboratory	MPL GENE SEQ ALYS EXON 10	277.80	277.80
81340	Clinical Laboratory	TRB@ GENE REARRANGE AMPLIFY	313.38	313.38
81341	Clinical Laboratory	TRB@ GENE REARRANGE DIRPROBE	74.39	74.39
81342	Clinical Laboratory	TRG GENE REARRANGEMENT ANAL	302.25	302.25
81343	Clinical Laboratory	PPP2R2B GEN DETC ABNOR ALLEL	205.50	205.50
81344	Clinical Laboratory	TBP GENE DETC ABNOR ALLELES	205.50	205.50
81345	Clinical Laboratory	TERT GENE TARGETED SEQ ALYS	277.80	277.80
81346	Clinical Laboratory	TYMS GENE COM VARIANTS	262.22	262.22
81347	Clinical Laboratory	SF3B1 GENE COMMON VARIANTS	289.88	289.88
81348	Clinical Laboratory	SRSF2 GENE COMMON VARIANTS	263.10	263.10
81349	Clinical Laboratory	CYTOG ALYS CHRML ABNR LW-PS	1740.00	1740.00
81350	Clinical Laboratory	UGT1A1 GENE COMMON VARIANTS	351.00	351.00
81351	Clinical Laboratory	TP53 GENE FULL GENE SEQUENCE	962.78	962.78
81352	Clinical Laboratory	TP53 GENE TRGT SEQUENCE ALYS	494.27	494.27
81353	Clinical Laboratory	TP53 GENE KNOWN FAMIL VRNT	462.00	462.00
81355	Clinical Laboratory	VKORC1 GENE	132.30	132.30
81357	Clinical Laboratory	U2AF1 GENE COMMON VARIANTS	289.88	289.88
81360	Clinical Laboratory	ZRSR2 GENE COMMON VARIANTS	289.88	289.88
81361	Clinical Laboratory	HBB GENE COM VARIANTS	262.22	262.22
81362	Clinical Laboratory	HBB GENE KNOWN FAM VARIANT	562.88	562.88
81363	Clinical Laboratory	HBB GENE DUP/DEL VARIANTS	303.60	303.60
81364	Clinical Laboratory	HBB FULL GENE SEQUENCE	486.87	486.87
81370	Clinical Laboratory	HLA I & II TYPING LR	603.18	603.18
81371	Clinical Laboratory	HLA I & II TYPE VERIFY LR	606.78	606.78
81372	Clinical Laboratory	HLA I TYPING COMPLETE LR	605.39	605.39
81373	Clinical Laboratory	HLA I TYPING 1 LOCUS LR	191.15	191.15
81374	Clinical Laboratory	HLA I TYPING 1 ANTIGEN LR	111.50	111.50
81375	Clinical Laboratory	HLA II TYPING AG EQUIV LR	331.11	331.11
81376	Clinical Laboratory	HLA II TYPING 1 LOCUS LR	183.33	183.33
81377	Clinical Laboratory	HLA II TYPE 1 AG EQUIV LR	142.11	142.11
81378	Clinical Laboratory	HLA I & II TYPING HR	518.36	518.36
81379	Clinical Laboratory	HLA I TYPING COMPLETE HR	503.07	503.07
81380	Clinical Laboratory	HLA I TYPING 1 LOCUS HR	265.88	265.88
81381	Clinical Laboratory	HLA I TYPING 1 ALLELE HR	254.85	254.85
81382	Clinical Laboratory	HLA II TYPING 1 LOC HR	185.52	185.52
81383	Clinical Laboratory	HLA II TYPING 1 ALLELE HR	163.70	163.70
81400	Clinical Laboratory	MOPATH PROCEDURE LEVEL 1	95.94	95.94
81401	Clinical Laboratory	MOPATH PROCEDURE LEVEL 2	205.50	205.50
81402	Clinical Laboratory	MOPATH PROCEDURE LEVEL 3	225.50	225.50
81403	Clinical Laboratory	MOPATH PROCEDURE LEVEL 4	277.80	277.80
81404	Clinical Laboratory	MOPATH PROCEDURE LEVEL 5	412.25	412.25
81405	Clinical Laboratory	MOPATH PROCEDURE LEVEL 6	452.03	452.03
81406	Clinical Laboratory	MOPATH PROCEDURE LEVEL 7	424.32	424.32
81407	Clinical Laboratory	MOPATH PROCEDURE LEVEL 8	1269.41	1269.41
81408	Clinical Laboratory	MOPATH PROCEDURE LEVEL 9	3000.00	3000.00
81410	Clinical Laboratory	AORTIC DYSFUNCTION/DILATION	756.00	756.00
81411	Clinical Laboratory	AORTIC DYSFUNCTION/DILATION	2025.29	2025.29
81412	Clinical Laboratory	ASHKENAZI JEWISH ASSOC DIS	3672.84	3672.84
81413	Clinical Laboratory	CAR ION CHNNLPATH INC 10 GNS	877.35	877.35
81414	Clinical Laboratory	CAR ION CHNNLPATH INC 2 GNS	877.35	877.35
81415	Clinical Laboratory	EXOME SEQUENCE ANALYSIS	7170.00	7170.00
81416	Clinical Laboratory	EXOME SEQUENCE ANALYSIS	18000.00	18000.00
81417	Clinical Laboratory	EXOME RE-EVALUATION	480.00	480.00
81418	Clinical Laboratory	RX METAB GEN SEQ ALYS PNL 6	1375.62	1375.62
81419	Clinical Laboratory	EPILEPSY GEN SEQ ALYS PANEL	3672.84	3672.84
81420	Clinical Laboratory	FETAL CHRMOML ANEUPLOIDY	1138.58	1138.58
81422	Clinical Laboratory	FETAL CHRMOML MICRODELTJ	1138.58	1138.58
81425	Clinical Laboratory	GENOME SEQUENCE ANALYSIS	7546.80	7546.80
81426	Clinical Laboratory	GENOME SEQUENCE ANALYSIS	4064.93	4064.93
81427	Clinical Laboratory	GENOME RE-EVALUATION	3506.48	3506.48
81430	Clinical Laboratory	HEARING LOSS SEQUENCE ANALYS	2437.50	2437.50
81431	Clinical Laboratory	HEARING LOSS DUP/DEL ANALYS	1019.36	1019.36
81432	Clinical Laboratory	HRDTRY BRST CA-RLATD DSORDRS	1018.58	1018.58
81433	Clinical Laboratory	HRDTRY BRST CA-RLATD DSORDRS	658.40	658.40
81434	Clinical Laboratory	HEREDITARY RETINAL DISORDERS	896.87	896.87
81435	Clinical Laboratory	HEREDITARY COLON CA DSORDRS	877.35	877.35
81436	Clinical Laboratory	HEREDITARY COLON CA DSORDRS	877.35	877.35
81437	Clinical Laboratory	HEREDTRY NURONDCRN TUM DSRDR	658.40	658.40
81438	Clinical Laboratory	HEREDTRY NURONDCRN TUM DSRDR	658.40	658.40
81439	Clinical Laboratory	HRDTRY CARDMYPY GENE PANEL	877.35	877.35
81440	Clinical Laboratory	MITOCHONDRIAL GENE	4986.00	4986.00
81441	Clinical Laboratory	IBMFS SEQ ALYS PNL 30 GENES	3672.84	3672.84
81442	Clinical Laboratory	NOONAN SPECTRUM DISORDERS	3215.40	3215.40
81443	Clinical Laboratory	GENETIC TSTG SEVERE INH COND	3672.84	3672.84
81445	Clinical Laboratory	SO NEO GSAP 5-50DNA/DNA&RNA	896.87	896.87
81448	Clinical Laboratory	HRDTRY PERPH NEURPHY PANEL	877.35	877.35
81449	Clinical Laboratory	SO NEO GSAP 5-50 RNA ALYS	896.87	896.87
81450	Clinical Laboratory	HL NEO GSAP 5-50DNA/DNA&RNA	1139.30	1139.30
81451	Clinical Laboratory	HL NEO GSAP 5-50 RNA ALYS	1139.30	1139.30
81455	Clinical Laboratory	SO/HL 51/>GSAP DNA/DNA&RNA	4379.40	4379.40
81456	Clinical Laboratory	SO/HL 51/>GSAP RNA ALYS	4379.40	4379.40
81457	Clinical Laboratory	SO NEO GSAP DNA MCRSTL INS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
81458	Clinical Laboratory	SO GSAP DNA CPY NMBR&MCRSTL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
81459	Clinical Laboratory	SO NEO GSAP DNA/DNA&RNA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
81460	Clinical Laboratory	WHOLE MITOCHONDRIAL GENOME	1930.50	1930.50
81462	Clinical Laboratory	SO GSAP CLL FR DNA/DNA&RNA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
81463	Clinical Laboratory	SO GSAP CL FR CPY NMBR&MCRST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
81464	Clinical Laboratory	SO GSAP CLL FR MCRSTL INS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
81465	Clinical Laboratory	WHOLE MITOCHONDRIAL GENOME	1404.00	1404.00
81470	Clinical Laboratory	X-LINKED INTELLECTUAL DBLT	1371.00	1371.00
81471	Clinical Laboratory	X-LINKED INTELLECTUAL DBLT	1371.00	1371.00
81479	Other professional services	UNLISTED MOLECULAR PATHOLOGY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
81490	Clinical Laboratory	AUTOIMMUNE RA ALYS 12 BMRK	1260.98	1260.98
81493	Clinical Laboratory	COR ARTERY DISEASE MRNA	1575.00	1575.00
81500	Clinical Laboratory	ONCO (OVAR) TWO PROTEINS	390.75	390.75
81503	Clinical Laboratory	ONCO (OVAR) FIVE PROTEINS	1345.50	1345.50
81504	Clinical Laboratory	ONCOLOGY TISSUE OF ORIGIN	780.00	780.00
81506	Clinical Laboratory	ENDO ASSAY SEVEN ANAL	103.38	103.38
81507	Clinical Laboratory	FETAL ANEUPLOIDY TRISOM RISK	1192.50	1192.50
81508	Clinical Laboratory	FTL CGEN ABNOR TWO PROTEINS	81.45	81.45
81509	Clinical Laboratory	FTL CGEN ABNOR 3 PROTEINS	2231.06	2231.06
81510	Clinical Laboratory	FTL CGEN ABNOR THREE ANAL	83.31	83.31
81511	Clinical Laboratory	FTL CGEN ABNOR FOUR ANAL	230.25	230.25
81512	Clinical Laboratory	FTL CGEN ABNOR FIVE ANAL	104.28	104.28
81513	Clinical Laboratory	NFCT DS BV RNA VAG FLU ALG	213.95	213.95
81514	Clinical Laboratory	NFCT DS BV&VAGINITIS DNA ALG	394.49	394.49
81517	Clinical Laboratory	LIVER DS ALYS 3 BMRK SRM ALG	264.29	264.29
81518	Clinical Laboratory	ONC BRST MRNA 11 GENES	5809.50	5809.50
81519	Clinical Laboratory	ONCOLOGY BREAST MRNA	5809.50	5809.50
81520	Clinical Laboratory	ONC BREAST MRNA 58 GENES	3765.32	3765.32
81521	Clinical Laboratory	ONC BREAST MRNA 70 GENES	5809.50	5809.50
81522	Clinical Laboratory	ONC BREAST MRNA 12 GENES	5809.50	5809.50
81523	Clinical Laboratory	ONC BRST MRNA 70 CNT 31 GENE	5809.50	5809.50
81525	Clinical Laboratory	ONCOLOGY COLON MRNA	4674.00	4674.00
81528	Clinical Laboratory	ONCOLOGY COLORECTAL SCR	763.31	763.31
81529	Clinical Laboratory	ONC CUTAN MLNMA MRNA 31 GENE	10789.50	10789.50
81535	Clinical Laboratory	ONCOLOGY GYNECOLOGIC	869.19	869.19
81536	Clinical Laboratory	ONCOLOGY GYNECOLOGIC	266.34	266.34
81538	Clinical Laboratory	ONCOLOGY LUNG	4306.50	4306.50
81539	Clinical Laboratory	ONCOLOGY PROSTATE PROB SCORE	1140.00	1140.00
81540	Clinical Laboratory	ONCOLOGY TUM UNKNOWN ORIGIN	5625.00	5625.00
81541	Clinical Laboratory	ONC PROSTATE MRNA 46 GENES	5809.50	5809.50
81542	Clinical Laboratory	ONC PROSTATE MRNA 22 CNT GEN	5809.50	5809.50
81546	Clinical Laboratory	ONC THYR MRNA 10,196 GEN ALG	5400.00	5400.00
81551	Clinical Laboratory	ONC PROSTATE 3 GENES	3045.00	3045.00
81552	Clinical Laboratory	ONC UVEAL MLNMA MRNA 15 GENE	11664.00	11664.00
81554	Clinical Laboratory	PULM DS IPF MRNA 190 GEN ALG	8250.00	8250.00
81560	Clinical Laboratory	TRNSPLJ PD LVR&BWL CD154+CLL	961.10	961.10
81595	Clinical Laboratory	CARDIOLOGY HRT TRNSPL MRNA	4860.00	4860.00
81596	Clinical Laboratory	NFCT DS CHRNC HCV 6 ASSAYS	108.29	108.29
81599	Other professional services	UNLISTED MAAA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
82009	Clinical Laboratory	TEST FOR ACETONE/KETONES	6.78	6.78
82010	Clinical Laboratory	ACETONE ASSAY	12.26	12.26
82013	Clinical Laboratory	ACETYLCHOLINESTERASE ASSAY	18.44	18.44
82016	Clinical Laboratory	ACYLCARNITINES QUAL	24.74	24.74
82017	Clinical Laboratory	ACYLCARNITINES QUANT	25.31	25.31
82024	Clinical Laboratory	ASSAY OF ACTH	57.93	57.93
82030	Clinical Laboratory	ASSAY OF ADP & AMP	38.70	38.70
82040	Clinical Laboratory	ASSAY OF SERUM ALBUMIN	7.43	7.43
82042	Clinical Laboratory	OTHER SOURCE ALBUMIN QUAN EA	11.67	11.67
82043	Clinical Laboratory	UR ALBUMIN QUANTITATIVE	8.67	8.67
82044	Clinical Laboratory	UR ALBUMIN SEMIQUANTITATIVE	9.35	9.35
82045	Clinical Laboratory	ALBUMIN ISCHEMIA MODIFIED	50.91	50.91
82075	Clinical Laboratory	ASSAY OF BREATH ETHANOL	45.00	45.00
82077	Clinical Laboratory	ASSAY SPEC XCP UR&BREATH IA	25.91	25.91
82085	Clinical Laboratory	ASSAY OF ALDOLASE	14.57	14.57
82088	Clinical Laboratory	ASSAY OF ALDOSTERONE	61.13	61.13
82103	Clinical Laboratory	ALPHA-1-ANTITRYPSIN TOTAL	20.16	20.16
82104	Clinical Laboratory	ALPHA-1-ANTITRYPSIN PHENO	21.69	21.69
82105	Clinical Laboratory	ALPHA-FETOPROTEIN SERUM	25.16	25.16
82106	Clinical Laboratory	ALPHA-FETOPROTEIN AMNIOTIC	25.50	25.50
82107	Clinical Laboratory	ALPHA-FETOPROTEIN L3	96.62	96.62
82108	Clinical Laboratory	ASSAY OF ALUMINUM	38.22	38.22
82120	Clinical Laboratory	AMINES VAGINAL FLUID QUAL	8.99	8.99
82127	Clinical Laboratory	AMINO ACID SINGLE QUAL	21.27	21.27
82128	Clinical Laboratory	AMINO ACIDS MULT QUAL	20.81	20.81
82131	Clinical Laboratory	AMINO ACIDS SINGLE QUANT	34.47	34.47
82135	Clinical Laboratory	ASSAY AMINOLEVULINIC ACID	24.68	24.68
82136	Clinical Laboratory	AMINO ACIDS QUANT 2-5	29.42	29.42
82139	Clinical Laboratory	AMINO ACIDS QUAN 6 OR MORE	25.31	25.31
82140	Clinical Laboratory	ASSAY OF AMMONIA	21.86	21.86
82143	Clinical Laboratory	AMNIOTIC FLUID SCAN	14.03	14.03
82150	Clinical Laboratory	ASSAY OF AMYLASE	9.72	9.72
82154	Clinical Laboratory	ANDROSTANEDIOL GLUCURONIDE	43.25	43.25
82157	Clinical Laboratory	ASSAY OF ANDROSTENEDIONE	43.92	43.92
82160	Clinical Laboratory	ASSAY OF ANDROSTERONE	38.33	38.33
82163	Clinical Laboratory	ASSAY OF ANGIOTENSIN II	30.78	30.78
82164	Clinical Laboratory	ANGIOTENSIN I ENZYME TEST	21.90	21.90
82166	Clinical Laboratory	ASSAY ANTI-MULLERIAN HORM	57.93	57.93
82172	Clinical Laboratory	ASSAY OF APOLIPOPROTEIN	31.64	31.64
82175	Clinical Laboratory	ASSAY OF ARSENIC	28.46	28.46
82180	Clinical Laboratory	ASSAY OF ASCORBIC ACID	14.84	14.84
82190	Clinical Laboratory	ATOMIC ABSORPTION	23.85	23.85
82232	Clinical Laboratory	ASSAY OF BETA-2 PROTEIN	24.27	24.27
82239	Clinical Laboratory	BILE ACIDS TOTAL	25.68	25.68
82240	Clinical Laboratory	BILE ACIDS CHOLYLGLYCINE	39.87	39.87
82247	Clinical Laboratory	BILIRUBIN TOTAL	7.53	7.53
82248	Clinical Laboratory	BILIRUBIN DIRECT	7.53	7.53
82252	Clinical Laboratory	FECAL BILIRUBIN TEST	6.84	6.84
82261	Clinical Laboratory	ASSAY OF BIOTINIDASE	25.31	25.31
82270	Clinical Laboratory	OCCULT BLOOD FECES	6.57	6.57
82271	Clinical Laboratory	OCCULT BLOOD OTHER SOURCES	7.98	7.98
82272	Clinical Laboratory	OCCULT BLD FECES 1-3 TESTS	6.35	6.35
82274	Clinical Laboratory	ASSAY TEST FOR BLOOD FECAL	23.88	23.88
82286	Clinical Laboratory	ASSAY OF BRADYKININ	7.74	7.74
82300	Clinical Laboratory	ASSAY OF CADMIUM	35.46	35.46
82306	Clinical Laboratory	VITAMIN D 25 HYDROXY	44.40	44.40
82308	Clinical Laboratory	ASSAY OF CALCITONIN	40.19	40.19
82310	Clinical Laboratory	ASSAY OF CALCIUM	7.74	7.74
82330	Clinical Laboratory	ASSAY OF CALCIUM	20.52	20.52
82331	Clinical Laboratory	CALCIUM INFUSION TEST	20.01	20.01
82340	Clinical Laboratory	ASSAY OF CALCIUM IN URINE	9.05	9.05
82355	Clinical Laboratory	CALCULUS ANALYSIS QUAL	17.37	17.37
82360	Clinical Laboratory	CALCULUS ASSAY QUANT	19.31	19.31
82365	Clinical Laboratory	CALCULUS SPECTROSCOPY	19.35	19.35
82370	Clinical Laboratory	X-RAY ASSAY CALCULUS	18.78	18.78
82373	Clinical Laboratory	ASSAY C-D TRANSFER MEASURE	27.09	27.09
82374	Clinical Laboratory	ASSAY BLOOD CARBON DIOXIDE	7.32	7.32
82375	Clinical Laboratory	ASSAY CARBOXYHB QUANT	18.48	18.48
82376	Clinical Laboratory	ASSAY CARBOXYHB QUAL	21.11	21.11
82378	Clinical Laboratory	CARCINOEMBRYONIC ANTIGEN	28.44	28.44
82379	Clinical Laboratory	ASSAY OF CARNITINE	25.31	25.31
82380	Clinical Laboratory	ASSAY OF CAROTENE	13.83	13.83
82382	Clinical Laboratory	ASSAY URINE CATECHOLAMINES	40.95	40.95
82383	Clinical Laboratory	ASSAY BLOOD CATECHOLAMINES	43.62	43.62
82384	Clinical Laboratory	ASSAY THREE CATECHOLAMINES	37.88	37.88
82387	Clinical Laboratory	ASSAY OF CATHEPSIN-D	27.09	27.09
82390	Clinical Laboratory	ASSAY OF CERULOPLASMIN	16.11	16.11
82397	Clinical Laboratory	CHEMILUMINESCENT ASSAY	21.18	21.18
82415	Clinical Laboratory	ASSAY OF CHLORAMPHENICOL	19.01	19.01
82435	Clinical Laboratory	ASSAY OF BLOOD CHLORIDE	6.90	6.90
82436	Clinical Laboratory	ASSAY OF URINE CHLORIDE	8.63	8.63
82438	Clinical Laboratory	ASSAY OTHER FLUID CHLORIDES	7.50	7.50
82441	Clinical Laboratory	TEST FOR CHLOROHYDROCARBONS	9.02	9.02
82465	Clinical Laboratory	ASSAY BLD/SERUM CHOLESTEROL	6.53	6.53
82480	Clinical Laboratory	ASSAY SERUM CHOLINESTERASE	11.81	11.81
82482	Clinical Laboratory	ASSAY RBC CHOLINESTERASE	14.72	14.72
82485	Clinical Laboratory	ASSAY CHONDROITIN SULFATE	30.98	30.98
82495	Clinical Laboratory	ASSAY OF CHROMIUM	30.42	30.42
82507	Clinical Laboratory	ASSAY OF CITRATE	41.70	41.70
82523	Clinical Laboratory	COLLAGEN CROSSLINKS	28.02	28.02
82525	Clinical Laboratory	ASSAY OF COPPER	18.62	18.62
82528	Clinical Laboratory	ASSAY OF CORTICOSTERONE	33.78	33.78
82530	Clinical Laboratory	CORTISOL FREE	25.07	25.07
82533	Clinical Laboratory	TOTAL CORTISOL	24.45	24.45
82540	Clinical Laboratory	ASSAY OF CREATINE	6.96	6.96
82542	Clinical Laboratory	COL CHROMOTOGRAPHY QUAL/QUAN	36.14	36.14
82550	Clinical Laboratory	ASSAY OF CK (CPK)	9.77	9.77
82552	Clinical Laboratory	ASSAY OF CPK IN BLOOD	20.09	20.09
82553	Clinical Laboratory	CREATINE MB FRACTION	17.33	17.33
82554	Clinical Laboratory	CREATINE ISOFORMS	17.81	17.81
82565	Clinical Laboratory	ASSAY OF CREATININE	7.68	7.68
82570	Clinical Laboratory	ASSAY OF URINE CREATININE	7.77	7.77
82575	Clinical Laboratory	CREATININE CLEARANCE TEST	14.19	14.19
82585	Clinical Laboratory	ASSAY OF CRYOFIBRINOGEN	21.21	21.21
82595	Clinical Laboratory	ASSAY OF CRYOGLOBULIN	9.71	9.71
82600	Clinical Laboratory	ASSAY OF CYANIDE	29.10	29.10
82607	Clinical Laboratory	VITAMIN B-12	22.62	22.62
82608	Clinical Laboratory	B-12 BINDING CAPACITY	21.48	21.48
82610	Clinical Laboratory	CYSTATIN C	27.78	27.78
82615	Clinical Laboratory	TEST FOR URINE CYSTINES	14.33	14.33
82626	Clinical Laboratory	DEHYDROEPIANDROSTERONE	37.91	37.91
82627	Clinical Laboratory	DEHYDROEPIANDROSTERONE	33.35	33.35
82633	Clinical Laboratory	DESOXYCORTICOSTERONE	46.47	46.47
82634	Clinical Laboratory	DEOXYCORTISOL	43.92	43.92
82638	Clinical Laboratory	ASSAY OF DIBUCAINE NUMBER	18.38	18.38
82642	Clinical Laboratory	DIHYDROTESTOSTERONE	43.92	43.92
82652	Clinical Laboratory	VIT D 1 25-DIHYDROXY	57.75	57.75
82653	Clinical Laboratory	EL-1 FECAL QUANTITATIVE	34.46	34.46
82656	Clinical Laboratory	EL-1 FECAL QUAL/SEMIQ	17.30	17.30
82657	Clinical Laboratory	ENZYME CELL ACTIVITY	33.26	33.26
82658	Clinical Laboratory	ENZYME CELL ACTIVITY RA	66.05	66.05
82664	Clinical Laboratory	ELECTROPHORETIC TEST	92.25	92.25
82668	Clinical Laboratory	ASSAY OF ERYTHROPOIETIN	28.19	28.19
82670	Clinical Laboratory	ASSAY OF TOTAL ESTRADIOL	41.91	41.91
82671	Clinical Laboratory	ASSAY OF ESTROGENS	48.45	48.45
82672	Clinical Laboratory	ASSAY OF ESTROGEN	32.55	32.55
82677	Clinical Laboratory	ASSAY OF ESTRIOL	36.27	36.27
82679	Clinical Laboratory	ASSAY OF ESTRONE	37.43	37.43
82681	Clinical Laboratory	ASSAY DIR MEAS FR ESTRADIOL	41.91	41.91
82693	Clinical Laboratory	ASSAY OF ETHYLENE GLYCOL	22.35	22.35
82696	Clinical Laboratory	ASSAY OF ETIOCHOLANOLONE	39.36	39.36
82705	Clinical Laboratory	FATS/LIPIDS FECES QUAL	7.65	7.65
82710	Clinical Laboratory	FATS/LIPIDS FECES QUANT	25.20	25.20
82715	Clinical Laboratory	ASSAY OF FECAL FAT	34.46	34.46
82725	Clinical Laboratory	ASSAY OF BLOOD FATTY ACIDS	28.16	28.16
82726	Clinical Laboratory	LONG CHAIN FATTY ACIDS	29.63	29.63
82728	Clinical Laboratory	ASSAY OF FERRITIN	20.45	20.45
82731	Clinical Laboratory	ASSAY OF FETAL FIBRONECTIN	96.62	96.62
82735	Clinical Laboratory	ASSAY OF FLUORIDE	27.81	27.81
82746	Clinical Laboratory	ASSAY OF FOLIC ACID SERUM	22.05	22.05
82747	Clinical Laboratory	ASSAY OF FOLIC ACID RBC	26.48	26.48
82757	Clinical Laboratory	ASSAY OF SEMEN FRUCTOSE	26.01	26.01
82759	Clinical Laboratory	ASSAY OF RBC GALACTOKINASE	32.22	32.22
82760	Clinical Laboratory	ASSAY OF GALACTOSE	16.80	16.80
82775	Clinical Laboratory	ASSAY GALACTOSE TRANSFERASE	31.61	31.61
82776	Clinical Laboratory	GALACTOSE TRANSFERASE TEST	17.61	17.61
82777	Clinical Laboratory	GALECTIN-3	66.38	66.38
82784	Clinical Laboratory	ASSAY IGA/IGD/IGG/IGM EACH	13.95	13.95
82785	Clinical Laboratory	ASSAY OF IGE	24.69	24.69
82787	Clinical Laboratory	IGG 1 2 3 OR 4 EACH	12.03	12.03
82800	Clinical Laboratory	BLOOD PH	16.50	16.50
82803	Clinical Laboratory	BLOOD GASES ANY COMBINATION	39.11	39.11
82805	Clinical Laboratory	BLOOD GASES W/O2 SATURATION	118.16	118.16
82810	Clinical Laboratory	BLOOD GASES O2 SAT ONLY	14.66	14.66
82820	Clinical Laboratory	HEMOGLOBIN-OXYGEN AFFINITY	20.01	20.01
82930	Clinical Laboratory	GASTRIC ANALY W/PH EA SPEC	10.07	10.07
82938	Clinical Laboratory	GASTRIN TEST	26.54	26.54
82941	Clinical Laboratory	ASSAY OF GASTRIN	26.45	26.45
82943	Clinical Laboratory	ASSAY OF GLUCAGON	21.44	21.44
82945	Clinical Laboratory	GLUCOSE OTHER FLUID	5.90	5.90
82946	Clinical Laboratory	GLUCAGON TOLERANCE TEST	26.66	26.66
82947	Clinical Laboratory	ASSAY GLUCOSE BLOOD QUANT	5.90	5.90
82948	Clinical Laboratory	REAGENT STRIP/BLOOD GLUCOSE	7.56	7.56
82950	Clinical Laboratory	GLUCOSE TEST	7.13	7.13
82951	Clinical Laboratory	GLUCOSE TOLERANCE TEST (GTT)	19.31	19.31
82952	Clinical Laboratory	GTT-ADDED SAMPLES	5.88	5.88
82955	Clinical Laboratory	ASSAY OF G6PD ENZYME	14.55	14.55
82960	Clinical Laboratory	TEST FOR G6PD ENZYME	9.08	9.08
82962	Clinical Laboratory	GLUCOSE BLOOD TEST	4.92	4.92
82963	Clinical Laboratory	ASSAY OF GLUCOSIDASE	32.22	32.22
82965	Clinical Laboratory	ASSAY OF GDH ENZYME	19.73	19.73
82977	Clinical Laboratory	ASSAY OF GGT	10.80	10.80
82978	Clinical Laboratory	ASSAY OF GLUTATHIONE	23.18	23.18
82979	Clinical Laboratory	ASSAY RBC GLUTATHIONE	14.16	14.16
82985	Clinical Laboratory	ASSAY OF GLYCATED PROTEIN	25.14	25.14
83001	Clinical Laboratory	ASSAY OF GONADOTROPIN (FSH)	27.87	27.87
83002	Clinical Laboratory	ASSAY OF GONADOTROPIN (LH)	27.78	27.78
83003	Clinical Laboratory	ASSAY GROWTH HORMONE (HGH)	25.01	25.01
83006	Clinical Laboratory	GROWTH STIMULATION GENE 2	113.40	113.40
83009	Clinical Laboratory	H PYLORI (C-13) BLOOD	101.04	101.04
83010	Clinical Laboratory	ASSAY OF HAPTOGLOBIN QUANT	18.87	18.87
83012	Clinical Laboratory	ASSAY OF HAPTOGLOBINS	40.34	40.34
83013	Clinical Laboratory	H PYLORI (C-13) BREATH	101.04	101.04
83014	Clinical Laboratory	H PYLORI DRUG ADMIN	11.79	11.79
83015	Clinical Laboratory	HEAVY METAL QUAL ANY ANAL	31.41	31.41
83018	Clinical Laboratory	HEAVY METAL QUANT EACH NES	32.94	32.94
83020	Clinical Laboratory	HEMOGLOBIN ELECTROPHORESIS	19.31	19.31
83020-26	Clinical Laboratory	HEMOGLOBIN ELECTROPHORESIS	24.87	24.87
83021	Clinical Laboratory	HEMOGLOBIN CHROMOTOGRAPHY	27.09	27.09
83026	Clinical Laboratory	HEMOGLOBIN COPPER SULFATE	6.02	6.02
83030	Clinical Laboratory	HEMOGLOBIN F FETAL CHEMICAL	16.11	16.11
83033	Clinical Laboratory	HEMOGLOBIN FTL F ASSAY QUAL	12.00	12.00
83036	Clinical Laboratory	HEMOGLOBIN GLYCOSYLATED A1C	14.57	14.57
83037	Clinical Laboratory	HB GLYCOSYLATED A1C HOME DEV	14.57	14.57
83045	Clinical Laboratory	HGB METHEMOGLOBIN QUAL	9.74	9.74
83050	Clinical Laboratory	HGB METHEMOGLOBIN QUAN	12.30	12.30
83051	Clinical Laboratory	HEMOGLOBIN PLASMA	10.97	10.97
83060	Clinical Laboratory	HGB SULFHEMOGLOBIN QUAN	13.20	13.20
83065	Clinical Laboratory	HEMOGLOBIN THERMOLABILE	13.50	13.50
83068	Clinical Laboratory	HEMOGLOBIN UNSTABLE SCREEN	14.21	14.21
83069	Clinical Laboratory	HEMOGLOBIN URINE	5.93	5.93
83070	Clinical Laboratory	ASSAY OF HEMOSIDERIN QUAL	7.13	7.13
83080	Clinical Laboratory	ASSAY OF B HEXOSAMINIDASE EA	25.31	25.31
83088	Clinical Laboratory	ASSAY OF HISTAMINE	44.30	44.30
83090	Clinical Laboratory	ASSAY OF HOMOCYSTEINE	26.88	26.88
83150	Clinical Laboratory	ASSAY OF HOMOVANILLIC ACID	33.62	33.62
83491	Clinical Laboratory	ASY HYDROXYCORTICOSTEROIDS17	26.85	26.85
83497	Clinical Laboratory	ASSAY OF 5-HIAA	19.35	19.35
83498	Clinical Laboratory	ASY HYDROXYPROGESTERONE 17-D	40.76	40.76
83500	Clinical Laboratory	ASSAY FREE HYDROXYPROLINE	33.98	33.98
83505	Clinical Laboratory	ASSAY TOTAL HYDROXYPROLINE	36.45	36.45
83516	Clinical Laboratory	IMMUNOASSAY NONANTIBODY	17.30	17.30
83518	Clinical Laboratory	IMMUNOASSAY DIPSTICK	14.46	14.46
83519	Clinical Laboratory	RIA NONANTIBODY	27.60	27.60
83520	Clinical Laboratory	IMMUNOASSAY QUANT NOS NONAB	25.91	25.91
83521	Clinical Laboratory	IG LIGHT CHAINS FREE EACH	25.91	25.91
83525	Clinical Laboratory	ASSAY OF INSULIN	17.15	17.15
83527	Clinical Laboratory	ASSAY OF INSULIN	19.43	19.43
83528	Clinical Laboratory	ASSAY OF INTRINSIC FACTOR	29.73	29.73
83529	Clinical Laboratory	ASAY OF INTERLEUKIN-6 (IL-6)	25.91	25.91
83540	Clinical Laboratory	ASSAY OF IRON	9.71	9.71
83550	Clinical Laboratory	IRON BINDING TEST	13.11	13.11
83570	Clinical Laboratory	ASSAY OF IDH ENZYME	13.28	13.28
83582	Clinical Laboratory	ASSAY OF KETOGENIC STEROIDS	23.21	23.21
83586	Clinical Laboratory	ASSAY 17- KETOSTEROIDS	19.20	19.20
83593	Clinical Laboratory	FRACTIONATION KETOSTEROIDS	42.75	42.75
83605	Clinical Laboratory	ASSAY OF LACTIC ACID	17.36	17.36
83615	Clinical Laboratory	LACTATE (LD) (LDH) ENZYME	9.06	9.06
83625	Clinical Laboratory	ASSAY OF LDH ENZYMES	19.19	19.19
83630	Clinical Laboratory	LACTOFERRIN FECAL (QUAL)	29.55	29.55
83631	Clinical Laboratory	LACTOFERRIN FECAL (QUANT)	29.45	29.45
83632	Clinical Laboratory	PLACENTAL LACTOGEN	30.33	30.33
83633	Clinical Laboratory	TEST URINE FOR LACTOSE	16.88	16.88
83655	Clinical Laboratory	ASSAY OF LEAD	18.17	18.17
83661	Clinical Laboratory	L/S RATIO FETAL LUNG	32.99	32.99
83662	Clinical Laboratory	FOAM STABILITY FETAL LUNG	28.37	28.37
83663	Clinical Laboratory	FLUORO POLARIZE FETAL LUNG	28.37	28.37
83664	Clinical Laboratory	LAMELLAR BDY FETAL LUNG	28.98	28.98
83670	Clinical Laboratory	ASSAY OF LAP ENZYME	14.72	14.72
83690	Clinical Laboratory	ASSAY OF LIPASE	10.34	10.34
83695	Clinical Laboratory	ASSAY OF LIPOPROTEIN(A)	21.48	21.48
83698	Clinical Laboratory	ASSAY LIPOPROTEIN PLA2	69.47	69.47
83700	Clinical Laboratory	LIPOPRO BLD ELECTROPHORETIC	16.89	16.89
83701	Clinical Laboratory	LIPOPROTEIN BLD HR FRACTION	50.79	50.79
83704	Clinical Laboratory	LIPOPROTEIN BLD QUAN PART	51.29	51.29
83718	Clinical Laboratory	ASSAY OF LIPOPROTEIN	12.29	12.29
83719	Clinical Laboratory	ASSAY OF BLOOD LIPOPROTEIN	19.13	19.13
83721	Clinical Laboratory	ASSAY OF BLOOD LIPOPROTEIN	15.75	15.75
83722	Clinical Laboratory	LIPOPRTN DIR MEAS SD LDL CHL	51.29	51.29
83727	Clinical Laboratory	ASSAY OF LRH HORMONE	25.79	25.79
83735	Clinical Laboratory	ASSAY OF MAGNESIUM	10.05	10.05
83775	Clinical Laboratory	ASSAY MALATE DEHYDROGENASE	11.06	11.06
83785	Clinical Laboratory	ASSAY OF MANGANESE	39.98	39.98
83789	Clinical Laboratory	MASS SPECTROMETRY QUAL/QUAN	36.17	36.17
83825	Clinical Laboratory	ASSAY OF MERCURY	24.39	24.39
83835	Clinical Laboratory	ASSAY OF METANEPHRINES	25.41	25.41
83857	Clinical Laboratory	ASSAY OF METHEMALBUMIN	16.11	16.11
83861	Clinical Laboratory	MICROFLUID ANALY TEARS	33.72	33.72
83864	Clinical Laboratory	MUCOPOLYSACCHARIDES	42.75	42.75
83872	Clinical Laboratory	ASSAY SYNOVIAL FLUID MUCIN	8.79	8.79
83873	Clinical Laboratory	ASSAY OF CSF PROTEIN	25.80	25.80
83874	Clinical Laboratory	ASSAY OF MYOGLOBIN	19.38	19.38
83876	Clinical Laboratory	ASSAY MYELOPEROXIDASE	76.29	76.29
83880	Clinical Laboratory	ASSAY OF NATRIURETIC PEPTIDE	58.89	58.89
83883	Clinical Laboratory	ASSAY NEPHELOMETRY NOT SPEC	20.40	20.40
83885	Clinical Laboratory	ASSAY OF NICKEL	36.77	36.77
83915	Clinical Laboratory	ASSAY OF NUCLEOTIDASE	16.73	16.73
83916	Clinical Laboratory	OLIGOCLONAL BANDS	41.09	41.09
83918	Clinical Laboratory	ORGANIC ACIDS TOTAL QUANT	35.40	35.40
83919	Clinical Laboratory	ORGANIC ACIDS QUAL EACH	24.68	24.68
83921	Clinical Laboratory	ORGANIC ACID SINGLE QUANT	31.82	31.82
83930	Clinical Laboratory	ASSAY OF BLOOD OSMOLALITY	9.92	9.92
83935	Clinical Laboratory	ASSAY OF URINE OSMOLALITY	10.23	10.23
83937	Clinical Laboratory	ASSAY OF OSTEOCALCIN	44.78	44.78
83945	Clinical Laboratory	ASSAY OF OXALATE	21.68	21.68
83950	Clinical Laboratory	ONCOPROTEIN HER-2/NEU	96.62	96.62
83951	Clinical Laboratory	ONCOPROTEIN DCP	96.62	96.62
83970	Clinical Laboratory	ASSAY OF PARATHORMONE	61.92	61.92
83986	Clinical Laboratory	ASSAY PH BODY FLUID NOS	5.37	5.37
83987	Clinical Laboratory	EXHALED BREATH CONDENSATE	5.37	5.37
83992	Clinical Laboratory	ASSAY FOR PHENCYCLIDINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
83993	Clinical Laboratory	ASSAY FOR CALPROTECTIN FECAL	29.45	29.45
84030	Clinical Laboratory	ASSAY OF BLOOD PKU	8.25	8.25
84035	Clinical Laboratory	ASSAY OF PHENYLKETONES	5.97	5.97
84060	Clinical Laboratory	ASSAY ACID PHOSPHATASE	11.46	11.46
84066	Clinical Laboratory	ASSAY PROSTATE PHOSPHATASE	14.49	14.49
84075	Clinical Laboratory	ASSAY ALKALINE PHOSPHATASE	7.77	7.77
84078	Clinical Laboratory	ASSAY ALKALINE PHOSPHATASE	12.39	12.39
84080	Clinical Laboratory	ASSAY ALKALINE PHOSPHATASES	22.17	22.17
84081	Clinical Laboratory	ASSAY PHOSPHATIDYLGLYCEROL	24.78	24.78
84085	Clinical Laboratory	ASSAY OF RBC PG6D ENZYME	14.16	14.16
84087	Clinical Laboratory	ASSAY PHOSPHOHEXOSE ENZYMES	16.10	16.10
84100	Clinical Laboratory	ASSAY OF PHOSPHORUS	7.11	7.11
84105	Clinical Laboratory	ASSAY OF URINE PHOSPHORUS	8.67	8.67
84106	Clinical Laboratory	TEST FOR PORPHOBILINOGEN	8.73	8.73
84110	Clinical Laboratory	ASSAY OF PORPHOBILINOGEN	12.66	12.66
84112	Clinical Laboratory	EVAL AMNIOTIC FLUID PROTEIN	147.17	147.17
84119	Clinical Laboratory	TEST URINE FOR PORPHYRINS	20.04	20.04
84120	Clinical Laboratory	ASSAY OF URINE PORPHYRINS	22.07	22.07
84126	Clinical Laboratory	ASSAY OF FECES PORPHYRINS	58.67	58.67
84132	Clinical Laboratory	ASSAY OF SERUM POTASSIUM	7.14	7.14
84133	Clinical Laboratory	ASSAY OF URINE POTASSIUM	7.10	7.10
84134	Clinical Laboratory	ASSAY OF PREALBUMIN	21.89	21.89
84135	Clinical Laboratory	ASSAY OF PREGNANEDIOL	31.91	31.91
84138	Clinical Laboratory	ASSAY OF PREGNANETRIOL	31.58	31.58
84140	Clinical Laboratory	ASSAY OF PREGNENOLONE	31.01	31.01
84143	Clinical Laboratory	ASSAY OF 17-HYDROXYPREGNENO	34.22	34.22
84144	Clinical Laboratory	ASSAY OF PROGESTERONE	31.29	31.29
84145	Clinical Laboratory	PROCALCITONIN (PCT)	40.83	40.83
84146	Clinical Laboratory	ASSAY OF PROLACTIN	29.07	29.07
84150	Clinical Laboratory	ASSAY OF PROSTAGLANDIN	62.66	62.66
84152	Clinical Laboratory	ASSAY OF PSA COMPLEXED	27.59	27.59
84153	Clinical Laboratory	ASSAY OF PSA TOTAL	27.59	27.59
84154	Clinical Laboratory	ASSAY OF PSA FREE	27.59	27.59
84155	Clinical Laboratory	ASSAY OF PROTEIN SERUM	5.51	5.51
84156	Clinical Laboratory	ASSAY OF PROTEIN URINE	5.51	5.51
84157	Clinical Laboratory	ASSAY OF PROTEIN OTHER	6.00	6.00
84160	Clinical Laboratory	ASSAY OF PROTEIN ANY SOURCE	8.42	8.42
84163	Clinical Laboratory	PAPPA SERUM	22.58	22.58
84165	Clinical Laboratory	PROTEIN E-PHORESIS SERUM	16.11	16.11
84165-26	Clinical Laboratory	PROTEIN E-PHORESIS SERUM	24.87	24.87
84166	Clinical Laboratory	PROTEIN E-PHORESIS/URINE/CSF	26.75	26.75
84166-26	Clinical Laboratory	PROTEIN E-PHORESIS/URINE/CSF	24.87	24.87
84181	Clinical Laboratory	WESTERN BLOT TEST	25.55	25.55
84181-26	Clinical Laboratory	WESTERN BLOT TEST	24.87	24.87
84182	Clinical Laboratory	PROTEIN WESTERN BLOT TEST	43.82	43.82
84182-26	Clinical Laboratory	PROTEIN WESTERN BLOT TEST	24.87	24.87
84202	Clinical Laboratory	ASSAY RBC PROTOPORPHYRIN	21.53	21.53
84203	Clinical Laboratory	TEST RBC PROTOPORPHYRIN	14.61	14.61
84206	Clinical Laboratory	ASSAY OF PROINSULIN	40.04	40.04
84207	Clinical Laboratory	ASSAY OF VITAMIN B-6	42.15	42.15
84210	Clinical Laboratory	ASSAY OF PYRUVATE	21.72	21.72
84220	Clinical Laboratory	ASSAY OF PYRUVATE KINASE	14.16	14.16
84228	Clinical Laboratory	ASSAY OF QUININE	17.45	17.45
84233	Clinical Laboratory	ASSAY OF ESTROGEN	131.82	131.82
84234	Clinical Laboratory	ASSAY OF PROGESTERONE	97.32	97.32
84235	Clinical Laboratory	ASSAY OF ENDOCRINE HORMONE	106.85	106.85
84238	Clinical Laboratory	ASSAY NONENDOCRINE RECEPTOR	54.86	54.86
84244	Clinical Laboratory	ASSAY OF RENIN	32.99	32.99
84252	Clinical Laboratory	ASSAY OF VITAMIN B-2	30.36	30.36
84255	Clinical Laboratory	ASSAY OF SELENIUM	38.30	38.30
84260	Clinical Laboratory	ASSAY OF SEROTONIN	46.47	46.47
84270	Clinical Laboratory	ASSAY OF SEX HORMONE GLOBUL	32.60	32.60
84275	Clinical Laboratory	ASSAY OF SIALIC ACID	20.16	20.16
84285	Clinical Laboratory	ASSAY OF SILICA	37.82	37.82
84295	Clinical Laboratory	ASSAY OF SERUM SODIUM	7.22	7.22
84300	Clinical Laboratory	ASSAY OF URINE SODIUM	7.59	7.59
84302	Clinical Laboratory	ASSAY OF SWEAT SODIUM	7.29	7.29
84305	Clinical Laboratory	ASSAY OF SOMATOMEDIN	31.89	31.89
84307	Clinical Laboratory	ASSAY OF SOMATOSTATIN	27.42	27.42
84311	Clinical Laboratory	SPECTROPHOTOMETRY	12.15	12.15
84315	Clinical Laboratory	BODY FLUID SPECIFIC GRAVITY	4.92	4.92
84375	Clinical Laboratory	CHROMATOGRAM ASSAY SUGARS	58.50	58.50
84376	Clinical Laboratory	SUGARS SINGLE QUAL	8.25	8.25
84377	Clinical Laboratory	SUGARS MULTIPLE QUAL	8.25	8.25
84378	Clinical Laboratory	SUGARS SINGLE QUANT	17.30	17.30
84379	Clinical Laboratory	SUGARS MULTIPLE QUANT	17.30	17.30
84392	Clinical Laboratory	ASSAY OF URINE SULFATE	8.24	8.24
84402	Clinical Laboratory	ASSAY OF FREE TESTOSTERONE	38.21	38.21
84403	Clinical Laboratory	ASSAY OF TOTAL TESTOSTERONE	38.72	38.72
84410	Clinical Laboratory	TESTOSTERONE BIOAVAILABLE	76.92	76.92
84425	Clinical Laboratory	ASSAY OF VITAMIN B-1	31.85	31.85
84430	Clinical Laboratory	ASSAY OF THIOCYANATE	17.45	17.45
84431	Clinical Laboratory	THROMBOXANE URINE	52.67	52.67
84432	Clinical Laboratory	ASSAY OF THYROGLOBULIN	24.09	24.09
84433	Clinical Laboratory	ASY THIOPURIN S-MTHYLTRNSFRS	33.26	33.26
84436	Clinical Laboratory	ASSAY OF TOTAL THYROXINE	10.31	10.31
84437	Clinical Laboratory	ASSAY OF NEONATAL THYROXINE	9.71	9.71
84439	Clinical Laboratory	ASSAY OF FREE THYROXINE	13.53	13.53
84442	Clinical Laboratory	ASSAY OF THYROID ACTIVITY	22.17	22.17
84443	Clinical Laboratory	ASSAY THYROID STIM HORMONE	25.20	25.20
84445	Clinical Laboratory	ASSAY OF TSI GLOBULIN	76.29	76.29
84446	Clinical Laboratory	ASSAY OF VITAMIN E	21.27	21.27
84449	Clinical Laboratory	ASSAY OF TRANSCORTIN	27.00	27.00
84450	Clinical Laboratory	TRANSFERASE (AST) (SGOT)	7.77	7.77
84460	Clinical Laboratory	ALANINE AMINO (ALT) (SGPT)	7.95	7.95
84466	Clinical Laboratory	ASSAY OF TRANSFERRIN	19.14	19.14
84478	Clinical Laboratory	ASSAY OF TRIGLYCERIDES	8.61	8.61
84479	Clinical Laboratory	ASSAY OF THYROID (T3 OR T4)	9.71	9.71
84480	Clinical Laboratory	ASSAY TRIIODOTHYRONINE (T3)	21.27	21.27
84481	Clinical Laboratory	FREE ASSAY (FT-3)	25.41	25.41
84482	Clinical Laboratory	T3 REVERSE	23.64	23.64
84484	Clinical Laboratory	ASSAY OF TROPONIN QUANT	18.71	18.71
84485	Clinical Laboratory	ASSAY DUODENAL FLUID TRYPSIN	10.80	10.80
84488	Clinical Laboratory	TEST FECES FOR TRYPSIN	10.95	10.95
84490	Clinical Laboratory	ASSAY OF FECES FOR TRYPSIN	14.90	14.90
84510	Clinical Laboratory	ASSAY OF TYROSINE	15.95	15.95
84512	Clinical Laboratory	ASSAY OF TROPONIN QUAL	15.14	15.14
84520	Clinical Laboratory	ASSAY OF UREA NITROGEN	5.93	5.93
84525	Clinical Laboratory	UREA NITROGEN SEMI-QUANT	7.70	7.70
84540	Clinical Laboratory	ASSAY OF URINE/UREA-N	8.34	8.34
84545	Clinical Laboratory	UREA-N CLEARANCE TEST	10.80	10.80
84550	Clinical Laboratory	ASSAY OF BLOOD/URIC ACID	6.78	6.78
84560	Clinical Laboratory	ASSAY OF URINE/URIC ACID	7.62	7.62
84577	Clinical Laboratory	ASSAY OF FECES/UROBILINOGEN	25.20	25.20
84578	Clinical Laboratory	TEST URINE UROBILINOGEN	6.71	6.71
84580	Clinical Laboratory	ASSAY OF URINE UROBILINOGEN	14.33	14.33
84583	Clinical Laboratory	ASSAY OF URINE UROBILINOGEN	9.08	9.08
84585	Clinical Laboratory	ASSAY OF URINE VMA	23.25	23.25
84586	Clinical Laboratory	ASSAY OF VIP	53.00	53.00
84588	Clinical Laboratory	ASSAY OF VASOPRESSIN	50.91	50.91
84590	Clinical Laboratory	ASSAY OF VITAMIN A	17.42	17.42
84591	Clinical Laboratory	ASSAY OF NOS VITAMIN	25.59	25.59
84597	Clinical Laboratory	ASSAY OF VITAMIN K	20.58	20.58
84600	Clinical Laboratory	ASSAY OF VOLATILES	25.67	25.67
84620	Clinical Laboratory	XYLOSE TOLERANCE TEST	19.37	19.37
84630	Clinical Laboratory	ASSAY OF ZINC	17.09	17.09
84681	Clinical Laboratory	ASSAY OF C-PEPTIDE	31.22	31.22
84702	Clinical Laboratory	CHORIONIC GONADOTROPIN TEST	22.58	22.58
84703	Clinical Laboratory	CHORIONIC GONADOTROPIN ASSAY	11.28	11.28
84704	Clinical Laboratory	HCG FREE BETACHAIN TEST	22.94	22.94
84830	Clinical Laboratory	OVULATION TESTS	19.05	19.05
84999	Other professional services	UNLISTED CHEMISTRY PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
85002	Clinical Laboratory	BLEEDING TIME TEST	7.23	7.23
85004	Clinical Laboratory	AUTOMATED DIFF WBC COUNT	9.71	9.71
85007	Clinical Laboratory	BL SMEAR W/DIFF WBC COUNT	5.70	5.70
85008	Clinical Laboratory	BL SMEAR W/O DIFF WBC COUNT	5.15	5.15
85009	Clinical Laboratory	MANUAL DIFF WBC COUNT B-COAT	7.61	7.61
85013	Clinical Laboratory	SPUN MICROHEMATOCRIT	10.50	10.50
85014	Clinical Laboratory	HEMATOCRIT	3.56	3.56
85018	Clinical Laboratory	HEMOGLOBIN	3.56	3.56
85025	Clinical Laboratory	COMPLETE CBC W/AUTO DIFF WBC	11.66	11.66
85027	Clinical Laboratory	COMPLETE CBC AUTOMATED	9.71	9.71
85032	Clinical Laboratory	MANUAL CELL COUNT EACH	6.47	6.47
85041	Clinical Laboratory	AUTOMATED RBC COUNT	4.53	4.53
85044	Clinical Laboratory	MANUAL RETICULOCYTE COUNT	6.47	6.47
85045	Clinical Laboratory	AUTOMATED RETICULOCYTE COUNT	5.99	5.99
85046	Clinical Laboratory	RETICYTE/HGB CONCENTRATE	8.36	8.36
85048	Clinical Laboratory	AUTOMATED LEUKOCYTE COUNT	3.81	3.81
85049	Clinical Laboratory	AUTOMATED PLATELET COUNT	6.72	6.72
85055	Clinical Laboratory	RETICULATED PLATELET ASSAY	53.61	53.61
85060	Other professional services	BLOOD SMEAR INTERPRETATION	33.09	33.09
85097	Other professional services	BONE MARROW INTERPRETATION	97.38	66.90
85130	Clinical Laboratory	CHROMOGENIC SUBSTRATE ASSAY	17.84	17.84
85170	Clinical Laboratory	BLOOD CLOT RETRACTION	24.45	24.45
85175	Clinical Laboratory	BLOOD CLOT LYSIS TIME	30.56	30.56
85210	Clinical Laboratory	CLOT FACTOR II PROTHROM SPEC	19.47	19.47
85220	Clinical Laboratory	BLOOC CLOT FACTOR V TEST	26.48	26.48
85230	Clinical Laboratory	CLOT FACTOR VII PROCONVERTIN	26.85	26.85
85240	Clinical Laboratory	CLOT FACTOR VIII AHG 1 STAGE	26.85	26.85
85244	Clinical Laboratory	CLOT FACTOR VIII RELTD ANTGN	30.63	30.63
85245	Clinical Laboratory	CLOT FACTOR VIII VW RISTOCTN	34.41	34.41
85246	Clinical Laboratory	CLOT FACTOR VIII VW ANTIGEN	34.41	34.41
85247	Clinical Laboratory	CLOT FACTOR VIII MULTIMETRIC	34.41	34.41
85250	Clinical Laboratory	CLOT FACTOR IX PTC/CHRSTMAS	28.56	28.56
85260	Clinical Laboratory	CLOT FACTOR X STUART-POWER	26.85	26.85
85270	Clinical Laboratory	CLOT FACTOR XI PTA	26.85	26.85
85280	Clinical Laboratory	CLOT FACTOR XII HAGEMAN	29.03	29.03
85290	Clinical Laboratory	CLOT FACTOR XIII FIBRIN STAB	24.51	24.51
85291	Clinical Laboratory	CLOT FACTOR XIII FIBRIN SCRN	13.67	13.67
85292	Clinical Laboratory	CLOT FACTOR FLETCHER FACT	28.40	28.40
85293	Clinical Laboratory	CLOT FACTOR WGHT KININOGEN	28.40	28.40
85300	Clinical Laboratory	ANTITHROMBIN III ACTIVITY	17.78	17.78
85301	Clinical Laboratory	ANTITHROMBIN III ANTIGEN	16.22	16.22
85302	Clinical Laboratory	CLOT INHIBIT PROT C ANTIGEN	18.02	18.02
85303	Clinical Laboratory	CLOT INHIBIT PROT C ACTIVITY	20.76	20.76
85305	Clinical Laboratory	CLOT INHIBIT PROT S TOTAL	17.42	17.42
85306	Clinical Laboratory	CLOT INHIBIT PROT S FREE	22.98	22.98
85307	Clinical Laboratory	ASSAY ACTIVATED PROTEIN C	22.98	22.98
85335	Clinical Laboratory	FACTOR INHIBITOR TEST	19.31	19.31
85337	Clinical Laboratory	THROMBOMODULIN	25.91	25.91
85345	Clinical Laboratory	COAGULATION TIME LEE & WHITE	7.04	7.04
85347	Clinical Laboratory	COAGULATION TIME ACTIVATED	6.42	6.42
85348	Clinical Laboratory	COAGULATION TIME OTR METHOD	6.74	6.74
85360	Clinical Laboratory	EUGLOBULIN LYSIS	12.62	12.62
85362	Clinical Laboratory	FIBRIN DEGRADATION PRODUCTS	10.34	10.34
85366	Clinical Laboratory	FIBRINOGEN TEST	120.69	120.69
85370	Clinical Laboratory	FIBRINOGEN TEST	18.65	18.65
85378	Clinical Laboratory	FIBRIN DEGRADE SEMIQUANT	14.58	14.58
85379	Clinical Laboratory	FIBRIN DEGRADATION QUANT	15.27	15.27
85380	Clinical Laboratory	FIBRIN DEGRADJ D-DIMER	15.27	15.27
85384	Clinical Laboratory	FIBRINOGEN ACTIVITY	14.58	14.58
85385	Clinical Laboratory	FIBRINOGEN ANTIGEN	21.69	21.69
85390	Clinical Laboratory	FIBRINOLYSINS SCREEN I&R	23.22	23.22
85390-26	Clinical Laboratory	FIBRINOLYSINS SCREEN I&R	50.69	50.69
85396	Other professional services	CLOTTING ASSAY WHOLE BLOOD	27.02	27.02
85397	Clinical Laboratory	CLOTTING FUNCT ACTIVITY	46.29	46.29
85400	Clinical Laboratory	FIBRINOLYTIC PLASMIN	11.57	11.57
85410	Clinical Laboratory	FIBRINOLYTIC ANTIPLASMIN	11.57	11.57
85415	Clinical Laboratory	FIBRINOLYTIC PLASMINOGEN	25.79	25.79
85420	Clinical Laboratory	FIBRINOLYTIC PLASMINOGEN	9.80	9.80
85421	Clinical Laboratory	FIBRINOLYTIC PLASMINOGEN	15.27	15.27
85441	Clinical Laboratory	HEINZ BODIES DIRECT	6.30	6.30
85445	Clinical Laboratory	HEINZ BODIES INDUCED	10.23	10.23
85460	Clinical Laboratory	HEMOGLOBIN FETAL	11.60	11.60
85461	Clinical Laboratory	HEMOGLOBIN FETAL	14.04	14.04
85475	Clinical Laboratory	HEMOLYSIN ACID	13.31	13.31
85520	Clinical Laboratory	HEPARIN ASSAY	19.64	19.64
85525	Clinical Laboratory	HEPARIN NEUTRALIZATION	17.76	17.76
85530	Clinical Laboratory	HEPARIN-PROTAMINE TOLERANCE	19.64	19.64
85536	Clinical Laboratory	IRON STAIN PERIPHERAL BLOOD	10.32	10.32
85540	Clinical Laboratory	WBC ALKALINE PHOSPHATASE	12.90	12.90
85547	Clinical Laboratory	RBC MECHANICAL FRAGILITY	12.90	12.90
85549	Clinical Laboratory	MURAMIDASE	28.13	28.13
85555	Clinical Laboratory	RBC OSMOTIC FRAGILITY	11.21	11.21
85557	Clinical Laboratory	RBC OSMOTIC FRAGILITY	20.04	20.04
85576	Clinical Laboratory	BLOOD PLATELET AGGREGATION	37.37	37.37
85576-26	Clinical Laboratory	BLOOD PLATELET AGGREGATION	24.87	24.87
85597	Clinical Laboratory	PHOSPHOLIPID PLTLT NEUTRALIZ	26.97	26.97
85598	Clinical Laboratory	HEXAGNAL PHOSPH PLTLT NEUTRL	26.97	26.97
85610	Clinical Laboratory	PROTHROMBIN TIME	6.44	6.44
85611	Clinical Laboratory	PROTHROMBIN TEST	5.91	5.91
85612	Clinical Laboratory	VIPER VENOM PROTHROMBIN TIME	26.24	26.24
85613	Clinical Laboratory	RUSSELL VIPER VENOM DILUTED	14.37	14.37
85635	Clinical Laboratory	REPTILASE TEST	14.78	14.78
85651	Clinical Laboratory	RBC SED RATE NONAUTOMATED	6.41	6.41
85652	Clinical Laboratory	RBC SED RATE AUTOMATED	4.05	4.05
85660	Clinical Laboratory	RBC SICKLE CELL TEST	8.27	8.27
85670	Clinical Laboratory	THROMBIN TIME PLASMA	8.66	8.66
85675	Clinical Laboratory	THROMBIN TIME TITER	10.28	10.28
85705	Clinical Laboratory	THROMBOPLASTIN INHIBITION	14.45	14.45
85730	Clinical Laboratory	THROMBOPLASTIN TIME PARTIAL	9.02	9.02
85732	Clinical Laboratory	THROMBOPLASTIN TIME PARTIAL	9.71	9.71
85810	Clinical Laboratory	BLOOD VISCOSITY EXAMINATION	17.51	17.51
85999	Other professional services	UNLISTED HEMATOLOGY&COAGJ PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86000	Clinical Laboratory	AGGLUTININS FEBRILE ANTIGEN	10.47	10.47
86001	Clinical Laboratory	ALLERGEN SPECIFIC IGG	11.73	11.73
86003	Clinical Laboratory	ALLG SPEC IGE CRUDE XTRC EA	7.83	7.83
86005	Clinical Laboratory	ALLG SPEC IGE MULTIALLG SCR	11.96	11.96
86008	Clinical Laboratory	ALLG SPEC IGE RECOMB EA	26.90	26.90
86015	Clinical Laboratory	ACTIN ANTIBODY EACH	18.08	18.08
86021	Clinical Laboratory	WBC ANTIBODY IDENTIFICATION	22.58	22.58
86022	Clinical Laboratory	PLATELET ANTIBODIES	27.56	27.56
86023	Clinical Laboratory	IMMUNOGLOBULIN ASSAY	18.69	18.69
86036	Clinical Laboratory	ANCA SCREEN EACH ANTIBODY	18.08	18.08
86037	Clinical Laboratory	ANCA TITER EACH ANTIBODY	18.08	18.08
86038	Clinical Laboratory	ANTINUCLEAR ANTIBODIES	18.14	18.14
86039	Clinical Laboratory	ANTINUCLEAR ANTIBODIES (ANA)	16.74	16.74
86041	Clinical Laboratory	ACETYLCHOLN RCPTR BNDNG ANTB	27.60	27.60
86042	Clinical Laboratory	ACETYLCHOLN RCPTR BLCKG ANTB	27.60	27.60
86043	Clinical Laboratory	ACETYLCHOLN RCPTR MODLG ANTB	18.08	18.08
86051	Clinical Laboratory	AQUAPORIN-4 ANTB ELISA	17.30	17.30
86052	Clinical Laboratory	AQUAPORIN-4 ANTB CBA EACH	18.08	18.08
86053	Clinical Laboratory	AQAPRN-4 ANTB FLO CYTMTRY EA	56.60	56.60
86060	Clinical Laboratory	ANTISTREPTOLYSIN O TITER	10.95	10.95
86063	Clinical Laboratory	ANTISTREPTOLYSIN O SCREEN	8.66	8.66
86077	Other professional services	PHYS BLOOD BANK SERV XMATCH	74.64	68.27
86078	Other professional services	PHYS BLOOD BANK SERV REACTJ	74.64	68.27
86079	Other professional services	PHYS BLOOD BANK SERV AUTHRJ	74.64	68.27
86140	Clinical Laboratory	C-REACTIVE PROTEIN	7.77	7.77
86141	Clinical Laboratory	C-REACTIVE PROTEIN HS	19.43	19.43
86146	Clinical Laboratory	BETA-2 GLYCOPROTEIN ANTIBODY	38.18	38.18
86147	Clinical Laboratory	CARDIOLIPIN ANTIBODY EA IG	38.18	38.18
86148	Clinical Laboratory	ANTI-PHOSPHOLIPID ANTIBODY	24.11	24.11
86152	Clinical Laboratory	CELL ENUMERATION & ID	376.17	376.17
86153	Other professional services	CELL ENUMERATION PHYS INTERP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86153-26	Clinical Laboratory	CELL ENUMERATION PHYS INTERP	46.83	46.83
86155	Clinical Laboratory	CHEMOTAXIS ASSAY	23.99	23.99
86156	Clinical Laboratory	COLD AGGLUTININ SCREEN	12.11	12.11
86157	Clinical Laboratory	COLD AGGLUTININ TITER	12.09	12.09
86160	Clinical Laboratory	COMPLEMENT ANTIGEN	18.00	18.00
86161	Clinical Laboratory	COMPLEMENT/FUNCTION ACTIVITY	18.00	18.00
86162	Clinical Laboratory	COMPLEMENT TOTAL (CH50)	30.48	30.48
86171	Clinical Laboratory	COMPLEMENT FIXATION EACH	15.02	15.02
86200	Clinical Laboratory	CCP ANTIBODY	19.43	19.43
86215	Clinical Laboratory	DEOXYRIBONUCLEASE ANTIBODY	19.88	19.88
86225	Clinical Laboratory	DNA ANTIBODY NATIVE	20.61	20.61
86226	Clinical Laboratory	DNA ANTIBODY SINGLE STRAND	18.17	18.17
86231	Clinical Laboratory	EMA EACH IG CLASS	18.14	18.14
86235	Clinical Laboratory	NUCLEAR ANTIGEN ANTIBODY	26.90	26.90
86255	Clinical Laboratory	FLUORESCENT ANTIBODY SCREEN	18.08	18.08
86255-26	Clinical Laboratory	FLUORESCENT ANTIBODY SCREEN	24.87	24.87
86256	Clinical Laboratory	FLUORESCENT ANTIBODY TITER	18.08	18.08
86256-26	Clinical Laboratory	FLUORESCENT ANTIBODY TITER	24.87	24.87
86258	Clinical Laboratory	DGP ANTIBODY EACH IG CLASS	18.08	18.08
86277	Clinical Laboratory	GROWTH HORMONE ANTIBODY	23.61	23.61
86280	Clinical Laboratory	HEMAGGLUTINATION INHIBITION	12.29	12.29
86294	Clinical Laboratory	IMMUNOASSAY TUMOR QUAL	38.36	38.36
86300	Clinical Laboratory	IMMUNOASSAY TUMOR CA 15-3	31.22	31.22
86301	Clinical Laboratory	IMMUNOASSAY TUMOR CA 19-9	31.22	31.22
86304	Clinical Laboratory	IMMUNOASSAY TUMOR CA 125	31.22	31.22
86305	Clinical Laboratory	HUMAN EPIDIDYMIS PROTEIN 4	31.22	31.22
86308	Clinical Laboratory	HETEROPHILE ANTIBODY SCREEN	7.77	7.77
86309	Clinical Laboratory	HETEROPHILE ANTIBODY TITER	9.71	9.71
86310	Clinical Laboratory	HETEROPHILE ANTIBODY ABSRBJ	11.06	11.06
86316	Clinical Laboratory	IMMUNOASSAY TUMOR OTHER	31.22	31.22
86317	Clinical Laboratory	IMMUNOASSAY INFECTIOUS AGENT	22.49	22.49
86318	Clinical Laboratory	IA INFECTIOUS AGENT ANTIBODY	27.14	27.14
86320	Clinical Laboratory	SERUM IMMUNOELECTROPHORESIS	44.88	44.88
86320-26	Clinical Laboratory	SERUM IMMUNOELECTROPHORESIS	24.87	24.87
86325	Clinical Laboratory	OTHER IMMUNOELECTROPHORESIS	34.70	34.70
86325-26	Clinical Laboratory	OTHER IMMUNOELECTROPHORESIS	24.87	24.87
86327	Clinical Laboratory	IMMUNOELECTROPHORESIS ASSAY	44.88	44.88
86327-26	Clinical Laboratory	IMMUNOELECTROPHORESIS ASSAY	30.05	30.05
86328	Clinical Laboratory	IA NFCT AB SARSCOV2 COVID19	67.92	67.92
86329	Clinical Laboratory	IMMUNODIFFUSION NES	21.08	21.08
86331	Clinical Laboratory	IMMUNODIFFUSION OUCHTERLONY	17.97	17.97
86332	Clinical Laboratory	IMMUNE COMPLEX ASSAY	36.56	36.56
86334	Clinical Laboratory	IMMUNOFIX E-PHORESIS SERUM	33.51	33.51
86334-26	Clinical Laboratory	IMMUNOFIX E-PHORESIS SERUM	24.87	24.87
86335	Clinical Laboratory	IMMUNFIX E-PHORSIS/URINE/CSF	44.03	44.03
86335-26	Clinical Laboratory	IMMUNFIX E-PHORSIS/URINE/CSF	24.87	24.87
86336	Clinical Laboratory	INHIBIN A	23.39	23.39
86337	Clinical Laboratory	INSULIN ANTIBODIES	32.12	32.12
86340	Clinical Laboratory	INTRINSIC FACTOR ANTIBODY	22.62	22.62
86341	Clinical Laboratory	ISLET CELL ANTIBODY	35.36	35.36
86343	Clinical Laboratory	LEUKOCYTE HISTAMINE RELEASE	18.69	18.69
86344	Clinical Laboratory	LEUKOCYTE PHAGOCYTOSIS	15.59	15.59
86352	Clinical Laboratory	CELL FUNCTION ASSAY W/STIM	203.79	203.79
86353	Clinical Laboratory	LYMPHOCYTE TRANSFORMATION	73.55	73.55
86355	Clinical Laboratory	B CELLS TOTAL COUNT	56.60	56.60
86356	Clinical Laboratory	MONONUCLEAR CELL ANTIGEN	40.17	40.17
86357	Clinical Laboratory	NK CELLS TOTAL COUNT	56.60	56.60
86359	Clinical Laboratory	T CELLS TOTAL COUNT	56.60	56.60
86360	Clinical Laboratory	T CELL ABSOLUTE COUNT/RATIO	70.47	70.47
86361	Clinical Laboratory	T CELL ABSOLUTE COUNT	40.17	40.17
86362	Clinical Laboratory	MOG-IGG1 ANTB CBA EACH	18.08	18.08
86363	Clinical Laboratory	MOG-IGG1 ANTB FLO CYTMTRY EA	56.60	56.60
86364	Clinical Laboratory	TISS TRNSGLTMNASE EA IG CLAS	17.30	17.30
86366	Clinical Laboratory	MUSCLE-SPECIFIC KINASE ANTB	27.60	27.60
86367	Clinical Laboratory	STEM CELLS TOTAL COUNT	116.67	116.67
86376	Clinical Laboratory	MICROSOMAL ANTIBODY EACH	21.83	21.83
86381	Clinical Laboratory	MITOCHONDRIAL ANTIBODY EACH	38.18	38.18
86382	Clinical Laboratory	NEUTRALIZATION TEST VIRAL	25.37	25.37
86384	Clinical Laboratory	NITROBLUE TETRAZOLIUM DYE	20.42	20.42
86386	Clinical Laboratory	NUCLEAR MATRIX PROTEIN 22	32.67	32.67
86403	Clinical Laboratory	PARTICLE AGGLUT ANTBDY SCRN	17.31	17.31
86406	Clinical Laboratory	PARTICLE AGGLUT ANTBDY TITR	15.96	15.96
86408	Clinical Laboratory	NEUTRLZG ANTB SARSCOV2 SCR	63.20	63.20
86409	Clinical Laboratory	NEUTRLZG ANTB SARSCOV2 TITER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86413	Clinical Laboratory	SARS-COV-2 ANTB QUANTITATIVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86430	Clinical Laboratory	RHEUMATOID FACTOR TEST QUAL	9.21	9.21
86431	Clinical Laboratory	RHEUMATOID FACTOR QUANT	8.51	8.51
86480	Clinical Laboratory	TB TEST CELL IMMUN MEASURE	92.97	92.97
86481	Clinical Laboratory	TB AG RESPONSE T-CELL SUSP	150.00	150.00
86485	Other professional services	SKIN TEST CANDIDA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86486	Other professional services	SKIN TEST UNLISTED ANTIGN EA	8.52	8.52
86490	Other professional services	COCCIDIOIDOMYCOSIS SKIN TEST	104.03	104.03
86510	Other professional services	HISTOPLASMOSIS SKIN TEST	10.34	10.34
86580	Other professional services	TB INTRADERMAL TEST	13.97	13.97
86590	Clinical Laboratory	STREPTOKINASE ANTIBODY	18.99	18.99
86592	Clinical Laboratory	SYPHILIS TEST NON-TREP QUAL	6.41	6.41
86593	Clinical Laboratory	SYPHILIS TEST NON-TREP QUANT	6.60	6.60
86596	Clinical Laboratory	VOLTAGE-GTD CA CHNL ANTB EA	18.08	18.08
86602	Clinical Laboratory	ANTINOMYCES ANTIBODY	15.27	15.27
86603	Clinical Laboratory	ADENOVIRUS ANTIBODY	19.31	19.31
86606	Clinical Laboratory	ASPERGILLUS ANTIBODY	22.58	22.58
86609	Clinical Laboratory	BACTERIUM ANTIBODY	19.32	19.32
86611	Clinical Laboratory	BARTONELLA ANTIBODY	15.27	15.27
86612	Clinical Laboratory	BLASTOMYCES ANTIBODY	19.35	19.35
86615	Clinical Laboratory	BORDETELLA ANTIBODY	19.79	19.79
86617	Clinical Laboratory	LYME DISEASE ANTIBODY	23.24	23.24
86618	Clinical Laboratory	LYME DISEASE ANTIBODY	25.55	25.55
86619	Clinical Laboratory	BORRELIA ANTIBODY	20.07	20.07
86622	Clinical Laboratory	BRUCELLA ANTIBODY	13.40	13.40
86625	Clinical Laboratory	CAMPYLOBACTER ANTIBODY	19.68	19.68
86628	Clinical Laboratory	CANDIDA ANTIBODY	18.02	18.02
86631	Clinical Laboratory	CHLAMYDIA ANTIBODY	17.73	17.73
86632	Clinical Laboratory	CHLAMYDIA IGM ANTIBODY	19.02	19.02
86635	Clinical Laboratory	COCCIDIOIDES ANTIBODY	17.21	17.21
86638	Clinical Laboratory	Q FEVER ANTIBODY	18.18	18.18
86641	Clinical Laboratory	CRYPTOCOCCUS ANTIBODY	21.62	21.62
86644	Clinical Laboratory	CMV ANTIBODY	21.59	21.59
86645	Clinical Laboratory	CMV ANTIBODY IGM	25.28	25.28
86648	Clinical Laboratory	DIPHTHERIA ANTIBODY	22.82	22.82
86651	Clinical Laboratory	ENCEPHALITIS CALIFORN ANTBDY	19.79	19.79
86652	Clinical Laboratory	ENCEPHALTIS EAST EQNE ANBDY	19.79	19.79
86653	Clinical Laboratory	ENCEPHALTIS ST LOUIS ANTBODY	19.79	19.79
86654	Clinical Laboratory	ENCEPHALTIS WEST EQNE ANTBDY	19.79	19.79
86658	Clinical Laboratory	ENTEROVIRUS ANTIBODY	19.55	19.55
86663	Clinical Laboratory	EPSTEIN-BARR ANTIBODY	19.68	19.68
86664	Clinical Laboratory	EPSTEIN-BARR NUCLEAR ANTIGEN	22.94	22.94
86665	Clinical Laboratory	EPSTEIN-BARR CAPSID VCA	27.21	27.21
86666	Clinical Laboratory	EHRLICHIA ANTIBODY	15.27	15.27
86668	Clinical Laboratory	FRANCISELLA TULARENSIS	21.24	21.24
86671	Clinical Laboratory	FUNGUS NES ANTIBODY	18.38	18.38
86674	Clinical Laboratory	GIARDIA LAMBLIA ANTIBODY	22.08	22.08
86677	Clinical Laboratory	HELICOBACTER PYLORI ANTIBODY	25.28	25.28
86682	Clinical Laboratory	HELMINTH ANTIBODY	19.52	19.52
86684	Clinical Laboratory	HEMOPHILUS INFLUENZA ANTIBDY	23.76	23.76
86687	Clinical Laboratory	HTLV-I ANTIBODY	13.64	13.64
86688	Clinical Laboratory	HTLV-II ANTIBODY	21.00	21.00
86689	Clinical Laboratory	HTLV/HIV CONFIRMJ ANTIBODY	29.03	29.03
86692	Clinical Laboratory	HEPATITIS DELTA AGENT ANTBDY	25.74	25.74
86694	Clinical Laboratory	HERPES SIMPLEX NES ANTBDY	21.59	21.59
86695	Clinical Laboratory	HERPES SIMPLEX TYPE 1 TEST	19.79	19.79
86696	Clinical Laboratory	HERPES SIMPLEX TYPE 2 TEST	29.03	29.03
86698	Clinical Laboratory	HISTOPLASMA ANTIBODY	20.69	20.69
86701	Clinical Laboratory	HIV-1ANTIBODY	13.34	13.34
86702	Clinical Laboratory	HIV-2 ANTIBODY	20.28	20.28
86703	Clinical Laboratory	HIV-1/HIV-2 1 RESULT ANTBDY	20.57	20.57
86704	Clinical Laboratory	HEP B CORE ANTIBODY TOTAL	18.08	18.08
86705	Clinical Laboratory	HEP B CORE ANTIBODY IGM	17.66	17.66
86706	Clinical Laboratory	HEP B SURFACE ANTIBODY	16.11	16.11
86707	Clinical Laboratory	HEPATITIS BE ANTIBODY	17.36	17.36
86708	Clinical Laboratory	HEPATITIS A ANTIBODY	18.59	18.59
86709	Clinical Laboratory	HEPATITIS A IGM ANTIBODY	16.89	16.89
86710	Clinical Laboratory	INFLUENZA VIRUS ANTIBODY	20.33	20.33
86711	Clinical Laboratory	JOHN CUNNINGHAM ANTIBODY	25.34	25.34
86713	Clinical Laboratory	LEGIONELLA ANTIBODY	22.95	22.95
86717	Clinical Laboratory	LEISHMANIA ANTIBODY	18.38	18.38
86720	Clinical Laboratory	LEPTOSPIRA ANTIBODY	24.30	24.30
86723	Clinical Laboratory	LISTERIA MONOCYTOGENES	19.79	19.79
86727	Clinical Laboratory	LYMPH CHORIOMENINGITIS AB	19.31	19.31
86732	Clinical Laboratory	MUCORMYCOSIS ANTIBODY	22.50	22.50
86735	Clinical Laboratory	MUMPS ANTIBODY	19.58	19.58
86738	Clinical Laboratory	MYCOPLASMA ANTIBODY	19.86	19.86
86741	Clinical Laboratory	NEISSERIA MENINGITIDIS	19.79	19.79
86744	Clinical Laboratory	NOCARDIA ANTIBODY	23.99	23.99
86747	Clinical Laboratory	PARVOVIRUS ANTIBODY	22.55	22.55
86750	Clinical Laboratory	MALARIA ANTIBODY	19.79	19.79
86753	Clinical Laboratory	PROTOZOA ANTIBODY NOS	18.59	18.59
86756	Clinical Laboratory	RESPIRATORY VIRUS ANTIBODY	23.84	23.84
86757	Clinical Laboratory	RICKETTSIA ANTIBODY	29.03	29.03
86759	Clinical Laboratory	ROTAVIRUS ANTIBODY	27.35	27.35
86762	Clinical Laboratory	RUBELLA ANTIBODY	21.59	21.59
86765	Clinical Laboratory	RUBEOLA ANTIBODY	19.32	19.32
86768	Clinical Laboratory	SALMONELLA ANTIBODY	19.79	19.79
86769	Clinical Laboratory	SARS-COV-2 COVID-19 ANTIBODY	63.20	63.20
86771	Clinical Laboratory	SHIGELLA ANTIBODY	36.72	36.72
86774	Clinical Laboratory	TETANUS ANTIBODY	22.20	22.20
86777	Clinical Laboratory	TOXOPLASMA ANTIBODY	21.59	21.59
86778	Clinical Laboratory	TOXOPLASMA ANTIBODY IGM	21.62	21.62
86780	Clinical Laboratory	TREPONEMA PALLIDUM	19.86	19.86
86784	Clinical Laboratory	TRICHINELLA ANTIBODY	18.84	18.84
86787	Clinical Laboratory	VARICELLA-ZOSTER ANTIBODY	19.32	19.32
86788	Clinical Laboratory	WEST NILE VIRUS AB IGM	25.28	25.28
86789	Clinical Laboratory	WEST NILE VIRUS ANTIBODY	21.59	21.59
86790	Clinical Laboratory	VIRUS ANTIBODY NOS	19.32	19.32
86793	Clinical Laboratory	YERSINIA ANTIBODY	19.79	19.79
86794	Clinical Laboratory	ZIKA VIRUS IGM ANTIBODY	25.28	25.28
86800	Clinical Laboratory	THYROGLOBULIN ANTIBODY	23.87	23.87
86803	Clinical Laboratory	HEPATITIS C AB TEST	21.41	21.41
86804	Clinical Laboratory	HEP C AB TEST CONFIRM	23.24	23.24
86805	Clinical Laboratory	LYMPHOCYTOTOXICITY ASSAY	284.27	284.27
86806	Clinical Laboratory	LYMPHOCYTOTOXICITY ASSAY	71.39	71.39
86807	Clinical Laboratory	CYTOTOXIC ANTIBODY SCREENING	117.98	117.98
86808	Clinical Laboratory	CYTOTOXIC ANTIBODY SCREENING	44.52	44.52
86812	Clinical Laboratory	HLA TYPING A B OR C	38.72	38.72
86813	Clinical Laboratory	HLA TYPING A B OR C	87.00	87.00
86816	Clinical Laboratory	HLA TYPING DR/DQ	45.26	45.26
86817	Clinical Laboratory	HLA TYPING DR/DQ	159.21	159.21
86821	Clinical Laboratory	LYMPHOCYTE CULTURE MIXED	54.84	54.84
86825	Clinical Laboratory	HLA X-MATH NON-CYTOTOXIC	164.24	164.24
86826	Clinical Laboratory	HLA X-MATCH NONCYTOTOXC ADDL	54.80	54.80
86828	Clinical Laboratory	HLA CLASS I&II ANTIBODY QUAL	96.29	96.29
86829	Clinical Laboratory	HLA CLASS I/II ANTIBODY QUAL	96.29	96.29
86830	Clinical Laboratory	HLA CLASS I PHENOTYPE QUAL	143.28	143.28
86831	Clinical Laboratory	HLA CLASS II PHENOTYPE QUAL	122.82	122.82
86832	Clinical Laboratory	HLA CLASS I HIGH DEFIN QUAL	485.63	485.63
86833	Clinical Laboratory	HLA CLASS II HIGH DEFIN QUAL	488.70	488.70
86834	Clinical Laboratory	HLA CLASS I SEMIQUANT PANEL	536.34	536.34
86835	Clinical Laboratory	HLA CLASS II SEMIQUANT PANEL	484.44	484.44
86849	Other professional services	IMMUNOLOGY PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86850	Clinical Laboratory	RBC ANTIBODY SCREEN	14.66	14.66
86860	Other professional services	RBC ANTIBODY ELUTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86870	Other professional services	RBC ANTIBODY IDENTIFICATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86880	Clinical Laboratory	COOMBS TEST DIRECT	8.09	8.09
86885	Clinical Laboratory	COOMBS TEST INDIRECT QUAL	8.58	8.58
86886	Clinical Laboratory	COOMBS TEST INDIRECT TITER	7.77	7.77
86890	Other professional services	AUTOLOGOUS BLOOD PROCESS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86891	Other professional services	AUTOLOGOUS BLOOD OP SALVAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86900	Clinical Laboratory	BLOOD TYPING SEROLOGIC ABO	4.49	4.49
86901	Clinical Laboratory	BLOOD TYPING SEROLOGIC RH(D)	4.49	4.49
86902	Clinical Laboratory	BLOOD TYPE ANTIGEN DONOR EA	9.53	9.53
86904	Clinical Laboratory	BLOOD TYPING PATIENT SERUM	24.51	24.51
86905	Clinical Laboratory	BLOOD TYPING RBC ANTIGENS	5.75	5.75
86906	Clinical Laboratory	BLD TYPING SEROLOGIC RH PHNT	11.63	11.63
86910	Other professional services	BLOOD TYPING PATERNITY TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86911	Other professional services	BLOOD TYPING ANTIGEN SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86920	Other professional services	COMPATIBILITY TEST SPIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86921	Other professional services	COMPATIBILITY TEST INCUBATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86922	Other professional services	COMPATIBILITY TEST ANTIGLOB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86923	Other professional services	COMPATIBILITY TEST ELECTRIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86927	Other professional services	PLASMA FRESH FROZEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86930	Other professional services	FROZEN BLOOD PREP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86931	Other professional services	FROZEN BLOOD THAW	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86932	Other professional services	FROZEN BLOOD FREEZE/THAW	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86940	Clinical Laboratory	HEMOLYSINS/AGGLUTININS AUTO	13.16	13.16
86941	Clinical Laboratory	HEMOLYSINS/AGGLUTININS	18.17	18.17
86945	Other professional services	BLOOD PRODUCT/IRRADIATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86950	Other professional services	LEUKACYTE TRANSFUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86960	Other professional services	VOL REDUCTION OF BLOOD/PROD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86965	Other professional services	POOLING BLOOD PLATELETS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86970	Other professional services	RBC PRETX INCUBATJ W/CHEMICL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86971	Other professional services	RBC PRETX INCUBATJ W/ENZYMES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86972	Other professional services	RBC PRETX INCUBATJ W/DENSITY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86975	Other professional services	RBC SERUM PRETX INCUBJ DRUGS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86976	Other professional services	RBC SERUM PRETX ID DILUTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86977	Other professional services	RBC SERUM PRETX INCUBJ/INHIB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86978	Other professional services	RBC PRETREATMENT SERUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86985	Other professional services	SPLIT BLOOD OR PRODUCTS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
86999	Other professional services	UNLISTED TRANSFUSION MED PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
87003	Clinical Laboratory	SMALL ANIMAL INOCULATION	25.26	25.26
87015	Clinical Laboratory	SPECIMEN INFECT AGNT CONCNTJ	10.02	10.02
87040	Clinical Laboratory	BLOOD CULTURE FOR BACTERIA	15.48	15.48
87045	Clinical Laboratory	FECES CULTURE AEROBIC BACT	14.16	14.16
87046	Clinical Laboratory	STOOL CULTR AEROBIC BACT EA	14.16	14.16
87070	Clinical Laboratory	CULTURE OTHR SPECIMN AEROBIC	12.93	12.93
87071	Clinical Laboratory	CULTURE AEROBIC QUANT OTHER	14.84	14.84
87073	Clinical Laboratory	CULTURE BACTERIA ANAEROBIC	14.49	14.49
87075	Clinical Laboratory	CULTR BACTERIA EXCEPT BLOOD	14.21	14.21
87076	Clinical Laboratory	CULTURE ANAEROBE IDENT EACH	12.12	12.12
87077	Clinical Laboratory	CULTURE AEROBIC IDENTIFY	12.12	12.12
87081	Clinical Laboratory	CULTURE SCREEN ONLY	9.95	9.95
87084	Clinical Laboratory	CULTURE OF SPECIMEN BY KIT	40.61	40.61
87086	Clinical Laboratory	URINE CULTURE/COLONY COUNT	12.11	12.11
87088	Clinical Laboratory	URINE BACTERIA CULTURE	12.14	12.14
87101	Clinical Laboratory	SKIN FUNGI CULTURE	11.57	11.57
87102	Clinical Laboratory	FUNGUS ISOLATION CULTURE	12.62	12.62
87103	Clinical Laboratory	BLOOD FUNGUS CULTURE	30.69	30.69
87106	Clinical Laboratory	FUNGI IDENTIFICATION YEAST	15.48	15.48
87107	Clinical Laboratory	FUNGI IDENTIFICATION MOLD	15.48	15.48
87109	Clinical Laboratory	MYCOPLASMA	23.09	23.09
87110	Clinical Laboratory	CHLAMYDIA CULTURE	29.40	29.40
87116	Clinical Laboratory	MYCOBACTERIA CULTURE	16.20	16.20
87118	Clinical Laboratory	MYCOBACTERIC IDENTIFICATION	21.92	21.92
87140	Clinical Laboratory	CULTURE TYPE IMMUNOFLUORESC	8.36	8.36
87143	Clinical Laboratory	CULTURE TYPING GLC/HPLC	18.78	18.78
87147	Clinical Laboratory	CULTURE TYPE IMMUNOLOGIC	7.77	7.77
87149	Clinical Laboratory	DNA/RNA DIRECT PROBE	30.08	30.08
87150	Clinical Laboratory	DNA/RNA AMPLIFIED PROBE	52.64	52.64
87152	Clinical Laboratory	CULTURE TYPE PULSE FIELD GEL	11.61	11.61
87153	Clinical Laboratory	DNA/RNA SEQUENCING	173.04	173.04
87154	Clinical Laboratory	CUL TYP ID BLD PTHGN 6+ TRGT	327.09	327.09
87158	Clinical Laboratory	CULTURE TYPING ADDED METHOD	11.61	11.61
87164	Clinical Laboratory	DARK FIELD EXAMINATION	16.11	16.11
87164-26	Clinical Laboratory	DARK FIELD EXAMINATION	26.69	26.69
87166	Clinical Laboratory	DARK FIELD EXAMINATION	16.95	16.95
87168	Clinical Laboratory	MACROSCOPIC EXAM ARTHROPOD	6.41	6.41
87169	Clinical Laboratory	MACROSCOPIC EXAM PARASITE	6.47	6.47
87172	Clinical Laboratory	PINWORM EXAM	6.41	6.41
87176	Clinical Laboratory	TISSUE HOMOGENIZATION CULTR	8.82	8.82
87177	Clinical Laboratory	OVA AND PARASITES SMEARS	13.35	13.35
87181	Clinical Laboratory	MICROBE SUSCEPTIBLE DIFFUSE	7.13	7.13
87184	Clinical Laboratory	MICROBE SUSCEPTIBLE DISK	11.22	11.22
87185	Clinical Laboratory	MICROBE SUSCEPTIBLE ENZYME	7.13	7.13
87186	Clinical Laboratory	MICROBE SUSCEPTIBLE MIC	12.98	12.98
87187	Clinical Laboratory	MICROBE SUSCEPTIBLE MLC	60.26	60.26
87188	Clinical Laboratory	MICROBE SUSCEPT MACROBROTH	9.96	9.96
87190	Clinical Laboratory	MICROBE SUSCEPT MYCOBACTERI	10.97	10.97
87197	Clinical Laboratory	BACTERICIDAL LEVEL SERUM	22.53	22.53
87205	Clinical Laboratory	SMEAR GRAM STAIN	6.41	6.41
87206	Clinical Laboratory	SMEAR FLUORESCENT/ACID STAI	8.09	8.09
87207	Clinical Laboratory	SMEAR SPECIAL STAIN	8.99	8.99
87207-26	Clinical Laboratory	SMEAR SPECIAL STAIN	24.87	24.87
87209	Clinical Laboratory	SMEAR COMPLEX STAIN	26.97	26.97
87210	Clinical Laboratory	SMEAR WET MOUNT SALINE/INK	8.73	8.73
87220	Clinical Laboratory	TISSUE EXAM FOR FUNGI	6.41	6.41
87230	Clinical Laboratory	ASSAY TOXIN OR ANTITOXIN	29.61	29.61
87250	Clinical Laboratory	VIRUS INOCULATE EGGS/ANIMAL	29.34	29.34
87252	Clinical Laboratory	VIRUS INOCULATION TISSUE	39.11	39.11
87253	Clinical Laboratory	VIRUS INOCULATE TISSUE ADDL	30.30	30.30
87254	Clinical Laboratory	VIRUS INOCULATION SHELL VIA	29.34	29.34
87255	Clinical Laboratory	GENET VIRUS ISOLATE HSV	50.79	50.79
87260	Clinical Laboratory	ADENOVIRUS AG IF	21.65	21.65
87265	Clinical Laboratory	PERTUSSIS AG IF	17.97	17.97
87267	Clinical Laboratory	ENTEROVIRUS ANTIBODY DFA	20.13	20.13
87269	Clinical Laboratory	GIARDIA AG IF	20.42	20.42
87270	Clinical Laboratory	CHLAMYDIA TRACHOMATIS AG IF	17.97	17.97
87271	Clinical Laboratory	CYTOMEGALOVIRUS DFA	20.13	20.13
87272	Clinical Laboratory	CRYPTOSPORIDIUM AG IF	17.97	17.97
87273	Clinical Laboratory	HERPES SIMPLEX 2 AG IF	17.97	17.97
87274	Clinical Laboratory	HERPES SIMPLEX 1 AG IF	17.97	17.97
87275	Clinical Laboratory	INFLUENZA B AG IF	18.38	18.38
87276	Clinical Laboratory	INFLUENZA A AG IF	24.11	24.11
87278	Clinical Laboratory	LEGION PNEUMOPHILIA AG IF	23.40	23.40
87279	Clinical Laboratory	PARAINFLUENZA AG IF	24.65	24.65
87280	Clinical Laboratory	RESPIRATORY SYNCYTIAL AG IF	20.13	20.13
87281	Clinical Laboratory	PNEUMOCYSTIS CARINII AG IF	17.97	17.97
87283	Clinical Laboratory	RUBEOLA AG IF	91.20	91.20
87285	Clinical Laboratory	TREPONEMA PALLIDUM AG IF	18.27	18.27
87290	Clinical Laboratory	VARICELLA ZOSTER AG IF	20.13	20.13
87299	Clinical Laboratory	ANTIBODY DETECTION NOS IF	24.15	24.15
87300	Clinical Laboratory	AG DETECTION POLYVAL IF	17.97	17.97
87301	Clinical Laboratory	ADENOVIRUS AG IA	17.97	17.97
87305	Clinical Laboratory	ASPERGILLUS AG IA	17.97	17.97
87320	Clinical Laboratory	CHLMYD TRACH AG IA	22.50	22.50
87324	Clinical Laboratory	CLOSTRIDIUM AG IA	17.97	17.97
87327	Clinical Laboratory	CRYPTOCOCCUS NEOFORM AG IA	20.13	20.13
87328	Clinical Laboratory	CRYPTOSPORIDIUM AG IA	20.73	20.73
87329	Clinical Laboratory	GIARDIA AG IA	17.97	17.97
87332	Clinical Laboratory	CYTOMEGALOVIRUS AG IA	17.97	17.97
87335	Clinical Laboratory	E COLI 0157 AG IA	18.99	18.99
87336	Clinical Laboratory	ENTAMOEB HIST DISPR AG IA	24.00	24.00
87337	Clinical Laboratory	ENTAMOEB HIST GROUP AG IA	17.97	17.97
87338	Clinical Laboratory	HPYLORI STOOL AG IA	21.57	21.57
87339	Clinical Laboratory	H PYLORI AG IA	24.00	24.00
87340	Clinical Laboratory	HEPATITIS B SURFACE AG IA	15.50	15.50
87341	Clinical Laboratory	HEP B SURFACE AG NEUTRLZJ IA	15.50	15.50
87350	Clinical Laboratory	HEPATITIS BE AG IA	17.30	17.30
87380	Clinical Laboratory	HEPATITIS DELTA AGENT AG IA	27.54	27.54
87385	Clinical Laboratory	HISTOPLASMA CAPSUL AG IA	19.88	19.88
87389	Clinical Laboratory	HIV-1 AG W/HIV-1&-2 AB AG IA	36.12	36.12
87390	Clinical Laboratory	HIV-1 AG IA	36.09	36.09
87391	Clinical Laboratory	HIV-2 AG IA	32.85	32.85
87400	Clinical Laboratory	INFLUENZA A/B EACH AG IA	21.20	21.20
87420	Clinical Laboratory	RESP SYNCYTIAL VIRUS AG IA	20.87	20.87
87425	Clinical Laboratory	ROTAVIRUS AG IA	17.97	17.97
87426	Clinical Laboratory	SARSCOV CORONAVIRUS AG IA	53.00	53.00
87427	Clinical Laboratory	SHIGA-LIKE TOXIN AG IA	17.97	17.97
87428	Clinical Laboratory	SARSCOV & INF VIR A&B AG IA	105.44	105.44
87430	Clinical Laboratory	STREP A AG IA	25.22	25.22
87449	Clinical Laboratory	NOS EACH ORGANISM AG IA	17.97	17.97
87451	Clinical Laboratory	POLYVALENT MULT ORG EA AG IA	15.77	15.77
87467	Clinical Laboratory	HEPATITIS B SURFACE AG QUAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
87468	Clinical Laboratory	ANAPLSMA PHGCYTOPHLM AMP PRB	52.64	52.64
87469	Clinical Laboratory	BABESIA MICROTI AMP PRB	52.64	52.64
87471	Clinical Laboratory	BARTONELLA DNA AMP PROBE	52.64	52.64
87472	Clinical Laboratory	BARTONELLA DNA QUANT	64.26	64.26
87475	Clinical Laboratory	LYME DIS DNA DIR PROBE	30.08	30.08
87476	Clinical Laboratory	LYME DIS DNA AMP PROBE	52.64	52.64
87478	Clinical Laboratory	BORRELIA MIYAMOTOI AMP PRB	52.64	52.64
87480	Clinical Laboratory	CANDIDA DNA DIR PROBE	30.08	30.08
87481	Clinical Laboratory	CANDIDA DNA AMP PROBE	52.64	52.64
87482	Clinical Laboratory	CANDIDA DNA QUANT	83.61	83.61
87483	Clinical Laboratory	CNS DNA AMP PROBE TYPE 12-25	625.17	625.17
87484	Clinical Laboratory	EHRLICHA CHAFFEENSIS AMP PRB	52.64	52.64
87485	Clinical Laboratory	CHLMYD PNEUM DNA DIR PROBE	30.08	30.08
87486	Clinical Laboratory	CHLMYD PNEUM DNA AMP PROBE	52.64	52.64
87487	Clinical Laboratory	CHLMYD PNEUM DNA QUANT	64.26	64.26
87490	Clinical Laboratory	CHLMYD TRACH DNA DIR PROBE	34.13	34.13
87491	Clinical Laboratory	CHLMYD TRACH DNA AMP PROBE	52.64	52.64
87492	Clinical Laboratory	CHLMYD TRACH DNA QUANT	80.21	80.21
87493	Clinical Laboratory	C DIFF AMPLIFIED PROBE	55.91	55.91
87495	Clinical Laboratory	CYTOMEG DNA DIR PROBE	45.05	45.05
87496	Clinical Laboratory	CYTOMEG DNA AMP PROBE	52.64	52.64
87497	Clinical Laboratory	CYTOMEG DNA QUANT	64.26	64.26
87498	Clinical Laboratory	ENTEROVIRUS PROBE&REVRS TRNS	52.64	52.64
87500	Clinical Laboratory	VANOMYCIN DNA AMP PROBE	52.64	52.64
87501	Clinical Laboratory	INFLUENZA DNA AMP PROB 1+	76.97	76.97
87502	Clinical Laboratory	INFLUENZA DNA AMP PROBE	143.70	143.70
87503	Clinical Laboratory	INFLUENZA DNA AMP PROB ADDL	43.83	43.83
87505	Clinical Laboratory	NFCT AGENT DETECTION GI	192.44	192.44
87506	Clinical Laboratory	IADNA-DNA/RNA PROBE TQ 6-11	394.49	394.49
87507	Clinical Laboratory	IADNA-DNA/RNA PROBE TQ 12-25	625.17	625.17
87510	Clinical Laboratory	GARDNER VAG DNA DIR PROBE	30.08	30.08
87511	Clinical Laboratory	GARDNER VAG DNA AMP PROBE	52.64	52.64
87512	Clinical Laboratory	GARDNER VAG DNA QUANT	62.64	62.64
87516	Clinical Laboratory	HEPATITIS B DNA AMP PROBE	52.64	52.64
87517	Clinical Laboratory	HEPATITIS B DNA QUANT	64.26	64.26
87520	Clinical Laboratory	HEPATITIS C RNA DIR PROBE	46.83	46.83
87521	Clinical Laboratory	HEPATITIS C PROBE&RVRS TRNSC	52.64	52.64
87522	Clinical Laboratory	HEPATITIS C REVRS TRNSCRPJ	64.26	64.26
87523	Clinical Laboratory	HEPATITIS D QUANTIFICATION	64.26	64.26
87525	Clinical Laboratory	HEPATITIS G DNA DIR PROBE	44.70	44.70
87526	Clinical Laboratory	HEPATITIS G DNA AMP PROBE	58.89	58.89
87527	Clinical Laboratory	HEPATITIS G DNA QUANT	62.64	62.64
87528	Clinical Laboratory	HSV DNA DIR PROBE	30.08	30.08
87529	Clinical Laboratory	HSV DNA AMP PROBE	52.64	52.64
87530	Clinical Laboratory	HSV DNA QUANT	64.26	64.26
87531	Clinical Laboratory	HHV-6 DNA DIR PROBE	87.00	87.00
87532	Clinical Laboratory	HHV-6 DNA AMP PROBE	52.64	52.64
87533	Clinical Laboratory	HHV-6 DNA QUANT	62.64	62.64
87534	Clinical Laboratory	HIV-1 DNA DIR PROBE	32.88	32.88
87535	Clinical Laboratory	HIV-1 PROBE&REVERSE TRNSCRPJ	52.64	52.64
87536	Clinical Laboratory	HIV-1 QUANT&REVRSE TRNSCRPJ	127.65	127.65
87537	Clinical Laboratory	HIV-2 DNA DIR PROBE	32.88	32.88
87538	Clinical Laboratory	HIV-2 PROBE&REVRSE TRNSCRIPJ	52.64	52.64
87539	Clinical Laboratory	HIV-2 QUANT&REVRSE TRNSCRIPJ	87.93	87.93
87540	Clinical Laboratory	LEGION PNEUMO DNA DIR PROB	30.08	30.08
87541	Clinical Laboratory	LEGION PNEUMO DNA AMP PROB	52.64	52.64
87542	Clinical Laboratory	LEGION PNEUMO DNA QUANT	62.64	62.64
87550	Clinical Laboratory	MYCOBACTERIA DNA DIR PROBE	30.08	30.08
87551	Clinical Laboratory	MYCOBACTERIA DNA AMP PROBE	72.36	72.36
87552	Clinical Laboratory	MYCOBACTERIA DNA QUANT	64.26	64.26
87555	Clinical Laboratory	M.TUBERCULO DNA DIR PROBE	40.32	40.32
87556	Clinical Laboratory	M.TUBERCULO DNA AMP PROBE	62.52	62.52
87557	Clinical Laboratory	M.TUBERCULO DNA QUANT	64.26	64.26
87560	Clinical Laboratory	M.AVIUM-INTRA DNA DIR PROB	40.94	40.94
87561	Clinical Laboratory	M.AVIUM-INTRA DNA AMP PROB	52.64	52.64
87562	Clinical Laboratory	M.AVIUM-INTRA DNA QUANT	64.26	64.26
87563	Clinical Laboratory	M. GENITALIUM AMP PROBE	52.64	52.64
87580	Clinical Laboratory	M.PNEUMON DNA DIR PROBE	30.08	30.08
87581	Clinical Laboratory	M.PNEUMON DNA AMP PROBE	52.64	52.64
87582	Clinical Laboratory	M.PNEUMON DNA QUANT	453.93	453.93
87590	Clinical Laboratory	N.GONORRHOEAE DNA DIR PROB	40.32	40.32
87591	Clinical Laboratory	N.GONORRHOEAE DNA AMP PROB	52.64	52.64
87592	Clinical Laboratory	N.GONORRHOEAE DNA QUANT	64.26	64.26
87593	Clinical Laboratory	ORTHOPOXVIRUS AMP PRB EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
87623	Clinical Laboratory	HPV LOW-RISK TYPES	52.64	52.64
87624	Clinical Laboratory	HPV HIGH-RISK TYPES	52.64	52.64
87625	Clinical Laboratory	HPV TYPES 16 & 18 ONLY	60.83	60.83
87631	Clinical Laboratory	RESP VIRUS 3-5 TARGETS	213.95	213.95
87632	Clinical Laboratory	RESP VIRUS 6-11 TARGETS	327.09	327.09
87633	Clinical Laboratory	RESP VIRUS 12-25 TARGETS	625.17	625.17
87634	Clinical Laboratory	RSV DNA/RNA AMP PROBE	105.30	105.30
87635	Clinical Laboratory	SARS-COV-2 COVID-19 AMP PRB	76.97	76.97
87636	Clinical Laboratory	SARSCOV2 & INF A&B AMP PRB	213.95	213.95
87637	Clinical Laboratory	SARSCOV2&INF A&B&RSV AMP PRB	213.95	213.95
87640	Clinical Laboratory	STAPH A DNA AMP PROBE	52.64	52.64
87641	Clinical Laboratory	MR-STAPH DNA AMP PROBE	52.64	52.64
87650	Clinical Laboratory	STREP A DNA DIR PROBE	30.08	30.08
87651	Clinical Laboratory	STREP A DNA AMP PROBE	52.64	52.64
87652	Clinical Laboratory	STREP A DNA QUANT	62.64	62.64
87653	Clinical Laboratory	STREP B DNA AMP PROBE	52.64	52.64
87660	Clinical Laboratory	TRICHOMONAS VAGIN DIR PROBE	30.08	30.08
87661	Clinical Laboratory	TRICHOMONAS VAGINALIS AMPLIF	52.64	52.64
87662	Clinical Laboratory	ZIKA VIRUS DNA/RNA AMP PROBE	76.97	76.97
87797	Clinical Laboratory	DETECT AGENT NOS DNA DIR	45.05	45.05
87798	Clinical Laboratory	DETECT AGENT NOS DNA AMP	52.64	52.64
87799	Clinical Laboratory	DETECT AGENT NOS DNA QUANT	64.26	64.26
87800	Clinical Laboratory	DETECT AGNT MULT DNA DIREC	65.51	65.51
87801	Clinical Laboratory	DETECT AGNT MULT DNA AMPLI	105.30	105.30
87802	Clinical Laboratory	STREP B ASSAY W/OPTIC	19.10	19.10
87803	Clinical Laboratory	CLOSTRIDIUM TOXIN A W/OPTIC	24.00	24.00
87804	Clinical Laboratory	INFLUENZA ASSAY W/OPTIC	24.83	24.83
87806	Clinical Laboratory	HIV AG W/HIV1&2 ANTB W/OPTIC	49.16	49.16
87807	Clinical Laboratory	RSV ASSAY W/OPTIC	19.65	19.65
87808	Clinical Laboratory	TRICHOMONAS ASSAY W/OPTIC	22.94	22.94
87809	Clinical Laboratory	ADENOVIRUS ASSAY W/OPTIC	32.64	32.64
87810	Clinical Laboratory	CHLMYD TRACH ASSAY W/OPTIC	52.94	52.94
87811	Clinical Laboratory	SARS-COV-2 COVID19 W/OPTIC	62.07	62.07
87850	Clinical Laboratory	N. GONORRHOEAE ASSAY W/OPTIC	36.84	36.84
87880	Clinical Laboratory	STREP A ASSAY W/OPTIC	24.80	24.80
87899	Clinical Laboratory	AGENT NOS ASSAY W/OPTIC	24.11	24.11
87900	Clinical Laboratory	PHENOTYPE INFECT AGENT DRUG	195.53	195.53
87901	Clinical Laboratory	NFCT AGT GNTYP ALYS HIV1 REV	386.18	386.18
87902	Clinical Laboratory	NFCT AGT GNTYP ALYS HEP C	386.18	386.18
87903	Clinical Laboratory	PHENOTYPE DNA HIV W/CULTURE	732.99	732.99
87904	Clinical Laboratory	PHENOTYPE DNA HIV W/CLT ADD	39.11	39.11
87905	Clinical Laboratory	SIALIDASE ENZYME ASSAY	18.33	18.33
87906	Clinical Laboratory	NFCT AGT GNTYP ALYS HIV1	193.10	193.10
87910	Clinical Laboratory	NFCT AGT GNTYP ALYS CMV	386.18	386.18
87912	Clinical Laboratory	NFCT AGT GNTYP ALYS HEP B	386.18	386.18
87913	Clinical Laboratory	NFCT AGT GNTYP ALYS SARSCOV2	386.18	386.18
87999	Other professional services	UNLISTED MICROBIOLOGY PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88000	Other professional services	AUTOPSY (NECROPSY) GROSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88005	Other professional services	AUTOPSY (NECROPSY) GROSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88007	Other professional services	AUTOPSY (NECROPSY) GROSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88012	Other professional services	AUTOPSY (NECROPSY) GROSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88014	Other professional services	AUTOPSY (NECROPSY) GROSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88016	Other professional services	AUTOPSY (NECROPSY) GROSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88020	Other professional services	AUTOPSY (NECROPSY) COMPLETE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88025	Other professional services	AUTOPSY (NECROPSY) COMPLETE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88027	Other professional services	AUTOPSY (NECROPSY) COMPLETE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88028	Other professional services	AUTOPSY (NECROPSY) COMPLETE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88029	Other professional services	AUTOPSY (NECROPSY) COMPLETE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88036	Other professional services	LIMITED AUTOPSY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88037	Other professional services	LIMITED AUTOPSY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88040	Other professional services	FORENSIC AUTOPSY (NECROPSY)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88045	Other professional services	CORONERS AUTOPSY (NECROPSY)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88099	Other professional services	UNLISTED NECROPSY (AUTOPSY)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88104	Other professional services	CYTOPATH FL NONGYN SMEARS	104.90	104.90
88104-26	Clinical Laboratory	CYTOPATH FL NONGYN SMEARS	38.30	38.30
88104-TC	Clinical Laboratory	CYTOPATH FL NONGYN SMEARS	66.60	66.60
88106	Other professional services	CYTOPATH FL NONGYN FILTER	98.30	98.30
88106-26	Clinical Laboratory	CYTOPATH FL NONGYN FILTER	26.24	26.24
88106-TC	Clinical Laboratory	CYTOPATH FL NONGYN FILTER	72.06	72.06
88108	Other professional services	CYTOPATH CONCENTRATE TECH	95.04	95.04
88108-26	Clinical Laboratory	CYTOPATH CONCENTRATE TECH	31.04	31.04
88108-TC	Clinical Laboratory	CYTOPATH CONCENTRATE TECH	64.01	64.01
88112	Other professional services	CYTOPATH CELL ENHANCE TECH	94.56	94.56
88112-26	Clinical Laboratory	CYTOPATH CELL ENHANCE TECH	38.30	38.30
88112-TC	Clinical Laboratory	CYTOPATH CELL ENHANCE TECH	56.27	56.27
88120	Other professional services	CYTP URNE 3-5 PROBES EA SPEC	794.64	794.64
88120-26	Clinical Laboratory	CYTP URNE 3-5 PROBES EA SPEC	80.52	80.52
88120-TC	Clinical Laboratory	CYTP URNE 3-5 PROBES EA SPEC	714.14	714.14
88121	Other professional services	CYTP URINE 3-5 PROBES CMPTR	575.28	575.28
88121-26	Clinical Laboratory	CYTP URINE 3-5 PROBES CMPTR	67.05	67.05
88121-TC	Clinical Laboratory	CYTP URINE 3-5 PROBES CMPTR	508.23	508.23
88125	Other professional services	FORENSIC CYTOPATHOLOGY	39.81	39.81
88125-26	Clinical Laboratory	FORENSIC CYTOPATHOLOGY	19.01	19.01
88125-TC	Clinical Laboratory	FORENSIC CYTOPATHOLOGY	20.79	20.79
88130	Clinical Laboratory	SEX CHROMATIN IDENTIFICATION	26.97	26.97
88140	Clinical Laboratory	SEX CHROMATIN IDENTIFICATION	11.99	11.99
88141	Other professional services	CYTOPATH C/V INTERPRET	33.57	33.57
88142	Clinical Laboratory	CYTOPATH C/V THIN LAYER	30.39	30.39
88143	Clinical Laboratory	CYTOPATH C/V THIN LAYER REDO	34.56	34.56
88147	Clinical Laboratory	CYTOPATH C/V AUTOMATED	75.84	75.84
88148	Clinical Laboratory	CYTOPATH C/V AUTO RESCREEN	26.64	26.64
88150	Clinical Laboratory	CYTOPATH C/V MANUAL	26.64	26.64
88152	Clinical Laboratory	CYTOPATH C/V AUTO REDO	41.46	41.46
88153	Clinical Laboratory	CYTOPATH C/V REDO	36.05	36.05
88155	Clinical Laboratory	CYTOPATH C/V INDEX ADD-ON	21.98	21.98
88160	Other professional services	CYTOPATH SMEAR OTHER SOURCE	110.13	110.13
88160-26	Clinical Laboratory	CYTOPATH SMEAR OTHER SOURCE	35.34	35.34
88160-TC	Clinical Laboratory	CYTOPATH SMEAR OTHER SOURCE	74.79	74.79
88161	Other professional services	CYTOPATH SMEAR OTHER SOURCE	112.41	112.41
88161-26	Clinical Laboratory	CYTOPATH SMEAR OTHER SOURCE	34.89	34.89
88161-TC	Clinical Laboratory	CYTOPATH SMEAR OTHER SOURCE	77.52	77.52
88162	Other professional services	CYTOPATH SMEAR OTHER SOURCE	177.81	177.81
88162-26	Clinical Laboratory	CYTOPATH SMEAR OTHER SOURCE	54.48	54.48
88162-TC	Clinical Laboratory	CYTOPATH SMEAR OTHER SOURCE	123.33	123.33
88164	Clinical Laboratory	CYTOPATH TBS C/V MANUAL	26.64	26.64
88165	Clinical Laboratory	CYTOPATH TBS C/V REDO	63.33	63.33
88166	Clinical Laboratory	CYTOPATH TBS C/V AUTO REDO	26.64	26.64
88167	Clinical Laboratory	CYTOPATH TBS C/V SELECT	26.64	26.64
88172	Other professional services	CYTP DX EVAL FNA 1ST EA SITE	78.21	78.21
88172-26	Clinical Laboratory	CYTP DX EVAL FNA 1ST EA SITE	48.77	48.77
88172-TC	Clinical Laboratory	CYTP DX EVAL FNA 1ST EA SITE	29.43	29.43
88173	Other professional services	CYTOPATH EVAL FNA REPORT	232.73	232.73
88173-26	Clinical Laboratory	CYTOPATH EVAL FNA REPORT	96.68	96.68
88173-TC	Clinical Laboratory	CYTOPATH EVAL FNA REPORT	136.07	136.07
88174	Clinical Laboratory	CYTOPATH C/V AUTO IN FLUID	38.06	38.06
88175	Clinical Laboratory	CYTOPATH C/V AUTO FLUID REDO	39.92	39.92
88177	Other professional services	CYTP FNA EVAL EA ADDL	41.42	41.42
88177-26	Clinical Laboratory	CYTP FNA EVAL EA ADDL	30.05	30.05
88177-TC	Clinical Laboratory	CYTP FNA EVAL EA ADDL	11.37	11.37
88182	Other professional services	CELL MARKER STUDY	229.89	229.89
88182-26	Clinical Laboratory	CELL MARKER STUDY	53.16	53.16
88182-TC	Clinical Laboratory	CELL MARKER STUDY	176.75	176.75
88184	Other professional services	FLOWCYTOMETRY/ TC 1 MARKER	106.17	106.17
88185	Other professional services	FLOWCYTOMETRY/TC ADD-ON	32.30	32.30
88187	Other professional services	FLOWCYTOMETRY/READ 2-8	50.06	50.06
88188	Other professional services	FLOWCYTOMETRY/READ 9-15	85.92	85.92
88189	Other professional services	FLOWCYTOMETRY/READ 16 & >	116.58	116.58
88199	Other professional services	UNLISTED CYTOPATHOLOGY PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88199-26	Clinical Laboratory	UNLISTED CYTOPATHOLOGY PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88199-TC	Clinical Laboratory	UNLISTED CYTOPATHOLOGY PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88230	Clinical Laboratory	TISSUE CULTURE LYMPHOCYTE	174.74	174.74
88233	Clinical Laboratory	TISSUE CULTURE SKIN/BIOPSY	211.10	211.10
88235	Clinical Laboratory	TISSUE CULTURE PLACENTA	225.45	225.45
88237	Clinical Laboratory	TISSUE CULTURE BONE MARROW	215.63	215.63
88239	Clinical Laboratory	TISSUE CULTURE TUMOR	221.28	221.28
88240	Clinical Laboratory	CELL CRYOPRESERVE/STORAGE	19.61	19.61
88241	Clinical Laboratory	FROZEN CELL PREPARATION	18.14	18.14
88245	Clinical Laboratory	CHROMOSOME ANALYSIS 20-25	259.76	259.76
88248	Clinical Laboratory	CHROMOSOME ANALYSIS 50-100	259.76	259.76
88249	Clinical Laboratory	CHROMOSOME ANALYSIS 100	259.76	259.76
88261	Clinical Laboratory	CHROMOSOME ANALYSIS 5	396.51	396.51
88262	Clinical Laboratory	CHROMOSOME ANALYSIS 15-20	188.24	188.24
88263	Clinical Laboratory	CHROMOSOME ANALYSIS 45	225.44	225.44
88264	Clinical Laboratory	CHROMOSOME ANALYSIS 20-25	216.92	216.92
88267	Clinical Laboratory	CHROMOSOME ANALYS PLACENTA	282.86	282.86
88269	Clinical Laboratory	CHROMOSOME ANALYS AMNIOTIC	260.49	260.49
88271	Clinical Laboratory	CYTOGENETICS DNA PROBE	32.13	32.13
88272	Clinical Laboratory	CYTOGENETICS 3-5	61.05	61.05
88273	Clinical Laboratory	CYTOGENETICS 10-30	52.22	52.22
88274	Clinical Laboratory	CYTOGENETICS 25-99	63.57	63.57
88275	Clinical Laboratory	CYTOGENETICS 100-300	76.79	76.79
88280	Clinical Laboratory	CHROMOSOME KARYOTYPE STUDY	50.21	50.21
88283	Clinical Laboratory	CHROMOSOME BANDING STUDY	102.90	102.90
88285	Clinical Laboratory	CHROMOSOME COUNT ADDITIONAL	40.37	40.37
88289	Clinical Laboratory	CHROMOSOME STUDY ADDITIONAL	51.65	51.65
88291	Other professional services	CYTO/MOLECULAR REPORT	47.12	47.12
88299	Other professional services	UNLISTED CYTOGENETIC STUDY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88300	Other professional services	SURGICAL PATH GROSS	22.32	22.32
88300-26	Clinical Laboratory	SURGICAL PATH GROSS	6.08	6.08
88300-TC	Clinical Laboratory	SURGICAL PATH GROSS	16.25	16.25
88302	Other professional services	TISSUE EXAM BY PATHOLOGIST	45.71	45.71
88302-26	Clinical Laboratory	TISSUE EXAM BY PATHOLOGIST	9.44	9.44
88302-TC	Clinical Laboratory	TISSUE EXAM BY PATHOLOGIST	36.26	36.26
88304	Other professional services	TISSUE EXAM BY PATHOLOGIST	59.22	59.22
88304-26	Clinical Laboratory	TISSUE EXAM BY PATHOLOGIST	15.68	15.68
88304-TC	Clinical Laboratory	TISSUE EXAM BY PATHOLOGIST	43.53	43.53
88305	Other professional services	TISSUE EXAM BY PATHOLOGIST	100.26	100.26
88305-26	Clinical Laboratory	TISSUE EXAM BY PATHOLOGIST	51.72	51.72
88305-TC	Clinical Laboratory	TISSUE EXAM BY PATHOLOGIST	48.54	48.54
88307	Other professional services	TISSUE EXAM BY PATHOLOGIST	397.85	397.85
88307-26	Clinical Laboratory	TISSUE EXAM BY PATHOLOGIST	113.19	113.19
88307-TC	Clinical Laboratory	TISSUE EXAM BY PATHOLOGIST	284.66	284.66
88309	Other professional services	TISSUE EXAM BY PATHOLOGIST	599.37	599.37
88309-26	Clinical Laboratory	TISSUE EXAM BY PATHOLOGIST	199.65	199.65
88309-TC	Clinical Laboratory	TISSUE EXAM BY PATHOLOGIST	399.72	399.72
88311	Other professional services	DECALCIFY TISSUE	28.37	28.37
88311-26	Clinical Laboratory	DECALCIFY TISSUE	16.67	16.67
88311-TC	Clinical Laboratory	DECALCIFY TISSUE	11.70	11.70
88312	Other professional services	SPECIAL STAINS GROUP 1	155.43	155.43
88312-26	Clinical Laboratory	SPECIAL STAINS GROUP 1	36.86	36.86
88312-TC	Clinical Laboratory	SPECIAL STAINS GROUP 1	118.58	118.58
88313	Other professional services	SPECIAL STAINS GROUP 2	113.87	113.87
88313-26	Clinical Laboratory	SPECIAL STAINS GROUP 2	16.67	16.67
88313-TC	Clinical Laboratory	SPECIAL STAINS GROUP 2	97.20	97.20
88314	Other professional services	HISTOCHEMICAL STAINS ADD-ON	122.24	122.24
88314-26	Clinical Laboratory	HISTOCHEMICAL STAINS ADD-ON	28.34	28.34
88314-TC	Clinical Laboratory	HISTOCHEMICAL STAINS ADD-ON	93.89	93.89
88319	Other professional services	ENZYME HISTOCHEMISTRY	188.01	188.01
88319-26	Clinical Laboratory	ENZYME HISTOCHEMISTRY	37.28	37.28
88319-TC	Clinical Laboratory	ENZYME HISTOCHEMISTRY	150.75	150.75
88321	Other professional services	CONSLTJ&REPRT SLD PREP ELSWR	136.34	115.88
88323	Other professional services	CONSLTJ&REPRT MATRL PREP SLD	163.19	163.19
88323-26	Clinical Laboratory	CONSLTJ&REPRT MATRL PREP SLD	122.84	122.84
88323-TC	Clinical Laboratory	CONSLTJ&REPRT MATRL PREP SLD	40.35	40.35
88325	Other professional services	CONSLTJ COMPRE RVW REC REPRT	219.41	187.11
88329	Other professional services	PATH CONSLTJ DRG SURG	76.97	48.77
88331	Other professional services	PATH CONSLTJ SURG 1 BLK 1SPC	141.75	141.75
88331-26	Clinical Laboratory	PATH CONSLTJ SURG 1 BLK 1SPC	85.49	85.49
88331-TC	Clinical Laboratory	PATH CONSLTJ SURG 1 BLK 1SPC	56.27	56.27
88332	Other professional services	PATH CONSLTJ SURG EA ADD BLK	76.02	76.02
88332-26	Clinical Laboratory	PATH CONSLTJ SURG EA ADD BLK	42.05	42.05
88332-TC	Clinical Laboratory	PATH CONSLTJ SURG EA ADD BLK	33.99	33.99
88333	Other professional services	PATH CONSLTJ SURG CYTO XM 1	128.60	128.60
88333-26	Clinical Laboratory	PATH CONSLTJ SURG CYTO XM 1	85.07	85.07
88333-TC	Clinical Laboratory	PATH CONSLTJ SURG CYTO XM 1	43.53	43.53
88334	Other professional services	PATH CONSLTJ SURG CYTO XM EA	78.03	78.03
88334-26	Clinical Laboratory	PATH CONSLTJ SURG CYTO XM EA	51.65	51.65
88334-TC	Clinical Laboratory	PATH CONSLTJ SURG CYTO XM EA	26.39	26.39
88341	Other professional services	IMHCHEM/IMCYTCHM EA ADD ANTB	125.61	125.61
88341-26	Clinical Laboratory	IMHCHEM/IMCYTCHM EA ADD ANTB	38.75	38.75
88341-TC	Clinical Laboratory	IMHCHEM/IMCYTCHM EA ADD ANTB	86.87	86.87
88342	Other professional services	IMHCHEM/IMCYTCHM 1ST ANTB	146.93	146.93
88342-26	Clinical Laboratory	IMHCHEM/IMCYTCHM 1ST ANTB	48.36	48.36
88342-TC	Clinical Laboratory	IMHCHEM/IMCYTCHM 1ST ANTB	98.57	98.57
88344	Other professional services	IMHCHEM/IMCYTCHM EA MLT ANTB	238.59	238.59
88344-26	Clinical Laboratory	IMHCHEM/IMCYTCHM EA MLT ANTB	53.16	53.16
88344-TC	Clinical Laboratory	IMHCHEM/IMCYTCHM EA MLT ANTB	185.43	185.43
88346	Other professional services	IMFLUOR 1ST 1ANTB STAIN PX	206.97	206.97
88346-26	Clinical Laboratory	IMFLUOR 1ST 1ANTB STAIN PX	49.86	49.86
88346-TC	Clinical Laboratory	IMFLUOR 1ST 1ANTB STAIN PX	157.11	157.11
88348	Other professional services	ELECTRON MICROSCOPY DX	664.92	664.92
88348-26	Clinical Laboratory	ELECTRON MICROSCOPY DX	106.65	106.65
88348-TC	Clinical Laboratory	ELECTRON MICROSCOPY DX	558.27	558.27
88350	Clinical Laboratory	IMFLUOR EA ADDL 1ANTB STN PX	157.44	157.44
88350-26	Clinical Laboratory	IMFLUOR EA ADDL 1ANTB STN PX	40.22	40.22
88350-TC	Clinical Laboratory	IMFLUOR EA ADDL 1ANTB STN PX	117.21	117.21
88355	Other professional services	M/PHMTRC ALYS SKELETAL MUSC	178.71	178.71
88355-26	Clinical Laboratory	M/PHMTRC ALYS SKELETAL MUSC	107.12	107.12
88355-TC	Clinical Laboratory	M/PHMTRC ALYS SKELETAL MUSC	71.61	71.61
88356	Other professional services	ANALYSIS NERVE	330.26	330.26
88356-26	Clinical Laboratory	ANALYSIS NERVE	171.38	171.38
88356-TC	Clinical Laboratory	ANALYSIS NERVE	158.87	158.87
88358	Other professional services	ANALYSIS TUMOR	189.54	189.54
88358-26	Clinical Laboratory	ANALYSIS TUMOR	68.24	68.24
88358-TC	Clinical Laboratory	ANALYSIS TUMOR	121.31	121.31
88360	Other professional services	TUMOR IMMUNOHISTOCHEM/MANUAL	167.03	167.03
88360-26	Clinical Laboratory	TUMOR IMMUNOHISTOCHEM/MANUAL	57.54	57.54
88360-TC	Clinical Laboratory	TUMOR IMMUNOHISTOCHEM/MANUAL	109.49	109.49
88361	Other professional services	TUMOR IMMUNOHISTOCHEM/COMPUT	166.02	166.02
88361-26	Clinical Laboratory	TUMOR IMMUNOHISTOCHEM/COMPUT	60.63	60.63
88361-TC	Clinical Laboratory	TUMOR IMMUNOHISTOCHEM/COMPUT	105.39	105.39
88362	Other professional services	NERVE TEASING PREPARATIONS	319.32	319.32
88362-26	Clinical Laboratory	NERVE TEASING PREPARATIONS	153.69	153.69
88362-TC	Clinical Laboratory	NERVE TEASING PREPARATIONS	165.63	165.63
88363	Other professional services	XM ARCHIVE TISSUE MOLEC ANAL	32.48	26.57
88364	Other professional services	INSITU HYBRIDIZATION (FISH)	184.22	184.22
88364-26	Clinical Laboratory	INSITU HYBRIDIZATION (FISH)	47.00	47.00
88364-TC	Clinical Laboratory	INSITU HYBRIDIZATION (FISH)	137.22	137.22
88365	Other professional services	INSITU HYBRIDIZATION (FISH)	244.77	244.77
88365-26	Clinical Laboratory	INSITU HYBRIDIZATION (FISH)	59.48	59.48
88365-TC	Clinical Laboratory	INSITU HYBRIDIZATION (FISH)	185.31	185.31
88366	Other professional services	INSITU HYBRIDIZATION (FISH)	374.67	374.67
88366-26	Clinical Laboratory	INSITU HYBRIDIZATION (FISH)	85.22	85.22
88366-TC	Clinical Laboratory	INSITU HYBRIDIZATION (FISH)	289.46	289.46
88367	Other professional services	INSITU HYBRIDIZATION AUTO	154.76	154.76
88367-26	Clinical Laboratory	INSITU HYBRIDIZATION AUTO	46.19	46.19
88367-TC	Clinical Laboratory	INSITU HYBRIDIZATION AUTO	108.57	108.57
88368	Other professional services	INSITU HYBRIDIZATION MANUAL	204.75	204.75
88368-26	Clinical Laboratory	INSITU HYBRIDIZATION MANUAL	58.56	58.56
88368-TC	Clinical Laboratory	INSITU HYBRIDIZATION MANUAL	146.19	146.19
88369	Other professional services	M/PHMTRC ALYSISHQUANT/SEMIQ	177.39	177.39
88369-26	Clinical Laboratory	M/PHMTRC ALYSISHQUANT/SEMIQ	46.53	46.53
88369-TC	Clinical Laboratory	M/PHMTRC ALYSISHQUANT/SEMIQ	130.86	130.86
88371	Clinical Laboratory	PROTEIN WESTERN BLOT TISSUE	33.35	33.35
88371-26	Clinical Laboratory	PROTEIN WESTERN BLOT TISSUE	26.69	26.69
88372	Clinical Laboratory	PROTEIN ANALYSIS W/PROBE	39.33	39.33
88372-26	Clinical Laboratory	PROTEIN ANALYSIS W/PROBE	24.87	24.87
88373	Other professional services	M/PHMTRC ALYS ISHQUANT/SEMIQ	94.31	94.31
88373-26	Clinical Laboratory	M/PHMTRC ALYS ISHQUANT/SEMIQ	35.31	35.31
88373-TC	Clinical Laboratory	M/PHMTRC ALYS ISHQUANT/SEMIQ	59.00	59.00
88374	Other professional services	M/PHMTRC ALYS ISHQUANT/SEMIQ	395.63	395.63
88374-26	Clinical Laboratory	M/PHMTRC ALYS ISHQUANT/SEMIQ	58.74	58.74
88374-TC	Clinical Laboratory	M/PHMTRC ALYS ISHQUANT/SEMIQ	336.89	336.89
88375	Other professional services	OPTICAL ENDOMICROSCPY INTERP	66.35	66.35
88377	Other professional services	M/PHMTRC ALYS ISHQUANT/SEMIQ	543.99	543.99
88377-26	Clinical Laboratory	M/PHMTRC ALYS ISHQUANT/SEMIQ	89.10	89.10
88377-TC	Clinical Laboratory	M/PHMTRC ALYS ISHQUANT/SEMIQ	454.89	454.89
88380	Other professional services	MICRODISSECTION LASER	173.28	173.28
88380-26	Clinical Laboratory	MICRODISSECTION LASER	73.14	73.14
88380-TC	Clinical Laboratory	MICRODISSECTION LASER	100.13	100.13
88381	Other professional services	MICRODISSECTION MANUAL	276.00	276.00
88381-26	Clinical Laboratory	MICRODISSECTION MANUAL	32.73	32.73
88381-TC	Clinical Laboratory	MICRODISSECTION MANUAL	243.27	243.27
88387	Other professional services	TISS EXAM MOLECULAR STUDY	47.03	47.03
88387-26	Clinical Laboratory	TISS EXAM MOLECULAR STUDY	37.14	37.14
88387-TC	Clinical Laboratory	TISS EXAM MOLECULAR STUDY	9.89	9.89
88388	Other professional services	TISS EX MOLECUL STUDY ADD-ON	50.51	50.51
88388-26	Clinical Laboratory	TISS EX MOLECUL STUDY ADD-ON	32.43	32.43
88388-TC	Clinical Laboratory	TISS EX MOLECUL STUDY ADD-ON	18.06	18.06
88399	Other professional services	UNLISTED SURGICAL PATH PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88399-26	Clinical Laboratory	UNLISTED SURGICAL PATH PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88399-TC	Clinical Laboratory	UNLISTED SURGICAL PATH PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
88720	Clinical Laboratory	BILIRUBIN TOTAL TRANSCUT	7.53	7.53
88738	Clinical Laboratory	HGB QUANT TRANSCUTANEOUS	7.53	7.53
88740	Clinical Laboratory	TRANSCUTANEOUS CARBOXYHB	14.06	14.06
88741	Clinical Laboratory	TRANSCUTANEOUS METHB	14.06	14.06
88749	Other professional services	UNLISTED IN VIVO LAB SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89049	Other professional services	CHCT FOR MAL HYPERTHERMIA	392.69	85.68
89050	Clinical Laboratory	BODY FLUID CELL COUNT	7.08	7.08
89051	Clinical Laboratory	BODY FLUID CELL COUNT	8.40	8.40
89055	Clinical Laboratory	LEUKOCYTE ASSESSMENT FECAL	6.41	6.41
89060	Clinical Laboratory	EXAM SYNOVIAL FLUID CRYSTALS	11.00	11.00
89060-26	Clinical Laboratory	EXAM SYNOVIAL FLUID CRYSTALS	24.87	24.87
89125	Clinical Laboratory	SPECIMEN FAT STAIN	8.82	8.82
89160	Clinical Laboratory	EXAM FECES FOR MEAT FIBERS	7.28	7.28
89190	Clinical Laboratory	NASAL SMEAR FOR EOSINOPHILS	8.69	8.69
89220	Other professional services	SPUTUM SPECIMEN COLLECTION	26.25	26.25
89230	Other professional services	COLLECT SWEAT FOR TEST	3.96	3.96
89240	Other professional services	UNLISTED MISC PATH TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89250	Other professional services	CULTR OOCYTE/EMBRYO <4 DAYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89251	Other professional services	CULTR OOCYTE/EMBRYO <4 DAYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89253	Other professional services	EMBRYO HATCHING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89254	Other professional services	OOCYTE IDENTIFICATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89255	Other professional services	PREPARE EMBRYO FOR TRANSFER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89257	Other professional services	SPERM IDENTIFICATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89258	Other professional services	CRYOPRESERVATION EMBRYO(S)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89259	Other professional services	CRYOPRESERVATION SPERM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89260	Other professional services	SPERM ISOLATION SIMPLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89261	Other professional services	SPERM ISOLATION COMPLEX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89264	Other professional services	IDENTIFY SPERM TISSUE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89268	Other professional services	INSEMINATION OF OOCYTES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89272	Other professional services	EXTENDED CULTURE OF OOCYTES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89280	Other professional services	ASSIST OOCYTE FERTILIZATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89281	Other professional services	ASSIST OOCYTE FERTILIZATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89290	Other professional services	BIOPSY OOCYTE POLAR BODY <=5	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89291	Other professional services	BIOPSY OOCYTE POLAR BODY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89300	Clinical Laboratory	SEMEN ANALYSIS W/HUHNER	14.76	14.76
89310	Clinical Laboratory	SEMEN ANALYSIS W/COUNT	12.92	12.92
89320	Clinical Laboratory	SEMEN ANAL VOL/COUNT/MOT	18.47	18.47
89321	Clinical Laboratory	SEMEN ANAL SPERM DETECTION	18.08	18.08
89322	Clinical Laboratory	SEMEN ANAL STRICT CRITERIA	23.25	23.25
89325	Clinical Laboratory	SPERM ANTIBODY TEST	16.01	16.01
89329	Clinical Laboratory	SPERM EVALUATION TEST	29.39	29.39
89330	Clinical Laboratory	EVALUATION CERVICAL MUCUS	15.57	15.57
89331	Clinical Laboratory	RETROGRADE EJACULATION ANAL	29.39	29.39
89335	Other professional services	CRYOPRESERVE TESTICULAR TISS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89337	Other professional services	CRYOPRESERVATION OOCYTE(S)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89342	Other professional services	STORAGE/YEAR EMBRYO(S)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89343	Other professional services	STORAGE/YEAR SPERM/SEMEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89344	Other professional services	STORAGE/YEAR REPROD TISSUE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89346	Other professional services	STORAGE/YEAR OOCYTE(S)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89352	Other professional services	THAWING CRYOPRESRVED EMBRYO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89353	Other professional services	THAWING CRYOPRESRVED SPERM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89354	Other professional services	THAW CRYOPRSVRD REPROD TISS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89356	Other professional services	THAWING CRYOPRESRVED OOCYTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
89398	Other professional services	UNLISTED REPROD MED LAB PROC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90281	Other professional services	HUMAN IG IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90283	Other professional services	HUMAN IG IV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90284	Other professional services	HUMAN IG SC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90287	Other professional services	BOTULINUM ANTITOXIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90288	Other professional services	BOTULISM IG IV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90291	Other professional services	CMV IG IV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90296	Other professional services	DIPHTHERIA ANTITOXIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90371	Other professional services	HEP B IG IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90375	Other professional services	RABIES IG IM/SC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90376	Other professional services	RABIES IG HEAT TREATED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90377	Other professional services	RABIES IG HT&SOL HUMAN IM/SC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90378	Other professional services	RSV MAB IM 50MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90380	Other professional services	RSV MONOC ANTB SEASN .5ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90381	Other professional services	RSV MONOC ANTB SEASN 1 ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90384	Other professional services	RH IG FULL-DOSE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90385	Other professional services	RH IG MINIDOSE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90386	Other professional services	RH IG IV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90389	Other professional services	TETANUS IG IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90393	Other professional services	VACCINA IG IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90396	Other professional services	VARICELLA-ZOSTER IG IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90399	Other professional services	UNLISTED IMMUNE GLOBULIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90460	Other professional services	IM ADMIN 1ST/ONLY COMPONENT	32.00	32.00
90461	Other professional services	IM ADMIN EACH ADDL COMPONENT	12.35	12.35
90471	Other professional services	IMMUNIZATION ADMIN	28.70	28.70
90472	Other professional services	IMMUNIZATION ADMIN EACH ADD	20.43	20.43
90473	Other professional services	IMMUNE ADMIN ORAL/NASAL	23.24	23.24
90474	Other professional services	IMMUNE ADMIN ORAL/NASAL ADDL	16.79	16.79
90476	Other professional services	ADENOVIRUS VACCINE TYPE 4	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90477	Other professional services	ADENOVIRUS VACCINE TYPE 7	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90480	Other professional services	ADMN SARSCOV2 VACC 1 DOSE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90581	Other professional services	ANTHRAX VACCINE SC OR IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90584	Other professional services	DENGUE VACC QUAD 2 DOSE SUBQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90585	Other professional services	BCG VACCINE PERCUT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90586	Other professional services	BCG VACCINE INTRAVESICAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90587	Other professional services	DENGUE VACC QUAD 3 DOSE SUBQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90589	Other professional services	CHIKUNGUNYA VACCINE LIVE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90611	Other professional services	SMALLPOX&MONKEYPOX VAC 0.5ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90619	Other professional services	MENACWY-TT VACCINE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90620	Other professional services	MENB-4C VACC 2 DOSE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90621	Other professional services	MENB-FHBP VACC 2/3 DOSE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90622	Other professional services	VACCINIA VRS VAC 0.3 ML PERQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90623	Other professional services	MENACWY-TT MENB-FHBP VACC IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90625	Other professional services	CHOLERA VACCINE LIVE ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90626	Other professional services	TIC-BRN ENCEPH VAC 0.25ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90627	Other professional services	TIC-BRN ENCEPH VAC 0.5ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90630	Other professional services	FLU VACC IIV4 NO PRESERV ID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90632	Other professional services	HEPA VACCINE ADULT IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90633	Other professional services	HEPA VACC PED/ADOL 2 DOSE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90634	Other professional services	HEPA VACC PED/ADOL 3 DOSE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90636	Other professional services	HEP A/HEP B VACC ADULT IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90644	Other professional services	HIB-MENCY VACC 6WK-18M0 IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90647	Other professional services	HIB PRP-OMP VACC 3 DOSE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90648	Other professional services	HIB PRP-T VACCINE 4 DOSE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90649	Other professional services	4VHPV VACCINE 3 DOSE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90650	Other professional services	2VHPV VACCINE 3 DOSE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90651	Other professional services	9VHPV VACCINE 2/3 DOSE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90653	Other professional services	IIV ADJUVANT VACCINE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90654	Other professional services	FLU VACC IIV3 NO PRESERV ID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90655	Other professional services	IIV3 VACC NO PRSV 0.25 ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90656	Other professional services	IIV3 VACC NO PRSV 0.5 ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90657	Other professional services	IIV3 VACCINE SPLT 0.25 ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90658	Other professional services	IIV3 VACCINE SPLT 0.5 ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90660	Other professional services	LAIV3 VACCINE INTRANASAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90661	Other professional services	CCIIV3 VAC NO PRSV 0.5 ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90662	Other professional services	IIV NO PRSV INCREASED AG IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90664	Other professional services	LAIV VACC PANDEMIC INTRANASL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90666	Other professional services	FLU VAC PANDEM PRSRV FREE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90667	Other professional services	IIV VACC PANDEMIC ADJUVT IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90668	Other professional services	IIV VACCINE PANDEMIC IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90670	Other professional services	PCV13 VACCINE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90671	Other professional services	PCV15 VACCINE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90672	Other professional services	LAIV4 VACCINE INTRANASAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90673	Other professional services	RIV3 VACCINE NO PRESERV IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90674	Other professional services	CCIIV4 VAC NO PRSV 0.5 ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90675	Other professional services	RABIES VACCINE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90676	Other professional services	RABIES VACCINE ID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90677	Other professional services	PCV20 VACCINE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90678	Other professional services	RSV VACC PREF BIVALENT IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90679	Other professional services	RSV VACC PREF RECOMB ADJT IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90680	Other professional services	RV5 VACC 3 DOSE LIVE ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90681	Other professional services	RV1 VACC 2 DOSE LIVE ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90682	Other professional services	RIV4 VACC RECOMBINANT DNA IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90683	Other professional services	RSV VACC MRNA LIPID NANO IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90685	Other professional services	IIV4 VACC NO PRSV 0.25 ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90686	Other professional services	IIV4 VACC NO PRSV 0.5 ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90687	Other professional services	IIV4 VACCINE SPLT 0.25 ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90688	Other professional services	IIV4 VACCINE SPLT 0.5 ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90689	Other professional services	VACC IIV4 NO PRSRV 0.25ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90690	Other professional services	TYPHOID VACCINE ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90691	Other professional services	TYPHOID VACCINE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90694	Other professional services	VACC AIIV4 NO PRSRV 0.5ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90696	Other professional services	DTAP-IPV VACCINE 4-6 YRS IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90697	Other professional services	DTAP-IPV-HIB-HEPB VACCINE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90698	Other professional services	DTAP-IPV/HIB VACCINE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90700	Other professional services	DTAP VACCINE < 7 YRS IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90702	Other professional services	DT VACCINE UNDER 7 YRS IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90707	Other professional services	MMR VACCINE SC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90710	Other professional services	MMRV VACCINE SC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90713	Other professional services	POLIOVIRUS IPV SC/IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90714	Other professional services	TD VACC NO PRESV 7 YRS+ IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90715	Other professional services	TDAP VACCINE 7 YRS/> IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90716	Other professional services	VAR VACCINE LIVE SUBQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90717	Other professional services	YELLOW FEVER VACCINE SUBQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90723	Other professional services	DTAP-HEP B-IPV VACCINE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90732	Other professional services	PPSV23 VACC 2 YRS+ SUBQ/IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90733	Other professional services	MPSV4 VACCINE SUBQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90734	Other professional services	MENACWYD/MENACWYCRM VACC IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90736	Other professional services	HZV VACCINE LIVE SUBQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90738	Other professional services	INACTIVATED JE VACC IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90739	Other professional services	HEPB VACC 2/4 DOSE ADULT IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90740	Other professional services	HEPB VACC 3 DOSE IMMUNSUP IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90743	Other professional services	HEPB VACC 2 DOSE ADOLESC IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90744	Other professional services	HEPB VACC 3 DOSE PED/ADOL IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90746	Other professional services	HEPB VACCINE 3 DOSE ADULT IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90747	Other professional services	HEPB VACC 4 DOSE IMMUNSUP IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90748	Other professional services	HIB-HEPB VACCINE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90749	Other professional services	UNLISTED VACCINE/TOXOID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90750	Other professional services	HZV VACC RECOMBINANT IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90756	Other professional services	CCIIV4 VACC ABX FREE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90758	Other professional services	ZAIRE EBOLAVIRUS VAC LIVE IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90759	Other professional services	HEP B VAC 3AG 10MCG 3 DOS IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90785	Other professional services	PSYTX COMPLEX INTERACTIVE	21.09	18.81
90791	Other professional services	PSYCH DIAGNOSTIC EVALUATION	247.82	214.16
90792	Other professional services	PSYCH DIAG EVAL W/MED SRVCS	277.65	243.99
90832	Other professional services	PSYTX W PT 30 MINUTES	112.71	99.06
90833	Other professional services	PSYTX W PT W E/M 30 MIN	103.05	92.13
90834	Other professional services	PSYTX W PT 45 MINUTES	148.77	131.03
90836	Other professional services	PSYTX W PT W E/M 45 MIN	130.37	116.73
90837	Other professional services	PSYTX W PT 60 MINUTES	219.32	193.38
90838	Other professional services	PSYTX W PT W E/M 60 MIN	172.76	154.56
90839	Other professional services	PSYTX CRISIS INITIAL 60 MIN	210.77	186.66
90840	Other professional services	PSYTX CRISIS EA ADDL 30 MIN	103.83	92.91
90845	Other professional services	PSYCHOANALYSIS	140.82	125.36
90846	Other professional services	FAMILY PSYTX W/O PT 50 MIN	141.48	141.03
90847	Other professional services	FAMILY PSYTX W/PT 50 MIN	148.26	147.35
90849	Other professional services	MULTIPLE FAMILY GROUP PSYTX	53.39	42.02
90853	Other professional services	GROUP PSYCHOTHERAPY	39.75	34.74
90863	Other professional services	PHARMACOLOGIC MGMT W/PSYTX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90865	Other professional services	NARCOSYNTHESIS	229.25	174.21
90867	Other professional services	TCRANIAL MAGN STIM TX PLAN	292.04	176.36
90868	Other professional services	TCRANIAL MAGN STIM TX DELI	270.38	36.98
90869	Other professional services	TCRAN MAGN STIM REDETEMINE	263.19	147.56
90870	Other professional services	ELECTROCONVULSIVE THERAPY	243.41	149.70
90875	Other professional services	PSYCHOPHYSIOLOGICAL THERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90876	Other professional services	PSYCHOPHYSIOLOGICAL THERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90880	Other professional services	HYPNOTHERAPY	147.27	124.08
90882	Other professional services	ENVIRONMENTAL MANIPULATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90885	Other professional services	PSY EVALUATION OF RECORDS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90887	Other professional services	CONSULTATION WITH FAMILY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90889	Other professional services	PREPARATION OF REPORT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90899	Other professional services	UNLISTED PSYC SVC/THERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90901	Other professional services	BIOFEEDBACK TRAIN ANY METH	57.18	27.17
90912	Other professional services	BFB TRAINING 1ST 15 MIN	112.70	59.94
90913	Major surgery	BFB TRAINING EA ADDL 15 MIN	58.62	43.84
90935	Other professional services	HEMODIALYSIS ONE EVALUATION	99.74	99.74
90937	Other professional services	HEMODIALYSIS REPEATED EVAL	143.36	143.36
90940	Other professional services	HEMODIALYSIS ACCESS STUDY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90945	Other professional services	DIALYSIS ONE EVALUATION	119.91	119.91
90947	Other professional services	DIALYSIS REPEATED EVAL	171.50	171.50
90951	Other professional services	ESRD SERV 4 VISITS P MO <2YR	1645.95	1645.95
90952	Other professional services	ESRD SERV 2-3 VSTS P MO <2YR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90953	Other professional services	ESRD SERV 1 VISIT P MO <2YRS	664.95	664.95
90954	Other professional services	ESRD SERV 4 VSTS P MO 2-11	1412.96	1412.96
90955	Other professional services	ESRD SRV 2-3 VSTS P MO 2-11	733.31	733.31
90956	Other professional services	ESRD SRV 1 VISIT P MO 2-11	488.84	488.84
90957	Other professional services	ESRD SRV 4 VSTS P MO 12-19	1080.48	1080.48
90958	Other professional services	ESRD SRV 2-3 VSTS P MO 12-19	702.87	702.87
90959	Other professional services	ESRD SERV 1 VST P MO 12-19	457.64	457.64
90960	Other professional services	ESRD SRV 4 VISITS P MO 20+	496.91	496.91
90961	Other professional services	ESRD SRV 2-3 VSTS P MO 20+	412.31	412.31
90962	Other professional services	ESRD SERV 1 VISIT P MO 20+	283.95	283.95
90963	Other professional services	ESRD HOME PT SERV P MO <2YRS	852.74	852.74
90964	Other professional services	ESRD HOME PT SERV P MO 2-11	730.58	730.58
90965	Other professional services	ESRD HOME PT SERV P MO 12-19	701.25	701.25
90966	Other professional services	ESRD HOME PT SERV P MO 20+	412.31	412.31
90967	Other professional services	ESRD SVC PR DAY PT <2	24.66	24.66
90968	Other professional services	ESRD SVC PR DAY PT 2-11	24.18	24.18
90969	Other professional services	ESRD SVC PR DAY PT 12-19	23.69	23.69
90970	Other professional services	ESRD SVC PR DAY PT 20+	13.26	13.26
90989	Other professional services	DIALYSIS TRAINING COMPLETE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90993	Other professional services	DIALYSIS TRAINING INCOMPL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
90997	Other professional services	HEMOPERFUSION	123.53	123.53
90999	Other professional services	UNLISTED DIALYSIS PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
91010	Other professional services	ESOPHAGUS MOTILITY STUDY	305.18	305.18
91010-26	Other professional services	ESOPHAGUS MOTILITY STUDY	90.30	90.30
91010-TC	Other professional services	ESOPHAGUS MOTILITY STUDY	214.88	214.88
91013	Other professional services	ESOPHGL MOTIL W/STIM/PERFUS	35.09	35.09
91013-26	Other professional services	ESOPHGL MOTIL W/STIM/PERFUS	12.81	12.81
91013-TC	Other professional services	ESOPHGL MOTIL W/STIM/PERFUS	22.29	22.29
91020	Other professional services	GASTRIC MOTILITY STUDIES	381.26	381.26
91020-26	Other professional services	GASTRIC MOTILITY STUDIES	101.48	101.48
91020-TC	Other professional services	GASTRIC MOTILITY STUDIES	279.78	279.78
91022	Other professional services	DUODENAL MOTILITY STUDY	241.29	241.29
91022-26	Other professional services	DUODENAL MOTILITY STUDY	101.48	101.48
91022-TC	Other professional services	DUODENAL MOTILITY STUDY	139.83	139.83
91030	Other professional services	ACID PERFUSION OF ESOPHAGUS	200.97	200.97
91030-26	Other professional services	ACID PERFUSION OF ESOPHAGUS	64.32	64.32
91030-TC	Other professional services	ACID PERFUSION OF ESOPHAGUS	136.65	136.65
91034	Other professional services	GASTROESOPHAGEAL REFLUX TEST	263.57	263.57
91034-26	Other professional services	GASTROESOPHAGEAL REFLUX TEST	69.17	69.17
91034-TC	Other professional services	GASTROESOPHAGEAL REFLUX TEST	194.40	194.40
91035	Other professional services	G-ESOPH REFLX TST W/ELECTROD	624.36	624.36
91035-26	Other professional services	G-ESOPH REFLX TST W/ELECTROD	112.94	112.94
91035-TC	Other professional services	G-ESOPH REFLX TST W/ELECTROD	511.41	511.41
91037	Other professional services	ESOPH IMPED FUNCTION TEST	232.89	232.89
91037-26	Other professional services	ESOPH IMPED FUNCTION TEST	68.06	68.06
91037-TC	Other professional services	ESOPH IMPED FUNCTION TEST	164.84	164.84
91038	Other professional services	ESOPH IMPED FUNCT TEST > 1HR	552.53	552.53
91038-26	Other professional services	ESOPH IMPED FUNCT TEST > 1HR	77.49	77.49
91038-TC	Other professional services	ESOPH IMPED FUNCT TEST > 1HR	475.02	475.02
91040	Other professional services	ESOPH BALLOON DISTENSION TST	707.01	707.01
91040-26	Other professional services	ESOPH BALLOON DISTENSION TST	68.58	68.58
91040-TC	Other professional services	ESOPH BALLOON DISTENSION TST	638.43	638.43
91065	Other professional services	BREATH HYDROGEN/METHANE TEST	101.45	101.45
91065-26	Other professional services	BREATH HYDROGEN/METHANE TEST	13.79	13.79
91065-TC	Other professional services	BREATH HYDROGEN/METHANE TEST	87.65	87.65
91110	Other professional services	GI TRC IMG INTRAL ESOPH-ILE	1003.17	1003.17
91110-26	Other professional services	GI TRC IMG INTRAL ESOPH-ILE	157.34	157.34
91110-TC	Other professional services	GI TRC IMG INTRAL ESOPH-ILE	845.84	845.84
91111	Other professional services	GI TRC IMG INTRAL ESOPHAGUS	1196.21	1196.21
91111-26	Other professional services	GI TRC IMG INTRAL ESOPHAGUS	63.38	63.38
91111-TC	Other professional services	GI TRC IMG INTRAL ESOPHAGUS	1132.82	1132.82
91112	Other professional services	GI WIRELESS CAPSULE MEASURE	2201.88	2201.88
91112-26	Other professional services	GI WIRELESS CAPSULE MEASURE	147.74	147.74
91112-TC	Other professional services	GI WIRELESS CAPSULE MEASURE	2054.15	2054.15
91113	Other professional services	GI TRC IMG INTRAL COLON I&R	1226.84	1226.84
91113-26	Other professional services	GI TRC IMG INTRAL COLON I&R	169.65	169.65
91113-TC	Other professional services	GI TRC IMG INTRAL COLON I&R	1057.20	1057.20
91117	Other professional services	COLON MOTILITY 6 HR STUDY	189.56	189.56
91120	Other professional services	RECTAL SENSATION TEST	684.98	684.98
91120-26	Other professional services	RECTAL SENSATION TEST	67.47	67.47
91120-TC	Other professional services	RECTAL SENSATION TEST	617.52	617.52
91122	Other professional services	ANAL PRESSURE RECORD	381.48	381.48
91122-26	Other professional services	ANAL PRESSURE RECORD	122.63	122.63
91122-TC	Other professional services	ANAL PRESSURE RECORD	258.86	258.86
91132	Other professional services	ELECTROGASTROGRAPHY	598.23	598.23
91132-26	Other professional services	ELECTROGASTROGRAPHY	36.66	36.66
91132-TC	Other professional services	ELECTROGASTROGRAPHY	561.57	561.57
91133	Other professional services	ELECTROGASTROGRAPHY W/TEST	629.21	629.21
91133-26	Other professional services	ELECTROGASTROGRAPHY W/TEST	46.26	46.26
91133-TC	Other professional services	ELECTROGASTROGRAPHY W/TEST	582.95	582.95
91200	Other professional services	LIVER ELASTOGRAPHY	42.35	42.35
91200-26	Other professional services	LIVER ELASTOGRAPHY	14.73	14.73
91200-TC	Other professional services	LIVER ELASTOGRAPHY	27.62	27.62
91299	Other professional services	UNLISTED DX GI PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
91299-26	Other professional services	UNLISTED DX GI PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
91299-TC	Other professional services	UNLISTED DX GI PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
91304	Other professional services	SARSCOV2 VAC 5MCG/0.5ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
91318	Other professional services	SARSCOV2 VAC 3MCG TRS-SUC IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
91319	Other professional services	SARSCV2 VAC 10MCG TRS-SUC IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
91320	Other professional services	SARSCV2 VAC 30MCG TRS-SUC IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
91321	Other professional services	SARSCOV2 VAC 25 MCG/.25ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
91322	Other professional services	SARSCOV2 VAC 50 MCG/0.5ML IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92002	Other professional services	INTRM OPH EXAM NEW PATIENT	118.47	63.89
92004	Other professional services	COMPRE OPH EXAM NEW PT 1/>	208.82	131.96
92012	Other professional services	INTRM OPH EXAM EST PATIENT	124.40	70.28
92014	Other professional services	COMPRE OPH EXAM EST PT 1/>	176.12	106.08
92015	Other professional services	DETERMINE REFRACTIVE STATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92018	Other professional services	COMPL OPH EXAM GENERAL ANES	194.73	194.73
92019	Other professional services	LMTD OPH EXAM GENERAL ANES	101.78	101.78
92020	Other professional services	GONIOSCOPY	38.51	28.50
92025	Other professional services	CPTRIZED CORNEAL TOPOGRAPHY	50.60	50.60
92025-26	Other professional services	CPTRIZED CORNEAL TOPOGRAPHY	27.08	27.08
92025-TC	Other professional services	CPTRIZED CORNEAL TOPOGRAPHY	23.52	23.52
92060	Other professional services	SENSORIMOTOR EXAMINATION	89.12	89.12
92060-26	Other professional services	SENSORIMOTOR EXAMINATION	51.96	51.96
92060-TC	Other professional services	SENSORIMOTOR EXAMINATION	37.17	37.17
92065	Other professional services	ORTHOP TRAING PFRMD PHYS/QHP	56.58	47.48
92065-26	Other professional services	ORTHOP TRAING PFRMD PHYS/QHP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92065-TC	Other professional services	ORTHOP TRAING PFRMD PHYS/QHP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92066	Other professional services	ORTHOP TRAING SUPVJ PHYS/QHP	35.81	35.81
92071	Other professional services	CONTACT LENS FITTING FOR TX	51.08	45.17
92072	Other professional services	FITG C-LENS KERATOCONUS 1ST	176.55	131.99
92081	Other professional services	LIMITED VISUAL FIELD XM	46.32	46.32
92081-26	Other professional services	LIMITED VISUAL FIELD XM	22.34	22.34
92081-TC	Other professional services	LIMITED VISUAL FIELD XM	23.97	23.97
92082	Other professional services	INTERMEDIATE VISUAL FIELD XM	65.33	65.33
92082-26	Other professional services	INTERMEDIATE VISUAL FIELD XM	29.07	29.07
92082-TC	Other professional services	INTERMEDIATE VISUAL FIELD XM	36.26	36.26
92083	Other professional services	EXTENDED VISUAL FIELD XM	87.98	87.98
92083-26	Other professional services	EXTENDED VISUAL FIELD XM	37.62	37.62
92083-TC	Other professional services	EXTENDED VISUAL FIELD XM	50.36	50.36
92100	Other professional services	SERIAL TONOMETRY	117.95	45.17
92132	Other professional services	CMPTR OPHTH DX IMG ANT SEGMT	43.59	43.59
92132-26	Other professional services	CMPTR OPHTH DX IMG ANT SEGMT	22.80	22.80
92132-TC	Other professional services	CMPTR OPHTH DX IMG ANT SEGMT	20.79	20.79
92133	Other professional services	CMPTR OPHTH IMG OPTIC NERVE	50.78	50.78
92133-26	Other professional services	CMPTR OPHTH IMG OPTIC NERVE	29.99	29.99
92133-TC	Other professional services	CMPTR OPHTH IMG OPTIC NERVE	20.79	20.79
92134	Other professional services	CPTR OPHTH DX IMG POST SEGMT	56.42	56.42
92134-26	Other professional services	CPTR OPHTH DX IMG POST SEGMT	34.71	34.71
92134-TC	Other professional services	CPTR OPHTH DX IMG POST SEGMT	21.71	21.71
92136	Other professional services	OPHTHALMIC BIOMETRY	65.84	65.84
92136-26	Other professional services	OPHTHALMIC BIOMETRY	42.32	42.32
92136-TC	Other professional services	OPHTHALMIC BIOMETRY	23.52	23.52
92145	Other professional services	CORNEAL HYSTERESIS DETER	17.85	17.85
92145-26	Other professional services	CORNEAL HYSTERESIS DETER	7.52	7.52
92145-TC	Other professional services	CORNEAL HYSTERESIS DETER	10.34	10.34
92201	Other professional services	OPSCPY EXTND RTA DRAW UNI/BI	34.86	31.67
92202	Other professional services	OPSCPY EXTND ON/MAC DRAW	21.74	20.37
92227	Other professional services	IMG RTA DETCJ/MNTR DS STAFF	23.97	23.97
92228	Other professional services	IMG RTA DETC/MNTR DS PHY/QHP	41.39	41.39
92228-26	Other professional services	IMG RTA DETC/MNTR DS PHY/QHP	23.33	23.33
92228-TC	Other professional services	IMG RTA DETC/MNTR DS PHY/QHP	18.06	18.06
92229	Other professional services	IMG RTA DETC/MNTR DS POC ALY	55.82	55.82
92230	Other professional services	FLUORESCEIN ANGIOSCOPY I&R	188.73	48.20
92235	Other professional services	FLUORESCEIN ANGRPH MLTIFRAME	223.97	223.97
92235-26	Other professional services	FLUORESCEIN ANGRPH MLTIFRAME	59.00	59.00
92235-TC	Other professional services	FLUORESCEIN ANGRPH MLTIFRAME	164.97	164.97
92240	Other professional services	ICG ANGIOGRAPHY I&R UNI/BI	258.41	258.41
92240-26	Other professional services	ICG ANGIOGRAPHY I&R UNI/BI	64.77	64.77
92240-TC	Other professional services	ICG ANGIOGRAPHY I&R UNI/BI	193.62	193.62
92242	Neurology	FLUORESCEIN&ICG ANGIOGRAPHY	394.08	394.08
92242-26	Other professional services	FLUORESCEIN&ICG ANGIOGRAPHY	75.39	75.39
92242-TC	Other professional services	FLUORESCEIN&ICG ANGIOGRAPHY	310.97	310.97
92250	Other professional services	FUNDUS PHOTOGRAPHY W/I&R	51.68	51.68
92250-26	Other professional services	FUNDUS PHOTOGRAPHY W/I&R	29.07	29.07
92250-TC	Other professional services	FUNDUS PHOTOGRAPHY W/I&R	22.62	22.62
92260	Other professional services	OPHTHALMODYNAMOMETRY	26.99	15.15
92265	Other professional services	NDL OCULOELECTROMYOGRAPHY 1+	121.40	121.40
92265-26	Other professional services	NDL OCULOELECTROMYOGRAPHY 1+	63.77	63.77
92265-TC	Other professional services	NDL OCULOELECTROMYOGRAPHY 1+	57.63	57.63
92270	Other professional services	ELECTRO-OCULOGRAPHY W/I&R	162.66	162.66
92270-26	Other professional services	ELECTRO-OCULOGRAPHY W/I&R	59.22	59.22
92270-TC	Other professional services	ELECTRO-OCULOGRAPHY W/I&R	103.44	103.44
92273	Other professional services	FULL FIELD ERG W/I&R	174.05	174.05
92273-26	Other professional services	FULL FIELD ERG W/I&R	50.60	50.60
92273-TC	Other professional services	FULL FIELD ERG W/I&R	123.45	123.45
92274	Other professional services	MULTIFOCAL ERG W/I&R	123.86	123.86
92274-26	Other professional services	MULTIFOCAL ERG W/I&R	46.20	46.20
92274-TC	Other professional services	MULTIFOCAL ERG W/I&R	77.64	77.64
92283	Other professional services	EXTND COLOR VISION XM	74.49	74.49
92283-26	Other professional services	EXTND COLOR VISION XM	11.87	11.87
92283-TC	Other professional services	EXTND COLOR VISION XM	62.64	62.64
92284	Other professional services	DX DARK ADAPTATION EXAM I&R	50.81	50.81
92284-26	Other professional services	DX DARK ADAPTATION EXAM I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92284-TC	Other professional services	DX DARK ADAPTATION EXAM I&R	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92285	Other professional services	EXTERNAL OCULAR PHOTOGRAPHY	31.77	31.77
92285-26	Other professional services	EXTERNAL OCULAR PHOTOGRAPHY	4.14	4.14
92285-TC	Other professional services	EXTERNAL OCULAR PHOTOGRAPHY	27.62	27.62
92286	Other professional services	ANT SGM IMG I&R SPECLR MIC	54.41	54.41
92286-26	Other professional services	ANT SGM IMG I&R SPECLR MIC	29.99	29.99
92286-TC	Other professional services	ANT SGM IMG I&R SPECLR MIC	24.44	24.44
92287	Other professional services	ANT SGM IMG IR FLRSCN ANGRPH	195.86	195.86
92287-26	Other professional services	ANT SGM IMG IR FLRSCN ANGRPH	40.89	40.89
92287-TC	Other professional services	ANT SGM IMG IR FLRSCN ANGRPH	154.97	154.97
92310	Other professional services	CONTACT LENS FITTING OU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92311	Other professional services	CONTACT LENS FITG APHAKIA 1	144.33	72.48
92312	Other professional services	CONTACT LENS FITG APHAKIA OU	172.16	86.19
92313	Other professional services	C-LENS FITG CORNEOSCLRL LENS	136.94	60.53
92314	Other professional services	C-LENS FITG TECH OU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92315	Other professional services	C-LENS FITG TECH APHAKIA 1	112.94	29.25
92316	Other professional services	C-LENS FITG TECH APHAKIA OU	140.16	44.19
92317	Other professional services	C-LENS FITG TECH CORNEOSCLRL	119.31	29.25
92325	Other professional services	MODIFICATION OF CONTACT LENS	55.82	55.82
92326	Other professional services	REPLACEMENT OF CONTACT LENS	53.54	53.54
92340	Other professional services	FIT SPECTACLES MONOFOCAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92341	Other professional services	FIT SPECTACLES BIFOCAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92342	Other professional services	FIT SPECTACLES MULTIFOCAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92352	Other professional services	FIT APHAKIA SPECTCL MONOFOCL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92353	Other professional services	FIT APHAKIA SPECTCL MULTIFOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92354	Other professional services	FITG SPECT LOW VIS 1SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92355	Other professional services	FITG SPECT LW VIS CMPND LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92358	Other professional services	APHAKIA PROSTH SERVICE TEMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92370	Other professional services	RPR&REFITG SPECT XCP APHAKIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92371	Other professional services	RPR&REFIT SPCT PRSTH APHAKIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92499	Other professional services	UNLISTED OPH SVC/PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92499-26	Other professional services	UNLISTED OPH SVC/PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92499-TC	Other professional services	UNLISTED OPH SVC/PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92502	Other professional services	EAR AND THROAT EXAMINATION	133.83	133.83
92504	Other professional services	EAR MICROSCOPY EXAMINATION	40.10	12.81
92507	Other professional services	SPEECH/HEARING THERAPY	108.50	108.50
92508	Other professional services	SPEECH/HEARING THERAPY	34.28	34.28
92511	Other professional services	NASOPHARYNGOSCOPY	161.81	53.10
92512	Other professional services	NASAL FUNCTION STUDIES	89.27	38.33
92516	Other professional services	FACIAL NERVE FUNCTION TEST	99.87	31.65
92517	Other professional services	VEMP TEST I&R CERVICAL	107.58	59.37
92518	Other professional services	VEMP TEST I&R OCULAR	108.69	60.03
92519	Other professional services	VEMP TST I&R CERVICAL&OCULAR	177.59	89.36
92520	Other professional services	LARYNGEAL FUNCTION STUDIES	121.97	56.01
92521	Other professional services	EVALUATION OF SPEECH FLUENCY	188.85	188.85
92522	Other professional services	EVALUATE SPEECH PRODUCTION	158.00	158.00
92523	Other professional services	SPEECH SOUND LANG COMPREHEN	323.78	323.78
92524	Other professional services	BEHAVRAL QUALIT ANALYS VOICE	155.72	155.72
92526	Other professional services	ORAL FUNCTION THERAPY	120.02	120.02
92531	Other professional services	SPONTANEOUS NYSTAGMUS STUDY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92532	Other professional services	POSITIONAL NYSTAGMUS TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92533	Other professional services	CALORIC VESTIBULAR TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92534	Other professional services	OPTOKINETIC NYSTAGMUS TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92537	Neurology	CALORIC VSTBLR TEST W/REC	57.18	57.18
92537-26	Other professional services	CALORIC VSTBLR TEST W/REC	43.44	43.44
92537-TC	Other professional services	CALORIC VSTBLR TEST W/REC	12.60	12.60
92538	Neurology	CALORIC VSTBLR TEST W/REC	31.93	31.93
92538-26	Other professional services	CALORIC VSTBLR TEST W/REC	22.34	22.34
92538-TC	Other professional services	CALORIC VSTBLR TEST W/REC	8.97	8.97
92540	Other professional services	BASIC VESTIBULAR EVALUATION	150.62	150.62
92540-26	Other professional services	BASIC VESTIBULAR EVALUATION	108.44	108.44
92540-TC	Other professional services	BASIC VESTIBULAR EVALUATION	42.17	42.17
92541	Other professional services	SPONTANEOUS NYSTAGMUS TEST	35.31	35.31
92541-26	Other professional services	SPONTANEOUS NYSTAGMUS TEST	29.52	29.52
92541-TC	Other professional services	SPONTANEOUS NYSTAGMUS TEST	5.79	5.79
92542	Other professional services	POSITIONAL NYSTAGMUS TEST	40.61	40.61
92542-26	Other professional services	POSITIONAL NYSTAGMUS TEST	34.82	34.82
92542-TC	Other professional services	POSITIONAL NYSTAGMUS TEST	5.79	5.79
92544	Other professional services	OPTOKINETIC NYSTAGMUS TEST	24.83	24.83
92544-26	Other professional services	OPTOKINETIC NYSTAGMUS TEST	19.95	19.95
92544-TC	Other professional services	OPTOKINETIC NYSTAGMUS TEST	4.88	4.88
92545	Other professional services	OSCILLATING TRACKING TEST	23.40	23.40
92545-26	Other professional services	OSCILLATING TRACKING TEST	18.53	18.53
92545-TC	Other professional services	OSCILLATING TRACKING TEST	4.88	4.88
92546	Other professional services	SINUSOIDAL ROTATIONAL TEST	181.68	181.68
92546-26	Other professional services	SINUSOIDAL ROTATIONAL TEST	20.94	20.94
92546-TC	Other professional services	SINUSOIDAL ROTATIONAL TEST	160.76	160.76
92547	Other professional services	SUPPLEMENTAL ELECTRICAL TEST	14.55	14.55
92548	Other professional services	CDP-SOT 6 COND W/I&R	66.18	66.18
92548-26	Other professional services	CDP-SOT 6 COND W/I&R	47.21	47.21
92548-TC	Other professional services	CDP-SOT 6 COND W/I&R	18.98	18.98
92549	Other professional services	CDP-SOT 6 COND W/I&R MCT&ADT	90.69	90.69
92549-26	Other professional services	CDP-SOT 6 COND W/I&R MCT&ADT	63.08	63.08
92549-TC	Other professional services	CDP-SOT 6 COND W/I&R MCT&ADT	27.62	27.62
92550	Other professional services	TYMPANOMETRY & REFLEX THRESH	30.71	30.71
92551	Other professional services	PURE TONE HEARING TEST AIR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92552	Other professional services	PURE TONE AUDIOMETRY AIR	51.72	51.72
92553	Other professional services	AUDIOMETRY AIR & BONE	62.64	62.64
92555	Other professional services	SPEECH THRESHOLD AUDIOMETRY	39.44	39.44
92556	Other professional services	SPEECH AUDIOMETRY COMPLETE	61.28	61.28
92557	Other professional services	COMPREHENSIVE HEARING TEST	51.50	44.67
92558	Other professional services	EVOKED AUDITORY TEST QUAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92562	Other professional services	LOUDNESS BALANCE TEST	65.82	65.82
92563	Other professional services	TONE DECAY HEARING TEST	47.18	47.18
92565	Other professional services	STENGER TEST PURE TONE	28.53	28.53
92567	Other professional services	TYMPANOMETRY	22.89	15.15
92568	Other professional services	ACOUSTIC REFL THRESHOLD TST	21.39	20.94
92570	Other professional services	ACOUSTIC IMMITANCE TESTING	45.41	40.86
92571	Other professional services	FILTERED SPEECH HEARING TEST	42.17	42.17
92572	Other professional services	STAGGERED SPONDAIC WORD TEST	72.65	72.65
92575	Other professional services	SENSORINEURAL ACUITY TEST	100.71	100.71
92576	Other professional services	SYNTHETIC SENTENCE TEST	58.10	58.10
92577	Other professional services	STENGER TEST SPEECH	29.90	29.90
92579	Other professional services	VISUAL AUDIOMETRY (VRA)	62.33	51.87
92582	Other professional services	CONDITIONING PLAY AUDIOMETRY	118.13	118.13
92583	Other professional services	SELECT PICTURE AUDIOMETRY	77.64	77.64
92584	Other professional services	ELECTROCOCHLEOGRAPHY	154.13	154.13
92587	Other professional services	EVOKED AUDITORY TEST LIMITED	30.12	30.12
92587-26	Other professional services	EVOKED AUDITORY TEST LIMITED	25.25	25.25
92587-TC	Other professional services	EVOKED AUDITORY TEST LIMITED	4.88	4.88
92588	Other professional services	EVOKED AUDITORY TST COMPLETE	46.77	46.77
92588-26	Other professional services	EVOKED AUDITORY TST COMPLETE	40.08	40.08
92588-TC	Other professional services	EVOKED AUDITORY TST COMPLETE	6.69	6.69
92590	Other professional services	HEARING AID EXAM ONE EAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92591	Other professional services	HEARING AID EXAM BOTH EARS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92592	Other professional services	HEARING AID CHECK ONE EAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92593	Other professional services	HEARING AID CHECK BOTH EARS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92594	Other professional services	ELECTRO HEARNG AID TEST ONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92595	Other professional services	ELECTRO HEARNG AID TST BOTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92596	Other professional services	EAR PROTECTOR EVALUATION	104.94	104.94
92597	Other professional services	ORAL SPEECH DEVICE EVAL	102.77	102.77
92601	Other professional services	COCHLEAR IMPLT F/UP EXAM <7	222.72	172.23
92602	Other professional services	REPROGRAM COCHLEAR IMPLT <7	139.88	97.13
92603	Other professional services	COCHLEAR IMPLT F/UP EXAM 7/>	209.81	167.51
92604	Other professional services	REPROGRAM COCHLEAR IMPLT 7/>	126.05	92.85
92605	Other professional services	EX FOR NONSPEECH DEVICE RX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92606	Other professional services	NON-SPEECH DEVICE SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92607	Other professional services	EX FOR SPEECH DEVICE RX 1HR	175.28	175.28
92608	Other professional services	EX FOR SPEECH DEVICE RX ADDL	68.69	68.69
92609	Other professional services	USE OF SPEECH DEVICE SERVICE	145.94	145.94
92610	Other professional services	EVALUATE SWALLOWING FUNCTION	120.65	99.72
92611	Other professional services	MOTION FLUOROSCOPY/SWALLOW	129.50	129.50
92612	Other professional services	ENDOSCOPY SWALLOW (FEES) VID	274.92	93.45
92613	Other professional services	ENDOSCOPY SWALLOW (FEES) I&R	51.20	51.20
92614	Other professional services	LARYNGOSCOPIC SENSORY VID	207.48	91.95
92615	Other professional services	LARYNGOSCOPIC SENSORY I&R	45.90	45.90
92616	Other professional services	FEES W/LARYNGEAL SENSE TEST	317.55	139.73
92617	Other professional services	FEES W/LARYNGEAL SENSE I&R	57.27	57.27
92618	Other professional services	EX FOR NONSPEECH DEV RX ADD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92620	Other professional services	AUDITORY FUNCTION 60 MIN	124.89	111.24
92621	Other professional services	AUDITORY FUNCTION + 15 MIN	30.71	26.16
92622	Other professional services	DX ALY AUD OI SND PRCSR 1ST	111.95	93.30
92623	Other professional services	DX ALY AUD OI SND PRCSR EACH	28.82	24.72
92625	Other professional services	TINNITUS ASSESSMENT	95.09	85.53
92626	Other professional services	EVAL AUD FUNCJ 1ST HOUR	121.92	104.64
92627	Other professional services	EVAL AUD FUNCJ EA ADDL 15	28.82	24.72
92630	Other professional services	AUD REHAB PRE-LING HEAR LOSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92633	Other professional services	AUD REHAB POSTLING HEAR LOSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92640	Other professional services	AUD BRAINSTEM IMPLT PROGRAMG	153.24	131.42
92650	Other professional services	AEP SCR AUDITORY POTENTIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92651	Other professional services	AEP HEARING STATUS DETER I&R	115.79	115.79
92652	Other professional services	AEP THRSHLD EST MLT FREQ I&R	157.25	157.25
92653	Other professional services	AEP NEURODIAGNOSTIC I&R	116.30	116.30
92700	Other professional services	UNLISTED ORL SERVICE/PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92920	Other professional services	PRQ CARDIAC ANGIOPLAST 1 ART	709.91	709.91
92921	Other professional services	PRQ CARDIAC ANGIO ADDL ART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92924	Other professional services	PRQ CARD ANGIO/ATHRECT 1 ART	846.68	846.68
92925	Other professional services	PRQ CARD ANGIO/ATHRECT ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92928	Other professional services	PRQ CARD STENT W/ANGIO 1 VSL	789.87	789.87
92929	Other professional services	PRQ CARD STENT W/ANGIO ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92933	Other professional services	PRQ CARD STENT/ATH/ANGIO	885.80	885.80
92934	Other professional services	PRQ CARD STENT/ATH/ANGIO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92937	Other professional services	PRQ REVASC BYP GRAFT 1 VSL	789.71	789.71
92938	Other professional services	PRQ REVASC BYP GRAFT ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92941	Other professional services	PRQ CARD REVASC MI 1 VSL	886.91	886.91
92943	Other professional services	PRQ CARD REVASC CHRONIC 1VSL	886.77	886.77
92944	Other professional services	PRQ CARD REVASC CHRONIC ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
92950	Other professional services	HEART/LUNG RESUSCITATION CPR	451.04	255.47
92953	Other professional services	TEMPORARY EXTERNAL PACING	1.28	1.28
92960	Other professional services	CARDIOVERSION ELECTRIC EXT	214.11	149.99
92961	Other professional services	CARDIOVERSION ELECTRIC INT	329.12	329.12
92970	Other professional services	CARDIOASSIST INTERNAL	253.11	253.11
92971	Other professional services	CARDIOASSIST EXTERNAL	134.57	134.57
92972	Other professional services	PERQ TRLUML CORONRY LITHOTRP	202.25	202.25
92973	Other professional services	PRQ CORONARY MECH THROMBECT	236.67	236.67
92974	Other professional services	CATH PLACE CARDIO BRACHYTX	216.86	216.86
92975	Other professional services	DISSOLVE CLOT HEART VESSEL	504.15	504.15
92977	Other professional services	DISSOLVE CLOT HEART VESSEL	73.71	73.71
92978	Other professional services	ENDOLUMINL IVUS OCT C 1ST	398.10	398.10
92978-26	Other professional services	ENDOLUMINL IVUS OCT C 1ST	127.71	127.71
92978-TC	Other professional services	ENDOLUMINL IVUS OCT C 1ST	270.39	270.39
92979	Other professional services	ENDOLUMINL IVUS OCT C EA	236.55	236.55
92979-26	Other professional services	ENDOLUMINL IVUS OCT C EA	101.51	101.51
92979-TC	Other professional services	ENDOLUMINL IVUS OCT C EA	135.05	135.05
92986	Major surgery	REVISION OF AORTIC VALVE	2325.53	2325.53
92987	Major surgery	REVISION OF MITRAL VALVE	2397.25	2397.25
92990	Major surgery	REVISION OF PULMONARY VALVE	1918.10	1918.10
92997	Other professional services	PUL ART BALLOON REPR PERCUT	856.46	856.46
92998	Other professional services	PUL ART BALLOON REPR PERCUT	428.09	428.09
93000	Other professional services	ELECTROCARDIOGRAM COMPLETE	19.92	19.92
93005	Other professional services	ELECTROCARDIOGRAM TRACING	8.52	8.52
93010	Other professional services	ELECTROCARDIOGRAM REPORT	11.40	11.40
93015	Other professional services	CARDIOVASCULAR STRESS TEST	100.46	100.46
93016	Other professional services	CARDIOVASCULAR STRESS TEST	29.70	29.70
93017	Other professional services	CARDIOVASCULAR STRESS TEST	51.14	51.14
93018	Other professional services	CARDIOVASCULAR STRESS TEST	19.61	19.61
93024	Other professional services	CARDIAC DRUG STRESS TEST	155.72	155.72
93024-26	Other professional services	CARDIAC DRUG STRESS TEST	76.97	76.97
93024-TC	Other professional services	CARDIAC DRUG STRESS TEST	78.75	78.75
93025	Other professional services	MICROVOLT T-WAVE ASSESS	172.77	172.77
93025-26	Other professional services	MICROVOLT T-WAVE ASSESS	52.05	52.05
93025-TC	Other professional services	MICROVOLT T-WAVE ASSESS	120.72	120.72
93040	Other professional services	RHYTHM ECG WITH REPORT	18.03	18.03
93041	Other professional services	RHYTHM ECG TRACING	8.52	8.52
93042	Other professional services	RHYTHM ECG REPORT	9.51	9.51
93050	Other professional services	ART PRESSURE WAVEFORM ANALYS	22.20	22.20
93050-26	Other professional services	ART PRESSURE WAVEFORM ANALYS	11.40	11.40
93050-TC	Other professional services	ART PRESSURE WAVEFORM ANALYS	10.79	10.79
93150	Other professional services	THERAPY ACTIVATION IPNSS	138.32	59.63
93151	Other professional services	INTERROG&PRGRMG IPNSS	120.84	56.27
93152	Other professional services	INTERROG&PRGRMG IPNSS POLYSM	219.62	131.39
93153	Other professional services	INTERROG W/O PRGRMG IPNSS	71.55	30.17
93224	Other professional services	ECG MONIT/REPRT UP TO 48 HRS	99.27	99.27
93225	Other professional services	ECG MONIT/REPRT UP TO 48 HRS	24.89	24.89
93226	Other professional services	ECG MONIT/REPRT UP TO 48 HRS	48.54	48.54
93227	Other professional services	ECG MONIT/REPRT UP TO 48 HRS	25.85	25.85
93228	Other professional services	REMOTE 30 DAY ECG REV/REPORT	35.01	35.01
93229	Other professional services	REMOTE 30 DAY ECG TECH SUPP	1109.51	1109.51
93241	Other professional services	EXT ECG>48HR<7D REC SCAN A/R	353.79	353.79
93242	Other professional services	EXT ECG>48HR<7D RECORDING	16.25	16.25
93243	Other professional services	EXT ECG>48HR<7D SCAN A/R	305.06	305.06
93244	Other professional services	EXT ECG>48HR<7D REV&INTERPJ	32.49	32.49
93245	Other professional services	EXT ECG>7D<15D REC SCAN A/R	372.17	372.17
93246	Other professional services	EXT ECG>7D<15D RECORDING	16.25	16.25
93247	Other professional services	EXT ECG>7D<15D SCAN A/R	320.07	320.07
93248	Other professional services	EXT ECG>7D<15D REV&INTERPJ	35.85	35.85
93260	Other professional services	PRGRMG DEV EVAL IMPLTBL SYS	105.36	105.36
93260-26	Other professional services	PRGRMG DEV EVAL IMPLTBL SYS	57.74	57.74
93260-TC	Other professional services	PRGRMG DEV EVAL IMPLTBL SYS	47.63	47.63
93261	Other professional services	INTERROGATE SUBQ DEFIB	96.90	96.90
93261-26	Other professional services	INTERROGATE SUBQ DEFIB	49.74	49.74
93261-TC	Other professional services	INTERROGATE SUBQ DEFIB	47.18	47.18
93264	Other professional services	REM MNTR WRLS P-ART PRS SNR	71.57	49.28
93268	Other professional services	ECG RECORD/REVIEW	240.15	240.15
93270	Other professional services	REMOTE 30 DAY ECG REV/REPORT	11.24	11.24
93271	Other professional services	ECG/MONITORING AND ANALYSIS	194.99	194.99
93272	Other professional services	ECG/REVIEW INTERPRET ONLY	33.93	33.93
93278	Other professional services	ECG/SIGNAL-AVERAGED	43.86	43.86
93278-26	Other professional services	ECG/SIGNAL-AVERAGED	17.61	17.61
93278-TC	Other professional services	ECG/SIGNAL-AVERAGED	26.25	26.25
93279	Other professional services	PRGRMG DEV EVAL PM/LDLS PM	93.39	93.39
93279-26	Other professional services	PRGRMG DEV EVAL PM/LDLS PM	43.50	43.50
93279-TC	Other professional services	PRGRMG DEV EVAL PM/LDLS PM	49.91	49.91
93280	Other professional services	PM DEVICE PROGR EVAL DUAL	109.29	109.29
93280-26	Other professional services	PM DEVICE PROGR EVAL DUAL	51.66	51.66
93280-TC	Other professional services	PM DEVICE PROGR EVAL DUAL	57.63	57.63
93281	Other professional services	PM DEVICE PROGR EVAL MULTI	116.28	116.28
93281-26	Other professional services	PM DEVICE PROGR EVAL MULTI	57.74	57.74
93281-TC	Other professional services	PM DEVICE PROGR EVAL MULTI	58.55	58.55
93282	Other professional services	PRGRMG EVAL IMPLANTABLE DFB	110.37	110.37
93282-26	Other professional services	PRGRMG EVAL IMPLANTABLE DFB	57.29	57.29
93282-TC	Other professional services	PRGRMG EVAL IMPLANTABLE DFB	53.09	53.09
93283	Other professional services	PRGRMG EVAL IMPLANTABLE DFB	135.89	135.89
93283-26	Other professional services	PRGRMG EVAL IMPLANTABLE DFB	77.81	77.81
93283-TC	Other professional services	PRGRMG EVAL IMPLANTABLE DFB	58.10	58.10
93284	Other professional services	PRGRMG EVAL IMPLANTABLE DFB	146.72	146.72
93284-26	Other professional services	PRGRMG EVAL IMPLANTABLE DFB	84.54	84.54
93284-TC	Other professional services	PRGRMG EVAL IMPLANTABLE DFB	62.18	62.18
93285	Other professional services	PRGRMG DEV EVAL SCRMS IP	82.92	82.92
93285-26	Other professional services	PRGRMG DEV EVAL SCRMS IP	35.30	35.30
93285-TC	Other professional services	PRGRMG DEV EVAL SCRMS IP	47.63	47.63
93286	Other professional services	PERI-PX EVAL PM/LDLS PM IP	62.24	62.24
93286-26	Other professional services	PERI-PX EVAL PM/LDLS PM IP	20.52	20.52
93286-TC	Other professional services	PERI-PX EVAL PM/LDLS PM IP	41.72	41.72
93287	Other professional services	PERI-PX DEVICE EVAL & PRGR	72.33	72.33
93287-26	Other professional services	PERI-PX DEVICE EVAL & PRGR	30.17	30.17
93287-TC	Other professional services	PERI-PX DEVICE EVAL & PRGR	42.17	42.17
93288	Other professional services	INTERROG EVL PM/LDLS PM IP	77.72	77.72
93288-26	Other professional services	INTERROG EVL PM/LDLS PM IP	28.73	28.73
93288-TC	Other professional services	INTERROG EVL PM/LDLS PM IP	48.99	48.99
93289	Other professional services	INTERROG DEVICE EVAL HEART	100.01	100.01
93289-26	Other professional services	INTERROG DEVICE EVAL HEART	50.55	50.55
93289-TC	Other professional services	INTERROG DEVICE EVAL HEART	49.44	49.44
93290	Other professional services	INTERROG DEV EVAL ICPMS IP	73.50	73.50
93290-26	Other professional services	INTERROG DEV EVAL ICPMS IP	29.06	29.06
93290-TC	Other professional services	INTERROG DEV EVAL ICPMS IP	44.45	44.45
93291	Other professional services	INTERROG DEV EVAL SCRMS IP	67.49	67.49
93291-26	Other professional services	INTERROG DEV EVAL SCRMS IP	24.87	24.87
93291-TC	Other professional services	INTERROG DEV EVAL SCRMS IP	42.63	42.63
93292	Other professional services	WCD DEVICE INTERROGATE	70.77	70.77
93292-26	Other professional services	WCD DEVICE INTERROGATE	29.06	29.06
93292-TC	Other professional services	WCD DEVICE INTERROGATE	41.72	41.72
93293	Other professional services	PM PHONE R-STRIP DEVICE EVAL	60.90	60.90
93293-26	Other professional services	PM PHONE R-STRIP DEVICE EVAL	20.10	20.10
93293-TC	Other professional services	PM PHONE R-STRIP DEVICE EVAL	40.80	40.80
93294	Other professional services	REM INTERROG EVL PM/LDLS PM	41.24	41.24
93295	Other professional services	DEV INTERROG REMOTE 1/2/MLT	51.17	51.17
93296	Other professional services	REM INTERROG EVL PM/IDS	28.98	28.98
93297	Other professional services	REM INTERROG DEV EVAL ICPMS	83.82	83.82
93297-26	Other professional services	REM INTERROG DEV EVAL ICPMS	34.83	34.83
93297-TC	Other professional services	REM INTERROG DEV EVAL ICPMS	48.99	48.99
93298	Other professional services	REM INTERROG DEV EVAL SCRMS	140.10	140.10
93298-26	Other professional services	REM INTERROG DEV EVAL SCRMS	34.83	34.83
93298-TC	Other professional services	REM INTERROG DEV EVAL SCRMS	105.26	105.26
93303	Other professional services	ECHO TRANSTHORACIC	303.09	303.09
93303-26	Other professional services	ECHO TRANSTHORACIC	86.09	86.09
93303-TC	Other professional services	ECHO TRANSTHORACIC	217.02	217.02
93304	Other professional services	ECHO TRANSTHORACIC	214.04	214.04
93304-26	Other professional services	ECHO TRANSTHORACIC	50.10	50.10
93304-TC	Other professional services	ECHO TRANSTHORACIC	163.94	163.94
93306	Other professional services	TTE W/DOPPLER COMPLETE	272.18	272.18
93306-26	Other professional services	TTE W/DOPPLER COMPLETE	96.54	96.54
93306-TC	Other professional services	TTE W/DOPPLER COMPLETE	175.64	175.64
93307	Other professional services	TTE W/O DOPPLER COMPLETE	188.73	188.73
93307-26	Other professional services	TTE W/O DOPPLER COMPLETE	60.72	60.72
93307-TC	Other professional services	TTE W/O DOPPLER COMPLETE	128.00	128.00
93308	Other professional services	TTE F-UP OR LMTD	136.04	136.04
93308-26	Other professional services	TTE F-UP OR LMTD	34.88	34.88
93308-TC	Other professional services	TTE F-UP OR LMTD	101.18	101.18
93312	Other professional services	ECHO TRANSESOPHAGEAL	328.05	328.05
93312-26	Other professional services	ECHO TRANSESOPHAGEAL	148.79	148.79
93312-TC	Other professional services	ECHO TRANSESOPHAGEAL	179.27	179.27
93313	Other professional services	ECHO TRANSESOPHAGEAL	15.71	15.71
93314	Other professional services	ECHO TRANSESOPHAGEAL	312.20	312.20
93314-26	Other professional services	ECHO TRANSESOPHAGEAL	122.93	122.93
93314-TC	Other professional services	ECHO TRANSESOPHAGEAL	189.27	189.27
93315	Other professional services	ECHO TRANSESOPHAGEAL	395.60	395.60
93315-26	Other professional services	ECHO TRANSESOPHAGEAL	176.45	176.45
93315-TC	Other professional services	ECHO TRANSESOPHAGEAL	219.15	219.15
93316	Other professional services	ECHO TRANSESOPHAGEAL	36.11	36.11
93317	Other professional services	ECHO TRANSESOPHAGEAL	341.19	341.19
93317-26	Other professional services	ECHO TRANSESOPHAGEAL	122.04	122.04
93317-TC	Other professional services	ECHO TRANSESOPHAGEAL	219.15	219.15
93318	Other professional services	ECHO TRANSESOPHAGEAL INTRAOP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93318-26	Other professional services	ECHO TRANSESOPHAGEAL INTRAOP	141.36	141.36
93318-TC	Other professional services	ECHO TRANSESOPHAGEAL INTRAOP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93319	Other professional services	3D ECHO IMG CGEN CAR ANOMAL	76.80	32.69
93320	Other professional services	DOPPLER ECHO EXAM HEART	70.26	70.26
93320-26	Other professional services	DOPPLER ECHO EXAM HEART	24.90	24.90
93320-TC	Other professional services	DOPPLER ECHO EXAM HEART	45.36	45.36
93321	Other professional services	DOPPLER ECHO EXAM HEART	34.53	34.53
93321-26	Other professional services	DOPPLER ECHO EXAM HEART	9.98	9.98
93321-TC	Other professional services	DOPPLER ECHO EXAM HEART	24.56	24.56
93325	Other professional services	DOPPLER COLOR FLOW ADD-ON	32.09	32.09
93325-26	Other professional services	DOPPLER COLOR FLOW ADD-ON	4.35	4.35
93325-TC	Other professional services	DOPPLER COLOR FLOW ADD-ON	27.75	27.75
93350	Other professional services	STRESS TTE ONLY	257.28	257.28
93350-26	Other professional services	STRESS TTE ONLY	96.54	96.54
93350-TC	Other professional services	STRESS TTE ONLY	160.76	160.76
93351	Other professional services	STRESS TTE COMPLETE	321.63	321.63
93351-26	Other professional services	STRESS TTE COMPLETE	115.65	115.65
93351-TC	Other professional services	STRESS TTE COMPLETE	205.98	205.98
93352	Other professional services	ADMIN ECG CONTRAST AGENT	47.73	47.73
93355	Other professional services	ECHO TRANSESOPHAGEAL (TEE)	311.97	311.97
93356	Major surgery	MYOCRD STRAIN IMG SPCKL TRCK	66.44	20.90
93451	Other professional services	RIGHT HEART CATH	1162.86	1162.86
93451-26	Other professional services	RIGHT HEART CATH	176.75	176.75
93451-TC	Other professional services	RIGHT HEART CATH	986.12	986.12
93452	Other professional services	LEFT HRT CATH W/VENTRCLGRPHY	1211.00	1211.00
93452-26	Other professional services	LEFT HRT CATH W/VENTRCLGRPHY	318.83	318.83
93452-TC	Other professional services	LEFT HRT CATH W/VENTRCLGRPHY	892.17	892.17
93453	Other professional services	R&L HRT CATH W/VENTRICLGRPHY	1545.62	1545.62
93453-26	Other professional services	R&L HRT CATH W/VENTRICLGRPHY	425.60	425.60
93453-TC	Other professional services	R&L HRT CATH W/VENTRICLGRPHY	1120.04	1120.04
93454	Other professional services	CORONARY ARTERY ANGIO S&I	1221.02	1221.02
93454-26	Other professional services	CORONARY ARTERY ANGIO S&I	322.04	322.04
93454-TC	Other professional services	CORONARY ARTERY ANGIO S&I	898.98	898.98
93455	Other professional services	CORONARY ART/GRFT ANGIO S&I	1360.55	1360.55
93455-26	Other professional services	CORONARY ART/GRFT ANGIO S&I	375.14	375.14
93455-TC	Other professional services	CORONARY ART/GRFT ANGIO S&I	985.40	985.40
93456	Other professional services	R HRT CORONARY ARTERY ANGIO	1519.50	1519.50
93456-26	Other professional services	R HRT CORONARY ARTERY ANGIO	419.48	419.48
93456-TC	Other professional services	R HRT CORONARY ARTERY ANGIO	1100.01	1100.01
93457	Other professional services	R HRT ART/GRFT ANGIO	1656.51	1656.51
93457-26	Other professional services	R HRT ART/GRFT ANGIO	471.12	471.12
93457-TC	Other professional services	R HRT ART/GRFT ANGIO	1185.39	1185.39
93458	Other professional services	L HRT ARTERY/VENTRICLE ANGIO	1405.02	1405.02
93458-26	Other professional services	L HRT ARTERY/VENTRICLE ANGIO	397.32	397.32
93458-TC	Other professional services	L HRT ARTERY/VENTRICLE ANGIO	1007.69	1007.69
93459	Other professional services	L HRT ART/GRFT ANGIO	1511.79	1511.79
93459-26	Other professional services	L HRT ART/GRFT ANGIO	450.11	450.11
93459-TC	Other professional services	L HRT ART/GRFT ANGIO	1061.69	1061.69
93460	Other professional services	R&L HRT ART/VENTRICLE ANGIO	1677.50	1677.50
93460-26	Other professional services	R&L HRT ART/VENTRICLE ANGIO	503.48	503.48
93460-TC	Other professional services	R&L HRT ART/VENTRICLE ANGIO	1174.02	1174.02
93461	Other professional services	R&L HRT ART/VENTRICLE ANGIO	1850.54	1850.54
93461-26	Other professional services	R&L HRT ART/VENTRICLE ANGIO	556.58	556.58
93461-TC	Other professional services	R&L HRT ART/VENTRICLE ANGIO	1293.96	1293.96
93462	Other professional services	L HRT CATH TRNSPTL PUNCTURE	278.28	278.28
93463	Other professional services	DRUG ADMIN & HEMODYNMIC MEAS	135.30	135.30
93464	Other professional services	EXERCISE W/HEMODYNAMIC MEAS	302.00	302.00
93464-26	Other professional services	EXERCISE W/HEMODYNAMIC MEAS	122.93	122.93
93464-TC	Other professional services	EXERCISE W/HEMODYNAMIC MEAS	179.07	179.07
93503	Other professional services	INSERT/PLACE HEART CATHETER	121.85	121.85
93505	Other professional services	BIOPSY OF HEART LINING	874.46	874.46
93505-26	Other professional services	BIOPSY OF HEART LINING	306.65	306.65
93505-TC	Other professional services	BIOPSY OF HEART LINING	567.81	567.81
93563	Other professional services	NJX CGEN CAR CTH SLCTV C ANG	70.26	70.26
93564	Other professional services	NJX CGEN CAR CATH SLCTV OPAC	74.34	74.34
93565	Other professional services	NJX CAR CTH SLCTV LV/LA ANG	36.21	36.21
93566	Other professional services	NJX CAR CTH SLCTV RV/RA ANG	35.24	35.24
93567	Other professional services	NJX CAR CTH SPRVLV AORTGRPHY	50.52	50.52
93568	Other professional services	NJX CAR CTH NSLC P-ART ANGRP	62.75	62.75
93569	Other professional services	NJX CTH SLCT P-ART ANGRP UNI	52.55	52.55
93571	Other professional services	HEART FLOW RESERVE MEASURE	367.16	367.16
93571-26	Other professional services	HEART FLOW RESERVE MEASURE	97.32	97.32
93571-TC	Other professional services	HEART FLOW RESERVE MEASURE	269.84	269.84
93572	Other professional services	HEART FLOW RESERVE MEASURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93572-26	Other professional services	HEART FLOW RESERVE MEASURE	70.79	70.79
93572-TC	Other professional services	HEART FLOW RESERVE MEASURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93573	Other professional services	NJX CATH SLCT P-ART ANGRP BI	87.26	87.26
93574	Other professional services	NJX CATH SLCT PULM VN ANGRPH	97.07	97.07
93575	Other professional services	NJX CATH SLCT P ANGRPH MAPCA	128.90	128.90
93580	Other professional services	TRANSCATH CLOSURE OF ASD	1310.66	1310.66
93581	Other professional services	TRANSCATH CLOSURE OF VSD	1776.50	1776.50
93582	Other professional services	PERQ TRANSCATH CLOSURE PDA	887.18	887.18
93583	Other professional services	PERQ TRANSCATH SEPTAL REDUXN	995.51	995.51
93584	Other professional services	VNGRPH CHD ANOM/PERSIST SVC	81.77	81.77
93585	Other professional services	VNGRPH CHD AZYGS/HEMIAZYGS	76.97	76.97
93586	Other professional services	VNGRPH CHD CORONARY SINUS	97.35	97.35
93587	Other professional services	VNGRPH CHD VNVN CLTRL AT/ABV	143.63	143.63
93588	Other professional services	VNGRPH CHD VNVN CLTRL BELOW	145.07	145.07
93590	Other professional services	PERQ TRANSCATH CLS MITRAL	1478.07	1478.07
93591	Other professional services	PERQ TRANSCATH CLS AORTIC	1217.01	1217.01
93592	Other professional services	PERQ TRANSCATH CLOSURE EACH	534.29	534.29
93593	Other professional services	R HRT CATH CHD NML NT CNJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93593-26	Other professional services	R HRT CATH CHD NML NT CNJ	263.31	263.31
93593-TC	Other professional services	R HRT CATH CHD NML NT CNJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93594	Other professional services	R HRT CATH CHD ABNL NT CNJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93594-26	Other professional services	R HRT CATH CHD ABNL NT CNJ	400.04	400.04
93594-TC	Other professional services	R HRT CATH CHD ABNL NT CNJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93595	Other professional services	L HRT CATH CHD NM/ABN NT CNJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93595-26	Other professional services	L HRT CATH CHD NM/ABN NT CNJ	363.02	363.02
93595-TC	Other professional services	L HRT CATH CHD NM/ABN NT CNJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93596	Other professional services	R&L HRT CATH CHD NML NT CNJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93596-26	Other professional services	R&L HRT CATH CHD NML NT CNJ	451.52	451.52
93596-TC	Other professional services	R&L HRT CATH CHD NML NT CNJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93597	Other professional services	R&L HRT CATH CHD ABNL NT CNJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93597-26	Other professional services	R&L HRT CATH CHD ABNL NT CNJ	589.22	589.22
93597-TC	Other professional services	R&L HRT CATH CHD ABNL NT CNJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93598	Other professional services	CAR OUTP MEAS DRG CATH CHD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93598-26	Other professional services	CAR OUTP MEAS DRG CATH CHD	93.29	93.29
93598-TC	Other professional services	CAR OUTP MEAS DRG CATH CHD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93600	Other professional services	BUNDLE OF HIS RECORDING	271.02	271.02
93600-26	Other professional services	BUNDLE OF HIS RECORDING	156.30	156.30
93600-TC	Other professional services	BUNDLE OF HIS RECORDING	114.72	114.72
93602	Other professional services	INTRA-ATRIAL RECORDING	216.92	216.92
93602-26	Other professional services	INTRA-ATRIAL RECORDING	153.84	153.84
93602-TC	Other professional services	INTRA-ATRIAL RECORDING	63.08	63.08
93603	Other professional services	RIGHT VENTRICULAR RECORDING	251.55	251.55
93603-26	Other professional services	RIGHT VENTRICULAR RECORDING	153.84	153.84
93603-TC	Other professional services	RIGHT VENTRICULAR RECORDING	97.71	97.71
93609	Other professional services	MAP TACHYCARDIA ADD-ON	520.74	520.74
93609-26	Other professional services	MAP TACHYCARDIA ADD-ON	366.75	366.75
93609-TC	Other professional services	MAP TACHYCARDIA ADD-ON	153.99	153.99
93610	Other professional services	INTRA-ATRIAL PACING	294.36	294.36
93610-26	Other professional services	INTRA-ATRIAL PACING	217.37	217.37
93610-TC	Other professional services	INTRA-ATRIAL PACING	77.00	77.00
93612	Other professional services	INTRAVENTRICULAR PACING	307.61	307.61
93612-26	Other professional services	INTRAVENTRICULAR PACING	214.56	214.56
93612-TC	Other professional services	INTRAVENTRICULAR PACING	93.05	93.05
93613	Other professional services	ELECTROPHYS MAP 3D ADD-ON	391.01	391.01
93615	Other professional services	ESOPHAGEAL RECORDING	66.06	66.06
93615-26	Other professional services	ESOPHAGEAL RECORDING	50.19	50.19
93615-TC	Other professional services	ESOPHAGEAL RECORDING	15.87	15.87
93616	Other professional services	ESOPHAGEAL RECORDING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93616-26	Other professional services	ESOPHAGEAL RECORDING	81.32	81.32
93616-TC	Other professional services	ESOPHAGEAL RECORDING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93618	Other professional services	HEART RHYTHM PACING	520.05	520.05
93618-26	Other professional services	HEART RHYTHM PACING	290.22	290.22
93618-TC	Other professional services	HEART RHYTHM PACING	229.83	229.83
93619	Other professional services	ELECTROPHYSIOLOGY EVALUATION	973.79	973.79
93619-26	Other professional services	ELECTROPHYSIOLOGY EVALUATION	518.01	518.01
93619-TC	Other professional services	ELECTROPHYSIOLOGY EVALUATION	455.78	455.78
93620	Other professional services	ELECTROPHYSIOLOGY EVALUATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93620-26	Other professional services	ELECTROPHYSIOLOGY EVALUATION	830.90	830.90
93620-TC	Other professional services	ELECTROPHYSIOLOGY EVALUATION	514.68	514.68
93621	Other professional services	ELECTROPHYSIOLOGY EVALUATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93621-26	Other professional services	ELECTROPHYSIOLOGY EVALUATION	110.43	110.43
93621-TC	Other professional services	ELECTROPHYSIOLOGY EVALUATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93622	Other professional services	ELECTROPHYSIOLOGY EVALUATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93622-26	Other professional services	ELECTROPHYSIOLOGY EVALUATION	227.93	227.93
93622-TC	Other professional services	ELECTROPHYSIOLOGY EVALUATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93623	Other professional services	STIMULATION PACING HEART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93623-26	Other professional services	STIMULATION PACING HEART	91.19	91.19
93623-TC	Other professional services	STIMULATION PACING HEART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93624	Other professional services	ELECTROPHYSIOLOGIC STUDY	436.38	436.38
93624-26	Other professional services	ELECTROPHYSIOLOGIC STUDY	322.26	322.26
93624-TC	Other professional services	ELECTROPHYSIOLOGIC STUDY	114.12	114.12
93631	Other professional services	HEART PACING MAPPING	907.59	907.59
93631-26	Other professional services	HEART PACING MAPPING	530.43	530.43
93631-TC	Other professional services	HEART PACING MAPPING	377.16	377.16
93640	Other professional services	EVALUATION HEART DEVICE	662.72	662.72
93640-26	Other professional services	EVALUATION HEART DEVICE	237.35	237.35
93640-TC	Other professional services	EVALUATION HEART DEVICE	425.37	425.37
93641	Other professional services	ELECTROPHYSIOLOGY EVALUATION	835.22	835.22
93641-26	Other professional services	ELECTROPHYSIOLOGY EVALUATION	414.48	414.48
93641-TC	Other professional services	ELECTROPHYSIOLOGY EVALUATION	420.74	420.74
93642	Other professional services	ELECTROPHYSIOLOGY EVALUATION	449.39	449.39
93642-26	Other professional services	ELECTROPHYSIOLOGY EVALUATION	338.34	338.34
93642-TC	Other professional services	ELECTROPHYSIOLOGY EVALUATION	111.05	111.05
93644	Other professional services	ELECTROPHYSIOLOGY EVALUATION	268.56	268.56
93644-26	Other professional services	ELECTROPHYSIOLOGY EVALUATION	199.56	199.56
93644-TC	Other professional services	ELECTROPHYSIOLOGY EVALUATION	69.00	69.00
93650	Other professional services	ABLATE HEART DYSRHYTHM FOCUS	780.66	780.66
93653	Other professional services	COMPRE EP EVAL TX SVT	1121.34	1121.34
93654	Other professional services	COMPRE EP EVAL TX VT	1351.04	1351.04
93655	Other professional services	ICAR CATH ABLTJ DSCRT ARRHYT	411.03	411.03
93656	Other professional services	COMPRE EP EVAL ABLTJ ATR FIB	1271.57	1271.57
93657	Other professional services	TX L/R ATRIAL FIB ADDL	411.48	411.48
93660	Other professional services	TILT TABLE EVALUATION	226.76	226.76
93660-26	Other professional services	TILT TABLE EVALUATION	127.53	127.53
93660-TC	Other professional services	TILT TABLE EVALUATION	99.23	99.23
93662	Other professional services	INTRACARDIAC ECG (ICE)	555.05	555.05
93662-26	Other professional services	INTRACARDIAC ECG (ICE)	97.97	97.97
93662-TC	Other professional services	INTRACARDIAC ECG (ICE)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93668	Other professional services	PERIPHERAL VASCULAR REHAB	19.89	19.89
93701	Other professional services	BIOIMPEDANCE CV ANALYSIS	36.71	36.71
93702	Other professional services	BIS XTRACELL FLUID ANALYSIS	166.67	166.67
93724	Other professional services	ANALYZE PACEMAKER SYSTEM	392.28	392.28
93724-26	Other professional services	ANALYZE PACEMAKER SYSTEM	329.19	329.19
93724-TC	Other professional services	ANALYZE PACEMAKER SYSTEM	63.09	63.09
93740	Other professional services	TEMPERATURE GRADIENT STUDIES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93745	Other professional services	SET-UP CARDIOVERT-DEFIBRILL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93745-26	Other professional services	SET-UP CARDIOVERT-DEFIBRILL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93745-TC	Other professional services	SET-UP CARDIOVERT-DEFIBRILL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93750	Other professional services	INTERROGATION VAD IN PERSON	70.32	54.86
93770	Other professional services	MEASURE VENOUS PRESSURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93784	Other professional services	AMBL BP MNTR W/SOFTWARE	63.77	63.77
93786	Other professional services	AMBL BP MNTR W/SW REC ONLY	30.80	30.80
93788	Other professional services	AMBL BP MNTR W/SW A/R	7.61	7.61
93790	Other professional services	AMBL BP MNTR W/SW I&R	25.37	25.37
93792	Other professional services	PT/CAREGIVER TRAING HOME INR	95.58	95.58
93793	Other professional services	ANTICOAG MGMT PT WARFARIN	15.99	15.99
93797	Other professional services	CARDIAC REHAB	23.72	12.35
93798	Other professional services	CARDIAC REHAB/MONITOR	35.78	18.96
93799	Other professional services	UNLISTED CV SVC/PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93799-26	Other professional services	UNLISTED CV SVC/PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93799-TC	Other professional services	UNLISTED CV SVC/PROCEDURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93880	Other professional services	EXTRACRANIAL BILAT STUDY	260.87	260.87
93880-26	Other professional services	EXTRACRANIAL BILAT STUDY	52.95	52.95
93880-TC	Other professional services	EXTRACRANIAL BILAT STUDY	207.92	207.92
93882	Other professional services	EXTRACRANIAL UNI/LTD STUDY	170.90	170.90
93882-26	Other professional services	EXTRACRANIAL UNI/LTD STUDY	32.88	32.88
93882-TC	Other professional services	EXTRACRANIAL UNI/LTD STUDY	138.02	138.02
93886	Other professional services	INTRACRANIAL COMPLETE STUDY	376.59	376.59
93886-26	Other professional services	INTRACRANIAL COMPLETE STUDY	64.52	64.52
93886-TC	Other professional services	INTRACRANIAL COMPLETE STUDY	312.08	312.08
93888	Other professional services	INTRACRANIAL LIMITED STUDY	219.03	219.03
93888-26	Other professional services	INTRACRANIAL LIMITED STUDY	34.64	34.64
93888-TC	Other professional services	INTRACRANIAL LIMITED STUDY	184.40	184.40
93890	Other professional services	TCD VASOREACTIVITY STUDY	390.12	390.12
93890-26	Other professional services	TCD VASOREACTIVITY STUDY	71.22	71.22
93890-TC	Other professional services	TCD VASOREACTIVITY STUDY	318.90	318.90
93892	Other professional services	TCD EMBOLI DETECT W/O INJ	449.54	449.54
93892-26	Other professional services	TCD EMBOLI DETECT W/O INJ	82.55	82.55
93892-TC	Other professional services	TCD EMBOLI DETECT W/O INJ	366.98	366.98
93893	Other professional services	TCD EMBOLI DETECT W/INJ	552.51	552.51
93893-26	Other professional services	TCD EMBOLI DETECT W/INJ	83.21	83.21
93893-TC	Other professional services	TCD EMBOLI DETECT W/INJ	469.32	469.32
93895	Other professional services	CAROTID INTIMA ATHEROMA EVAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93895-26	Other professional services	CAROTID INTIMA ATHEROMA EVAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93895-TC	Other professional services	CAROTID INTIMA ATHEROMA EVAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
93922	Other professional services	UPR/L XTREMITY ART 2 LEVELS	112.61	112.61
93922-26	Other professional services	UPR/L XTREMITY ART 2 LEVELS	16.44	16.44
93922-TC	Other professional services	UPR/L XTREMITY ART 2 LEVELS	96.17	96.17
93923	Other professional services	UPR/LXTR ART STDY 3+ LVLS	178.32	178.32
93923-26	Other professional services	UPR/LXTR ART STDY 3+ LVLS	29.97	29.97
93923-TC	Other professional services	UPR/LXTR ART STDY 3+ LVLS	148.34	148.34
93924	Other professional services	LWR XTR VASC STDY BILAT	218.97	218.97
93924-26	Other professional services	LWR XTR VASC STDY BILAT	32.88	32.88
93924-TC	Other professional services	LWR XTR VASC STDY BILAT	186.09	186.09
93925	Other professional services	LOWER EXTREMITY STUDY	329.42	329.42
93925-26	Other professional services	LOWER EXTREMITY STUDY	52.50	52.50
93925-TC	Other professional services	LOWER EXTREMITY STUDY	276.93	276.93
93926	Other professional services	LOWER EXTREMITY STUDY	197.28	197.28
93926-26	Other professional services	LOWER EXTREMITY STUDY	32.10	32.10
93926-TC	Other professional services	LOWER EXTREMITY STUDY	165.17	165.17
93930	Other professional services	UPPER EXTREMITY STUDY	271.67	271.67
93930-26	Other professional services	UPPER EXTREMITY STUDY	52.82	52.82
93930-TC	Other professional services	UPPER EXTREMITY STUDY	218.84	218.84
93931	Other professional services	UPPER EXTREMITY STUDY	169.65	169.65
93931-26	Other professional services	UPPER EXTREMITY STUDY	32.57	32.57
93931-TC	Other professional services	UPPER EXTREMITY STUDY	137.10	137.10
93970	Other professional services	EXTREMITY STUDY	256.55	256.55
93970-26	Other professional services	EXTREMITY STUDY	45.89	45.89
93970-TC	Other professional services	EXTREMITY STUDY	210.65	210.65
93971	Other professional services	EXTREMITY STUDY	163.37	163.37
93971-26	Other professional services	EXTREMITY STUDY	29.45	29.45
93971-TC	Other professional services	EXTREMITY STUDY	133.92	133.92
93975	Other professional services	VASCULAR STUDY	363.23	363.23
93975-26	Other professional services	VASCULAR STUDY	76.74	76.74
93975-TC	Other professional services	VASCULAR STUDY	286.47	286.47
93976	Other professional services	VASCULAR STUDY	218.51	218.51
93976-26	Other professional services	VASCULAR STUDY	53.21	53.21
93976-TC	Other professional services	VASCULAR STUDY	165.30	165.30
93978	Other professional services	VASCULAR STUDY	247.29	247.29
93978-26	Other professional services	VASCULAR STUDY	52.56	52.56
93978-TC	Other professional services	VASCULAR STUDY	194.73	194.73
93979	Other professional services	VASCULAR STUDY	161.79	161.79
93979-26	Other professional services	VASCULAR STUDY	32.88	32.88
93979-TC	Other professional services	VASCULAR STUDY	128.91	128.91
93980	Other professional services	PENILE VASCULAR STUDY	163.41	163.41
93980-26	Other professional services	PENILE VASCULAR STUDY	83.96	83.96
93980-TC	Other professional services	PENILE VASCULAR STUDY	79.47	79.47
93981	Other professional services	PENILE VASCULAR STUDY	97.52	97.52
93981-26	Other professional services	PENILE VASCULAR STUDY	29.42	29.42
93981-TC	Other professional services	PENILE VASCULAR STUDY	68.10	68.10
93985	Other professional services	DUP-SCAN HEMO COMPL BI STD	338.79	338.79
93985-26	Other professional services	DUP-SCAN HEMO COMPL BI STD	51.86	51.86
93985-TC	Other professional services	DUP-SCAN HEMO COMPL BI STD	286.94	286.94
93986	Other professional services	DUP-SCAN HEMO COMPL UNI STD	199.29	199.29
93986-26	Other professional services	DUP-SCAN HEMO COMPL UNI STD	32.30	32.30
93986-TC	Other professional services	DUP-SCAN HEMO COMPL UNI STD	167.00	167.00
93990	Other professional services	DOPPLER FLOW TESTING	200.99	200.99
93990-26	Other professional services	DOPPLER FLOW TESTING	32.18	32.18
93990-TC	Other professional services	DOPPLER FLOW TESTING	168.81	168.81
93998	Other professional services	UNLISTD NONINVAS VASC DX STD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94002	Other professional services	VENT MGMT INPAT INIT DAY	127.98	127.98
94003	Other professional services	VENT MGMT INPAT SUBQ DAY	89.99	89.99
94004	Other professional services	VENT MGMT NF PER DAY	66.74	66.74
94005	Other professional services	HOME VENT MGMT SUPERVISION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94010	Other professional services	BREATHING CAPACITY TEST	37.65	37.65
94010-26	Other professional services	BREATHING CAPACITY TEST	11.40	11.40
94010-TC	Other professional services	BREATHING CAPACITY TEST	26.25	26.25
94011	Other professional services	SPIROMETRY UP TO 2 YRS OLD	118.98	118.98
94012	Other professional services	SPIRMTRY W/BRNCHDIL INF-2 YR	194.27	194.27
94013	Other professional services	MEAS LUNG VOL THRU 2 YRS	26.12	26.12
94014	Other professional services	PATIENT RECORDED SPIROMETRY	77.91	77.91
94015	Other professional services	PATIENT RECORDED SPIROMETRY	43.53	43.53
94016	Other professional services	REVIEW PATIENT SPIROMETRY	34.38	34.38
94060	Other professional services	EVALUATION OF WHEEZING	53.76	53.76
94060-26	Other professional services	EVALUATION OF WHEEZING	14.31	14.31
94060-TC	Other professional services	EVALUATION OF WHEEZING	39.44	39.44
94070	Other professional services	EVALUATION OF WHEEZING	87.63	87.63
94070-26	Other professional services	EVALUATION OF WHEEZING	38.76	38.76
94070-TC	Other professional services	EVALUATION OF WHEEZING	48.87	48.87
94150	Other professional services	VITAL CAPACITY TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94150-26	Other professional services	VITAL CAPACITY TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94150-TC	Other professional services	VITAL CAPACITY TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94200	Other professional services	LUNG FUNCTION TEST (MBC/MVV)	20.39	20.39
94200-26	Other professional services	LUNG FUNCTION TEST (MBC/MVV)	3.69	3.69
94200-TC	Other professional services	LUNG FUNCTION TEST (MBC/MVV)	16.70	16.70
94375	Other professional services	RESPIRATORY FLOW VOLUME LOOP	54.09	54.09
94375-26	Other professional services	RESPIRATORY FLOW VOLUME LOOP	20.10	20.10
94375-TC	Other professional services	RESPIRATORY FLOW VOLUME LOOP	33.99	33.99
94450	Other professional services	HYPOXIA RESPONSE CURVE	109.77	109.77
94450-26	Other professional services	HYPOXIA RESPONSE CURVE	27.26	27.26
94450-TC	Other professional services	HYPOXIA RESPONSE CURVE	82.52	82.52
94452	Other professional services	HAST W/REPORT	69.56	69.56
94452-26	Other professional services	HAST W/REPORT	19.65	19.65
94452-TC	Other professional services	HAST W/REPORT	49.91	49.91
94453	Other professional services	HAST W/OXYGEN TITRATE	92.36	92.36
94453-26	Other professional services	HAST W/OXYGEN TITRATE	25.76	25.76
94453-TC	Other professional services	HAST W/OXYGEN TITRATE	66.60	66.60
94610	Other professional services	SURFACTANT ADMIN THRU TUBE	79.14	79.14
94617	Neurology	EXERCISE TST BRNCSPSM W/ECG	125.93	125.93
94617-26	Other professional services	EXERCISE TST BRNCSPSM W/ECG	44.72	44.72
94617-TC	Other professional services	EXERCISE TST BRNCSPSM W/ECG	78.75	78.75
94618	Neurology	PULMONARY STRESS TESTING	48.70	48.70
94618-26	Other professional services	PULMONARY STRESS TESTING	31.05	31.05
94618-TC	Other professional services	PULMONARY STRESS TESTING	16.70	16.70
94619	Other professional services	EXERCISE TST BRNCSPSM WO ECG	90.09	90.09
94619-26	Other professional services	EXERCISE TST BRNCSPSM WO ECG	30.30	30.30
94619-TC	Other professional services	EXERCISE TST BRNCSPSM WO ECG	59.78	59.78
94621	Other professional services	CARDIOPULM EXERCISE TESTING	214.79	214.79
94621-26	Other professional services	CARDIOPULM EXERCISE TESTING	94.65	94.65
94621-TC	Other professional services	CARDIOPULM EXERCISE TESTING	120.14	120.14
94625	Other professional services	PHY/QHP OP PULM RHB W/O MNTR	101.76	25.82
94626	Other professional services	PHY/QHP OP PULM RHB W/MNTR	111.00	38.24
94640	Other professional services	AIRWAY INHALATION TREATMENT	10.79	10.79
94642	Other professional services	AEROSOL INHALATION TREATMENT	18.17	18.17
94644	Other professional services	CBT 1ST HOUR	81.15	81.15
94645	Other professional services	CBT EACH ADDL HOUR	22.16	22.16
94660	Other professional services	POS AIRWAY PRESSURE CPAP	90.23	52.02
94662	Other professional services	NEG PRESS VENTILATION CNP	48.84	48.84
94664	Other professional services	EVALUATE PT USE OF INHALER	24.30	24.30
94667	Other professional services	CHEST WALL MANIPULATION	33.86	33.86
94668	Other professional services	CHEST WALL MANIPULATION	53.28	53.28
94669	Other professional services	MECHANICAL CHEST WALL OSCILL	27.95	27.95
94680	Other professional services	EXHALED AIR ANALYSIS O2	74.12	74.12
94680-26	Other professional services	EXHALED AIR ANALYSIS O2	17.52	17.52
94680-TC	Other professional services	EXHALED AIR ANALYSIS O2	56.60	56.60
94681	Other professional services	EXHALED AIR ANALYSIS O2/CO2	65.84	65.84
94681-26	Other professional services	EXHALED AIR ANALYSIS O2/CO2	13.34	13.34
94681-TC	Other professional services	EXHALED AIR ANALYSIS O2/CO2	52.50	52.50
94690	Other professional services	EXHALED AIR ANALYSIS	66.41	66.41
94690-26	Other professional services	EXHALED AIR ANALYSIS	5.13	5.13
94690-TC	Other professional services	EXHALED AIR ANALYSIS	61.28	61.28
94726	Other professional services	PULM FUNCT TST PLETHYSMOGRAP	76.97	76.97
94726-26	Other professional services	PULM FUNCT TST PLETHYSMOGRAP	16.74	16.74
94726-TC	Other professional services	PULM FUNCT TST PLETHYSMOGRAP	60.24	60.24
94727	Other professional services	PULM FUNCTION TEST BY GAS	61.64	61.64
94727-26	Other professional services	PULM FUNCTION TEST BY GAS	16.74	16.74
94727-TC	Other professional services	PULM FUNCTION TEST BY GAS	44.90	44.90
94728	Other professional services	AIRWY RESIST BY OSCILLOMETRY	61.19	61.19
94728-26	Other professional services	AIRWY RESIST BY OSCILLOMETRY	17.19	17.19
94728-TC	Other professional services	AIRWY RESIST BY OSCILLOMETRY	44.00	44.00
94729	Other professional services	CO/MEMBANE DIFFUSE CAPACITY	77.76	77.76
94729-26	Other professional services	CO/MEMBANE DIFFUSE CAPACITY	12.39	12.39
94729-TC	Other professional services	CO/MEMBANE DIFFUSE CAPACITY	65.37	65.37
94760	Other professional services	MEASURE BLOOD OXYGEN LEVEL	3.51	3.51
94761	Other professional services	MEASURE BLOOD OXYGEN LEVEL	5.33	5.33
94762	Other professional services	MEASURE BLOOD OXYGEN LEVEL	34.44	34.44
94772	Other professional services	BREATH RECORDING INFANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94772-26	Other professional services	BREATH RECORDING INFANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94772-TC	Other professional services	BREATH RECORDING INFANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94774	Other professional services	PED HOME APNEA REC COMPL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94775	Other professional services	PED HOME APNEA REC HK-UP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94776	Other professional services	PED HOME APNEA REC DOWNLD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94777	Other professional services	PED HOME APNEA REC REPORT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94780	Other professional services	CARS/BD TST INFT-12MO 60 MIN	74.13	32.75
94781	Other professional services	CARS/BD TST INFT-12MO +30MIN	29.60	11.40
94799	Other professional services	UNLISTED PULMONARY SVC/PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94799-26	Other professional services	UNLISTED PULMONARY SVC/PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
94799-TC	Other professional services	UNLISTED PULMONARY SVC/PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95004	Other professional services	PERCUT ALLERGY SKIN TESTS	4.91	4.91
95012	Other professional services	EXHALED NITRIC OXIDE MEAS	25.80	25.80
95017	Other professional services	PERQ & ICUT ALLG TEST VENOMS	11.96	5.13
95018	Other professional services	PERQ&IC ALLG TEST DRUGS/BIOL	27.68	9.93
95024	Other professional services	ICUT ALLERGY TEST DRUG/BUG	10.83	1.28
95027	Other professional services	ICUT ALLERGY TITRATE-AIRBORN	6.74	6.74
95028	Other professional services	ICUT ALLERGY TEST-DELAYED	17.16	17.16
95044	Other professional services	ALLERGY PATCH TESTS	6.69	6.69
95052	Other professional services	PHOTO PATCH TEST	8.52	8.52
95056	Other professional services	PHOTOSENSITIVITY TESTS	71.15	71.15
95060	Other professional services	EYE ALLERGY TESTS	53.54	53.54
95065	Other professional services	NOSE ALLERGY TEST	39.44	39.44
95070	Other professional services	BRONCHIAL ALLERGY TESTS	47.51	47.51
95076	Other professional services	INGEST CHALLENGE INI 120 MIN	172.97	103.83
95079	Other professional services	INGEST CHALLENGE ADDL 60 MIN	120.68	95.67
95115	Other professional services	IMMUNOTHERAPY ONE INJECTION	13.97	13.97
95117	Other professional services	IMMUNOTHERAPY INJECTIONS	16.70	16.70
95120	Other professional services	IMMUNOTHERAPY ONE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95125	Other professional services	IMMUNOTHERAPY 2/> INJECTIONS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95130	Other professional services	IMMNTX 1 STING INSECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95131	Other professional services	IMMNTX 2 STING INSECTS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95132	Other professional services	IMMNTX 3 STING INSECTS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95133	Other professional services	IMMNTX 4 STING INSECTS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95134	Other professional services	IMMNTX 5 STING INSECTS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95144	Other professional services	ANTIGEN THERAPY SERVICES	22.83	4.64
95145	Other professional services	ANTIGEN THERAPY SERVICES	49.67	4.19
95146	Other professional services	ANTIGEN THERAPY SERVICES	92.42	4.19
95147	Other professional services	ANTIGEN THERAPY SERVICES	88.79	4.19
95148	Other professional services	ANTIGEN THERAPY SERVICES	131.99	4.19
95149	Other professional services	ANTIGEN THERAPY SERVICES	175.65	4.19
95165	Other professional services	ANTIGEN THERAPY SERVICES	20.10	4.64
95170	Other professional services	ANTIGEN THERAPY SERVICES	15.11	4.19
95180	Other professional services	RAPID DESENSITIZATION	195.03	144.09
95199	Other professional services	UNLISTED ALL/IMMLG SVC/PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95249	Other professional services	CONT GLUC MNTR PT PROV EQP	88.64	88.64
95250	Other professional services	CONT GLUC MNTR PHYS/QHP EQP	200.97	200.97
95251	Other professional services	CONT GLUC MNTR ANALYSIS I&R	48.89	48.89
95700	Neurology	EEG CONT REC W/VID EEG TECH	346.22	346.22
95705	Neurology	EEG W/O VID 2-12 HR UNMNTR	180.54	180.54
95706	Neurology	EEG WO VID 2-12HR INTMT MNTR	551.63	551.63
95707	Neurology	EEG W/O VID 2-12HR CONT MNTR	697.63	697.63
95708	Neurology	EEG WO VID EA 12-26HR UNMNTR	266.62	266.62
95709	Neurology	EEG W/O VID EA 12-26HR INTMT	1045.07	1045.07
95710	Neurology	EEG W/O VID EA 12-26HR CONT	1307.29	1307.29
95711	Neurology	VEEG 2-12 HR UNMONITORED	233.17	233.17
95712	Neurology	VEEG 2-12 HR INTMT MNTR	696.24	696.24
95713	Neurology	VEEG 2-12 HR CONT MNTR	944.85	944.85
95714	Neurology	VEEG EA 12-26 HR UNMNTR	341.86	341.86
95715	Neurology	VEEG EA 12-26HR INTMT MNTR	1242.62	1242.62
95716	Neurology	VEEG EA 12-26HR CONT MNTR	1628.13	1628.13
95717	Neurology	EEG PHYS/QHP 2-12 HR W/O VID	152.85	150.52
95718	Neurology	EEG PHYS/QHP 2-12 HR W/VEEG	193.94	190.70
95719	Neurology	EEG PHYS/QHP EA INCR W/O VID	231.60	227.88
95720	Neurology	EEG PHY/QHP EA INCR W/VEEG	298.69	293.58
95721	Neurology	EEG PHY/QHP>36<60 HR W/O VID	298.81	293.24
95722	Neurology	EEG PHY/QHP>36<60 HR W/VEEG	362.12	355.62
95723	Neurology	EEG PHY/QHP>60<84 HR W/O VID	362.69	356.20
95724	Neurology	EEG PHY/QHP>60<84 HR W/VEEG	456.15	448.26
95725	Neurology	EEG PHY/QHP>84 HR W/O VID	420.32	410.58
95726	Neurology	EEG PHY/QHP>84 HR W/VEEG	584.84	573.70
95782	Other professional services	POLYSOM <6 YRS 4/> PARAMTRS	1341.35	1341.35
95782-26	Other professional services	POLYSOM <6 YRS 4/> PARAMTRS	173.52	173.52
95782-TC	Other professional services	POLYSOM <6 YRS 4/> PARAMTRS	1167.83	1167.83
95783	Other professional services	POLYSOM <6 YRS CPAP/BILVL	1422.17	1422.17
95783-26	Other professional services	POLYSOM <6 YRS CPAP/BILVL	189.24	189.24
95783-TC	Other professional services	POLYSOM <6 YRS CPAP/BILVL	1232.93	1232.93
95800	Other professional services	SLP STDY UNATTENDED	188.01	188.01
95800-26	Other professional services	SLP STDY UNATTENDED	55.47	55.47
95800-TC	Other professional services	SLP STDY UNATTENDED	132.56	132.56
95801	Other professional services	SLP STDY UNATND W/ANAL	135.26	135.26
95801-26	Other professional services	SLP STDY UNATND W/ANAL	57.29	57.29
95801-TC	Other professional services	SLP STDY UNATND W/ANAL	77.97	77.97
95803	Neurology	ACTIGRAPHY TESTING	191.30	191.30
95803-26	Neurology	ACTIGRAPHY TESTING	60.13	60.13
95803-TC	Neurology	ACTIGRAPHY TESTING	131.15	131.15
95805	Neurology	MULTIPLE SLEEP LATENCY TEST	603.59	603.59
95805-26	Neurology	MULTIPLE SLEEP LATENCY TEST	81.87	81.87
95805-TC	Neurology	MULTIPLE SLEEP LATENCY TEST	521.73	521.73
95806	Neurology	SLEEP STUDY UNATT&RESP EFFT	134.07	134.07
95806-26	Neurology	SLEEP STUDY UNATT&RESP EFFT	62.90	62.90
95806-TC	Neurology	SLEEP STUDY UNATT&RESP EFFT	71.18	71.18
95807	Neurology	SLEEP STUDY ATTENDED	573.26	573.26
95807-26	Neurology	SLEEP STUDY ATTENDED	84.81	84.81
95807-TC	Neurology	SLEEP STUDY ATTENDED	488.45	488.45
95808	Neurology	POLYSOM ANY AGE 1-3> PARAM	717.00	717.00
95808-26	Neurology	POLYSOM ANY AGE 1-3> PARAM	118.87	118.87
95808-TC	Neurology	POLYSOM ANY AGE 1-3> PARAM	598.14	598.14
95810	Neurology	POLYSOM 6/> YRS 4/> PARAM	874.58	874.58
95810-26	Neurology	POLYSOM 6/> YRS 4/> PARAM	169.07	169.07
95810-TC	Neurology	POLYSOM 6/> YRS 4/> PARAM	705.51	705.51
95811	Neurology	POLYSOM 6/>YRS CPAP 4/> PARM	914.11	914.11
95811-26	Neurology	POLYSOM 6/>YRS CPAP 4/> PARM	175.80	175.80
95811-TC	Neurology	POLYSOM 6/>YRS CPAP 4/> PARM	738.32	738.32
95812	Neurology	EEG 41-60 MINUTES	490.87	490.87
95812-26	Neurology	EEG 41-60 MINUTES	80.83	80.83
95812-TC	Neurology	EEG 41-60 MINUTES	410.04	410.04
95813	Neurology	EEG EXTND MNTR 61-119 MIN	621.49	621.49
95813-26	Neurology	EEG EXTND MNTR 61-119 MIN	122.03	122.03
95813-TC	Neurology	EEG EXTND MNTR 61-119 MIN	499.44	499.44
95816	Neurology	EEG AWAKE AND DROWSY	552.44	552.44
95816-26	Neurology	EEG AWAKE AND DROWSY	80.83	80.83
95816-TC	Neurology	EEG AWAKE AND DROWSY	471.61	471.61
95819	Neurology	EEG AWAKE AND ASLEEP	635.81	635.81
95819-26	Neurology	EEG AWAKE AND ASLEEP	80.83	80.83
95819-TC	Neurology	EEG AWAKE AND ASLEEP	554.98	554.98
95822	Neurology	EEG COMA OR SLEEP ONLY	577.94	577.94
95822-26	Neurology	EEG COMA OR SLEEP ONLY	80.83	80.83
95822-TC	Neurology	EEG COMA OR SLEEP ONLY	497.13	497.13
95824	Neurology	EEG CEREBRAL DEATH ONLY	81.12	81.12
95824-26	Neurology	EEG CEREBRAL DEATH ONLY	55.23	55.23
95824-TC	Neurology	EEG CEREBRAL DEATH ONLY	25.89	25.89
95829	Neurology	SURGERY ELECTROCORTICOGRAM	2479.89	2479.89
95829-26	Neurology	SURGERY ELECTROCORTICOGRAM	466.88	466.88
95829-TC	Neurology	SURGERY ELECTROCORTICOGRAM	2013.01	2013.01
95830	Neurology	INSERT ELECTRODES FOR EEG	961.05	130.19
95836	Neurology	ECOG IMPLTD BRN NPGT <30 D	150.46	150.46
95851	Neurology	RANGE OF MOTION MEASUREMENTS	30.62	11.14
95852	Neurology	RANGE OF MOTION MEASUREMENTS	25.32	7.70
95857	Neurology	CHOLINESTERASE CHALLENGE	90.06	40.41
95860	Neurology	MUSCLE TEST ONE LIMB	159.24	159.24
95860-26	Neurology	MUSCLE TEST ONE LIMB	72.15	72.15
95860-TC	Neurology	MUSCLE TEST ONE LIMB	87.09	87.09
95861	Neurology	MUSCLE TEST 2 LIMBS	226.41	226.41
95861-26	Neurology	MUSCLE TEST 2 LIMBS	115.21	115.21
95861-TC	Neurology	MUSCLE TEST 2 LIMBS	111.22	111.22
95863	Neurology	MUSCLE TEST 3 LIMBS	293.85	293.85
95863-26	Neurology	MUSCLE TEST 3 LIMBS	140.42	140.42
95863-TC	Neurology	MUSCLE TEST 3 LIMBS	153.43	153.43
95864	Neurology	MUSCLE TEST 4 LIMBS	327.89	327.89
95864-26	Neurology	MUSCLE TEST 4 LIMBS	149.56	149.56
95864-TC	Neurology	MUSCLE TEST 4 LIMBS	178.35	178.35
95865	Neurology	MUSCLE TEST LARYNX	211.81	211.81
95865-26	Neurology	MUSCLE TEST LARYNX	117.31	117.31
95865-TC	Neurology	MUSCLE TEST LARYNX	94.51	94.51
95866	Neurology	MUSCLE TEST HEMIDIAPHRAGM	174.10	174.10
95866-26	Neurology	MUSCLE TEST HEMIDIAPHRAGM	90.27	90.27
95866-TC	Neurology	MUSCLE TEST HEMIDIAPHRAGM	83.84	83.84
95867	Neurology	MUSCLE TEST CRAN NERV UNILAT	150.26	150.26
95867-26	Neurology	MUSCLE TEST CRAN NERV UNILAT	59.00	59.00
95867-TC	Neurology	MUSCLE TEST CRAN NERV UNILAT	91.26	91.26
95868	Neurology	MUSCLE TEST CRAN NERVE BILAT	196.12	196.12
95868-26	Neurology	MUSCLE TEST CRAN NERVE BILAT	88.62	88.62
95868-TC	Neurology	MUSCLE TEST CRAN NERVE BILAT	107.50	107.50
95869	Neurology	MUSCLE TEST THOR PARASPINAL	133.20	133.20
95869-26	Neurology	MUSCLE TEST THOR PARASPINAL	28.01	28.01
95869-TC	Neurology	MUSCLE TEST THOR PARASPINAL	105.17	105.17
95870	Neurology	MUSCLE TEST NONPARASPINAL	116.49	116.49
95870-26	Neurology	MUSCLE TEST NONPARASPINAL	28.01	28.01
95870-TC	Neurology	MUSCLE TEST NONPARASPINAL	88.48	88.48
95872	Neurology	MUSCLE TEST ONE FIBER	269.89	269.89
95872-26	Neurology	MUSCLE TEST ONE FIBER	211.11	211.11
95872-TC	Neurology	MUSCLE TEST ONE FIBER	58.78	58.78
95873	Neurology	GUIDE NERV DESTR ELEC STIM	99.13	99.13
95873-26	Neurology	GUIDE NERV DESTR ELEC STIM	27.68	27.68
95873-TC	Neurology	GUIDE NERV DESTR ELEC STIM	71.44	71.44
95874	Neurology	GUIDE NERV DESTR NEEDLE EMG	107.01	107.01
95874-26	Neurology	GUIDE NERV DESTR NEEDLE EMG	27.68	27.68
95874-TC	Neurology	GUIDE NERV DESTR NEEDLE EMG	79.33	79.33
95875	Neurology	LIMB EXERCISE TEST	173.09	173.09
95875-26	Neurology	LIMB EXERCISE TEST	83.22	83.22
95875-TC	Neurology	LIMB EXERCISE TEST	89.87	89.87
95885	Neurology	MUSC TST DONE W/NERV TST LIM	87.00	87.00
95885-26	Neurology	MUSC TST DONE W/NERV TST LIM	26.22	26.22
95885-TC	Neurology	MUSC TST DONE W/NERV TST LIM	60.77	60.77
95886	Neurology	MUSC TEST DONE W/N TEST COMP	136.40	136.40
95886-26	Neurology	MUSC TEST DONE W/N TEST COMP	64.03	64.03
95886-TC	Neurology	MUSC TEST DONE W/N TEST COMP	72.37	72.37
95887	Neurology	MUSC TST DONE W/N TST NONEXT	117.29	117.29
95887-26	Neurology	MUSC TST DONE W/N TST NONEXT	52.34	52.34
95887-TC	Neurology	MUSC TST DONE W/N TST NONEXT	64.95	64.95
95905	Neurology	MOTOR &/ SENS NRVE CNDJ TEST	46.77	46.77
95905-26	Neurology	MOTOR &/ SENS NRVE CNDJ TEST	3.76	3.76
95905-TC	Neurology	MOTOR &/ SENS NRVE CNDJ TEST	43.01	43.01
95907	Neurology	NVR CNDJ TST 1-2 STUDIES	128.31	128.31
95907-26	Neurology	NVR CNDJ TST 1-2 STUDIES	75.09	75.09
95907-TC	Neurology	NVR CNDJ TST 1-2 STUDIES	53.21	53.21
95908	Neurology	NRV CNDJ TST 3-4 STUDIES	159.26	159.26
95908-26	Neurology	NRV CNDJ TST 3-4 STUDIES	93.97	93.97
95908-TC	Neurology	NRV CNDJ TST 3-4 STUDIES	65.29	65.29
95909	Neurology	NRV CNDJ TST 5-6 STUDIES	191.14	191.14
95909-26	Neurology	NRV CNDJ TST 5-6 STUDIES	112.41	112.41
95909-TC	Neurology	NRV CNDJ TST 5-6 STUDIES	78.73	78.73
95910	Neurology	NRV CNDJ TEST 7-8 STUDIES	249.79	249.79
95910-26	Neurology	NRV CNDJ TEST 7-8 STUDIES	149.71	149.71
95910-TC	Neurology	NRV CNDJ TEST 7-8 STUDIES	100.08	100.08
95911	Neurology	NRV CNDJ TEST 9-10 STUDIES	301.49	301.49
95911-26	Neurology	NRV CNDJ TEST 9-10 STUDIES	187.03	187.03
95911-TC	Neurology	NRV CNDJ TEST 9-10 STUDIES	114.46	114.46
95912	Neurology	NRV CNDJ TEST 11-12 STUDIES	352.59	352.59
95912-26	Neurology	NRV CNDJ TEST 11-12 STUDIES	223.41	223.41
95912-TC	Neurology	NRV CNDJ TEST 11-12 STUDIES	129.18	129.18
95913	Neurology	NRV CNDJ TEST 13/> STUDIES	407.29	407.29
95913-26	Neurology	NRV CNDJ TEST 13/> STUDIES	264.20	264.20
95913-TC	Neurology	NRV CNDJ TEST 13/> STUDIES	143.09	143.09
95919	Other professional services	QUAN PUPLMTRY PHY/QHP UNI/BI	21.78	21.78
95919-26	Other professional services	QUAN PUPLMTRY PHY/QHP UNI/BI	13.71	13.71
95919-TC	Other professional services	QUAN PUPLMTRY PHY/QHP UNI/BI	8.06	8.06
95921	Neurology	AUTONOMIC NRV PARASYM INERVJ	124.82	124.82
95921-26	Neurology	AUTONOMIC NRV PARASYM INERVJ	63.25	63.25
95921-TC	Neurology	AUTONOMIC NRV PARASYM INERVJ	61.57	61.57
95922	Neurology	AUTONOMIC NRV ADRENRG INERVJ	134.66	134.66
95922-26	Neurology	AUTONOMIC NRV ADRENRG INERVJ	65.79	65.79
95922-TC	Neurology	AUTONOMIC NRV ADRENRG INERVJ	68.87	68.87
95923	Neurology	AUTONOMIC NRV SYST FUNJ TEST	172.48	172.48
95923-26	Neurology	AUTONOMIC NRV SYST FUNJ TEST	63.59	63.59
95923-TC	Neurology	AUTONOMIC NRV SYST FUNJ TEST	108.89	108.89
95924	Neurology	ANS PARASYMP & SYMP W/TILT	215.13	215.13
95924-26	Neurology	ANS PARASYMP & SYMP W/TILT	123.53	123.53
95924-TC	Neurology	ANS PARASYMP & SYMP W/TILT	91.59	91.59
95925	Neurology	SOMATOSENSORY TESTING	246.16	246.16
95925-26	Neurology	SOMATOSENSORY TESTING	39.66	39.66
95925-TC	Neurology	SOMATOSENSORY TESTING	206.52	206.52
95926	Neurology	SOMATOSENSORY TESTING	220.78	220.78
95926-26	Neurology	SOMATOSENSORY TESTING	38.85	38.85
95926-TC	Neurology	SOMATOSENSORY TESTING	181.93	181.93
95927	Neurology	SOMATOSENSORY TESTING	254.97	254.97
95927-26	Neurology	SOMATOSENSORY TESTING	38.85	38.85
95927-TC	Neurology	SOMATOSENSORY TESTING	216.13	216.13
95928	Neurology	C MOTOR EVOKED UPPR LIMBS	339.32	339.32
95928-26	Neurology	C MOTOR EVOKED UPPR LIMBS	112.27	112.27
95928-TC	Neurology	C MOTOR EVOKED UPPR LIMBS	227.05	227.05
95929	Neurology	C MOTOR EVOKED LWR LIMBS	343.18	343.18
95929-26	Neurology	C MOTOR EVOKED LWR LIMBS	111.93	111.93
95929-TC	Neurology	C MOTOR EVOKED LWR LIMBS	231.23	231.23
95930	Neurology	VISUAL EP TEST CNS W/I&R	94.75	94.75
95930-26	Neurology	VISUAL EP TEST CNS W/I&R	26.22	26.22
95930-TC	Neurology	VISUAL EP TEST CNS W/I&R	68.53	68.53
95933	Neurology	BLINK REFLEX TEST	116.25	116.25
95933-26	Neurology	BLINK REFLEX TEST	44.48	44.48
95933-TC	Neurology	BLINK REFLEX TEST	71.77	71.77
95937	Neurology	NEUROMUSCULAR JUNCTION TEST	146.64	146.64
95937-26	Neurology	NEUROMUSCULAR JUNCTION TEST	48.87	48.87
95937-TC	Neurology	NEUROMUSCULAR JUNCTION TEST	97.75	97.75
95938	Neurology	SOMATOSENSORY TESTING	523.92	523.92
95938-26	Neurology	SOMATOSENSORY TESTING	64.37	64.37
95938-TC	Neurology	SOMATOSENSORY TESTING	459.55	459.55
95939	Neurology	C MOTOR EVOKED UPR&LWR LIMBS	782.84	782.84
95939-26	Neurology	C MOTOR EVOKED UPR&LWR LIMBS	168.01	168.01
95939-TC	Neurology	C MOTOR EVOKED UPR&LWR LIMBS	614.83	614.83
95940	Neurology	IONM IN OPERATNG ROOM 15 MIN	45.78	45.78
95941	Neurology	IONM REMOTE/>1 PT OR PER HR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95954	Neurology	EEG MONITORING/GIVING DRUGS	554.49	554.49
95954-26	Neurology	EEG MONITORING/GIVING DRUGS	160.74	160.74
95954-TC	Neurology	EEG MONITORING/GIVING DRUGS	393.75	393.75
95955	Neurology	EEG DURING SURGERY	267.98	267.98
95955-26	Neurology	EEG DURING SURGERY	75.60	75.60
95955-TC	Neurology	EEG DURING SURGERY	192.40	192.40
95957	Neurology	EEG DIGITAL ANALYSIS	414.02	414.02
95957-26	Neurology	EEG DIGITAL ANALYSIS	145.00	145.00
95957-TC	Neurology	EEG DIGITAL ANALYSIS	269.00	269.00
95958	Neurology	EEG MONITORING/FUNCTION TEST	986.74	986.74
95958-26	Neurology	EEG MONITORING/FUNCTION TEST	318.48	318.48
95958-TC	Neurology	EEG MONITORING/FUNCTION TEST	668.24	668.24
95961	Neurology	ELECTRODE STIMULATION BRAIN	463.51	463.51
95961-26	Neurology	ELECTRODE STIMULATION BRAIN	227.65	227.65
95961-TC	Neurology	ELECTRODE STIMULATION BRAIN	235.86	235.86
95962	Neurology	ELECTRODE STIM BRAIN ADD-ON	395.87	395.87
95962-26	Neurology	ELECTRODE STIM BRAIN ADD-ON	243.97	243.97
95962-TC	Neurology	ELECTRODE STIM BRAIN ADD-ON	151.90	151.90
95965	Neurology	MEG SPONTANEOUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95965-26	Neurology	MEG SPONTANEOUS	585.00	585.00
95965-TC	Neurology	MEG SPONTANEOUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95966	Neurology	MEG EVOKED SINGLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95966-26	Neurology	MEG EVOKED SINGLE	281.40	281.40
95966-TC	Neurology	MEG EVOKED SINGLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95967	Neurology	MEG EVOKED EACH ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95967-26	Neurology	MEG EVOKED EACH ADDL	244.08	244.08
95967-TC	Neurology	MEG EVOKED EACH ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
95970	Neurology	ALYS NPGT W/O PRGRMG	26.88	25.96
95971	Neurology	ALYS SMPL SP/PN NPGT W/PRGRM	68.77	55.32
95972	Neurology	ALYS CPLX SP/PN NPGT W/PRGRM	80.78	57.13
95976	Neurology	ALYS SMPL CN NPGT PRGRMG	56.07	55.14
95977	Neurology	ALYS CPLX CN NPGT PRGRMG	74.66	73.27
95980	Neurology	IO ANAL GAST N-STIM INIT	62.64	62.64
95981	Neurology	IO ANAL GAST N-STIM SUBSQ	54.61	24.91
95982	Neurology	IO GA N-STIM SUBSQ W/REPROG	83.42	50.95
95983	Neurology	ALYS BRN NPGT PRGRMG 15 MIN	71.31	69.92
95984	Neurology	ALYS BRN NPGT PRGRMG ADDL 15	62.23	61.31
95990	Neurology	SPIN/BRAIN PUMP REFIL & MAIN	125.06	125.06
95991	Neurology	SPIN/BRAIN PUMP REFIL & MAIN	155.69	56.43
95992	Neurology	CANALITH REPOSITIONING PROC	61.31	51.56
95999	Neurology	UNLISTED NEUROLOGICAL DX PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96000	Neurology	MOTION ANALYSIS VIDEO/3D	120.01	120.01
96001	Neurology	MOTION TEST W/FT PRESS MEAS	157.12	157.12
96002	Neurology	DYNAMIC SURFACE EMG	30.36	30.36
96003	Neurology	DYNAMIC FINE WIRE EMG	23.98	23.98
96004	Neurology	PHYS REVIEW OF MOTION TESTS	153.83	153.83
96020	Neurology	FUNCTIONAL BRAIN MAPPING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96020-26	Neurology	FUNCTIONAL BRAIN MAPPING	225.22	225.22
96020-TC	Neurology	FUNCTIONAL BRAIN MAPPING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96040	Other professional services	GENETIC COUNSELING 30 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96105	Other professional services	ASSESSMENT OF APHASIA	136.46	136.46
96110	Other professional services	DEVELOPMENTAL SCREEN W/SCORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96112	Other professional services	DEVEL TST PHYS/QHP 1ST HR	176.58	175.22
96113	Other professional services	DEVEL TST PHYS/QHP EA ADDL	85.19	80.19
96116	Other professional services	NUBHVL XM PHYS/QHP 1ST HR	131.27	113.52
96121	Other professional services	NUBHVL XM PHY/QHP EA ADDL HR	108.03	95.30
96125	Other professional services	COGNITIVE TEST BY HC PRO	145.04	145.04
96127	Other professional services	BRIEF EMOTIONAL/BEHAV ASSMT	6.24	6.24
96130	Other professional services	PSYCL TST EVAL PHYS/QHP 1ST	171.50	155.58
96131	Other professional services	PSYCL TST EVAL PHYS/QHP EA	123.38	108.81
96132	Other professional services	NRPSYC TST EVAL PHYS/QHP 1ST	183.26	150.96
96133	Other professional services	NRPSYC TST EVAL PHYS/QHP EA	139.29	109.28
96136	Other professional services	PSYCL/NRPSYC TST PHY/QHP 1ST	58.59	33.12
96137	Other professional services	PSYCL/NRPSYC TST PHY/QHP EA	52.94	25.65
96138	Other professional services	PSYCL/NRPSYC TECH 1ST	46.73	46.73
96139	Other professional services	PSYCL/NRPSYC TST TECH EA	48.08	48.08
96146	Other professional services	PSYCL/NRPSYC TST AUTO RESULT	3.06	3.06
96156	Other professional services	HLTH BHV ASSMT/REASSESSMENT	142.19	126.72
96158	Other professional services	HLTH BHV IVNTJ INDIV 1ST 30	96.44	85.07
96159	Major surgery	HLTH BHV IVNTJ INDIV EA ADDL	42.49	37.17
96160	Other professional services	PT-FOCUSED HLTH RISK ASSMT	4.10	4.10
96161	Other professional services	CAREGIVER HEALTH RISK ASSMT	4.10	4.10
96164	Other professional services	HLTH BHV IVNTJ GRP 1ST 30	14.78	13.41
96165	Major surgery	HLTH BHV IVNTJ GRP EA ADDL	8.76	7.57
96167	Other professional services	HLTH BHV IVNTJ FAM 1ST 30	101.79	89.97
96168	Major surgery	HLTH BHV IVNTJ FAM EA ADDL	47.50	41.59
96170	Other professional services	HLTH BHV IVNTJ FAM WO PT 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96171	Major surgery	HLTH BHV IVNTJ FAM W/O PT EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96202	Other professional services	MLT FAM GRP BHV TRAIN 1ST 60	33.72	30.09
96203	Other professional services	MLT FAM GRP BHV TRAIN EA ADD	8.18	8.18
96360	Other professional services	HYDRATION IV INFUSION INIT	44.61	44.61
96361	Other professional services	HYDRATE IV INFUSION ADD-ON	17.03	17.03
96365	Other professional services	THER/PROPH/DIAG IV INF INIT	85.76	85.76
96366	Other professional services	THER/PROPH/DIAG IV INF ADDON	28.28	28.28
96367	Other professional services	TX/PROPH/DG ADDL SEQ IV INF	39.23	39.23
96368	Other professional services	THER/DIAG CONCURRENT INF	27.33	27.33
96369	Other professional services	SC THER INFUSION UP TO 1 HR	193.22	193.22
96370	Other professional services	SC THER INFUSION ADDL HR	22.35	22.35
96371	Other professional services	SC THER INFUSION RESET PUMP	82.20	82.20
96372	Other professional services	THER/PROPH/DIAG INJ SC/IM	20.04	20.04
96373	Other professional services	THER/PROPH/DIAG INJ IA	25.97	25.97
96374	Other professional services	THER/PROPH/DIAG INJ IV PUSH	50.43	50.43
96375	Other professional services	TX/PRO/DX INJ NEW DRUG ADDON	21.15	21.15
96376	Other professional services	TX/PRO/DX INJ SAME DRUG ADON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96377	Other professional services	APPLICATON ON-BODY INJECTOR	25.50	25.50
96379	Other professional services	UNL THER/PROP/DIAG INJ/INF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96380	Other professional services	ADMN RSV MONOC ANTB IM CNSL	31.67	31.67
96381	Other professional services	ADMN RSV MONOC ANTB IM NJX	27.33	27.33
96401	Other professional services	CHEMO ANTI-NEOPL SQ/IM	98.04	98.04
96402	Other professional services	CHEMO HORMON ANTINEOPL SQ/IM	48.65	48.65
96405	Other professional services	CHEMO INTRALESIONAL UP TO 7	114.75	40.17
96406	Other professional services	CHEMO INTRALESIONAL OVER 7	179.06	62.18
96409	Other professional services	CHEMO IV PUSH SNGL DRUG	136.55	136.55
96411	Other professional services	CHEMO IV PUSH ADDL DRUG	74.48	74.48
96413	Other professional services	CHEMO IV INFUSION 1 HR	176.60	176.60
96415	Other professional services	CHEMO IV INFUSION ADDL HR	38.19	38.19
96416	Other professional services	CHEMO PROLONG INFUSE W/PUMP	173.61	173.61
96417	Other professional services	CHEMO IV INFUS EACH ADDL SEQ	87.12	87.12
96420	Other professional services	CHEMO IA PUSH TECNIQUE	139.02	139.02
96422	Other professional services	CHEMO IA INFUSION UP TO 1 HR	212.33	212.33
96423	Other professional services	CHEMO IA INFUSE EACH ADDL HR	99.12	99.12
96425	Other professional services	CHEMOTHERAPY INFUSION METHOD	228.89	228.89
96440	Other professional services	CHMOTX ADMN PLRL CAV THRCNTS	1023.80	188.30
96446	Other professional services	CHEMOTX ADMN PERTL CAV IMPL	218.06	27.93
96450	Other professional services	CHEMOTHERAPY INTO CNS	224.36	106.56
96521	Other professional services	REFILL/MAINT PORTABLE PUMP	169.07	169.07
96522	Other professional services	REFILL/MAINT PUMP/RESVR SYST	160.41	160.41
96523	Other professional services	IRRIG DRUG DELIVERY DEVICE	34.13	34.13
96542	Other professional services	CHEMOTHERAPY INJECTION	180.24	58.82
96547	Other professional services	INTRAOP HIPEC PX 1ST 60 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96548	Other professional services	NTRAOP HIPEC PX EA ADD 30MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96549	Other professional services	UNLISTED CHEMOTHERAPY PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96567	Other professional services	PDT DSTR PRMLG LES SKN	186.80	186.80
96570	Other professional services	PHOTODYNMC TX 30 MIN ADD-ON	70.61	70.61
96571	Other professional services	PHOTODYNAMIC TX ADDL 15 MIN	35.15	35.15
96573	Other professional services	PDT DSTR PRMLG LES PHYS/QHP	310.77	310.77
96574	Other professional services	DBRDMT PRMLG LES W/PDT	381.89	381.89
96900	Other professional services	ULTRAVIOLET LIGHT THERAPY	33.99	33.99
96902	Other professional services	TRICHOGRAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
96904	Other professional services	WHOLE BODY PHOTOGRAPHY	93.57	93.57
96910	Other professional services	PHOTOCHEMOTHERAPY WITH UV-B	161.66	161.66
96912	Other professional services	PHOTOCHEMOTHERAPY WITH UV-A	137.55	137.55
96913	Other professional services	PHOTOCHEMOTHERAPY UV-A OR B	208.38	208.38
96920	Other professional services	EXCIMER LSR PSRIASIS<250SQCM	215.94	89.04
96921	Other professional services	EXCIMER LSR PSRIASIS 250-500	236.82	100.83
96922	Other professional services	EXCIMER LSR PSRIASIS>500SQCM	323.49	162.48
96931	Other professional services	RCM CELULR SUBCELULR IMG SKN	233.90	233.90
96932	Other professional services	RCM CELULR SUBCELULR IMG SKN	173.16	173.16
96933	Other professional services	RCM CELULR SUBCELULR IMG SKN	60.74	60.74
96934	Other professional services	RCM CELULR SUBCELULR IMG SKN	162.93	162.93
96935	Other professional services	RCM CELULR SUBCELULR IMG SKN	105.53	105.53
96936	Other professional services	RCM CELULR SUBCELULR IMG SKN	57.41	57.41
96999	Other professional services	UNLISTED SPEC DERM SVC/PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97010	Physical Medicine	HOT OR COLD PACKS THERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97012	Physical Medicine	MECHANICAL TRACTION THERAPY	18.56	18.56
97014	Physical Medicine	ELECTRIC STIMULATION THERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97016	Physical Medicine	VASOPNEUMATIC DEVICE THERAPY	15.34	15.34
97018	Physical Medicine	PARAFFIN BATH THERAPY	7.29	7.29
97022	Physical Medicine	WHIRLPOOL THERAPY	22.11	22.11
97024	Physical Medicine	DIATHERMY EG MICROWAVE	9.42	9.42
97026	Physical Medicine	INFRARED THERAPY	8.57	8.57
97028	Physical Medicine	ULTRAVIOLET THERAPY	10.77	10.77
97032	Physical Medicine	APPL MODALITY 1+ESTIM EA 15	18.98	18.98
97033	Physical Medicine	APP MDLTY 1+IONTPHRSIS EA 15	25.38	25.38
97034	Physical Medicine	APP MDLTY 1+CNTRST BTH EA 15	18.42	18.42
97035	Physical Medicine	APP MDLTY 1+ULTRASOUND EA 15	18.42	18.42
97036	Physical Medicine	APP MDLTY 1+HUBBRD TNK EA 15	45.40	45.40
97037	Other professional services	APPL MODALITY 1+LLLT PO PAIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97039	Physical Medicine	UNLISTED MODALITY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97110	Physical Medicine	THERAPEUTIC EXERCISES	38.77	38.77
97112	Physical Medicine	NEUROMUSCULAR REEDUCATION	44.45	44.45
97113	Physical Medicine	AQUATIC THERAPY/EXERCISES	48.20	48.20
97116	Physical Medicine	GAIT TRAINING THERAPY	38.77	38.77
97124	Physical Medicine	MASSAGE THERAPY	39.69	39.69
97129	Physical Medicine	THER IVNTJ 1ST 15 MIN	30.02	29.60
97130	Major surgery	THER IVNTJ EA ADDL 15 MIN	39.94	39.35
97139	Physical Medicine	UNLISTED THERAPEUTIC PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97140	Physical Medicine	MANUAL THERAPY 1/> REGIONS	35.73	35.73
97150	Physical Medicine	GROUP THERAPEUTIC PROCEDURES	23.79	23.79
97151	Other professional services	BHV ID ASSMT BY PHYS/QHP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97152	Other professional services	BHV ID SUPRT ASSMT BY 1 TECH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97153	Other professional services	ADAPTIVE BEHAVIOR TX BY TECH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97154	Other professional services	GRP ADAPT BHV TX BY TECH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97155	Other professional services	ADAPT BEHAVIOR TX PHYS/QHP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97156	Other professional services	FAM ADAPT BHV TX GDN PHY/QHP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97157	Other professional services	MULT FAM ADAPT BHV TX GDN	76.01	76.01
97158	Other professional services	GRP ADAPT BHV TX BY PHY/QHP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97161	Physical Medicine	PT EVAL LOW COMPLEX 20 MIN	132.52	132.52
97162	Physical Medicine	PT EVAL MOD COMPLEX 30 MIN	132.52	132.52
97163	Physical Medicine	PT EVAL HIGH COMPLEX 45 MIN	132.52	132.52
97164	Physical Medicine	PT RE-EVAL EST PLAN CARE	91.62	91.62
97165	Physical Medicine	OT EVAL LOW COMPLEX 30 MIN	133.80	133.80
97166	Physical Medicine	OT EVAL MOD COMPLEX 45 MIN	133.80	133.80
97167	Physical Medicine	OT EVAL HIGH COMPLEX 60 MIN	133.80	133.80
97168	Physical Medicine	OT RE-EVAL EST PLAN CARE	92.04	92.04
97169	Physical Medicine	ATHLETIC TRN EVAL LOW CMPLX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97170	Physical Medicine	ATHLETIC TRN EVAL MOD CMPLX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97171	Physical Medicine	ATHLETIC TRN EVAL HIGH CMPLX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97172	Physical Medicine	ATHLETIC TRN RE-EVAL PLAN CR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97530	Physical Medicine	THERAPEUTIC ACTIVITIES	48.06	48.06
97533	Physical Medicine	SENSORY INTEGRATION	80.89	80.89
97535	Physical Medicine	SELF CARE MNGMENT TRAINING	43.01	43.01
97537	Physical Medicine	COMMUNITY/WORK REINTEGRATION	41.83	41.83
97542	Physical Medicine	WHEELCHAIR MNGMENT TRAINING	41.83	41.83
97545	Physical Medicine	WORK HARDENING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97546	Physical Medicine	WORK HARDENING ADD-ON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97550	Other professional services	CAREGIVER TRAING 1ST 30 MIN	75.57	65.10
97551	Other professional services	CAREGIVER TRAING EA ADDL 15	37.77	35.04
97552	Other professional services	GROUP CAREGIVER TRAINING	31.19	15.26
97597	Physical Medicine	DBRDMT OPN WND 1ST 20 CM/<	130.52	46.47
97598	Physical Medicine	DBRDMT OPN WND ADDL 20CM/<	58.28	31.96
97602	Physical Medicine	WOUND(S) CARE NON-SELECTIVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97605	Physical Medicine	NEG PRS WND THER DME<=50SQCM	56.50	32.31
97606	Physical Medicine	NEG PRS WND THER DME>50 SQCM	66.86	35.45
97607	Physical Medicine	NEG PRS WND THR NDME<=50SQCM	444.28	27.41
97608	Physical Medicine	NEG PRS WND THER NDME>50SQCM	459.37	31.89
97610	Physical Medicine	LOW FREQUENCY NON-THERMAL US	545.86	23.73
97750	Physical Medicine	PHYSICAL PERFORMANCE TEST	44.70	44.70
97755	Physical Medicine	ASSISTIVE TECHNOLOGY ASSESS	50.68	50.68
97760	Physical Medicine	ORTHOTIC MGMT&TRAING 1ST ENC	62.29	62.29
97761	Physical Medicine	PROSTHETIC TRAING 1ST ENC	54.64	54.64
97763	Physical Medicine	ORTHC/PROSTC MGMT SBSQ ENC	68.15	68.15
97799	Physical Medicine	UNLISTED PHYSCL MED/REHAB PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
97802	Other professional services	MEDICAL NUTRITION INDIV IN	51.38	45.00
97803	Other professional services	MED NUTRITION INDIV SUBSEQ	44.72	38.36
97804	Other professional services	MEDICAL NUTRITION GROUP	23.52	21.71
97810	Pain management	ACUPUNCT W/O STIMUL 15 MIN	58.65	46.78
97811	Pain management	ACUPUNCT W/O STIMUL ADDL 15M	43.57	39.12
97813	Pain management	ACUPUNCT W/STIMUL 15 MIN	69.23	50.94
97814	Pain management	ACUPUNCT W/STIMUL ADDL 15M	55.97	43.13
98925	Pain management	OSTEOPATH MANJ 1-2 REGIONS	47.86	35.01
98926	Pain management	OSTEOPATH MANJ 3-4 REGIONS	68.97	53.15
98927	Pain management	OSTEOPATH MANJ 5-6 REGIONS	90.07	70.81
98928	Pain management	OSTEOPATH MANJ 7-8 REGIONS	110.06	89.31
98929	Pain management	OSTEOPATH MANJ 9-10 REGIONS	129.70	106.96
98940	Pain management	CHIROPRACT MANJ 1-2 REGIONS	42.20	33.81
98941	Pain management	CHIROPRACT MANJ 3-4 REGIONS	60.98	52.09
98942	Pain management	CHIROPRACTIC MANJ 5 REGIONS	78.78	69.88
98943	Pain management	CHIROPRACT MANJ XTRSPINL 1/>	UCR or Pay Per Agreement	UCR or Pay Per Agreement
98960	Other professional services	SELF-MGMT EDUC & TRAIN 1 PT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
98961	Other professional services	SELF-MGMT EDUC/TRAIN 2-4 PT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
98962	Other professional services	SELF-MGMT EDUC/TRAIN 5-8 PT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
98966	Other professional services	HC PRO PHONE CALL 5-10 MIN	18.53	16.25
98967	Other professional services	HC PRO PHONE CALL 11-20 MIN	34.31	31.58
98968	Other professional services	HC PRO PHONE CALL 21-30 MIN	47.49	44.31
98970	Other professional services	QNHP OL DIG ASSMT&MGMT 5-10	16.70	16.70
98971	Other professional services	QNHP OL DIG ASSMT&MGMT 11-20	29.54	29.54
98972	Other professional services	QNHP OL DIG ASSMT&MGMT 21+	44.10	43.64
98975	Other professional services	REM THER MNTR 1ST SETUP&EDU	27.03	27.03
98976	Other professional services	REM THER MNTR DEV SPLY RESP	64.46	64.46
98977	Other professional services	REM THER MNTR DV SPLY MSCSKL	64.46	64.46
98978	Other professional services	REM THER MNTR DEV SPLY CBT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
98980	Other professional services	REM THER MNTR 1ST 20 MIN	70.88	43.13
98981	Other professional services	REM THER MNTR EA ADDL 20 MIN	56.28	42.65
99000	Other professional services	SPECIMEN HANDLING OFFICE-LAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99001	Other professional services	SPECIMEN HANDLING PT-LAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99002	Other professional services	DEVICE HANDLING PHYS/QHP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99024	Other professional services	POSTOP FOLLOW-UP VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99026	Other professional services	IN-HOSPITAL ON CALL SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99027	Other professional services	OUT-OF-HOSP ON CALL SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99050	Other professional services	MEDICAL SERVICES AFTER HRS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99051	Other professional services	MED SERV EVE/WKEND/HOLIDAY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99053	Other professional services	MED SERV 10PM-8AM 24 HR FAC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99056	Other professional services	MED SERVICE OUT OF OFFICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99058	Other professional services	OFFICE EMERGENCY CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99060	Other professional services	OUT OF OFFICE EMERG MED SERV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99070	Other professional services	SPECIAL SUPPLIES PHYS/QHP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99071	Other professional services	PATIENT EDUCATION MATERIALS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99072	Other professional services	ADDL SUPL MATRL&STAF TM PHE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99075	Other professional services	MEDICAL TESTIMONY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99078	Other professional services	GROUP HEALTH EDUCATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99080	Other professional services	SPECIAL REPORTS OR FORMS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99082	Other professional services	UNUSUAL PHYSICIAN TRAVEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99091	Other professional services	COLLJ & INTERPJ DATA EA 30 D	76.20	76.20
99100	Other professional services	ANES PT EXTEME AGE<1 YR&>70	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99116	Other professional services	ANES COMP TOT BDY HYPTHRM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99135	Other professional services	ANES COMP CTRLD HYPOTENSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99140	Other professional services	ANES COMP EMERGENCY COND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99151	Other professional services	MOD SED SAME PHYS/QHP <5 YRS	84.21	33.72
99152	Other professional services	MOD SED SAME PHYS/QHP 5/>YRS	69.20	16.89
99153	Other professional services	MOD SED SAME PHYS/QHP EA	15.66	15.66
99155	Other professional services	MOD SED OTH PHYS/QHP <5 YRS	115.65	115.65
99156	Other professional services	MOD SED OTH PHYS/QHP 5/>YRS	104.79	104.79
99157	Other professional services	MOD SED OTHER PHYS/QHP EA	83.18	83.18
99170	Other professional services	ANOGENITAL EXAM CHILD W IMAG	229.95	118.98
99172	Other professional services	OCULAR FUNCTION SCREEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99173	Other professional services	VISUAL ACUITY SCREEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99174	Other professional services	OCULAR INSTRUMNT SCREEN BIL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99175	Other professional services	INDUCTION OF VOMITING	40.80	40.80
99177	Other professional services	OCULAR INSTRUMNT SCREEN BIL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99183	Other professional services	HYPERBARIC OXYGEN THERAPY	147.15	147.15
99184	Other professional services	HYPOTHERMIA ILL NEONATE	300.74	300.74
99188	Other professional services	APP TOPICAL FLUORIDE VARNISH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99190	Other professional services	SPECIAL PUMP SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99191	Other professional services	SPECIAL PUMP SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99192	Other professional services	SPECIAL PUMP SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99195	Other professional services	PHLEBOTOMY	129.77	129.77
99199	Other professional services	UNLISTED SPECIAL SVC PX/RPRT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99202	Evaluation & Management	OFFICE O/P NEW SF 15 MIN	94.32	62.05
99203	Evaluation & Management	OFFICE O/P NEW LOW 30 MIN	145.73	107.09
99204	Evaluation & Management	OFFICE O/P NEW MOD 45 MIN	219.04	174.47
99205	Evaluation & Management	OFFICE O/P NEW HI 60 MIN	288.95	237.15
99211	Evaluation & Management	OFF/OP EST MAY X REQ PHY/QHP	30.21	11.52
99212	Evaluation & Management	OFFICE O/P EST SF 10 MIN	73.82	46.23
99213	Evaluation & Management	OFFICE O/P EST LOW 20 MIN	119.10	86.41
99214	Evaluation & Management	OFFICE O/P EST MOD 30 MIN	168.27	127.51
99215	Evaluation & Management	OFFICE O/P EST HI 40 MIN	236.94	188.97
99221	Evaluation & Management	1ST HOSP IP/OBS SF/LOW 40	107.80	107.80
99222	Evaluation & Management	1ST HOSP IP/OBS MODERATE 55	170.77	170.77
99223	Evaluation & Management	1ST HOSP IP/OBS HIGH 75	226.95	226.95
99231	Evaluation & Management	SBSQ HOSP IP/OBS SF/LOW 25	64.72	64.72
99232	Evaluation & Management	SBSQ HOSP IP/OBS MODERATE 35	103.29	103.29
99233	Evaluation & Management	SBSQ HOSP IP/OBS HIGH 50	155.41	155.41
99234	Evaluation & Management	HOSP IP/OBS SM DT SF/LOW 45	127.85	127.85
99235	Evaluation & Management	HOSP IP/OBS SAME DATE MOD 70	208.91	208.91
99236	Evaluation & Management	HOSP IP/OBS SAME DATE HI 85	273.10	273.10
99238	Evaluation & Management	HOSP IP/OBS DSCHRG MGMT 30/<	106.08	106.08
99239	Evaluation & Management	HOSP IP/OBS DSCHRG MGMT >30	149.83	149.83
99242	Evaluation & Management	OFF/OP CONSLTJ NEW/EST SF 20	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99243	Evaluation & Management	OFF/OP CNSLTJ NEW/EST LOW 30	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99244	Evaluation & Management	OFF/OP CNSLTJ NEW/EST MOD 40	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99245	Evaluation & Management	OFF/OP CONSLTJ NEW/EST HI 55	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99252	Evaluation & Management	IP/OBS CONSLTJ NEW/EST SF 35	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99253	Evaluation & Management	IP/OBS CNSLTJ NEW/EST LOW 45	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99254	Evaluation & Management	IP/OBS CNSLTJ NEW/EST MOD 60	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99255	Evaluation & Management	IP/OBS CONSLTJ NEW/EST HI 80	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99281	Emergency Medicine	EMR DPT VST MAYX REQ PHY/QHP	18.02	18.02
99282	Emergency Medicine	EMERGENCY DEPT VISIT SF MDM	65.91	65.91
99283	Emergency Medicine	EMERGENCY DEPT VISIT LOW MDM	112.22	112.22
99284	Emergency Medicine	EMERGENCY DEPT VISIT MOD MDM	190.99	190.99
99285	Emergency Medicine	EMERGENCY DEPT VISIT HI MDM	276.77	276.77
99288	Emergency Medicine	DIRECT ADVANCED LIFE SUPPORT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99291	Emergency Medicine	CRITICAL CARE FIRST HOUR	431.52	335.70
99292	Emergency Medicine	CRITICAL CARE ADDL 30 MIN	189.35	168.85
99304	Evaluation & Management	1ST NF CARE SF/LOW MDM 25	105.22	105.22
99305	Evaluation & Management	1ST NF CARE MODERATE MDM 35	174.97	174.97
99306	Evaluation & Management	1ST NF CARE HIGH MDM 50	239.20	239.20
99307	Evaluation & Management	SBSQ NF CARE SF MDM 10	52.71	52.71
99308	Evaluation & Management	SBSQ NF CARE LOW MDM 20	97.57	97.57
99309	Evaluation & Management	SBSQ NF CARE MODERATE MDM 30	141.22	141.22
99310	Evaluation & Management	SBSQ NF CARE HIGH MDM 45	201.53	201.53
99315	Evaluation & Management	NF DSCHRG MGMT 30 MIN/LESS	107.04	107.04
99316	Evaluation & Management	NF DSCHRG MGMT 30 MIN+	172.00	172.00
99341	Evaluation & Management	HOME/RES VST NEW SF MDM 15	65.20	65.20
99342	Evaluation & Management	HOME/RES VST NEW LOW MDM 30	103.54	103.54
99344	Evaluation & Management	HOME/RES VST NEW MOD MDM 60	187.39	187.39
99345	Evaluation & Management	HOME/RES VST NEW HIGH MDM 75	265.29	265.29
99347	Evaluation & Management	HOME/RES VST EST SF MDM 20	59.77	59.77
99348	Evaluation & Management	HOME/RES VST EST LOW MDM 30	100.91	100.91
99349	Evaluation & Management	HOME/RES VST EST MOD MDM 40	167.24	167.24
99350	Evaluation & Management	HOME/RES VST EST HIGH MDM 60	243.66	243.66
99358	Evaluation & Management	PROLONG SERVICE W/O CONTACT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99359	Evaluation & Management	PROLONG SERV W/O CONTACT ADD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99360	Evaluation & Management	PHYSICIAN STANDBY SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99366	Evaluation & Management	TEAM CONF W/PAT BY HC PROF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99367	Evaluation & Management	TEAM CONF W/O PAT BY PHYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99368	Evaluation & Management	TEAM CONF W/O PAT BY HC PRO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99374	Evaluation & Management	HOME HEALTH CARE SUPERVISION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99375	Evaluation & Management	HOME HEALTH CARE SUPERVISION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99377	Evaluation & Management	HOSPICE CARE SUPERVISION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99378	Evaluation & Management	HOSPICE CARE SUPERVISION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99379	Evaluation & Management	NURSING FAC CARE SUPERVISION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99380	Evaluation & Management	NURSING FAC CARE SUPERVISION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99381	Evaluation & Management	INIT PM E/M NEW PAT INFANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99382	Evaluation & Management	INIT PM E/M NEW PAT 1-4 YRS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99383	Evaluation & Management	PREV VISIT NEW AGE 5-11	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99384	Evaluation & Management	PREV VISIT NEW AGE 12-17	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99385	Evaluation & Management	PREV VISIT NEW AGE 18-39	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99386	Evaluation & Management	PREV VISIT NEW AGE 40-64	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99387	Evaluation & Management	INIT PM E/M NEW PAT 65+ YRS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99391	Evaluation & Management	PER PM REEVAL EST PAT INFANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99392	Evaluation & Management	PREV VISIT EST AGE 1-4	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99393	Evaluation & Management	PREV VISIT EST AGE 5-11	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99394	Evaluation & Management	PREV VISIT EST AGE 12-17	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99395	Evaluation & Management	PREV VISIT EST AGE 18-39	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99396	Evaluation & Management	PREV VISIT EST AGE 40-64	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99397	Evaluation & Management	PER PM REEVAL EST PAT 65+ YR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99401	Evaluation & Management	PREV MED CNSL INDIV APPRX 15	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99402	Evaluation & Management	PREV MED CNSL INDIV APPRX 30	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99403	Evaluation & Management	PREV MED CNSL INDIV APPRX 45	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99404	Evaluation & Management	PREV MED CNSL INDIV APPRX 60	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99406	Evaluation & Management	BEHAV CHNG SMOKING 3-10 MIN	19.25	15.43
99407	Evaluation & Management	BEHAV CHNG SMOKING > 10 MIN	36.02	32.63
99408	Evaluation & Management	AUDIT/DAST 15-30 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99409	Evaluation & Management	AUDIT/DAST OVER 30 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99411	Evaluation & Management	PREVENTIVE COUNSELING GROUP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99412	Evaluation & Management	PREVENTIVE COUNSELING GROUP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99415	Evaluation & Management	PROLNG CLIN STAFF SVC 1ST HR	26.08	26.08
99416	Evaluation & Management	PROLNG CLIN STAFF SVC EA ADD	12.19	12.19
99417	Evaluation & Management	PROLNG OP E/M EACH 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99418	Evaluation & Management	PROLNG IP/OBS E/M EA 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99421	Evaluation & Management	OL DIG E/M SVC 5-10 MIN	19.71	16.74
99422	Evaluation & Management	OL DIG E/M SVC 11-20 MIN	38.57	33.05
99423	Evaluation & Management	OL DIG E/M SVC 21+ MIN	61.43	52.93
99424	Evaluation & Management	PRIN CARE MGMT PHYS 1ST 30	108.88	97.41
99425	Evaluation & Management	PRIN CARE MGMT PHYS EA ADDL	78.96	67.07
99426	Evaluation & Management	PRIN CARE MGMT STAFF 1ST 30	81.40	64.83
99427	Evaluation & Management	PRIN CARE MGMT STAFF EA ADDL	62.09	45.53
99429	Evaluation & Management	UNLISTED PREVENTIVE SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99437	Evaluation & Management	CHRNC CARE MGMT PHYS EA ADDL	78.54	66.23
99439	Evaluation & Management	CHRNC CARE MGMT STAF EA ADDL	62.90	45.92
99441	Evaluation & Management	PHONE E/M PHYS/QHP 5-10 MIN	73.51	45.92
99442	Evaluation & Management	PHONE E/M PHYS/QHP 11-20 MIN	118.79	86.11
99443	Evaluation & Management	PHONE E/M PHYS/QHP 21-30 MIN	168.27	127.51
99446	Evaluation & Management	NTRPROF PH1/NTRNET/EHR 5-10	23.32	23.32
99447	Evaluation & Management	NTRPROF PH1/NTRNET/EHR 11-20	47.38	47.38
99448	Evaluation & Management	NTRPROF PH1/NTRNET/EHR 21-30	70.41	70.41
99449	Evaluation & Management	NTRPROF PH1/NTRNET/EHR 31/>	93.86	93.86
99450	Evaluation & Management	BASIC LIFE DISABILITY EXAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99451	Evaluation & Management	NTRPROF PH1/NTRNET/EHR 5/>	45.92	45.92
99452	Evaluation & Management	NTRPROF PH1/NTRNET/EHR RFRL	44.77	44.77
99453	Evaluation & Management	REM MNTR PHYSIOL PARAM SETUP	25.23	25.23
99454	Evaluation & Management	REM MNTR PHYSIOL PARAM DEV	60.16	60.16
99455	Evaluation & Management	WORK RELATED DISABILITY EXAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99456	Evaluation & Management	DISABILITY EXAMINATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99457	Evaluation & Management	REM PHYSIOL MNTR 1ST 20 MIN	63.99	39.37
99458	Major surgery	REM PHYSIOL MNTR EA ADDL 20	71.99	54.83
99459	Other professional services	PELVIC EXAMINATION	30.93	30.93
99460	Evaluation & Management	INIT NB EM PER DAY HOSP	121.69	121.69
99461	Evaluation & Management	INIT NB EM PER DAY NON-FAC	119.94	80.04
99462	Evaluation & Management	SBSQ NB EM PER DAY HOSP	53.49	53.49
99463	Evaluation & Management	SAME DAY NB DISCHARGE	141.69	141.69
99464	Evaluation & Management	ATTENDANCE AT DELIVERY	95.16	95.16
99465	Evaluation & Management	NB RESUSCITATION	186.26	186.26
99466	Emergency Medicine	PED CRIT CARE TRANSPORT	366.88	366.88
99467	Emergency Medicine	PED CRIT CARE TRANSPORT ADDL	184.16	184.16
99468	Emergency Medicine	NEONATE CRIT CARE INITIAL	1414.31	1414.31
99469	Emergency Medicine	NEONATE CRIT CARE SUBSQ	611.64	611.64
99471	Emergency Medicine	PED CRITICAL CARE INITIAL	1224.91	1224.91
99472	Emergency Medicine	PED CRITICAL CARE SUBSQ	625.57	625.57
99473	Emergency Medicine	SELF-MEAS BP PT EDUCAJ/TRAIN	21.89	21.89
99474	Emergency Medicine	SELF-MEAS BP 2 READG BID 30D	26.21	13.91
99475	Emergency Medicine	PED CRIT CARE AGE 2-5 INIT	879.53	879.53
99476	Emergency Medicine	PED CRIT CARE AGE 2-5 SUBSQ	529.43	529.43
99477	Emergency Medicine	INIT DAY HOSP NEONATE CARE	535.85	535.85
99478	Emergency Medicine	IC LBW INF < 1500 GM SUBSQ	210.93	210.93
99479	Emergency Medicine	IC LBW INF 1500-2500 G SUBSQ	191.75	191.75
99480	Emergency Medicine	IC INF PBW 2501-5000 G SUBSQ	184.16	184.16
99483	Evaluation & Management	ASSMT & CARE PLN PT COG IMP	357.57	253.58
99484	Evaluation & Management	CARE MGMT SVC BHVL HLTH COND	72.48	58.04
99485	Emergency Medicine	SUPRV INTERFACILTY TRANSPORT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99486	Emergency Medicine	SUPRV INTERFAC TRNSPORT ADDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99487	Evaluation & Management	CPLX CHRNC CARE 1ST 60 MIN	175.77	118.47
99489	Evaluation & Management	CPLX CHRNC CARE EA ADDL 30	94.67	65.80
99490	Evaluation & Management	CHRNC CARE MGMT STAFF 1ST 20	82.36	65.80
99491	Evaluation & Management	CHRNC CARE MGMT PHYS 1ST 30	111.72	98.98
99492	Evaluation & Management	1ST PSYC COLLAB CARE MGMT	200.21	123.38
99493	Evaluation & Management	SBSQ PSYC COLLAB CARE MGMT	183.57	134.75
99494	Evaluation & Management	1ST/SBSQ PSYC COLLAB CARE	77.74	53.97
99495	Evaluation & Management	TRANSJ CARE MGMT MOD F2F 14D	270.89	183.86
99496	Evaluation & Management	TRANSJ CARE MGMT HIGH F2F 7D	366.56	249.83
99497	Evaluation & Management	ADVNCD CARE PLAN 30 MIN	108.32	98.98
99498	Evaluation & Management	ADVNCD CARE PLAN ADDL 30 MIN	93.97	93.13
99499	Evaluation & Management	UNLISTED E&M SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99500	Other professional services	HOME VISIT PRENATAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99501	Other professional services	HOME VISIT POSTNATAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99502	Other professional services	HOME VISIT NB CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99503	Other professional services	HOME VISIT RESP THERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99504	Other professional services	HOME VISIT MECH VENTILATOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99505	Other professional services	HOME VISIT STOMA CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99506	Other professional services	HOME VISIT IM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99507	Other professional services	HOME VISIT CATH MAINTAIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99509	Other professional services	HOME VISIT DAY LIFE ACTIVITY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99510	Other professional services	HOME VISIT SING/M/FAM COUNS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99511	Other professional services	HOME VISIT FECAL/ENEMA MGMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99512	Other professional services	HOME VISIT FOR HEMODIALYSIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99600	Other professional services	UNLISTED HOME VISIT SVC/PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99601	Other professional services	HOME NFS VISIT <2 HRS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99602	Other professional services	HOME NFS VISIT EACH ADDL HR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99605	Pain management	MTMS BY PHARM NP 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99606	Pain management	MTMS BY PHARM EST 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
99607	Pain management	MTMS BY PHARM ADDL 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0021	Other professional services	OUTSIDE STATE AMBULANCE SERV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0080	Other professional services	NONINTEREST ESCORT IN NON ER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0090	Other professional services	INTEREST ESCORT IN NON ER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0100	Other professional services	NONEMERGENCY TRANSPORT TAXI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0110	Other professional services	NONEMERGENCY TRANSPORT BUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0120	Other professional services	NONER TRANSPORT MINI-BUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0130	Other professional services	NONER TRANSPORT WHEELCH VAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0140	Other professional services	NONEMERGENCY TRANSPORT AIR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0160	Other professional services	NONER TRANSPORT CASE WORKER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0170	Other professional services	TRANSPORT PARKING FEES/TOLLS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0180	Other professional services	NONER TRANSPORT LODGNG RECIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0190	Other professional services	NONER TRANSPORT MEALS RECIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0200	Other professional services	NONER TRANSPORT LODGNG ESCRT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0210	Other professional services	NONER TRANSPORT MEALS ESCORT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0225	Other professional services	NEONATAL EMERGENCY TRANSPORT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0380	Other professional services	BASIC LIFE SUPPORT MILEAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0382	Other professional services	BASIC SUPPORT ROUTINE SUPPLS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0384	Other professional services	BLS DEFIBRILLATION SUPPLIES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0390	Other professional services	ADVANCED LIFE SUPPORT MILEAG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0392	Other professional services	ALS DEFIBRILLATION SUPPLIES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0394	Other professional services	ALS IV DRUG THERAPY SUPPLIES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0396	Other professional services	ALS ESOPHAGEAL INTUB SUPPLS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0398	Other professional services	ALS ROUTINE DISPOSBLE SUPPLS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0420	Other professional services	AMBULANCE WAITING 1/2 HR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0422	Other professional services	AMBULANCE 02 LIFE SUSTAINING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0424	Other professional services	EXTRA AMBULANCE ATTENDANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0425	Other professional services	GROUND MILEAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0426	Other professional services	ALS 1	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0427	Other professional services	ALS1-EMERGENCY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0428	Other professional services	BLS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0429	Other professional services	BLS-EMERGENCY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0430	Other professional services	FIXED WING AIR TRANSPORT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0431	Other professional services	ROTARY WING AIR TRANSPORT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0432	Other professional services	PI VOLUNTEER AMBULANCE CO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0433	Other professional services	ALS 2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0434	Other professional services	SPECIALTY CARE TRANSPORT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0435	Other professional services	FIXED WING AIR MILEAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0436	Other professional services	ROTARY WING AIR MILEAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0888	Other professional services	NONCOVERED AMBULANCE MILEAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0998	Other professional services	AMBULANCE RESPONSE/TREATMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A0999	Other professional services	UNLISTED AMBULANCE SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2001	DMEPOS	INNOVAMATRIX AC, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2002	DMEPOS	MIRRAGEN ADV WND MAT PER SQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2003	DMEPOS	BIO-CONNEKT WOUND MATRIX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2004	DMEPOS	XCELLISTEM, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2005	DMEPOS	MICROLYTE MATRIX, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2006	DMEPOS	NOVOSORB SYNPATH PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2007	DMEPOS	RESTRATA, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2008	DMEPOS	THERAGENESIS, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2009	DMEPOS	SYMPHONY, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2010	DMEPOS	APIS, PER SQUARE CENTIMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2011	Other professional services	SUPRA SDRM, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2012	Other professional services	SUPRATHEL, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2013	Other professional services	INNOVAMATRIX FS, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2014	Other professional services	OMEZA COLLAG PER 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2015	Other professional services	PHOENIX WND MTRX, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2016	Other professional services	PERMEADERM B, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2017	Other professional services	PERMEADERM GLOVE, EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2018	Other professional services	PERMEADERM C, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2019	DMEPOS	KERECIS MARIGEN SHLD SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2020	DMEPOS	AC5 WOUND SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2021	DMEPOS	NEOMATRIX PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2022	DMEPOS	INNOVABRN/INNOVAMATX XL SQCM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2023	DMEPOS	INNOVAMATRIX PD, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2024	DMEPOS	RESOLVE MATRIX PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A2025	DMEPOS	MIRO3D PER CUBIC CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4100	Other professional services	SKIN SUB FDA CLRD AS DEV NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4206	Other professional services	1 CC STERILE SYRINGE&NEEDLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4207	Other professional services	2 CC STERILE SYRINGE&NEEDLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4208	Other professional services	3 CC STERILE SYRINGE&NEEDLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4209	Other professional services	5+ CC STERILE SYRINGE&NEEDLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4210	Other professional services	NONNEEDLE INJECTION DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4211	Other professional services	SUPP FOR SELF-ADM INJECTIONS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4212	Other professional services	NON CORING NEEDLE OR STYLET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4213	Other professional services	20+ CC SYRINGE ONLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4215	Other professional services	STERILE NEEDLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4216	DMEPOS	STERILE WATER/SALINE, 10 ML	0.52	0.52
A4217	DMEPOS	STERILE WATER/SALINE, 500 ML	3.64	3.64
A4218	Other professional services	STERILE SALINE OR WATER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4220	Other professional services	INFUSION PUMP REFILL KIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4221	DMEPOS	SUPP NON-INSULIN INF CATH/WK	24.46	24.46
A4222	DMEPOS	INFUSION SUPPLIES WITH PUMP	46.39	46.39
A4223	Other professional services	INFUSION SUPPLIES W/O PUMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4224	DMEPOS	SUPPLY INSULIN INF CATH/WK	24.46	24.46
A4225	DMEPOS	SUP/EXT INSULIN INF PUMP SYR	3.28	3.28
A4226	DMEPOS	WEEKLY SUPPLY MAINT CGS PUMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4230	Other professional services	INFUS INSULIN PUMP NON NEEDL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4231	Other professional services	INFUSION INSULIN PUMP NEEDLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4232	Other professional services	SYRINGE W/NEEDLE INSULIN 3CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4233-NU	DMEPOS	ALKALIN BATT FOR GLUCOSE MON	0.51	0.51
A4234-NU	DMEPOS	J-CELL BATT FOR GLUCOSE MON	2.36	2.36
A4235-NU	DMEPOS	LITHIUM BATT FOR GLUCOSE MON	1.00	1.00
A4236-NU	DMEPOS	SILVR OXIDE BATT GLUCOSE MON	1.16	1.16
A4238	DMEPOS	ADJU CGM SUPPLY ALLOWANCE	268.76	268.76
A4239	DMEPOS	NON-ADJU CGM SUPPLY ALLOW	304.43	304.43
A4244	Other professional services	ALCOHOL OR PEROXIDE PER PINT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4245	Other professional services	ALCOHOL WIPES PER BOX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4246	Other professional services	BETADINE/PHISOHEX SOLUTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4247	Other professional services	BETADINE/IODINE SWABS/WIPES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4248	Other professional services	CHLORHEXIDINE ANTISEPT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4250	Other professional services	URINE REAGENT STRIPS/TABLETS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4252	Other professional services	BLOOD KETONE TEST OR STRIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4253-NU	DMEPOS	BLOOD GLUCOSE/REAGENT STRIPS	8.32	8.32
A4255	DMEPOS	GLUCOSE MONITOR PLATFORMS	5.46	5.46
A4256	DMEPOS	CALIBRATOR SOLUTION/CHIPS	3.38	3.38
A4257	DMEPOS	REPLACE LENSSHIELD CARTRIDGE	17.41	17.41
A4258	DMEPOS	LANCET DEVICE EACH	2.12	2.12
A4259	DMEPOS	LANCETS PER BOX	1.42	1.42
A4261	Other professional services	CERVICAL CAP CONTRACEPTIVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4262	Other professional services	TEMPORARY TEAR DUCT PLUG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4263	Other professional services	PERMANENT TEAR DUCT PLUG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4264	Other professional services	INTRATUBAL OCCLUSION DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4265	DMEPOS	PARAFFIN	4.65	4.65
A4266	Other professional services	DIAPHRAGM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4267	Other professional services	MALE CONDOM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4268	Other professional services	FEMALE CONDOM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4269	Other professional services	SPERMICIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4270	Other professional services	DISPOSABLE ENDOSCOPE SHEATH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4280	DMEPOS	BRST PRSTHS ADHSV ATTCHMNT	7.29	7.29
A4281	Other professional services	REPLACEMENT BREASTPUMP TUBE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4282	Other professional services	REPLACEMENT BREASTPUMP ADPT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4283	Other professional services	REPLACEMENT BREASTPUMP CAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4284	Other professional services	REPLCMNT BREAST PUMP SHIELD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4285	Other professional services	REPLCMNT BREAST PUMP BOTTLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4286	Other professional services	REPLCMNT BREASTPUMP LOK RING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4287	DMEPOS	DISP COL STO BAG BREAST MILK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4290	Other professional services	SACRAL NERVE STIM TEST LEAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4300	Other professional services	CATH IMPL VASC ACCESS PORTAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4301	Other professional services	IMPLANTABLE ACCESS SYST PERC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4305	Other professional services	DRUG DELIVERY SYSTEM >=50 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4306	Other professional services	DRUG DELIVERY SYSTEM <=50 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4310	DMEPOS	INSERT TRAY W/O BAG/CATH	8.96	8.96
A4311	DMEPOS	CATHETER W/O BAG 2-WAY LATEX	20.21	20.21
A4312	DMEPOS	CATH W/O BAG 2-WAY SILICONE	24.61	24.61
A4313	DMEPOS	CATHETER W/BAG 3-WAY	25.27	25.27
A4314	DMEPOS	CATH W/DRAINAGE 2-WAY LATEX	34.49	34.49
A4315	DMEPOS	CATH W/DRAINAGE 2-WAY SILCNE	35.99	35.99
A4316	DMEPOS	CATH W/DRAINAGE 3-WAY	38.75	38.75
A4320	DMEPOS	IRRIGATION TRAY	6.20	6.20
A4321	DMEPOS	CATH THERAPEUTIC IRRIG AGENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4322	DMEPOS	IRRIGATION SYRINGE	4.01	4.01
A4326	DMEPOS	MALE EXTERNAL CATHETER	14.72	14.72
A4327	DMEPOS	FEM URINARY COLLECT DEV CUP	60.86	60.86
A4328	DMEPOS	FEM URINARY COLLECT POUCH	13.99	13.99
A4330	DMEPOS	STOOL COLLECTION POUCH	9.74	9.74
A4331	DMEPOS	EXTENSION DRAINAGE TUBING	4.34	4.34
A4332	DMEPOS	LUBE STERILE PACKET	0.15	0.15
A4333	DMEPOS	URINARY CATH ANCHOR DEVICE	3.03	3.03
A4334	DMEPOS	URINARY CATH LEG STRAP	6.71	6.71
A4335	Other professional services	INCONTINENCE SUPPLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4336	DMEPOS	URETHRAL INSERT	1.96	1.96
A4337	Other professional services	INCONTINENT RECTAL INSERT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4338	DMEPOS	INDWELLING CATHETER LATEX	14.82	14.82
A4340	DMEPOS	INDWELLING CATHETER SPECIAL	36.82	36.82
A4341	DMEPOS	IDUC VALVE PAT INST REPL	332.94	332.94
A4342	DMEPOS	IDUC VALVE SPLY REPL	840.66	840.66
A4344	DMEPOS	CATH INDW FOLEY 2 WAY SILICN	19.59	19.59
A4346	DMEPOS	CATH INDW FOLEY 3 WAY	22.71	22.71
A4349	DMEPOS	DISPOSABLE MALE EXTERNAL CAT	2.74	2.74
A4351	DMEPOS	STRAIGHT TIP URINE CATHETER	2.10	2.10
A4352	DMEPOS	COUDE TIP URINARY CATHETER	8.08	8.08
A4353	DMEPOS	INTERMITTENT URINARY CATH	9.56	9.56
A4354	DMEPOS	CATH INSERTION TRAY W/BAG	16.11	16.11
A4355	DMEPOS	BLADDER IRRIGATION TUBING	12.17	12.17
A4356	DMEPOS	EXT URETH CLMP OR COMPR DVC	61.89	61.89
A4357	DMEPOS	BEDSIDE DRAINAGE BAG	13.25	13.25
A4358	DMEPOS	URINARY LEG OR ABDOMEN BAG	9.05	9.05
A4360	DMEPOS	DISPOSABLE EXT URETHRAL DEV	0.67	0.67
A4361	DMEPOS	OSTOMY FACE PLATE	25.05	25.05
A4362	DMEPOS	SOLID SKIN BARRIER	4.74	4.74
A4363	DMEPOS	OSTOMY CLAMP, REPLACEMENT	3.23	3.23
A4364	DMEPOS	ADHESIVE, LIQUID OR EQUAL	3.41	3.41
A4366	DMEPOS	OSTOMY VENT	1.76	1.76
A4367	DMEPOS	OSTOMY BELT	8.53	8.53
A4368	DMEPOS	OSTOMY FILTER	0.34	0.34
A4369	DMEPOS	SKIN BARRIER LIQUID PER OZ	3.31	3.31
A4371	DMEPOS	SKIN BARRIER POWDER PER OZ	4.98	4.98
A4372	DMEPOS	SKIN BARRIER SOLID 4X4 EQUIV	5.73	5.73
A4373	DMEPOS	SKIN BARRIER WITH FLANGE	8.55	8.55
A4375	DMEPOS	DRAINABLE PLASTIC PCH W FCPL	23.43	23.43
A4376	DMEPOS	DRAINABLE RUBBER PCH W FCPLT	64.92	64.92
A4377	DMEPOS	DRAINABLE PLSTIC PCH W/O FP	5.85	5.85
A4378	DMEPOS	DRAINABLE RUBBER PCH W/O FP	41.95	41.95
A4379	DMEPOS	URINARY PLASTIC POUCH W FCPL	20.49	20.49
A4380	DMEPOS	URINARY RUBBER POUCH W FCPLT	50.94	50.94
A4381	DMEPOS	URINARY PLASTIC POUCH W/O FP	6.31	6.31
A4382	DMEPOS	URINARY HVY PLSTC PCH W/O FP	33.59	33.59
A4383	DMEPOS	URINARY RUBBER POUCH W/O FP	38.46	38.46
A4384	DMEPOS	OSTOMY FACEPLT/SILICONE RING	13.11	13.11
A4385	DMEPOS	OST SKN BARRIER SLD EXT WEAR	6.95	6.95
A4387	DMEPOS	OST CLSD POUCH W ATT ST BARR	3.07	3.07
A4388	DMEPOS	DRAINABLE PCH W EX WEAR BARR	5.95	5.95
A4389	DMEPOS	DRAINABLE PCH W ST WEAR BARR	8.47	8.47
A4390	DMEPOS	DRAINABLE PCH EX WEAR CONVEX	13.10	13.10
A4391	DMEPOS	URINARY POUCH W EX WEAR BARR	9.64	9.64
A4392	DMEPOS	URINARY POUCH W ST WEAR BARR	11.15	11.15
A4393	DMEPOS	URINE PCH W EX WEAR BAR CONV	12.33	12.33
A4394	DMEPOS	OSTOMY POUCH LIQ DEODORANT	3.54	3.54
A4395	DMEPOS	OSTOMY POUCH SOLID DEODORANT	0.05	0.05
A4396	DMEPOS	PERISTOMAL HERNIA SUPPRT BLT	55.23	55.23
A4398	DMEPOS	OSTOMY IRRIGATION BAG	18.86	18.86
A4399	DMEPOS	OSTOMY IRRIG CONE/CATH W BRS	16.58	16.58
A4400	DMEPOS	OSTOMY IRRIGATION SET	56.68	56.68
A4402	DMEPOS	LUBRICANT PER OUNCE	1.85	1.85
A4404	DMEPOS	OSTOMY RING EACH	1.95	1.95
A4405	DMEPOS	NONPECTIN BASED OSTOMY PASTE	4.66	4.66
A4406	DMEPOS	PECTIN BASED OSTOMY PASTE	7.81	7.81
A4407	DMEPOS	EXT WEAR OST SKN BARR <=4SQ"	11.95	11.95
A4408	DMEPOS	EXT WEAR OST SKN BARR >4SQ"	13.47	13.47
A4409	DMEPOS	OST SKN BARR CONVEX <=4 SQ I	8.47	8.47
A4410	DMEPOS	OST SKN BARR EXTND >4 SQ	12.33	12.33
A4411	DMEPOS	OST SKN BARR EXTND =4SQ	6.95	6.95
A4412	DMEPOS	OST POUCH DRAIN HIGH OUTPUT	3.69	3.69
A4413	DMEPOS	2 PC DRAINABLE OST POUCH	7.52	7.52
A4414	DMEPOS	OST SKNBAR W/O CONV<=4 SQ IN	6.71	6.71
A4415	DMEPOS	OST SKN BARR W/O CONV >4 SQI	8.18	8.18
A4416	DMEPOS	OST PCH CLSD W BARRIER/FILTR	3.76	3.76
A4417	DMEPOS	OST PCH W BAR/BLTINCONV/FLTR	5.09	5.09
A4418	DMEPOS	OST PCH CLSD W/O BAR W FILTR	2.47	2.47
A4419	DMEPOS	OST PCH FOR BAR W FLANGE/FLT	2.35	2.35
A4420	DMEPOS	OST PCH CLSD FOR BAR W LK FL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4421	Other professional services	OSTOMY SUPPLY MISC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4422	DMEPOS	OST POUCH ABSORBENT MATERIAL	0.15	0.15
A4423	DMEPOS	OST PCH FOR BAR W LK FL/FLTR	2.53	2.53
A4424	DMEPOS	OST PCH DRAIN W BAR & FILTER	6.49	6.49
A4425	DMEPOS	OST PCH DRAIN FOR BARRIER FL	4.88	4.88
A4426	DMEPOS	OST PCH DRAIN 2 PIECE SYSTEM	3.72	3.72
A4427	DMEPOS	OST PCH DRAIN/BARR LK FLNG/F	3.81	3.81
A4428	DMEPOS	URINE OST POUCH W FAUCET/TAP	8.90	8.90
A4429	DMEPOS	URINE OST POUCH W BLTINCONV	11.26	11.26
A4430	DMEPOS	OST URINE PCH W B/BLTIN CONV	11.62	11.62
A4431	DMEPOS	OST PCH URINE W BARRIER/TAPV	8.47	8.47
A4432	DMEPOS	OS PCH URINE W BAR/FANGE/TAP	4.89	4.89
A4433	DMEPOS	URINE OST PCH BAR W LOCK FLN	4.58	4.58
A4434	DMEPOS	OST PCH URINE W LOCK FLNG/FT	5.13	5.13
A4435	DMEPOS	1PC OST PCH DRAIN HGH OUTPUT	7.86	7.86
A4436	DMEPOS	IRR SUPPLY SLEEV REUS PER MO	22.24	22.24
A4437	DMEPOS	IRR SUPPLY SLEEV DISP PER MO	22.24	22.24
A4450	DMEPOS	NON-WATERPROOF TAPE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4452	DMEPOS	WATERPROOF TAPE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4453	DMEPOS	REC CATH MAN PUMP ENEMA REPL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4455	DMEPOS	ADHESIVE REMOVER PER OUNCE	1.65	1.65
A4456	DMEPOS	ADHESIVE REMOVER, WIPES	0.33	0.33
A4457	DMEPOS	ENEMA TUBE ANY TYPE REPL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4458	Other professional services	REUSABLE ENEMA BAG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4459	Other professional services	MANUAL PUMP ENEMA, REUSABLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4461	DMEPOS	SURGICL DRESS HOLD NON-REUSE	4.50	4.50
A4463	DMEPOS	SURGICAL DRESS HOLDER REUSE	18.16	18.16
A4465	Other professional services	NON-ELASTIC EXTREMITY BINDER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4467	Other professional services	BELT STRAP SLEEV GRMNT COVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4468	DMEPOS	EXSUFF BELT INCL ALL SUP ACC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4470	Other professional services	GRAVLEE JET WASHER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4480	Other professional services	VABRA ASPIRATOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4481	DMEPOS	TRACHEOSTOMA FILTER	0.50	0.50
A4483	DMEPOS	MOISTURE EXCHANGER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4490	Other professional services	ABOVE KNEE SURGICAL STOCKING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4495	Other professional services	THIGH LENGTH SURG STOCKING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4500	Other professional services	BELOW KNEE SURGICAL STOCKING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4510	Other professional services	FULL LENGTH SURG STOCKING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4520	Other professional services	INCONTINENCE GARMENT ANYTYPE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4540	DMEPOS	TRANS ELEC NERV PERIPH NERV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4541	DMEPOS	MONTHLY SUPP USE WITH E0733	39.32	39.32
A4542	DMEPOS	SUPP EXT UP LIMB TREMOR STIM	504.41	504.41
A4550	Other professional services	SURGICAL TRAYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4553	Other professional services	NONDISP UNDERPADS, ALL SIZES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4554	Other professional services	DISPOSABLE UNDERPADS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4555	Other professional services	CA TX E-STIM ELECTR/TRANSDUC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4556	DMEPOS	ELECTRODES, PAIR	14.08	14.08
A4557	DMEPOS	LEAD WIRES, PAIR	12.74	12.74
A4558	DMEPOS	CONDUCTIVE GEL OR PASTE	7.44	7.44
A4559	DMEPOS	COUPLING GEL OR PASTE	0.13	0.13
A4560	DMEPOS	NMES DISPOSABLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4561	DMEPOS	PESSARY RUBBER, ANY TYPE	28.09	28.09
A4562	DMEPOS	PESSARY, NON RUBBER,ANY TYPE	69.85	69.85
A4563	DMEPOS	VAG INSER RECTAL CONTROL SYS	1617.77	1617.77
A4565	DMEPOS	SLINGS	10.51	10.51
A4566	Other professional services	SHOULD SLING/VEST/ABRESTRAIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4570	Other professional services	SPLINT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4575	Other professional services	HYPERBARIC O2 CHAMBER DISPS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4580	Other professional services	CAST SUPPLIES (PLASTER)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4590	Other professional services	SPECIAL CASTING MATERIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4595	DMEPOS	TENS SUPPL 2 LEAD PER MONTH	12.52	12.52
A4596	DMEPOS	CES SYSTEM MONTHLY SUPP	39.32	39.32
A4600	Other professional services	SLEEVE, INTER LIMB COMP DEV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4601	Other professional services	LITH ION NON PROSTH RECHARGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4602-NU	DMEPOS	REPLACE LITHIUM BATTERY 1.5V	5.09	5.09
A4604-NU	DMEPOS	TUBING WITH HEATING ELEMENT	46.67	46.67
A4605-NU	DMEPOS	TRACH SUCTION CATH CLOSE SYS	22.38	22.38
A4606	Other professional services	OXYGEN PROBE USED W OXIMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4608	DMEPOS	TRANSTRACHEAL OXYGEN CATH	68.40	68.40
A4611	Other professional services	HEAVY DUTY BATTERY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4612	Other professional services	BATTERY CABLES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4613	Other professional services	BATTERY CHARGER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4614	DMEPOS	HAND-HELD PEFR METER	32.45	32.45
A4615	DMEPOS	CANNULA NASAL	1.00	1.00
A4616	DMEPOS	TUBING (OXYGEN) PER FOOT	0.08	0.08
A4617	DMEPOS	MOUTH PIECE	4.23	4.23
A4618-NU	DMEPOS	BREATHING CIRCUITS	10.32	10.32
A4618-RR	DMEPOS	BREATHING CIRCUITS	1.20	1.20
A4618-UE	DMEPOS	BREATHING CIRCUITS	7.74	7.74
A4619-NU	DMEPOS	FACE TENT	2.43	2.43
A4620	DMEPOS	VARIABLE CONCENTRATION MASK	0.87	0.87
A4623	DMEPOS	TRACHEOSTOMY INNER CANNULA	7.61	7.61
A4624-NU	DMEPOS	TRACHEAL SUCTION TUBE	3.06	3.06
A4625	DMEPOS	TRACH CARE KIT FOR NEW TRACH	8.03	8.03
A4626	DMEPOS	TRACHEOSTOMY CLEANING BRUSH	3.70	3.70
A4627	Other professional services	SPACER BAG/RESERVOIR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4628-NU	DMEPOS	OROPHARYNGEAL SUCTION CATH	5.11	5.11
A4629	DMEPOS	TRACHEOSTOMY CARE KIT	6.35	6.35
A4630-NU	DMEPOS	REPL BAT T.E.N.S. OWN BY PT	8.51	8.51
A4633-NU	DMEPOS	UVL REPLACEMENT BULB	56.00	56.00
A4634	Other professional services	REPLACEMENT BULB TH LIGHTBOX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4635-NU	DMEPOS	UNDERARM CRUTCH PAD	5.92	5.92
A4635-RR	DMEPOS	UNDERARM CRUTCH PAD	0.81	0.81
A4635-UE	DMEPOS	UNDERARM CRUTCH PAD	3.95	3.95
A4636-NU	DMEPOS	HANDGRIP FOR CANE ETC	3.75	3.75
A4636-RR	DMEPOS	HANDGRIP FOR CANE ETC	0.38	0.38
A4636-UE	DMEPOS	HANDGRIP FOR CANE ETC	2.81	2.81
A4637-NU	DMEPOS	REPL TIP CANE/CRUTCH/WALKER	2.08	2.08
A4637-RR	DMEPOS	REPL TIP CANE/CRUTCH/WALKER	0.21	0.21
A4637-UE	DMEPOS	REPL TIP CANE/CRUTCH/WALKER	1.56	1.56
A4638-NU	DMEPOS	REPL BATT PULSE GEN SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4638-RR	DMEPOS	REPL BATT PULSE GEN SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4638-UE	DMEPOS	REPL BATT PULSE GEN SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4639	DMEPOS	INFRARED HT SYS REPLCMNT PAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4639-RR	DMEPOS	INFRARED HT SYS REPLCMNT PAD	39.20	39.20
A4640-NU	DMEPOS	ALTERNATING PRESSURE PAD	59.86	59.86
A4640-RR	DMEPOS	ALTERNATING PRESSURE PAD	5.99	5.99
A4640-UE	DMEPOS	ALTERNATING PRESSURE PAD	44.89	44.89
A4641	Other professional services	RADIOPHARM DX AGENT NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4642	Other professional services	IN111 SATUMOMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4648	Other professional services	IMPLANTABLE TISSUE MARKER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4649	Other professional services	SURGICAL SUPPLIES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4650	Other professional services	IMPLANT RADIATION DOSIMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4651	Other professional services	CALIBRATED MICROCAP TUBE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4652	Other professional services	MICROCAPILLARY TUBE SEALANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4653	Other professional services	PD CATHETER ANCHOR BELT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4657	Other professional services	SYRINGE W/WO NEEDLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4660	Other professional services	SPHYG/BP APP W CUFF AND STET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4663	Other professional services	DIALYSIS BLOOD PRESSURE CUFF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4670	Other professional services	AUTOMATIC BP MONITOR, DIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4671	Other professional services	DISPOSABLE CYCLER SET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4672	Other professional services	DRAINAGE EXT LINE, DIALYSIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4673	Other professional services	EXT LINE W EASY LOCK CONNECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4674	Other professional services	CHEM/ANTISEPT SOLUTION, 8OZ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4680	Other professional services	ACTIVATED CARBON FILTER, EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4690	Other professional services	DIALYZER, EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4706	Other professional services	BICARBONATE CONC SOL PER GAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4707	Other professional services	BICARBONATE CONC POW PER PAC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4708	Other professional services	ACETATE CONC SOL PER GALLON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4709	Other professional services	ACID CONC SOL PER GALLON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4714	Other professional services	TREATED WATER PER GALLON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4719	Other professional services	"Y SET" TUBING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4720	Other professional services	DIALYSAT SOL FLD VOL > 249CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4721	Other professional services	DIALYSAT SOL FLD VOL > 999CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4722	Other professional services	DIALYS SOL FLD VOL > 1999CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4723	Other professional services	DIALYS SOL FLD VOL > 2999CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4724	Other professional services	DIALYS SOL FLD VOL > 3999CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4725	Other professional services	DIALYS SOL FLD VOL > 4999CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4726	Other professional services	DIALYS SOL FLD VOL > 5999CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4728	Other professional services	DIALYSATE SOLUTION, NON-DEX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4730	Other professional services	FISTULA CANNULATION SET, EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4736	Other professional services	TOPICAL ANESTHETIC, PER GRAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4737	Other professional services	INJ ANESTHETIC PER 10 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4740	Other professional services	SHUNT ACCESSORY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4750	Other professional services	ART OR VENOUS BLOOD TUBING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4755	Other professional services	COMB ART/VENOUS BLOOD TUBING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4760	Other professional services	DIALYSATE SOL TEST KIT, EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4765	Other professional services	DIALYSATE CONC POW PER PACK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4766	Other professional services	DIALYSATE CONC SOL ADD 10 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4770	Other professional services	BLOOD COLLECTION TUBE/VACUUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4771	Other professional services	SERUM CLOTTING TIME TUBE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4772	Other professional services	BLOOD GLUCOSE TEST STRIPS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4773	Other professional services	OCCULT BLOOD TEST STRIPS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4774	Other professional services	AMMONIA TEST STRIPS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4802	Other professional services	PROTAMINE SULFATE PER 50 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4860	Other professional services	DISPOSABLE CATHETER TIPS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4870	Other professional services	PLUMB/ELEC WK HM HEMO EQUIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4890	Other professional services	REPAIR/MAINT CONT HEMO EQUIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4911	Other professional services	DRAIN BAG/BOTTLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4913	Other professional services	MISC DIALYSIS SUPPLIES NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4918	Other professional services	VENOUS PRESSURE CLAMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4927	Other professional services	NON-STERILE GLOVES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4928	Other professional services	SURGICAL MASK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4929	Other professional services	TOURNIQUET FOR DIALYSIS, EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4930	Other professional services	STERILE, GLOVES PER PAIR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4931	Other professional services	REUSABLE ORAL THERMOMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A4932	Other professional services	REUSABLE RECTAL THERMOMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A5051	DMEPOS	POUCH CLSD W BARR ATTACHED	2.81	2.81
A5052	DMEPOS	CLSD OSTOMY POUCH W/O BARR	2.03	2.03
A5053	DMEPOS	CLSD OSTOMY POUCH FACEPLATE	2.00	2.00
A5054	DMEPOS	CLSD OSTOMY POUCH W/FLANGE	2.45	2.45
A5055	DMEPOS	STOMA CAP	1.69	1.69
A5056	DMEPOS	1 PC OST POUCH W FILTER	6.38	6.38
A5057	DMEPOS	1 PC OST POU W BUILT-IN CONV	13.10	13.10
A5061	DMEPOS	POUCH DRAINABLE W BARRIER AT	4.82	4.82
A5062	DMEPOS	DRNBLE OSTOMY POUCH W/O BARR	3.05	3.05
A5063	DMEPOS	DRAIN OSTOMY POUCH W/FLANGE	3.69	3.69
A5071	DMEPOS	URINARY POUCH W/BARRIER	8.20	8.20
A5072	DMEPOS	URINARY POUCH W/O BARRIER	4.66	4.66
A5073	DMEPOS	URINARY POUCH ON BARR W/FLNG	4.34	4.34
A5081	DMEPOS	STOMA PLUG OR SEAL, ANY TYPE	3.97	3.97
A5082	DMEPOS	CONTINENT STOMA CATHETER	15.34	15.34
A5083	DMEPOS	STOMA ABSORPTIVE COVER	0.88	0.88
A5093	DMEPOS	OSTOMY ACCESSORY CONVEX INSE	2.27	2.27
A5102	DMEPOS	BEDSIDE DRAIN BTL W/WO TUBE	30.79	30.79
A5105	DMEPOS	URINARY SUSPENSORY	55.63	55.63
A5112	DMEPOS	URINARY LEG BAG	47.25	47.25
A5113	DMEPOS	LATEX LEG STRAP	5.47	5.47
A5114	DMEPOS	FOAM/FABRIC LEG STRAP	10.38	10.38
A5120	DMEPOS	SKIN BARRIER, WIPE OR SWAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A5121	DMEPOS	SOLID SKIN BARRIER 6X6	10.17	10.17
A5122	DMEPOS	SOLID SKIN BARRIER 8X8	17.13	17.13
A5126	DMEPOS	DISK/FOAM PAD +OR- ADHESIVE	1.52	1.52
A5131	DMEPOS	APPLIANCE CLEANER	19.73	19.73
A5200	DMEPOS	PERCUTANEOUS CATHETER ANCHOR	15.43	15.43
A5500	DMEPOS	DIAB SHOE FOR DENSITY INSERT	86.77	86.77
A5501	DMEPOS	DIABETIC CUSTOM MOLDED SHOE	260.22	260.22
A5503	DMEPOS	DIABETIC SHOE W/ROLLER/ROCKR	44.25	44.25
A5504	DMEPOS	DIABETIC SHOE WITH WEDGE	44.25	44.25
A5505	DMEPOS	DIAB SHOE W/METATARSAL BAR	44.25	44.25
A5506	DMEPOS	DIABETIC SHOE W/OFF SET HEEL	44.25	44.25
A5507	DMEPOS	MODIFICATION DIABETIC SHOE	44.25	44.25
A5508	Other professional services	DIABETIC DELUXE SHOE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A5510	Other professional services	COMPRESSION FORM SHOE INSERT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A5512	DMEPOS	MULTI DEN INSERT DIRECT FORM	35.39	35.39
A5513	DMEPOS	MULTI DEN INSERT CUSTOM MOLD	52.81	52.81
A5514	DMEPOS	MULT DEN INSERT DIR CARV/CAM	52.81	52.81
A6000	Other professional services	WOUND WARMING WOUND COVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6010	DMEPOS	COLLAGEN BASED WOUND FILLER	42.26	42.26
A6011	DMEPOS	COLLAGEN GEL/PASTE WOUND FIL	3.12	3.12
A6021	DMEPOS	COLLAGEN DRESSING <=16 SQ IN	28.69	28.69
A6022	DMEPOS	COLLAGEN DRSG>16<=48 SQ IN	28.69	28.69
A6023	DMEPOS	COLLAGEN DRESSING >48 SQ IN	259.67	259.67
A6024	DMEPOS	COLLAGEN DSG WOUND FILLER	8.44	8.44
A6025	Other professional services	SILICONE GEL SHEET, EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6154	DMEPOS	WOUND POUCH EACH	19.60	19.60
A6196	DMEPOS	ALGINATE DRESSING <=16 SQ IN	10.04	10.04
A6197	DMEPOS	ALGINATE DRSG >16 <=48 SQ IN	22.44	22.44
A6198	Other professional services	ALGINATE DRESSING > 48 SQ IN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6199	DMEPOS	ALGINATE DRSG WOUND FILLER	7.20	7.20
A6203	DMEPOS	COMPOSITE DRSG <= 16 SQ IN	4.60	4.60
A6204	DMEPOS	COMPOSITE DRSG >16<=48 SQ IN	8.49	8.49
A6205	Other professional services	COMPOSITE DRSG > 48 SQ IN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6206	Other professional services	CONTACT LAYER <= 16 SQ IN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6207	DMEPOS	CONTACT LAYER >16<= 48 SQ IN	10.02	10.02
A6208	Other professional services	CONTACT LAYER > 48 SQ IN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6209	DMEPOS	FOAM DRSG <=16 SQ IN W/O BDR	10.20	10.20
A6210	DMEPOS	FOAM DRG >16<=48 SQ IN W/O B	27.19	27.19
A6211	DMEPOS	FOAM DRG > 48 SQ IN W/O BRDR	40.08	40.08
A6212	DMEPOS	FOAM DRG <=16 SQ IN W/BORDER	13.25	13.25
A6213	Other professional services	FOAM DRG >16<=48 SQ IN W/BDR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6214	DMEPOS	FOAM DRG > 48 SQ IN W/BORDER	14.05	14.05
A6215	Other professional services	FOAM DRESSING WOUND FILLER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6216	DMEPOS	NON-STERILE GAUZE<=16 SQ IN	0.05	0.05
A6217	DMEPOS	NON-STERILE GAUZE>16<=48 SQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6218	Other professional services	NON-STERILE GAUZE > 48 SQ IN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6219	DMEPOS	GAUZE <= 16 SQ IN W/BORDER	1.30	1.30
A6220	DMEPOS	GAUZE >16 <=48 SQ IN W/BORDR	3.54	3.54
A6221	Other professional services	GAUZE > 48 SQ IN W/BORDER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6222	DMEPOS	GAUZE <=16 IN NO W/SAL W/O B	2.91	2.91
A6223	DMEPOS	GAUZE >16<=48 NO W/SAL W/O B	3.31	3.31
A6224	DMEPOS	GAUZE > 48 IN NO W/SAL W/O B	4.91	4.91
A6228	Other professional services	GAUZE <= 16 SQ IN WATER/SAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6229	DMEPOS	GAUZE >16<=48 SQ IN WATR/SAL	4.91	4.91
A6230	Other professional services	GAUZE > 48 SQ IN WATER/SALNE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6231	DMEPOS	HYDROGEL DSG<=16 SQ IN	6.40	6.40
A6232	DMEPOS	HYDROGEL DSG>16<=48 SQ IN	9.37	9.37
A6233	DMEPOS	HYDROGEL DRESSING >48 SQ IN	26.16	26.16
A6234	DMEPOS	HYDROCOLLD DRG <=16 W/O BDR	8.94	8.94
A6235	DMEPOS	HYDROCOLLD DRG >16<=48 W/O B	22.95	22.95
A6236	DMEPOS	HYDROCOLLD DRG > 48 IN W/O B	37.18	37.18
A6237	DMEPOS	HYDROCOLLD DRG <=16 IN W/BDR	10.79	10.79
A6238	DMEPOS	HYDROCOLLD DRG >16<=48 W/BDR	31.11	31.11
A6239	Other professional services	HYDROCOLLD DRG > 48 IN W/BDR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6240	DMEPOS	HYDROCOLLD DRG FILLER PASTE	16.71	16.71
A6241	DMEPOS	HYDROCOLLOID DRG FILLER DRY	3.51	3.51
A6242	DMEPOS	HYDROGEL DRG <=16 IN W/O BDR	8.26	8.26
A6243	DMEPOS	HYDROGEL DRG >16<=48 W/O BDR	16.82	16.82
A6244	DMEPOS	HYDROGEL DRG >48 IN W/O BDR	53.60	53.60
A6245	DMEPOS	HYDROGEL DRG <= 16 IN W/BDR	9.92	9.92
A6246	DMEPOS	HYDROGEL DRG >16<=48 IN W/B	13.55	13.55
A6247	DMEPOS	HYDROGEL DRG > 48 SQ IN W/B	32.45	32.45
A6248	DMEPOS	HYDROGEL DRSG GEL FILLER	22.17	22.17
A6250	Other professional services	SKIN SEAL PROTECT MOISTURIZR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6251	DMEPOS	ABSORPT DRG <=16 SQ IN W/O B	2.71	2.71
A6252	DMEPOS	ABSORPT DRG >16 <=48 W/O BDR	4.44	4.44
A6253	DMEPOS	ABSORPT DRG > 48 SQ IN W/O B	8.64	8.64
A6254	DMEPOS	ABSORPT DRG <=16 SQ IN W/BDR	1.63	1.63
A6255	DMEPOS	ABSORPT DRG >16<=48 IN W/BDR	4.15	4.15
A6256	Other professional services	ABSORPT DRG > 48 SQ IN W/BDR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6257	DMEPOS	TRANSPARENT FILM <= 16 SQ IN	2.09	2.09
A6258	DMEPOS	TRANSPARENT FILM >16<=48 IN	5.88	5.88
A6259	DMEPOS	TRANSPARENT FILM > 48 SQ IN	14.92	14.92
A6260	Other professional services	WOUND CLEANSER ANY TYPE/SIZE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6261	Other professional services	WOUND FILLER GEL/PASTE /OZ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6262	Other professional services	WOUND FILLER DRY FORM / GRAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6266	DMEPOS	IMPREG GAUZE NO H20/SAL/YARD	2.61	2.61
A6402	DMEPOS	STERILE GAUZE <= 16 SQ IN	0.15	0.15
A6403	DMEPOS	STERILE GAUZE>16 <= 48 SQ IN	0.56	0.56
A6404	Other professional services	STERILE GAUZE > 48 SQ IN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6407	DMEPOS	PACKING STRIPS, NON-IMPREG	2.55	2.55
A6410	DMEPOS	STERILE EYE PAD	0.51	0.51
A6411	DMEPOS	NON-STERILE EYE PAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6412	Other professional services	OCCLUSIVE EYE PATCH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6413	Other professional services	ADHESIVE BANDAGE, FIRST-AID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6441	DMEPOS	PAD BAND W>=3" <5"/YD	0.93	0.93
A6442	DMEPOS	CONFORM BAND N/S W<3"/YD	0.22	0.22
A6443	DMEPOS	CONFORM BAND N/S W>=3"<5"/YD	0.38	0.38
A6444	DMEPOS	CONFORM BAND N/S W>=5"/YD	0.76	0.76
A6445	DMEPOS	CONFORM BAND S W <3"/YD	0.43	0.43
A6446	DMEPOS	CONFORM BAND S W>=3" <5"/YD	0.53	0.53
A6447	DMEPOS	CONFORM BAND S W >=5"/YD	0.93	0.93
A6448	DMEPOS	LT COMPRES BAND <3"/YD	1.57	1.57
A6449	DMEPOS	LT COMPRES BAND >=3" <5"/YD	2.39	2.39
A6450	DMEPOS	LT COMPRES BAND >=5"/YD	2.39	2.39
A6451	DMEPOS	MOD COMPRES BAND W>=3"<5"/YD	2.39	2.39
A6452	DMEPOS	HIGH COMPRES BAND W>=3"<5"YD	8.05	8.05
A6453	DMEPOS	SELF-ADHER BAND W <3"/YD	0.86	0.86
A6454	DMEPOS	SELF-ADHER BAND W>=3" <5"/YD	1.07	1.07
A6455	DMEPOS	SELF-ADHER BAND >=5"/YD	1.90	1.90
A6456	DMEPOS	ZINC PASTE BAND W >=3"<5"/YD	1.71	1.71
A6457	DMEPOS	TUBULAR DRESSING	1.55	1.55
A6460	Other professional services	SYNTHETIC DRSG <= 16 SQ IN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6461	Other professional services	SYNTHETIC DRSG >16<=48 SQ IN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6501	DMEPOS	COMPRES BURNGARMENT BODYSUIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6502	DMEPOS	COMPRES BURNGARMENT CHINSTRP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6503	DMEPOS	COMPRES BURNGARMENT FACEHOOD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6504	DMEPOS	CMPRSBURNGARMENT GLOVE-WRIST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6505	DMEPOS	CMPRSBURNGARMENT GLOVE-ELBOW	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6506	DMEPOS	CMPRSBURNGRMNT GLOVE-AXILLA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6507	DMEPOS	CMPRS BURNGARMENT FOOT-KNEE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6508	DMEPOS	CMPRS BURNGARMENT FOOT-THIGH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6509	DMEPOS	COMPRES BURN GARMENT JACKET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6510	DMEPOS	COMPRES BURN GARMENT LEOTARD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6511	DMEPOS	COMPRES BURN GARMENT PANTY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6512	Other professional services	COMPRES BURN GARMENT, NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6513	DMEPOS	COMPRESS BURN MASK FACE/NECK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6520	DMEPOS	G COM GARMNT GLOVE NGHTTIME	119.54	119.54
A6521	DMEPOS	G COM GARMNT GLOVE NGHT CUST	474.33	474.33
A6522	DMEPOS	G COM GARMENT ARM NIGHTTIME	290.47	290.47
A6523	DMEPOS	G COM GARMENT ARM NGHT CUSTM	689.17	689.17
A6524	DMEPOS	G COM GARMNT LWR LEG/FT NGHT	362.39	362.39
A6525	DMEPOS	G COM GARM LWRLEG/FT NGT CUS	731.60	731.60
A6526	DMEPOS	G COM GARMT FULL LEG/FT NGHT	655.18	655.18
A6527	DMEPOS	G GARMT FULL LEG/FT NGHT CUS	1204.80	1204.80
A6528	DMEPOS	G COM GARMENT BRA NIGHTTIME	630.00	630.00
A6529	DMEPOS	G COM GARMT BRA NIGHT CUSTM	995.50	995.50
A6530	DMEPOS	COMPRESSION STOCKING BK18-30	36.93	36.93
A6531	DMEPOS	COMPRESS STKING BK30-40 SURG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6532	Other professional services	COMPRESS STKING BK40-50 SURG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6533	DMEPOS	GC STOCKING THIGHLNGTH 18-30	51.86	51.86
A6534	DMEPOS	GC STOCKING THIGHLNGTH 30-40	59.22	59.22
A6535	DMEPOS	GC STOCKING THIGHLNGTH 40-50	68.18	68.18
A6536	DMEPOS	GC STOCKING FULL LNGTH 18-30	69.91	69.91
A6537	DMEPOS	GC STOCKING FULL LNGTH 30-40	82.88	82.88
A6538	DMEPOS	GC STOCKING FULL LNGTH 40-50	97.04	97.04
A6539	DMEPOS	GC STOCKING WAISTLNGTH 18-30	92.51	92.51
A6540	DMEPOS	GC STOCKING WAISTLNGTH 30-40	110.30	110.30
A6541	DMEPOS	GC STOCKING WAISTLNGTH 40-50	130.66	130.66
A6544	Other professional services	GC STOCKING GARTER BELT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6545	DMEPOS	GRAD COM NON-ELASTIC BK SURG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6549	Other professional services	G COMPRESSION STOCKING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6550	DMEPOS	NEG PRES WOUND THER DRSG SET	29.63	29.63
A6552	DMEPOS	GRAD COM STOCKING BK 30-40	54.81	54.81
A6553	DMEPOS	G COM STCKING BK 30-40 CUSTM	214.01	214.01
A6554	DMEPOS	GRAD COM STOCKING BK 40+	75.36	75.36
A6555	DMEPOS	G COM STCKING BK 40+ CUSTM	214.01	214.01
A6556	DMEPOS	G COM STCKING THGH18-30 CUST	293.29	293.29
A6557	DMEPOS	G COM STCKING THGH30-40 CUST	293.29	293.29
A6558	DMEPOS	G COM STCKING THGH 40+ CUST	302.67	302.67
A6559	DMEPOS	G STCKNG FULL/CHAP18-30 CUST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6560	DMEPOS	G STCKNG FULL/CHAP30-40 CUST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6561	DMEPOS	G STOCKNG FULL/CHAP 40+ CUST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6562	DMEPOS	G COM STCKNG WAIST18-30 CUST	959.88	959.88
A6563	DMEPOS	G COM STCKNG WAIST30-40 CUST	959.88	959.88
A6564	DMEPOS	G COM STCKNG WAIST 40+ CUST	1034.00	1034.00
A6565	DMEPOS	GRAD COMP GAUNTLET CUSTOM	165.86	165.86
A6566	DMEPOS	GRAD COM GARMENT NECK/HEAD	240.83	240.83
A6567	DMEPOS	G COM GARMENT NECK/HEAD CUST	756.68	756.68
A6568	DMEPOS	G COM GARMENT TORSO/SHLDR	157.17	157.17
A6569	DMEPOS	G COM GARMNT TORSO/SHDR CUST	895.00	895.00
A6570	DMEPOS	GRAD COM GARMENT GENITAL	107.09	107.09
A6571	DMEPOS	G COM GARMENT GENITAL CUSTM	643.63	643.63
A6572	DMEPOS	GRAD COM GARMENT TOE CAPS	99.37	99.37
A6573	DMEPOS	GRAD COM GARMNT TOE CAP CUST	235.80	235.80
A6574	DMEPOS	CUSTOM GRADIENT SLEEV/GLOV	300.61	300.61
A6575	DMEPOS	GRADIENT COMP SLEEV/GLOV	97.42	97.42
A6576	DMEPOS	CUSTOM GRAD COM SLEEVE MED	184.50	184.50
A6577	DMEPOS	CUSTOM GRAD CM SLEEVE HEAVY	152.70	152.70
A6578	DMEPOS	GRADIENT COMP SLEEVE	75.20	75.20
A6579	DMEPOS	CUSTOM GRAD COM GLOVE MED	296.14	296.14
A6580	DMEPOS	CUSTOM GRAD COM GLOVE HEAVY	293.96	293.96
A6581	DMEPOS	GRADIENT COMP GLOVE	69.00	69.00
A6582	DMEPOS	GRADIENT COMP GAUNTLET	46.02	46.02
A6583	DMEPOS	GRAD COM WRAP W STRAPS BK	151.38	151.38
A6584	DMEPOS	GRAD COM WRAP W STRAPS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6585	DMEPOS	GRAD COM WRAP W STRAPS AK	179.24	179.24
A6586	DMEPOS	GRAD COM WRAP W STRAPS LEG	528.06	528.06
A6587	DMEPOS	GRAD COM WRAP W STRAPS FOOT	69.17	69.17
A6588	DMEPOS	GRAD COM WRAP W STRAPS ARM	230.54	230.54
A6589	DMEPOS	GRAD COM WRAP W STRAPS BRA	91.01	91.01
A6590	DMEPOS	URINARY CATH DISP SUC PUMP	419.70	419.70
A6591	DMEPOS	URINARY CATH SUC PUMP	86.78	86.78
A6593	DMEPOS	GRAD COM ACCESSORY GMT_WRAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6594	DMEPOS	G COMP BANDGE LINER LWR EXTR	33.14	33.14
A6595	DMEPOS	G COMP BANDGE LINER UPR EXTR	32.59	32.59
A6596	DMEPOS	G COMP BANDGE CONFORM GAUZE	0.17	0.17
A6597	DMEPOS	G COMP BANDAGE LONG STRETCH	1.47	1.47
A6598	DMEPOS	G COMP BANDAGE MED STRETCH	0.71	0.71
A6599	DMEPOS	G COMP BANDAGE SHORT STRETCH	1.61	1.61
A6600	DMEPOS	G COM BANDGE HGH DN FOAM SHT	2.90	2.90
A6601	DMEPOS	G COM BANDGE HGH DN FOAM PAD	3.26	3.26
A6602	DMEPOS	G COM BANDGE HGH DN FOAMROLL	4.76	4.76
A6603	DMEPOS	G COM BANDGE LOW DN FOAMCHNL	2.23	2.23
A6604	DMEPOS	G COM BANDGE LOW DN FOAM FLT	1.30	1.30
A6605	DMEPOS	G COM BANDAGE PADDED FOAM	1.49	1.49
A6606	DMEPOS	G COM BANDAGE PADDED TEXTILE	4.42	4.42
A6607	DMEPOS	G COM BANDAGE TUB PROTCT LYR	1.18	1.18
A6608	DMEPOS	G COM BANDAGE TUB PROTCT PAD	4.92	4.92
A6609	DMEPOS	G COMPRESSION BANDAGING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A6610	DMEPOS	G COM STCKING BK 18-30 CUSTM	214.01	214.01
A7000-NU	DMEPOS	DISPOSABLE CANISTER FOR PUMP	9.93	9.93
A7001-NU	DMEPOS	NONDISPOSABLE PUMP CANISTER	39.13	39.13
A7002-NU	DMEPOS	TUBING USED W SUCTION PUMP	4.45	4.45
A7003-NU	DMEPOS	NEBULIZER ADMINISTRATION SET	1.78	1.78
A7004-NU	DMEPOS	DISPOSABLE NEBULIZER SML VOL	1.50	1.50
A7005-NU	DMEPOS	NONDISPOSABLE NEBULIZER SET	14.20	14.20
A7006-NU	DMEPOS	FILTERED NEBULIZER ADMIN SET	9.04	9.04
A7007-NU	DMEPOS	LG VOL NEBULIZER DISPOSABLE	3.95	3.95
A7008-NU	DMEPOS	DISPOSABLE NEBULIZER PREFILL	12.75	12.75
A7009-NU	DMEPOS	NEBULIZER RESERVOIR BOTTLE	54.88	54.88
A7010-NU	DMEPOS	DISPOSABLE CORRUGATED TUBING	19.08	19.08
A7012-NU	DMEPOS	NEBULIZER WATER COLLEC DEVIC	3.50	3.50
A7013-NU	DMEPOS	DISPOSABLE COMPRESSOR FILTER	0.69	0.69
A7014-NU	DMEPOS	COMPRESSOR NONDISPOS FILTER	3.87	3.87
A7015-NU	DMEPOS	AEROSOL MASK USED W NEBULIZE	1.55	1.55
A7016-NU	DMEPOS	NEBULIZER DOME & MOUTHPIECE	9.14	9.14
A7017-NU	DMEPOS	NEBULIZER NOT USED W OXYGEN	147.77	147.77
A7017-RR	DMEPOS	NEBULIZER NOT USED W OXYGEN	14.78	14.78
A7017-UE	DMEPOS	NEBULIZER NOT USED W OXYGEN	110.83	110.83
A7018	DMEPOS	WATER DISTILLED W/NEBULIZER	0.38	0.38
A7020-NU	DMEPOS	INTERFACE, COUGH STIM DEVICE	19.60	19.60
A7023	DMEPOS	MECH ALLERGEN PARTI BARRIER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A7025-RR	DMEPOS	REPLACE CHEST COMPRESS VEST	59.35	59.35
A7026-NU	DMEPOS	REPLACE CHST CMPRSS SYS HOSE	39.22	39.22
A7027-NU	DMEPOS	COMBINATION ORAL/NASAL MASK	145.28	145.28
A7028-NU	DMEPOS	REPL ORAL CUSHION COMBO MASK	40.62	40.62
A7029-NU	DMEPOS	REPL NASAL PILLOW COMB MASK	18.16	18.16
A7030-NU	DMEPOS	CPAP FULL FACE MASK	104.51	104.51
A7031-NU	DMEPOS	REPLACEMENT FACEMASK INTERFA	40.53	40.53
A7032-NU	DMEPOS	REPLACEMENT NASAL CUSHION	22.74	22.74
A7033-NU	DMEPOS	REPLACEMENT NASAL PILLOWS	18.30	18.30
A7034-NU	DMEPOS	NASAL APPLICATION DEVICE	65.94	65.94
A7035-NU	DMEPOS	POS AIRWAY PRESS HEADGEAR	21.64	21.64
A7036-NU	DMEPOS	POS AIRWAY PRESS CHINSTRAP	12.59	12.59
A7037-NU	DMEPOS	POS AIRWAY PRESSURE TUBING	13.97	13.97
A7038-NU	DMEPOS	POS AIRWAY PRESSURE FILTER	2.44	2.44
A7039-NU	DMEPOS	FILTER, NON DISPOSABLE W PAP	7.15	7.15
A7040	DMEPOS	ONE WAY CHEST DRAIN VALVE	55.49	55.49
A7041	DMEPOS	WATER SEAL DRAIN CONTAINER	104.29	104.29
A7044-NU	DMEPOS	PAP ORAL INTERFACE	100.42	100.42
A7045-NU	DMEPOS	REPL EXHALATION PORT FOR PAP	13.82	13.82
A7045-RR	DMEPOS	REPL EXHALATION PORT FOR PAP	1.38	1.38
A7045-UE	DMEPOS	REPL EXHALATION PORT FOR PAP	10.37	10.37
A7046-NU	DMEPOS	REPL WATER CHAMBER, PAP DEV	16.08	16.08
A7047-NU	DMEPOS	RESP SUCTION ORAL INTERFACE	164.97	164.97
A7048	DMEPOS	VACUUM DRAIN BOTTLE/TUBE KIT	58.05	58.05
A7049	DMEPOS	EPAP NASAL VALVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A7501	DMEPOS	TRACHEOSTOMA VALVE W DIAPHRA	143.29	143.29
A7502	DMEPOS	REPLACEMENT DIAPHRAGM/FPLATE	68.12	68.12
A7503	DMEPOS	HMES FILTER HOLDER OR CAP	15.48	15.48
A7504	DMEPOS	TRACHEOSTOMA HMES FILTER	0.93	0.93
A7505	DMEPOS	HMES OR TRACH VALVE HOUSING	6.40	6.40
A7506	DMEPOS	HMES/TRACHVALVE ADHESIVEDISK	0.44	0.44
A7507	DMEPOS	INTEGRATED FILTER & HOLDER	3.41	3.41
A7508	DMEPOS	HOUSING & INTEGRATED ADHESIV	3.92	3.92
A7509	DMEPOS	HEAT & MOISTURE EXCHANGE SYS	1.92	1.92
A7520	DMEPOS	TRACH/LARYN TUBE NON-CUFFED	64.78	64.78
A7521	DMEPOS	TRACH/LARYN TUBE CUFFED	64.19	64.19
A7522	DMEPOS	TRACH/LARYN TUBE STAINLESS	61.62	61.62
A7523	Other professional services	TRACHEOSTOMY SHOWER PROTECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A7524	DMEPOS	TRACHEOSTOMA STENT/STUD/BTTN	105.63	105.63
A7525	DMEPOS	TRACHEOSTOMY MASK	2.81	2.81
A7526	DMEPOS	TRACHEOSTOMY TUBE COLLAR	4.63	4.63
A7527	DMEPOS	TRACH/LARYN TUBE PLUG/STOP	4.88	4.88
A8000-NU	DMEPOS	SOFT PROTECT HELMET PREFAB	209.26	209.26
A8000-RR	DMEPOS	SOFT PROTECT HELMET PREFAB	20.93	20.93
A8000-UE	DMEPOS	SOFT PROTECT HELMET PREFAB	156.98	156.98
A8001-NU	DMEPOS	HARD PROTECT HELMET PREFAB	209.26	209.26
A8001-RR	DMEPOS	HARD PROTECT HELMET PREFAB	20.93	20.93
A8001-UE	DMEPOS	HARD PROTECT HELMET PREFAB	156.98	156.98
A8002-NU	DMEPOS	SOFT PROTECT HELMET CUSTOM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A8002-RR	DMEPOS	SOFT PROTECT HELMET CUSTOM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A8002-UE	DMEPOS	SOFT PROTECT HELMET CUSTOM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A8003-NU	DMEPOS	HARD PROTECT HELMET CUSTOM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A8003-RR	DMEPOS	HARD PROTECT HELMET CUSTOM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A8003-UE	DMEPOS	HARD PROTECT HELMET CUSTOM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A8004-NU	DMEPOS	REPL SOFT INTERFACE, HELMET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A8004-RR	DMEPOS	REPL SOFT INTERFACE, HELMET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A8004-UE	DMEPOS	REPL SOFT INTERFACE, HELMET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9150	Other professional services	MISC/EXPER NON-PRESCRIPT DRU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9152	Other professional services	SINGLE VITAMIN NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9153	Other professional services	MULTI-VITAMIN NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9155	Other professional services	ARTIFICIAL SALIVA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9156	DMEPOS	ORAL MUCOADHESIVE PER 1 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9180	Other professional services	LICE TREATMENT, TOPICAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9268	DMEPOS	PROGRAMMER ORALLY INGEST CAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9269	DMEPOS	PROGRAMABLE INGEST CAPSULE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9270	Other professional services	NON-COVERED ITEM OR SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9272	Other professional services	DISP WOUND SUCT, DRSG/ACCESS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9273	Other professional services	HOT/COLD BOTLE/CAP/COL/WRAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9274	Other professional services	EXT AMB INSULIN DELIVERY SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9275	Other professional services	DISP HOME GLUCOSE MONITOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9276	Other professional services	DISPOSABLE SENSOR, CGM SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9277	Other professional services	EXTERNAL TRANSMITTER, CGM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9278	Other professional services	EXTERNAL RECEIVER, CGM SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9279	Other professional services	MONITORING FEATURE/DEVICENOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9280	Other professional services	ALERT DEVICE, NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9281	Other professional services	REACHING/GRABBING DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9282	Other professional services	WIG ANY TYPE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9283	Other professional services	FOOT PRESS OFF LOAD SUPP DEV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9284	Other professional services	NON-ELECTRONIC SPIROMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9285	Other professional services	INVERSION EVERSION COR DEVIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9286	Other professional services	ANY HYGIENIC ITEM, DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9291	Other professional services	PRES DIG COG BEHAV THERA FDA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9292	DMEPOS	PRES DIG VISUAL THERAPY FDA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9300	Other professional services	EXERCISE EQUIPMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9500	Other professional services	TC99M SESTAMIBI	165.39	165.39
A9501	Other professional services	TECHNETIUM TC-99M TEBOROXIME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9502	Other professional services	TC99M TETROFOSMIN	173.60	173.60
A9503	Other professional services	TC99M MEDRONATE	71.96	71.96
A9504	Other professional services	TC99M APCITIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9505	Other professional services	TL201 THALLIUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9507	Other professional services	IN111 CAPROMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9508	Other professional services	I131 IODOBENGUATE, DX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9509	Other professional services	IODINE I-123 SOD IODIDE MIL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9510	Other professional services	TC99M DISOFENIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9512	Other professional services	TC99M PERTECHNETATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9513	Other professional services	LUTETIUM LU 177 DOTATAT THER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9515	Other professional services	CHOLINE C-11	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9516	Other professional services	IODINE I-123 SOD IODIDE MIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9517	Other professional services	I131 IODIDE CAP, RX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9520	Other professional services	TC99 TILMANOCEPT DIAG 0.5MCI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9521	Other professional services	TC99M EXAMETAZIME	2614.20	2614.20
A9524	Other professional services	I131 SERUM ALBUMIN, DX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9526	Other professional services	NITROGEN N-13 AMMONIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9527	Other professional services	IODINE I-125 SODIUM IODIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9528	Other professional services	IODINE I-131 IODIDE CAP, DX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9529	Other professional services	I131 IODIDE SOL, DX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9530	Other professional services	I131 IODIDE SOL, RX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9531	Other professional services	I131 MAX 100UCI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9532	Other professional services	I125 SERUM ALBUMIN, DX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9536	Other professional services	TC99M DEPREOTIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9537	Other professional services	TC99M MEBROFENIN	94.59	94.59
A9538	Other professional services	TC99M PYROPHOSPHATE	24.35	24.35
A9539	Other professional services	TC99M PENTETATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9540	Other professional services	TC99M MAA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9541	Other professional services	TC99M SULFUR COLLOID	237.95	237.95
A9542	Other professional services	IN111 IBRITUMOMAB, DX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9543	Other professional services	Y90 IBRITUMOMAB, RX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9546	Other professional services	CO57/58	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9547	Other professional services	IN111 OXYQUINOLINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9548	Other professional services	IN111 PENTETATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9550	Other professional services	TC99M GLUCEPTATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9551	Other professional services	TC99M SUCCIMER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9552	Other professional services	F18 FDG	375.00	375.00
A9553	Other professional services	CR51 CHROMATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9554	Other professional services	I125 IOTHALAMATE, DX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9555	Other professional services	RB82 RUBIDIUM	437.82	437.82
A9556	Other professional services	GA67 GALLIUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9557	Other professional services	TC99M BICISATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9558	Other professional services	XE133 XENON 10MCI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9559	Other professional services	CO57 CYANO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9560	Other professional services	TC99M LABELED RBC	159.72	159.72
A9561	Other professional services	TC99M OXIDRONATE	75.24	75.24
A9562	Other professional services	TC99M MERTIATIDE	897.75	897.75
A9563	Other professional services	P32 NA PHOSPHATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9564	Other professional services	P32 CHROMIC PHOSPHATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9566	Other professional services	TC99M FANOLESOMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9567	Other professional services	TECHNETIUM TC-99M AEROSOL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9568	Other professional services	TECHNETIUM TC99M ARCITUMOMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9569	Other professional services	TECHNETIUM TC-99M AUTO WBC	2614.20	2614.20
A9570	Other professional services	INDIUM IN-111 AUTO WBC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9571	Other professional services	INDIUM IN-111 AUTO PLATELET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9572	Other professional services	INDIUM IN-111 PENTETREOTIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9573	DMEPOS	INJ, GADOPICLENOL, 1 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9575	Other professional services	INJ GADOTERATE MEGLUMI 0.1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9576	Other professional services	INJ PROHANCE MULTIPACK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9577	Other professional services	INJ MULTIHANCE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9578	Other professional services	INJ MULTIHANCE MULTIPACK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9579	Other professional services	GAD-BASE MR CONTRAST NOS,1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9580	Other professional services	SODIUM FLUORIDE F-18	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9581	Other professional services	GADOXETATE DISODIUM INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9582	Other professional services	IODINE I-123 IOBENGUANE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9583	Other professional services	GADOFOSVESET TRISODIUM INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9584	Other professional services	IODINE I-123 IOFLUPANE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9585	Other professional services	GADOBUTROL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9586	Other professional services	FLORBETAPIR F18	4886.16	4886.16
A9587	Other professional services	GALLIUM GA-68	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9588	Other professional services	FLUCICLOVINE F-18	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9589	Other professional services	INSTI HEXAMINOLEVULINATE HCL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9590	Other professional services	IODINE I-131 IOBENGUANE 1MCI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9591	DMEPOS	FLUOROESTRADIOL F 18	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9592	DMEPOS	COPPER CU 64 DOTATATE DIAG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9593	DMEPOS	GALLIUM GA-68 PSMA-11 UCSF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9594	DMEPOS	GALLIUM GA-68 PSMA-11, UCLA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9595	DMEPOS	PIFLU F-18, DIA 1 MILLICURIE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9596	Other professional services	GALLIUM ILLUCCIX 1 MILLICURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9597	Other professional services	PET, DX, FOR TUMOR ID, NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9598	Other professional services	PET DX FOR NON-TUMOR ID, NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9600	Other professional services	SR89 STRONTIUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9601	Other professional services	FLORTAUCIPIR INJ 1 MILLICURI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9602	Other professional services	FLUORODOPA F-18 DIAG PER MCI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9603	DMEPOS	INJ, PAFOLACIANINE, 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9604	Other professional services	SM 153 LEXIDRONAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9606	DMEPOS	RADIUM RA223 DICHLORIDE THER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9607	Other professional services	LUTETIUM LU 177 VIPIVOTIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9608	DMEPOS	FLOTUFOLASTAT F18 DIAG 1 MCI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9609	DMEPOS	F18 FDG, 15 MILLICURIES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9697	DMEPOS	INJ, MAGTRACE PER STUDY DOSE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9698	Other professional services	NON-RAD CONTRAST MATERIALNOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9699	Other professional services	RADIOPHARM RX AGENT NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9700	Other professional services	ECHOCARDIOGRAPHY CONTRAST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9800	Other professional services	GALLIUM LOCAMETZ 1 MILLICURI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9900	Other professional services	SUPPLY/ACCESSORY/SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9901	Other professional services	DELIVERY/SET UP/DISPENSING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
A9999	Other professional services	DME SUPPLY OR ACCESSORY, NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4034	Other professional services	ENTER FEED SUPKIT SYR BY DAY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4035	Other professional services	ENTERAL FEED SUPP PUMP PER D	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4036	Other professional services	ENTERAL FEED SUP KIT GRAV BY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4081	Other professional services	ENTERAL NG TUBING W/ STYLET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4082	Other professional services	ENTERAL NG TUBING W/O STYLET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4083	Other professional services	ENTERAL STOMACH TUBE LEVINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4087	Other professional services	GASTRO/JEJUNO TUBE, STD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4088	Other professional services	GASTRO/JEJUNO TUBE, LOW-PRO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4100	Other professional services	FOOD THICKENER ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4102	Other professional services	EF ADULT FLUIDS AND ELECTRO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4103	Other professional services	EF PED FLUID AND ELECTROLYTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4104	Other professional services	ADDITIVE FOR ENTERAL FORMULA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4105	Other professional services	ENZYME CARTRIDGE ENTERAL NUT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4148	DMEPOS	ENTERAL FEED ELASTOMER DAILY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4149	Other professional services	EF BLENDERIZED FOODS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4150	Other professional services	EF COMPLET W/INTACT NUTRIENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4152	Other professional services	EF CALORIE DENSE>/=1.5KCAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4153	Other professional services	EF HYDROLYZED/AMINO ACIDS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4154	Other professional services	EF SPEC METABOLIC NONINHERIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4155	Other professional services	EF INCOMPLETE/MODULAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4157	Other professional services	EF SPECIAL METABOLIC INHERIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4158	Other professional services	EF PED COMPLETE INTACT NUT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4159	Other professional services	EF PED COMPLETE SOY BASED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4160	Other professional services	EF PED CALORIC DENSE>/=0.7KC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4161	Other professional services	EF PED HYDROLYZED/AMINO ACID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4162	Other professional services	EF PED SPECMETABOLIC INHERIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4164	Other professional services	PARENTERAL 50% DEXTROSE SOLU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4168	Other professional services	PARENTERAL SOL AMINO ACID 3.	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4172	Other professional services	PARENTERAL SOL AMINO ACID 5.	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4176	Other professional services	PARENTERAL SOL AMINO ACID 7-	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4178	Other professional services	PARENTERAL SOL AMINO ACID >	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4180	Other professional services	PARENTERAL SOL CARB > 50%	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4185	Other professional services	PN SOLN NOS 10 GRAMS LIPIDS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4187	DMEPOS	OMEGAVEN, 10 GRAMS LIPIDS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4189	Other professional services	PARENTERAL SOL AMINO ACID &	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4193	Other professional services	PARENTERAL SOL 52-73 GM PROT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4197	Other professional services	PARENTERAL SOL 74-100 GM PRO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4199	Other professional services	PARENTERAL SOL > 100GM PROTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4216	Other professional services	PARENTERAL NUTRITION ADDITIV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4220	Other professional services	PARENTERAL SUPPLY KIT PREMIX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4222	Other professional services	PARENTERAL SUPPLY KIT HOMEMI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B4224	Other professional services	PARENTERAL ADMINISTRATION KI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B5000	Other professional services	PARENTERAL SOL RENAL-AMIROSY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B5100	Other professional services	PARENTERAL SOLUTION HEPATIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B5200	Other professional services	PARENTERAL SOL HEPATIC FREAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B9002	Other professional services	ENTER NUTR INF PUMP ANY TYPE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B9004	Other professional services	PARENTERAL INFUS PUMP PORTAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B9006	Other professional services	PARENTERAL INFUS PUMP STATIO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B9998	Other professional services	ENTERAL SUPP NOT OTHERWISE C	UCR or Pay Per Agreement	UCR or Pay Per Agreement
B9999	Other professional services	PARENTERAL SUPP NOT OTHRWS C	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1052	Other professional services	HEMOSTATIC AGENT, GI, TOPIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1062	Major surgery	INTRAVERTEBRAL FX AUG IMPL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1713	Other professional services	ANCHOR/SCREW BN/BN,TIS/BN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1714	Other professional services	CATH, TRANS ATHERECTOMY, DIR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1715	Other professional services	BRACHYTHERAPY NEEDLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1716	Other professional services	BRACHYTX, NON-STR, GOLD-198	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1717	Other professional services	BRACHYTX, NON-STR,HDR IR-192	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1719	Other professional services	BRACHYTX, NS, NON-HDRIR-192	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1721	Other professional services	AICD, DUAL CHAMBER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1722	Other professional services	AICD, SINGLE CHAMBER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1724	Other professional services	CATH, TRANS ATHEREC,ROTATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1725	Other professional services	CATH, TRANSLUMIN NON-LASER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1726	Other professional services	CATH, BAL DIL, NON-VASCULAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1727	Other professional services	CATH, BAL TIS DIS, NON-VAS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1728	Other professional services	CATH, BRACHYTX SEED ADM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1729	Other professional services	CATH, DRAINAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1730	Other professional services	CATH, EP, 19 OR FEW ELECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1731	Other professional services	CATH, EP, 20 OR MORE ELEC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1732	Other professional services	CATH, EP, DIAG/ABL, 3D/VECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1733	Other professional services	CATH, EP, OTHR THAN COOL-TIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1734	Other professional services	ORTH/DEVIC/DRUG BN/BN,TIS/BN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1748	Other professional services	ENDOSCOPE, SINGLE, UGI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1749	Other professional services	ENDO, COLON, RETRO IMAGING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1750	Other professional services	CATH, HEMODIALYSIS,LONG-TERM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1751	Other professional services	CATH, INF, PER/CENT/MIDLINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1752	Other professional services	CATH,HEMODIALYSIS,SHORT-TERM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1753	Other professional services	CATH, INTRAVAS ULTRASOUND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1754	Other professional services	CATHETER, INTRADISCAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1755	Other professional services	CATHETER, INTRASPINAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1756	Other professional services	CATH, PACING, TRANSESOPH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1757	Other professional services	CATH, THROMBECTOMY/EMBOLECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1758	Other professional services	CATHETER, URETERAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1759	Other professional services	CATH, INTRA ECHOCARDIOGRAPHY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1760	Other professional services	CLOSURE DEV, VASC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1761	DMEPOS	CATH, TRANS INTRA LITHO/CORO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1762	Other professional services	CONN TISS, HUMAN(INC FASCIA)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1763	Other professional services	CONN TISS, NON-HUMAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1764	Other professional services	EVENT RECORDER, CARDIAC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1765	Other professional services	ADHESION BARRIER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1766	Other professional services	INTRO/SHEATH,STRBLE,NON-PEEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1767	Other professional services	GENERATOR, NEURO NON-RECHARG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1768	Other professional services	GRAFT, VASCULAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1769	Other professional services	GUIDE WIRE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1770	Other professional services	IMAGING COIL, MR, INSERTABLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1771	Other professional services	REP DEV, URINARY, W/SLING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1772	Other professional services	INFUSION PUMP, PROGRAMMABLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1773	Other professional services	RET DEV, INSERTABLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1776	Other professional services	JOINT DEVICE (IMPLANTABLE)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1777	Other professional services	LEAD, AICD, ENDO SINGLE COIL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1778	Other professional services	LEAD, NEUROSTIMULATOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1779	Other professional services	LEAD, PMKR, TRANSVENOUS VDD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1780	Other professional services	LENS, INTRAOCULAR (NEW TECH)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1781	Other professional services	MESH (IMPLANTABLE)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1782	Other professional services	MORCELLATOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1783	Other professional services	OCULAR IMP, AQUEOUS DRAIN DE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1784	Other professional services	OCULAR DEV, INTRAOP, DET RET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1785	Other professional services	PMKR, DUAL, RATE-RESP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1786	Other professional services	PMKR, SINGLE, RATE-RESP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1787	Other professional services	PATIENT PROGR, NEUROSTIM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1788	Other professional services	PORT, INDWELLING, IMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1789	Other professional services	PROSTHESIS, BREAST, IMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1813	Other professional services	PROSTHESIS, PENILE, INFLATAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1814	Other professional services	RETINAL TAMP, SILICONE OIL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1815	Other professional services	PROS, URINARY SPH, IMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1816	Other professional services	RECEIVER/TRANSMITTER, NEURO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1817	Other professional services	SEPTAL DEFECT IMP SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1818	Other professional services	INTEGRATED KERATOPROSTHESIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1819	Other professional services	TISSUE LOCALIZATION-EXCISION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1820	Other professional services	GENERATOR NEURO RECHG BAT SY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1821	Other professional services	INTERSPINOUS IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1822	Other professional services	GEN, NEURO, HF, RECHG BAT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1823	Other professional services	GEN, NEURO, TRANS SEN/STIM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1824	Other professional services	GENERATOR, CCM, IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1825	Other professional services	GEN, NEURO, CAROT SINUS BARO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1830	Other professional services	POWER BONE MARROW BX NEEDLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1831	DMEPOS	PERSONALIZED INTERBODY CAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1832	DMEPOS	AUTO CELL PROCESS SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1833	DMEPOS	CARDIAC MONITOR SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1839	Other professional services	IRIS PROSTHESIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1840	Other professional services	TELESCOPIC INTRAOCULAR LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1874	Other professional services	STENT, COATED/COV W/DEL SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1875	Other professional services	STENT, COATED/COV W/O DEL SY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1876	Other professional services	STENT, NON-COA/NON-COV W/DEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1877	Other professional services	STENT, NON-COAT/COV W/O DEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1878	Other professional services	MATRL FOR VOCAL CORD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1880	Other professional services	VENA CAVA FILTER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1881	Other professional services	DIALYSIS ACCESS SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1882	Other professional services	AICD, OTHER THAN SING/DUAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1883	Other professional services	ADAPT/EXT, PACING/NEURO LEAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1884	Other professional services	EMBOLIZATION PROTECT SYST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1885	Other professional services	CATH, TRANSLUMIN ANGIO LASER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1886	Other professional services	CATHETER, ABLATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1887	Other professional services	CATHETER, GUIDING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1888	Other professional services	ENDOVAS NON-CARDIAC ABL CATH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1889	Other professional services	IMPLANT/INSERT DEVICE, NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1890	Other professional services	NO DEVICE W/DEV-INTENSIVE PX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1891	Other professional services	INFUSION PUMP,NON-PROG, PERM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1892	Other professional services	INTRO/SHEATH,FIXED,PEEL-AWAY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1893	Other professional services	INTRO/SHEATH, FIXED,NON-PEEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1894	Other professional services	INTRO/SHEATH, NON-LASER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1895	Other professional services	LEAD, AICD, ENDO DUAL COIL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1896	Other professional services	LEAD, AICD, NON SING/DUAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1897	Other professional services	LEAD, NEUROSTIM TEST KIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1898	Other professional services	LEAD, PMKR, OTHER THAN TRANS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1899	Other professional services	LEAD, PMKR/AICD COMBINATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1900	Other professional services	LEAD, CORONARY VENOUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C1982	Other professional services	CATH, PRESSURE,VALVE-OCCLU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2596	Other professional services	PROBE, ROBOTIC, WATER-JET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2613	Other professional services	LUNG BX PLUG W/DEL SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2614	Other professional services	PROBE, PERC LUMB DISC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2615	Other professional services	SEALANT, PULMONARY, LIQUID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2616	Other professional services	BRACHYTX, NON-STR,YTTRIUM-90	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2617	Other professional services	STENT, NON-COR, TEM W/O DEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2618	Other professional services	PROBE/NEEDLE, CRYO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2619	Other professional services	PMKR, DUAL, NON RATE-RESP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2620	Other professional services	PMKR, SINGLE, NON RATE-RESP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2621	Other professional services	PMKR, OTHER THAN SING/DUAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2622	Other professional services	PROSTHESIS, PENILE, NON-INF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2623	Other professional services	CATH, TRANSLUMIN, DRUG-COAT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2624	Other professional services	WIRELESS PRESSURE SENSOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2625	Other professional services	STENT, NON-COR, TEM W/DEL SY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2626	Other professional services	INFUSION PUMP, NON-PROG,TEMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2627	Other professional services	CATH, SUPRAPUBIC/CYSTOSCOPIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2628	Other professional services	CATHETER, OCCLUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2629	Other professional services	INTRO/SHEATH, LASER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2630	Other professional services	CATH, EP, COOL-TIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2631	Other professional services	REP DEV, URINARY, W/O SLING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2634	Other professional services	BRACHYTX, NON-STR, HA, I-125	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2635	Other professional services	BRACHYTX, NON-STR, HA, P-103	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2636	Other professional services	BRACHY LINEAR, NON-STR,P-103	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2637	Other professional services	BRACHY,NON-STR,YTTERBIUM-169	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2638	Other professional services	BRACHYTX, STRANDED, I-125	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2639	Other professional services	BRACHYTX, NON-STRANDED,I-125	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2640	Other professional services	BRACHYTX, STRANDED, P-103	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2641	Other professional services	BRACHYTX, NON-STRANDED,P-103	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2642	Other professional services	BRACHYTX, STRANDED, C-131	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2643	Other professional services	BRACHYTX, NON-STRANDED,C-131	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2644	Other professional services	BRACHYTX CESIUM-131 CHLORIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2645	Other professional services	BRACHYTX PLANAR, P-103	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2698	Other professional services	BRACHYTX, STRANDED, NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C2699	Other professional services	BRACHYTX, NON-STRANDED, NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C5271	Other professional services	LOW COST SKIN SUBSTITUTE APP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C5272	Other professional services	LOW COST SKIN SUBSTITUTE APP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C5273	Other professional services	LOW COST SKIN SUBSTITUTE APP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C5274	Other professional services	LOW COST SKIN SUBSTITUTE APP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C5275	Other professional services	LOW COST SKIN SUBSTITUTE APP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C5276	Other professional services	LOW COST SKIN SUBSTITUTE APP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C5277	Other professional services	LOW COST SKIN SUBSTITUTE APP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C5278	Other professional services	LOW COST SKIN SUBSTITUTE APP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C7556	Other professional services	BRONCH LAVAGE W/EBUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C7557	Other professional services	COR ANGIO/VENT W/FFR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C7558	Other professional services	COR ANGIO/VENT W/DRUG ADMIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C7560	Other professional services	ERCP REMOVE FORGN BODY&ENDO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C7903	Other professional services	HOPD MNTL HLT, GRP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8900	Other professional services	MRA W/CONT, ABD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8901	Other professional services	MRA W/O CONT, ABD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8902	Other professional services	MRA W/O FOL W/CONT, ABD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8903	Other professional services	MRI W/CONT, BREAST, UNI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8905	Other professional services	MRI W/O FOL W/CONT, BRST, UN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8906	Other professional services	MRI W/CONT, BREAST, BI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8908	Other professional services	MRI W/O FOL W/CONT, BREAST,	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8909	Other professional services	MRA W/CONT, CHEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8910	Other professional services	MRA W/O CONT, CHEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8911	Other professional services	MRA W/O FOL W/CONT, CHEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8912	Other professional services	MRA W/CONT, LWR EXT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8913	Other professional services	MRA W/O CONT, LWR EXT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8914	Other professional services	MRA W/O FOL W/CONT, LWR EXT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8918	Other professional services	MRA W/CONT, PELVIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8919	Other professional services	MRA W/O CONT, PELVIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8920	Other professional services	MRA W/O FOL W/CONT, PELVIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8921	Other professional services	TTE W OR W/O FOL W/CONT, COM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8922	Other professional services	TTE W OR W/O FOL W/CONT, F/U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8923	Other professional services	2D TTE W OR W/O FOL W/CON,CO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8924	Other professional services	2D TTE W OR W/O FOL W/CON,FU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8925	Other professional services	2D TEE W OR W/O FOL W/CON,IN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8926	Other professional services	TEE W OR W/O FOL W/CONT,CONG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8927	Other professional services	TEE W OR W/O FOL W/CONT, MON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8928	Other professional services	TTE W OR W/O FOL W/CON,STRES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8929	Other professional services	TTE W OR WO FOL WCON,DOPPLER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8930	Other professional services	TTE W OR W/O CONTR, CONT ECG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8931	Other professional services	MRA, W/DYE, SPINAL CANAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8932	Other professional services	MRA, W/O DYE, SPINAL CANAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8933	Other professional services	MRA, W/O&W/DYE, SPINAL CANAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8934	Other professional services	MRA, W/DYE, UPPER EXTREMITY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8935	Other professional services	MRA, W/O DYE, UPPER EXTR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8936	Other professional services	MRA, W/O&W/DYE, UPPER EXTR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8937	Other professional services	CAD BREAST MRI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C8957	Other professional services	PROLONGED IV INF, REQ PUMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9046	Other professional services	COCAINE HCL NASAL SOLUTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9047	Other professional services	INJECTION, CAPLACIZUMAB-YHDP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9067	DMEPOS	GALLIUM GA-68 DOTATOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9088	DMEPOS	INSTILL, BUPIVAC AND MELOXIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9089	DMEPOS	BUPIVACAINE IMPLANT, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9113	Other professional services	INJ PANTOPRAZOLE SODIUM, VIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9248	Other professional services	INJ, CLEVIDIPINE BUTYRATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9250	Other professional services	ARTISS FIBRIN SEALANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9254	Other professional services	INJECTION, LACOSAMIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9257	Other professional services	BEVACIZUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9285	Other professional services	PATCH, LIDOCAINE/TETRACAINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9290	Other professional services	INJ, BUPIVACAINE LIPOSOME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9293	Other professional services	INJECTION, GLUCARPIDASE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9352	Other professional services	NEURAGEN NERVE GUIDE, PER CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9353	Other professional services	NEURAWRAP NERVE PROTECTOR,CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9354	Other professional services	VERITAS COLLAGEN MATRIX, CM2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9355	Other professional services	NEUROMATRIX NERVE CUFF, CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9356	Other professional services	TENOGLIDE TENDON PROT, CM2	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9358	Other professional services	SURGIMEND, FETAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9359	Other professional services	IMPLNT,BON VOID FILLER-PUTTY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9360	Other professional services	SURGIMEND, NEONATAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9361	Other professional services	NEUROMEND NERVE WRAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9362	Other professional services	IMPLNT,BON VOID FILLER-STRIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9363	Other professional services	INTEGRA MESHED BIL WOUND MAT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9364	Other professional services	PORCINE IMPLANT, PERMACOL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9399	Other professional services	UNCLASSIFIED DRUGS OR BIOLOG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9460	Other professional services	INJECTION, CANGRELOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9462	Other professional services	INJECTION, DELAFLOXACIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9482	Other professional services	SOTALOL HYDROCHLORIDE IV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9488	Other professional services	CONIVAPTAN HCL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9507	Other professional services	COVID-19 CONVALESCENT PLASMA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9600	Other professional services	PERC DRUG-EL COR STENT SING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9601	Other professional services	PERC DRUG-EL COR STENT BRAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9602	Other professional services	PERC D-E COR STENT ATHER S	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9603	Other professional services	PERC D-E COR STENT ATHER BR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9604	Other professional services	PERC D-E COR REVASC T CABG S	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9605	Other professional services	PERC D-E COR REVASC T CABG B	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9606	Other professional services	PERC D-E COR REVASC W AMI S	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9607	Other professional services	PERC D-E COR REVASC CHRO SIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9608	Other professional services	PERC D-E COR REVASC CHRO ADD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9725	Other professional services	PLACE ENDORECTAL APP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9726	Other professional services	RXT BREAST APPL PLACE/REMOV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9727	Other professional services	INSERT PALATE IMPLANTS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9728	Other professional services	PLACE DEVICE/MARKER, NON PRO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9733	Other professional services	NON-OPHTHALMIC FVA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9734	Other professional services	U/S TRTMT, NOT LEIOMYOMATA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9738	Other professional services	BLUE LIGHT CYSTO IMAG AGENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9739	Other professional services	CYSTOSCOPY PROSTATIC IMP 1-3	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9740	Other professional services	CYSTO IMPL 4 OR MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9751	Other professional services	MICROWAVE BRONCH, 3D, EBUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9756	Other professional services	FLUORESCENCE LYMPH MAP W/ICG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9757	Other professional services	SPINE DEVICE IMPLANT SURGERY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9758	Other professional services	INTERATRIAL SHUNT IDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9759	Other professional services	TRANSCATH INTRAOP MICROINF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9760	Other professional services	NON-BLIND INTERATRIAL SHUNT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9761	Major surgery	CYSTO, LITHO, VACUUM KIDNEY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9762	Radiology	CARDIAC MRI SEG DYS STRAIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9763	Radiology	CARDIAC MRI SEG DYS STRESS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9764	Radiology	REVASC INTRAVASC LITHOTRIPSY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9765	Radiology	REVASC INTRA LITHOTRIP-STENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9766	Radiology	REVASC INTRA LITHOTRIP-ATHER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9767	Radiology	REVASC LITHOTRIP-STENT-ATHER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9768	Other professional services	ENDO US-GUIDE HEP PORTO GRAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9769	Radiology	CYSTO W/TEMP PROS IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9772	Major surgery	REVASC LITHOTRIP TIBI/PERONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9773	Major surgery	REVASC LITHOTR-STENT TIB/PER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9774	Major surgery	REVASC LITHOTR-ATHER TIB/PER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9775	Major surgery	REVASC LITH-STEN-ATH TIB/PER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9776	DMEPOS	FLUO BILE DUCT IMAGING W/ICG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9777	DMEPOS	ESOPHAG MUC INTEG W/ESO EGD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9778	DMEPOS	COLPOPEXY, MIN/INV, EX-PERIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9779	DMEPOS	ESD ENDOSCOPY OR COLONOSCOPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9780	DMEPOS	INSERT CV CATH INF & SUP APP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9789	Other professional services	INSTILL PHARM RENAL PELVIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9790	Radiology	KIDNEY HISTOTRIPSY W/IMAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9791	Radiology	MRI HYPERPOLARIZED XENON129	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9792	Other professional services	BLIND/NONBLIND TRANS ATRIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9793	Radiology	PRE-PLAN 3D MODEL W/CCTA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9794	Radiology	COMPLEX SIMULATION W/PET-CT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9795	Radiology	SBRT W/POSITRON EMISSION DEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9898	Other professional services	INPNT STAY RADIOLABELED ITEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
C9899	Other professional services	INPT IMPLANT PROS DEV,NO COV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0100-NU	DMEPOS	CANE ADJUST/FIXED WITH TIP	24.45	24.45
E0100-RR	DMEPOS	CANE ADJUST/FIXED WITH TIP	6.87	6.87
E0100-UE	DMEPOS	CANE ADJUST/FIXED WITH TIP	19.48	19.48
E0105-NU	DMEPOS	CANE ADJUST/FIXED QUAD/3 PRO	64.92	64.92
E0105-RR	DMEPOS	CANE ADJUST/FIXED QUAD/3 PRO	10.29	10.29
E0105-UE	DMEPOS	CANE ADJUST/FIXED QUAD/3 PRO	48.69	48.69
E0110-NU	DMEPOS	CRUTCH FOREARM PAIR	102.10	102.10
E0110-RR	DMEPOS	CRUTCH FOREARM PAIR	18.54	18.54
E0110-UE	DMEPOS	CRUTCH FOREARM PAIR	76.58	76.58
E0111-NU	DMEPOS	CRUTCH FOREARM EACH	61.75	61.75
E0111-RR	DMEPOS	CRUTCH FOREARM EACH	9.78	9.78
E0111-UE	DMEPOS	CRUTCH FOREARM EACH	47.68	47.68
E0112-NU	DMEPOS	CRUTCH UNDERARM PAIR WOOD	45.87	45.87
E0112-RR	DMEPOS	CRUTCH UNDERARM PAIR WOOD	11.53	11.53
E0112-UE	DMEPOS	CRUTCH UNDERARM PAIR WOOD	34.37	34.37
E0113-NU	DMEPOS	CRUTCH UNDERARM EACH WOOD	24.52	24.52
E0113-RR	DMEPOS	CRUTCH UNDERARM EACH WOOD	5.96	5.96
E0113-UE	DMEPOS	CRUTCH UNDERARM EACH WOOD	18.39	18.39
E0114-NU	DMEPOS	CRUTCH UNDERARM PAIR NO WOOD	54.73	54.73
E0114-RR	DMEPOS	CRUTCH UNDERARM PAIR NO WOOD	9.94	9.94
E0114-UE	DMEPOS	CRUTCH UNDERARM PAIR NO WOOD	41.38	41.38
E0116-NU	DMEPOS	CRUTCH UNDERARM EACH NO WOOD	32.18	32.18
E0116-RR	DMEPOS	CRUTCH UNDERARM EACH NO WOOD	6.28	6.28
E0116-UE	DMEPOS	CRUTCH UNDERARM EACH NO WOOD	24.23	24.23
E0117-RR	DMEPOS	UNDERARM SPRINGASSIST CRUTCH	26.28	26.28
E0118	DMEPOS	CRUTCH SUBSTITUTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0130-NU	DMEPOS	WALKER RIGID ADJUST/FIXED HT	54.23	54.23
E0130-RR	DMEPOS	WALKER RIGID ADJUST/FIXED HT	5.42	5.42
E0130-UE	DMEPOS	WALKER RIGID ADJUST/FIXED HT	40.67	40.67
E0135-NU	DMEPOS	WALKER FOLDING ADJUST/FIXED	54.47	54.47
E0135-RR	DMEPOS	WALKER FOLDING ADJUST/FIXED	5.45	5.45
E0135-UE	DMEPOS	WALKER FOLDING ADJUST/FIXED	40.85	40.85
E0140-RR	DMEPOS	WALKER W TRUNK SUPPORT	34.05	34.05
E0141-NU	DMEPOS	RIGID WHEELED WALKER ADJ/FIX	57.56	57.56
E0141-RR	DMEPOS	RIGID WHEELED WALKER ADJ/FIX	5.76	5.76
E0141-UE	DMEPOS	RIGID WHEELED WALKER ADJ/FIX	43.17	43.17
E0143-NU	DMEPOS	WALKER FOLDING WHEELED W/O S	57.56	57.56
E0143-RR	DMEPOS	WALKER FOLDING WHEELED W/O S	5.76	5.76
E0143-UE	DMEPOS	WALKER FOLDING WHEELED W/O S	43.17	43.17
E0144-RR	DMEPOS	ENCLOSED WALKER W REAR SEAT	32.48	32.48
E0147-NU	DMEPOS	WALKER VARIABLE WHEEL RESIST	479.51	479.51
E0147-RR	DMEPOS	WALKER VARIABLE WHEEL RESIST	47.95	47.95
E0147-UE	DMEPOS	WALKER VARIABLE WHEEL RESIST	359.64	359.64
E0148-NU	DMEPOS	HEAVYDUTY WALKER NO WHEELS	99.54	99.54
E0148-RR	DMEPOS	HEAVYDUTY WALKER NO WHEELS	9.95	9.95
E0148-UE	DMEPOS	HEAVYDUTY WALKER NO WHEELS	74.66	74.66
E0149-RR	DMEPOS	HEAVY DUTY WHEELED WALKER	14.83	14.83
E0153-NU	DMEPOS	FOREARM CRUTCH PLATFORM ATTA	94.69	94.69
E0153-RR	DMEPOS	FOREARM CRUTCH PLATFORM ATTA	10.71	10.71
E0153-UE	DMEPOS	FOREARM CRUTCH PLATFORM ATTA	71.00	71.00
E0154-NU	DMEPOS	WALKER PLATFORM ATTACHMENT	56.27	56.27
E0154-RR	DMEPOS	WALKER PLATFORM ATTACHMENT	5.63	5.63
E0154-UE	DMEPOS	WALKER PLATFORM ATTACHMENT	42.20	42.20
E0155-NU	DMEPOS	WALKER WHEEL ATTACHMENT,PAIR	24.00	24.00
E0155-RR	DMEPOS	WALKER WHEEL ATTACHMENT,PAIR	2.40	2.40
E0155-UE	DMEPOS	WALKER WHEEL ATTACHMENT,PAIR	18.00	18.00
E0156-NU	DMEPOS	WALKER SEAT ATTACHMENT	18.98	18.98
E0156-RR	DMEPOS	WALKER SEAT ATTACHMENT	1.90	1.90
E0156-UE	DMEPOS	WALKER SEAT ATTACHMENT	14.24	14.24
E0157-NU	DMEPOS	WALKER CRUTCH ATTACHMENT	67.89	67.89
E0157-RR	DMEPOS	WALKER CRUTCH ATTACHMENT	6.79	6.79
E0157-UE	DMEPOS	WALKER CRUTCH ATTACHMENT	50.92	50.92
E0158-NU	DMEPOS	WALKER LEG EXTENDERS SET OF4	25.47	25.47
E0158-RR	DMEPOS	WALKER LEG EXTENDERS SET OF4	2.55	2.55
E0158-UE	DMEPOS	WALKER LEG EXTENDERS SET OF4	19.10	19.10
E0159-NU	DMEPOS	BRAKE FOR WHEELED WALKER	17.69	17.69
E0159-RR	DMEPOS	BRAKE FOR WHEELED WALKER	1.77	1.77
E0159-UE	DMEPOS	BRAKE FOR WHEELED WALKER	13.27	13.27
E0160-NU	DMEPOS	SITZ TYPE BATH OR EQUIPMENT	31.57	31.57
E0160-RR	DMEPOS	SITZ TYPE BATH OR EQUIPMENT	3.15	3.15
E0160-UE	DMEPOS	SITZ TYPE BATH OR EQUIPMENT	23.68	23.68
E0161-NU	DMEPOS	SITZ BATH/EQUIPMENT W/FAUCET	29.57	29.57
E0161-RR	DMEPOS	SITZ BATH/EQUIPMENT W/FAUCET	2.96	2.96
E0161-UE	DMEPOS	SITZ BATH/EQUIPMENT W/FAUCET	22.18	22.18
E0162-NU	DMEPOS	SITZ BATH CHAIR	168.99	168.99
E0162-RR	DMEPOS	SITZ BATH CHAIR	17.74	17.74
E0162-UE	DMEPOS	SITZ BATH CHAIR	131.04	131.04
E0163-NU	DMEPOS	COMMODE CHAIR WITH FIXED ARM	64.52	64.52
E0163-RR	DMEPOS	COMMODE CHAIR WITH FIXED ARM	6.45	6.45
E0163-UE	DMEPOS	COMMODE CHAIR WITH FIXED ARM	48.39	48.39
E0165-RR	DMEPOS	COMMODE CHAIR WITH DETACHARM	14.86	14.86
E0167-NU	DMEPOS	COMMODE CHAIR PAIL OR PAN	11.94	11.94
E0167-RR	DMEPOS	COMMODE CHAIR PAIL OR PAN	1.19	1.19
E0167-UE	DMEPOS	COMMODE CHAIR PAIL OR PAN	8.96	8.96
E0168-NU	DMEPOS	HEAVYDUTY/WIDE COMMODE CHAIR	142.28	142.28
E0168-RR	DMEPOS	HEAVYDUTY/WIDE COMMODE CHAIR	14.23	14.23
E0168-UE	DMEPOS	HEAVYDUTY/WIDE COMMODE CHAIR	106.71	106.71
E0170-RR	DMEPOS	COMMODE CHAIR ELECTRIC	190.96	190.96
E0171-RR	DMEPOS	COMMODE CHAIR NON-ELECTRIC	35.09	35.09
E0172	DMEPOS	SEAT LIFT MECHANISM TOILET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0175-NU	DMEPOS	COMMODE CHAIR FOOT REST	90.37	90.37
E0175-RR	DMEPOS	COMMODE CHAIR FOOT REST	9.03	9.03
E0175-UE	DMEPOS	COMMODE CHAIR FOOT REST	66.52	66.52
E0181-RR	DMEPOS	PRESS PAD ALTERNATING W/ PUM	18.69	18.69
E0182-RR	DMEPOS	REPLACE PUMP, ALT PRESS PAD	23.19	23.19
E0183-RR	DMEPOS	PRESS UNDERLAY ALTER W/PUMP	18.69	18.69
E0184-NU	DMEPOS	DRY PRESSURE MATTRESS	191.11	191.11
E0184-RR	DMEPOS	DRY PRESSURE MATTRESS	19.11	19.11
E0184-UE	DMEPOS	DRY PRESSURE MATTRESS	143.33	143.33
E0185-NU	DMEPOS	GEL PRESSURE MATTRESS PAD	204.06	204.06
E0185-RR	DMEPOS	GEL PRESSURE MATTRESS PAD	20.41	20.41
E0185-UE	DMEPOS	GEL PRESSURE MATTRESS PAD	153.05	153.05
E0186-RR	DMEPOS	AIR PRESSURE MATTRESS	21.30	21.30
E0187-RR	DMEPOS	WATER PRESSURE MATTRESS	23.22	23.22
E0188-NU	DMEPOS	SYNTHETIC SHEEPSKIN PAD	28.41	28.41
E0188-RR	DMEPOS	SYNTHETIC SHEEPSKIN PAD	2.84	2.84
E0188-UE	DMEPOS	SYNTHETIC SHEEPSKIN PAD	21.31	21.31
E0189-NU	DMEPOS	LAMBSWOOL SHEEPSKIN PAD	59.00	59.00
E0189-RR	DMEPOS	LAMBSWOOL SHEEPSKIN PAD	5.90	5.90
E0189-UE	DMEPOS	LAMBSWOOL SHEEPSKIN PAD	44.25	44.25
E0190	DMEPOS	POSITIONING CUSHION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0191-NU	DMEPOS	PROTECTOR HEEL OR ELBOW	11.59	11.59
E0191-RR	DMEPOS	PROTECTOR HEEL OR ELBOW	1.20	1.20
E0191-UE	DMEPOS	PROTECTOR HEEL OR ELBOW	8.64	8.64
E0193-RR	DMEPOS	POWERED AIR FLOTATION BED	817.57	817.57
E0194-RR	DMEPOS	AIR FLUIDIZED BED	3881.88	3881.88
E0196-RR	DMEPOS	GEL PRESSURE MATTRESS	35.65	35.65
E0197-RR	DMEPOS	AIR PRESSURE PAD FOR MATTRES	19.96	19.96
E0198-RR	DMEPOS	WATER PRESSURE PAD FOR MATTR	29.85	29.85
E0199-NU	DMEPOS	DRY PRESSURE PAD FOR MATTRES	34.93	34.93
E0199-RR	DMEPOS	DRY PRESSURE PAD FOR MATTRES	3.49	3.49
E0199-UE	DMEPOS	DRY PRESSURE PAD FOR MATTRES	26.20	26.20
E0200-NU	DMEPOS	HEAT LAMP WITHOUT STAND	108.17	108.17
E0200-RR	DMEPOS	HEAT LAMP WITHOUT STAND	14.69	14.69
E0200-UE	DMEPOS	HEAT LAMP WITHOUT STAND	81.18	81.18
E0202-RR	DMEPOS	PHOTOTHERAPY LIGHT W/ PHOTOM	85.45	85.45
E0203	DMEPOS	THERAPEUTIC LIGHTBOX TABLETP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0205-NU	DMEPOS	HEAT LAMP WITH STAND	264.79	264.79
E0205-RR	DMEPOS	HEAT LAMP WITH STAND	29.13	29.13
E0205-UE	DMEPOS	HEAT LAMP WITH STAND	198.59	198.59
E0210-NU	DMEPOS	ELECTRIC HEAT PAD STANDARD	37.88	37.88
E0210-RR	DMEPOS	ELECTRIC HEAT PAD STANDARD	3.57	3.57
E0210-UE	DMEPOS	ELECTRIC HEAT PAD STANDARD	28.38	28.38
E0215-NU	DMEPOS	ELECTRIC HEAT PAD MOIST	96.66	96.66
E0215-RR	DMEPOS	ELECTRIC HEAT PAD MOIST	9.65	9.65
E0215-UE	DMEPOS	ELECTRIC HEAT PAD MOIST	72.51	72.51
E0217-NU	DMEPOS	WATER CIRC HEAT PAD W PUMP	677.40	677.40
E0217-RR	DMEPOS	WATER CIRC HEAT PAD W PUMP	75.41	75.41
E0217-UE	DMEPOS	WATER CIRC HEAT PAD W PUMP	508.02	508.02
E0218	DMEPOS	FLUID CIRC COLD PAD W PUMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0221	DMEPOS	INFRARED HEATING PAD SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0225-NU	DMEPOS	HYDROCOLLATOR UNIT	530.29	530.29
E0225-RR	DMEPOS	HYDROCOLLATOR UNIT	52.27	52.27
E0225-UE	DMEPOS	HYDROCOLLATOR UNIT	397.72	397.72
E0231	DMEPOS	WOUND WARMING DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0232	DMEPOS	WARMING CARD FOR NWT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0235-RR	DMEPOS	PARAFFIN BATH UNIT PORTABLE	22.48	22.48
E0236-RR	DMEPOS	PUMP FOR WATER CIRCULATING P	60.37	60.37
E0239-NU	DMEPOS	HYDROCOLLATOR UNIT PORTABLE	521.70	521.70
E0239-RR	DMEPOS	HYDROCOLLATOR UNIT PORTABLE	52.18	52.18
E0239-UE	DMEPOS	HYDROCOLLATOR UNIT PORTABLE	391.29	391.29
E0240	DMEPOS	BATH/SHOWER CHAIR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0241	DMEPOS	BATH TUB WALL RAIL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0242	DMEPOS	BATH TUB RAIL FLOOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0243	DMEPOS	TOILET RAIL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0244	DMEPOS	TOILET SEAT RAISED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0245	DMEPOS	TUB STOOL OR BENCH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0246	DMEPOS	TRANSFER TUB RAIL ATTACHMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0247	DMEPOS	TRANS BENCH W/WO COMM OPEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0248	DMEPOS	HDTRANS BENCH W/WO COMM OPEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0249-NU	DMEPOS	PAD WATER CIRCULATING HEAT U	135.90	135.90
E0249-RR	DMEPOS	PAD WATER CIRCULATING HEAT U	14.93	14.93
E0249-UE	DMEPOS	PAD WATER CIRCULATING HEAT U	101.91	101.91
E0250-RR	DMEPOS	HOSP BED FIXED HT W/ MATTRES	72.75	72.75
E0251-RR	DMEPOS	HOSP BED FIXD HT W/O MATTRES	67.23	67.23
E0255-RR	DMEPOS	HOSPITAL BED VAR HT W/ MATTR	73.68	73.68
E0256-RR	DMEPOS	HOSPITAL BED VAR HT W/O MATT	70.11	70.11
E0260-RR	DMEPOS	HOSP BED SEMI-ELECTR W/ MATT	73.89	73.89
E0261-RR	DMEPOS	HOSP BED SEMI-ELECTR W/O MAT	73.60	73.60
E0265-RR	DMEPOS	HOSP BED TOTAL ELECTR W/ MAT	173.95	173.95
E0266-RR	DMEPOS	HOSP BED TOTAL ELEC W/O MATT	151.36	151.36
E0270	DMEPOS	HOSPITAL BED INSTITUTIONAL T	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0271-NU	DMEPOS	MATTRESS INNERSPRING	149.98	149.98
E0271-RR	DMEPOS	MATTRESS INNERSPRING	15.00	15.00
E0271-UE	DMEPOS	MATTRESS INNERSPRING	112.49	112.49
E0272-NU	DMEPOS	MATTRESS FOAM RUBBER	168.43	168.43
E0272-RR	DMEPOS	MATTRESS FOAM RUBBER	16.84	16.84
E0272-UE	DMEPOS	MATTRESS FOAM RUBBER	126.32	126.32
E0273	DMEPOS	BED BOARD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0274	DMEPOS	OVER-BED TABLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0275-NU	DMEPOS	BED PAN STANDARD	16.12	16.12
E0275-RR	DMEPOS	BED PAN STANDARD	1.61	1.61
E0275-UE	DMEPOS	BED PAN STANDARD	12.09	12.09
E0276-NU	DMEPOS	BED PAN FRACTURE	13.43	13.43
E0276-RR	DMEPOS	BED PAN FRACTURE	1.34	1.34
E0276-UE	DMEPOS	BED PAN FRACTURE	10.08	10.08
E0277-RR	DMEPOS	POWERED PRES-REDU AIR MATTRS	237.80	237.80
E0280-NU	DMEPOS	BED CRADLE	36.09	36.09
E0280-RR	DMEPOS	BED CRADLE	3.61	3.61
E0280-UE	DMEPOS	BED CRADLE	27.06	27.06
E0290-RR	DMEPOS	HOSP BED FX HT W/O RAILS W/M	66.74	66.74
E0291-RR	DMEPOS	HOSP BED FX HT W/O RAIL W/O	50.81	50.81
E0292-RR	DMEPOS	HOSP BED VAR HT NO SR W/MATT	70.70	70.70
E0293-RR	DMEPOS	HOSP BED VAR HT NO SR NO MAT	64.46	64.46
E0294-RR	DMEPOS	HOSP BED SEMI-ELECT W/ MATTR	73.76	73.76
E0295-RR	DMEPOS	HOSP BED SEMI-ELECT W/O MATT	73.60	73.60
E0296-RR	DMEPOS	HOSP BED TOTAL ELECT W/ MATT	135.72	135.72
E0297-RR	DMEPOS	HOSP BED TOTAL ELECT W/O MAT	119.77	119.77
E0300-RR	DMEPOS	ENCLOSED PED CRIB HOSP GRADE	302.43	302.43
E0301-RR	DMEPOS	HD HOSP BED, 350-600 LBS	198.45	198.45
E0302-RR	DMEPOS	EX HD HOSP BED > 600 LBS	570.70	570.70
E0303-RR	DMEPOS	HOSP BED HVY DTY XTRA WIDE	202.23	202.23
E0304-RR	DMEPOS	HOSP BED XTRA HVY DTY X WIDE	592.83	592.83
E0305-RR	DMEPOS	RAILS BED SIDE HALF LENGTH	12.99	12.99
E0310-NU	DMEPOS	RAILS BED SIDE FULL LENGTH	137.32	137.32
E0310-RR	DMEPOS	RAILS BED SIDE FULL LENGTH	13.73	13.73
E0310-UE	DMEPOS	RAILS BED SIDE FULL LENGTH	102.99	102.99
E0315	DMEPOS	BED ACCESSORY BRD/TBL/SUPPRT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0316-RR	DMEPOS	BED SAFETY ENCLOSURE	248.46	248.46
E0325-NU	DMEPOS	URINAL MALE JUG-TYPE	10.41	10.41
E0325-RR	DMEPOS	URINAL MALE JUG-TYPE	1.04	1.04
E0325-UE	DMEPOS	URINAL MALE JUG-TYPE	7.76	7.76
E0326-NU	DMEPOS	URINAL FEMALE JUG-TYPE	11.14	11.14
E0326-RR	DMEPOS	URINAL FEMALE JUG-TYPE	1.11	1.11
E0326-UE	DMEPOS	URINAL FEMALE JUG-TYPE	8.36	8.36
E0328	DMEPOS	PED HOSPITAL BED, MANUAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0329	DMEPOS	PED HOSPITAL BED SEMI/ELECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0350	DMEPOS	CONTROL UNIT BOWEL SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0352	DMEPOS	DISPOSABLE PACK W/BOWEL SYST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0370	DMEPOS	AIR ELEVATOR FOR HEEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0371-RR	DMEPOS	NONPOWER MATTRESS OVERLAY	237.80	237.80
E0372-RR	DMEPOS	POWERED AIR MATTRESS OVERLAY	237.80	237.80
E0373-RR	DMEPOS	NONPOWERED PRESSURE MATTRESS	237.80	237.80
E0424-RR	DMEPOS	STATIONARY COMPRESSED GAS 02	94.73	94.73
E0425	DMEPOS	GAS SYSTEM STATIONARY COMPRE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0430	DMEPOS	OXYGEN SYSTEM GAS PORTABLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0431-RR	DMEPOS	PORTABLE GASEOUS 02	47.37	47.37
E0433-RR	DMEPOS	PORTABLE LIQUID OXYGEN SYS	47.37	47.37
E0434-RR	DMEPOS	PORTABLE LIQUID 02	47.37	47.37
E0435	DMEPOS	OXYGEN SYSTEM LIQUID PORTABL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0439-RR	DMEPOS	STATIONARY LIQUID 02	94.73	94.73
E0440	DMEPOS	OXYGEN SYSTEM LIQUID STATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0441	DMEPOS	STATIONARY O2 CONTENTS, GAS	64.55	64.55
E0442	DMEPOS	STATIONARY O2 CONTENTS, LIQ	64.55	64.55
E0443	DMEPOS	PORTABLE 02 CONTENTS, GAS	58.48	58.48
E0444	DMEPOS	PORTABLE 02 CONTENTS, LIQUID	58.48	58.48
E0445	DMEPOS	OXIMETER NON-INVASIVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0446	DMEPOS	TOPICAL OX DELIVER SYS, NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0447	DMEPOS	PORT O2 CONT, LIQ OVER 4 LPM	87.72	87.72
E0455	DMEPOS	OXYGEN TENT EXCL CROUP/PED T	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0457	DMEPOS	CHEST SHELL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0459	DMEPOS	CHEST WRAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0462-RR	DMEPOS	ROCKING BED W/ OR W/O SIDE R	377.56	377.56
E0465-RR	DMEPOS	HOME VENT INVASIVE INTERFACE	1302.40	1302.40
E0466-RR	DMEPOS	HOME VENT NON-INVASIVE INTER	1302.40	1302.40
E0467-RR	DMEPOS	HOME VENT MULTI-FUNCTION	1506.05	1506.05
E0470-RR	DMEPOS	RAD W/O BACKUP NON-INV INTFC	126.62	126.62
E0471-RR	DMEPOS	RAD W/BACKUP NON INV INTRFC	311.84	311.84
E0472-RR	DMEPOS	RAD W BACKUP INVASIVE INTRFC	471.42	471.42
E0480-RR	DMEPOS	PERCUSSOR ELECT/PNEUM HOME M	53.59	53.59
E0481	DMEPOS	INTRPULMNRY PERCUSS VENT SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0482-RR	DMEPOS	COUGH STIMULATING DEVICE	586.76	586.76
E0483-RR	DMEPOS	HI FREQ CHEST WALL OSCIL SYS	1450.60	1450.60
E0484-NU	DMEPOS	NON-ELEC OSCILLATORY PEP DVC	50.40	50.40
E0484-RR	DMEPOS	NON-ELEC OSCILLATORY PEP DVC	5.04	5.04
E0484-UE	DMEPOS	NON-ELEC OSCILLATORY PEP DVC	37.80	37.80
E0485-NU	DMEPOS	ORAL DEVICE/APPLIANCE PREFAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0485-RR	DMEPOS	ORAL DEVICE/APPLIANCE PREFAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0485-UE	DMEPOS	ORAL DEVICE/APPLIANCE PREFAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0486-NU	DMEPOS	ORAL DEVICE/APPLIANCE CUSFAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0486-RR	DMEPOS	ORAL DEVICE/APPLIANCE CUSFAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0486-UE	DMEPOS	ORAL DEVICE/APPLIANCE CUSFAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0487	DMEPOS	ELECTRONIC SPIROMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0490-RR	DMEPOS	CONTROL UNIT NM HW REMOTE	106.60	106.60
E0491	DMEPOS	ORAL DV NM MOUTHPC HW REMOTE	100.88	100.88
E0500-RR	DMEPOS	IPPB ALL TYPES	139.67	139.67
E0530-RR	DMEPOS	ELECTRONIC POSA TREATMENT	35.54	35.54
E0550-RR	DMEPOS	HUMIDIF EXTENS SUPPLE W IPPB	68.41	68.41
E0555	DMEPOS	HUMIDIFIER FOR USE W/ REGULA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0560-NU	DMEPOS	HUMIDIFIER SUPPLEMENTAL W/ I	192.14	192.14
E0560-RR	DMEPOS	HUMIDIFIER SUPPLEMENTAL W/ I	20.09	20.09
E0560-UE	DMEPOS	HUMIDIFIER SUPPLEMENTAL W/ I	144.09	144.09
E0561-NU	DMEPOS	HUMIDIFIER NONHEATED W PAP	87.19	87.19
E0561-RR	DMEPOS	HUMIDIFIER NONHEATED W PAP	8.72	8.72
E0561-UE	DMEPOS	HUMIDIFIER NONHEATED W PAP	65.39	65.39
E0562-NU	DMEPOS	HUMIDIFIER HEATED USED W PAP	164.33	164.33
E0562-RR	DMEPOS	HUMIDIFIER HEATED USED W PAP	16.43	16.43
E0562-UE	DMEPOS	HUMIDIFIER HEATED USED W PAP	123.24	123.24
E0565-RR	DMEPOS	COMPRESSOR AIR POWER SOURCE	49.14	49.14
E0570-RR	DMEPOS	NEBULIZER WITH COMPRESSION	6.95	6.95
E0572-RR	DMEPOS	AEROSOL COMPRESSOR ADJUST PR	37.29	37.29
E0574-RR	DMEPOS	ULTRASONIC GENERATOR W SVNEB	54.92	54.92
E0575-RR	DMEPOS	NEBULIZER ULTRASONIC	119.20	119.20
E0580-NU	DMEPOS	NEBULIZER FOR USE W/ REGULAT	157.64	157.64
E0580-RR	DMEPOS	NEBULIZER FOR USE W/ REGULAT	15.77	15.77
E0580-UE	DMEPOS	NEBULIZER FOR USE W/ REGULAT	118.21	118.21
E0585-RR	DMEPOS	NEBULIZER W/ COMPRESSOR & HE	35.17	35.17
E0600-RR	DMEPOS	SUCTION PUMP PORTAB HOM MODL	62.47	62.47
E0601-RR	DMEPOS	CONT AIRWAY PRESSURE DEVICE	49.11	49.11
E0602-NU	DMEPOS	MANUAL BREAST PUMP	40.27	40.27
E0602-RR	DMEPOS	MANUAL BREAST PUMP	4.06	4.06
E0602-UE	DMEPOS	MANUAL BREAST PUMP	30.21	30.21
E0603	DMEPOS	ELECTRIC BREAST PUMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0604	DMEPOS	HOSP GRADE ELEC BREAST PUMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0605-NU	DMEPOS	VAPORIZER ROOM TYPE	30.63	30.63
E0605-RR	DMEPOS	VAPORIZER ROOM TYPE	3.57	3.57
E0605-UE	DMEPOS	VAPORIZER ROOM TYPE	25.26	25.26
E0606-RR	DMEPOS	DRAINAGE BOARD POSTURAL	31.31	31.31
E0607-NU	DMEPOS	BLOOD GLUCOSE MONITOR HOME	91.17	91.17
E0607-RR	DMEPOS	BLOOD GLUCOSE MONITOR HOME	9.11	9.11
E0607-UE	DMEPOS	BLOOD GLUCOSE MONITOR HOME	68.36	68.36
E0610-NU	DMEPOS	PACEMAKER MONITR AUDIBLE/VIS	287.11	287.11
E0610-RR	DMEPOS	PACEMAKER MONITR AUDIBLE/VIS	29.10	29.10
E0610-UE	DMEPOS	PACEMAKER MONITR AUDIBLE/VIS	215.31	215.31
E0615-NU	DMEPOS	PACEMAKER MONITR DIGITAL/VIS	653.28	653.28
E0615-RR	DMEPOS	PACEMAKER MONITR DIGITAL/VIS	79.82	79.82
E0615-UE	DMEPOS	PACEMAKER MONITR DIGITAL/VIS	490.02	490.02
E0616	DMEPOS	CARDIAC EVENT RECORDER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0617-RR	DMEPOS	AUTOMATIC EXT DEFIBRILLATOR	460.60	460.60
E0618-RR	DMEPOS	APNEA MONITOR	382.54	382.54
E0619-RR	DMEPOS	APNEA MONITOR W RECORDER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0620-RR	DMEPOS	CAP BLD SKIN PIERCING LASER	119.29	119.29
E0621-NU	DMEPOS	PATIENT LIFT SLING OR SEAT	94.31	94.31
E0621-RR	DMEPOS	PATIENT LIFT SLING OR SEAT	9.43	9.43
E0621-UE	DMEPOS	PATIENT LIFT SLING OR SEAT	70.74	70.74
E0625	DMEPOS	PATIENT LIFT BATHROOM OR TOI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0627-NU	DMEPOS	SEAT LIFT MECH, ELECTRIC ANY	306.43	306.43
E0627-RR	DMEPOS	SEAT LIFT MECH, ELECTRIC ANY	30.64	30.64
E0627-UE	DMEPOS	SEAT LIFT MECH, ELECTRIC ANY	229.83	229.83
E0629-NU	DMEPOS	SEAT LIFT MECH, NON-ELECTRIC	305.05	305.05
E0629-RR	DMEPOS	SEAT LIFT MECH, NON-ELECTRIC	30.51	30.51
E0629-UE	DMEPOS	SEAT LIFT MECH, NON-ELECTRIC	228.79	228.79
E0630-RR	DMEPOS	PATIENT LIFT HYDRAULIC	70.02	70.02
E0635-RR	DMEPOS	PATIENT LIFT ELECTRIC	136.99	136.99
E0636-RR	DMEPOS	PT SUPPORT & POSITIONING SYS	1157.61	1157.61
E0637	DMEPOS	COMBINATION SIT TO STAND SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0638	DMEPOS	STANDING FRAME SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0639-RR	DMEPOS	MOVEABLE PATIENT LIFT SYSTEM	152.21	152.21
E0640-RR	DMEPOS	FIXED PATIENT LIFT SYSTEM	152.21	152.21
E0641	DMEPOS	MULTI-POSITION STND FRAM SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0642	DMEPOS	DYNAMIC STANDING FRAME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0650-NU	DMEPOS	PNEUMA COMPRESOR NON-SEGMENT	866.14	866.14
E0650-RR	DMEPOS	PNEUMA COMPRESOR NON-SEGMENT	103.08	103.08
E0650-UE	DMEPOS	PNEUMA COMPRESOR NON-SEGMENT	649.65	649.65
E0651-NU	DMEPOS	PNEUM COMPRESSOR SEGMENTAL	1253.12	1253.12
E0651-RR	DMEPOS	PNEUM COMPRESSOR SEGMENTAL	128.02	128.02
E0651-UE	DMEPOS	PNEUM COMPRESSOR SEGMENTAL	939.87	939.87
E0652-NU	DMEPOS	PNEUM COMPRES W/CAL PRESSURE	7233.56	7233.56
E0652-RR	DMEPOS	PNEUM COMPRES W/CAL PRESSURE	714.89	714.89
E0652-UE	DMEPOS	PNEUM COMPRES W/CAL PRESSURE	5420.32	5420.32
E0655-NU	DMEPOS	PNEUMATIC APPLIANCE HALF ARM	131.79	131.79
E0655-RR	DMEPOS	PNEUMATIC APPLIANCE HALF ARM	14.71	14.71
E0655-UE	DMEPOS	PNEUMATIC APPLIANCE HALF ARM	98.84	98.84
E0656-RR	DMEPOS	SEGMENTAL PNEUMATIC TRUNK	78.85	78.85
E0657-RR	DMEPOS	SEGMENTAL PNEUMATIC CHEST	74.07	74.07
E0660-NU	DMEPOS	PNEUMATIC APPLIANCE FULL LEG	217.97	217.97
E0660-RR	DMEPOS	PNEUMATIC APPLIANCE FULL LEG	22.12	22.12
E0660-UE	DMEPOS	PNEUMATIC APPLIANCE FULL LEG	163.47	163.47
E0665-NU	DMEPOS	PNEUMATIC APPLIANCE FULL ARM	179.42	179.42
E0665-RR	DMEPOS	PNEUMATIC APPLIANCE FULL ARM	17.94	17.94
E0665-UE	DMEPOS	PNEUMATIC APPLIANCE FULL ARM	134.56	134.56
E0666-NU	DMEPOS	PNEUMATIC APPLIANCE HALF LEG	176.78	176.78
E0666-RR	DMEPOS	PNEUMATIC APPLIANCE HALF LEG	17.68	17.68
E0666-UE	DMEPOS	PNEUMATIC APPLIANCE HALF LEG	132.64	132.64
E0667-NU	DMEPOS	SEG PNEUMATIC APPL FULL LEG	441.76	441.76
E0667-RR	DMEPOS	SEG PNEUMATIC APPL FULL LEG	49.88	49.88
E0667-UE	DMEPOS	SEG PNEUMATIC APPL FULL LEG	331.34	331.34
E0668-NU	DMEPOS	SEG PNEUMATIC APPL FULL ARM	602.92	602.92
E0668-RR	DMEPOS	SEG PNEUMATIC APPL FULL ARM	59.50	59.50
E0668-UE	DMEPOS	SEG PNEUMATIC APPL FULL ARM	452.21	452.21
E0669-NU	DMEPOS	SEG PNEUMATIC APPLI HALF LEG	244.64	244.64
E0669-RR	DMEPOS	SEG PNEUMATIC APPLI HALF LEG	24.45	24.45
E0669-UE	DMEPOS	SEG PNEUMATIC APPLI HALF LEG	183.46	183.46
E0670-NU	DMEPOS	SEG PNEUM INT LEGS/TRUNK	1715.18	1715.18
E0670-RR	DMEPOS	SEG PNEUM INT LEGS/TRUNK	183.60	183.60
E0670-UE	DMEPOS	SEG PNEUM INT LEGS/TRUNK	1286.32	1286.32
E0671-NU	DMEPOS	PRESSURE PNEUM APPL FULL LEG	566.73	566.73
E0671-RR	DMEPOS	PRESSURE PNEUM APPL FULL LEG	56.71	56.71
E0671-UE	DMEPOS	PRESSURE PNEUM APPL FULL LEG	425.01	425.01
E0672-NU	DMEPOS	PRESSURE PNEUM APPL FULL ARM	440.33	440.33
E0672-RR	DMEPOS	PRESSURE PNEUM APPL FULL ARM	44.07	44.07
E0672-UE	DMEPOS	PRESSURE PNEUM APPL FULL ARM	330.27	330.27
E0673-NU	DMEPOS	PRESSURE PNEUM APPL HALF LEG	365.89	365.89
E0673-RR	DMEPOS	PRESSURE PNEUM APPL HALF LEG	36.59	36.59
E0673-UE	DMEPOS	PRESSURE PNEUM APPL HALF LEG	274.47	274.47
E0675-RR	DMEPOS	PNEUMATIC COMPRESSION DEVICE	524.69	524.69
E0676	DMEPOS	INTER LIMB COMPRESS DEV NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0677-RR	DMEPOS	NON PNEUM SEQ COMP TRUNK	78.85	78.85
E0678-RR	DMEPOS	NON PNEUM SEQ COMP FULL LEG	44.18	44.18
E0679-RR	DMEPOS	NON PNEUM SEQ COMP HALF LEG	24.46	24.46
E0680-RR	DMEPOS	NON PNEUM COMP CONTROL CAL	723.36	723.36
E0681-RR	DMEPOS	NON PNEU COMP CONTROL W/O CA	125.31	125.31
E0682-RR	DMEPOS	NON PNEUM COMPRESS FULL ARM	60.29	60.29
E0691-NU	DMEPOS	UVL PNL 2 SQ FT OR LESS	1226.07	1226.07
E0691-RR	DMEPOS	UVL PNL 2 SQ FT OR LESS	122.60	122.60
E0691-UE	DMEPOS	UVL PNL 2 SQ FT OR LESS	919.56	919.56
E0692-NU	DMEPOS	UVL SYS PANEL 4 FT	1539.62	1539.62
E0692-RR	DMEPOS	UVL SYS PANEL 4 FT	153.94	153.94
E0692-UE	DMEPOS	UVL SYS PANEL 4 FT	1154.71	1154.71
E0693-NU	DMEPOS	UVL SYS PANEL 6 FT	1897.91	1897.91
E0693-RR	DMEPOS	UVL SYS PANEL 6 FT	189.80	189.80
E0693-UE	DMEPOS	UVL SYS PANEL 6 FT	1423.43	1423.43
E0694-NU	DMEPOS	UVL MD CABINET SYS 6 FT	6040.88	6040.88
E0694-RR	DMEPOS	UVL MD CABINET SYS 6 FT	604.08	604.08
E0694-UE	DMEPOS	UVL MD CABINET SYS 6 FT	4530.69	4530.69
E0700	DMEPOS	SAFETY EQUIPMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0705-NU	DMEPOS	TRANSFER DEVICE	75.23	75.23
E0705-RR	DMEPOS	TRANSFER DEVICE	7.65	7.65
E0705-UE	DMEPOS	TRANSFER DEVICE	55.08	55.08
E0710	DMEPOS	RESTRAINTS ANY TYPE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0720-NU	DMEPOS	TENS TWO LEAD	86.39	86.39
E0730-NU	DMEPOS	TENS FOUR LEAD	87.29	87.29
E0731-NU	DMEPOS	CONDUCTIVE GARMENT FOR TENS/	108.21	108.21
E0732-RR	DMEPOS	CES SYSTEM	50.15	50.15
E0733-RR	DMEPOS	TRANS ELEC NERV FOR TRIGEMIN	50.15	50.15
E0734-RR	DMEPOS	EXT UP LIMB TREMOR STIM WRIS	429.24	429.24
E0735-RR	DMEPOS	NON-INVASIVE VAGUS NERV STIM	50.15	50.15
E0740-RR	DMEPOS	NON-IMPLANT PELV FLR E-STIM	71.35	71.35
E0744-RR	DMEPOS	NEUROMUSCULAR STIM FOR SCOLI	106.60	106.60
E0745-RR	DMEPOS	NEUROMUSCULAR STIM FOR SHOCK	106.60	106.60
E0746	DMEPOS	ELECTROMYOGRAPH BIOFEEDBACK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0747-NU	DMEPOS	ELEC OSTEOGEN STIM NOT SPINE	5343.27	5343.27
E0747-RR	DMEPOS	ELEC OSTEOGEN STIM NOT SPINE	530.96	530.96
E0747-UE	DMEPOS	ELEC OSTEOGEN STIM NOT SPINE	3969.95	3969.95
E0748-NU	DMEPOS	ELEC OSTEOGEN STIM SPINAL	5308.67	5308.67
E0748-RR	DMEPOS	ELEC OSTEOGEN STIM SPINAL	530.83	530.83
E0748-UE	DMEPOS	ELEC OSTEOGEN STIM SPINAL	3981.51	3981.51
E0749-RR	DMEPOS	ELEC OSTEOGEN STIM IMPLANTED	329.80	329.80
E0755	DMEPOS	ELECTRONIC SALIVARY REFLEX S	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0760-NU	DMEPOS	OSTEOGEN ULTRASOUND STIMLTOR	4411.40	4411.40
E0760-RR	DMEPOS	OSTEOGEN ULTRASOUND STIMLTOR	441.14	441.14
E0760-UE	DMEPOS	OSTEOGEN ULTRASOUND STIMLTOR	3308.51	3308.51
E0761	DMEPOS	NONTHERM ELECTROMGNTC DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0762-RR	DMEPOS	TRANS ELEC JT STIM DEV SYS	150.03	150.03
E0764-RR	DMEPOS	FUNCTIONAL NEUROMUSCULARSTIM	1509.98	1509.98
E0765-NU	DMEPOS	NERVE STIMULATOR FOR TX N&V	114.79	114.79
E0765-RR	DMEPOS	NERVE STIMULATOR FOR TX N&V	11.50	11.50
E0765-UE	DMEPOS	NERVE STIMULATOR FOR TX N&V	86.12	86.12
E0766	DMEPOS	ELEC STIM CANCER TREATMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0766-RR	DMEPOS	ELEC STIM CANCER TREATMENT	15686.97	15686.97
E0769	DMEPOS	ELECTRIC WOUND TREATMENT DEV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0770	DMEPOS	FUNCTIONAL ELECTRIC STIM NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0776-NU	DMEPOS	IV POLE	173.68	173.68
E0776-RR	DMEPOS	IV POLE	17.37	17.37
E0776-UE	DMEPOS	IV POLE	130.26	130.26
E0779-RR	DMEPOS	AMB INFUSION PUMP MECHANICAL	22.53	22.53
E0780-NU	DMEPOS	MECH AMB INFUSION PUMP <8HRS	14.15	14.15
E0781-RR	DMEPOS	EXTERNAL AMBULATORY INFUS PU	292.42	292.42
E0782-NU	DMEPOS	NON-PROGRAMBLE INFUSION PUMP	5858.15	5858.15
E0782-RR	DMEPOS	NON-PROGRAMBLE INFUSION PUMP	585.84	585.84
E0782-UE	DMEPOS	NON-PROGRAMBLE INFUSION PUMP	4393.61	4393.61
E0783-NU	DMEPOS	PROGRAMMABLE INFUSION PUMP	9495.00	9495.00
E0783-RR	DMEPOS	PROGRAMMABLE INFUSION PUMP	949.52	949.52
E0783-UE	DMEPOS	PROGRAMMABLE INFUSION PUMP	7121.28	7121.28
E0784-RR	DMEPOS	EXT AMB INFUSN PUMP INSULIN	527.27	527.27
E0785	DMEPOS	REPLACEMENT IMPL PUMP CATHET	548.01	548.01
E0786-NU	DMEPOS	IMPLANTABLE PUMP REPLACEMENT	10896.22	10896.22
E0786-RR	DMEPOS	IMPLANTABLE PUMP REPLACEMENT	1089.61	1089.61
E0786-UE	DMEPOS	IMPLANTABLE PUMP REPLACEMENT	8172.17	8172.17
E0787	DMEPOS	CGS DOSE ADJ INSULIN INF PMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0791-RR	DMEPOS	PARENTERAL INFUSION PUMP STA	347.39	347.39
E0830	DMEPOS	AMBULATORY TRACTION DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0840-NU	DMEPOS	TRACT FRAME ATTACH HEADBOARD	84.97	84.97
E0840-RR	DMEPOS	TRACT FRAME ATTACH HEADBOARD	18.94	18.94
E0840-UE	DMEPOS	TRACT FRAME ATTACH HEADBOARD	63.71	63.71
E0849-RR	DMEPOS	CERVICAL PNEUM TRAC EQUIP	70.32	70.32
E0850-NU	DMEPOS	TRACTION STAND FREE STANDING	128.01	128.01
E0850-RR	DMEPOS	TRACTION STAND FREE STANDING	16.74	16.74
E0850-UE	DMEPOS	TRACTION STAND FREE STANDING	95.98	95.98
E0855-RR	DMEPOS	CERVICAL TRACTION EQUIPMENT	68.58	68.58
E0856-RR	DMEPOS	CERVIC COLLAR W AIR BLADDERS	21.00	21.00
E0860-NU	DMEPOS	TRACT EQUIP CERVICAL TRACT	46.36	46.36
E0860-RR	DMEPOS	TRACT EQUIP CERVICAL TRACT	7.57	7.57
E0860-UE	DMEPOS	TRACT EQUIP CERVICAL TRACT	34.76	34.76
E0870-NU	DMEPOS	TRACT FRAME ATTACH FOOTBOARD	134.90	134.90
E0870-RR	DMEPOS	TRACT FRAME ATTACH FOOTBOARD	15.56	15.56
E0870-UE	DMEPOS	TRACT FRAME ATTACH FOOTBOARD	101.63	101.63
E0880-NU	DMEPOS	TRAC STAND FREE STAND EXTREM	145.60	145.60
E0880-RR	DMEPOS	TRAC STAND FREE STAND EXTREM	22.86	22.86
E0880-UE	DMEPOS	TRAC STAND FREE STAND EXTREM	110.20	110.20
E0890-NU	DMEPOS	TRACTION FRAME ATTACH PELVIC	139.64	139.64
E0890-RR	DMEPOS	TRACTION FRAME ATTACH PELVIC	38.08	38.08
E0890-UE	DMEPOS	TRACTION FRAME ATTACH PELVIC	112.49	112.49
E0900-NU	DMEPOS	TRAC STAND FREE STAND PELVIC	148.61	148.61
E0900-RR	DMEPOS	TRAC STAND FREE STAND PELVIC	32.05	32.05
E0900-UE	DMEPOS	TRAC STAND FREE STAND PELVIC	111.49	111.49
E0910-RR	DMEPOS	TRAPEZE BAR ATTACHED TO BED	13.19	13.19
E0911-RR	DMEPOS	HD TRAPEZE BAR ATTACH TO BED	50.12	50.12
E0912-RR	DMEPOS	HD TRAPEZE BAR FREE STANDING	100.60	100.60
E0920-RR	DMEPOS	FRACTURE FRAME ATTACHED TO B	62.98	62.98
E0930-RR	DMEPOS	FRACTURE FRAME FREE STANDING	62.32	62.32
E0935-RR	DMEPOS	CONT PAS MOTION EXERCISE DEV	28.67	28.67
E0936	DMEPOS	CPM DEVICE, OTHER THAN KNEE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0940-RR	DMEPOS	TRAPEZE BAR FREE STANDING	24.89	24.89
E0941-RR	DMEPOS	GRAVITY ASSISTED TRACTION DE	59.22	59.22
E0942-NU	DMEPOS	CERVICAL HEAD HARNESS/HALTER	23.02	23.02
E0942-RR	DMEPOS	CERVICAL HEAD HARNESS/HALTER	2.73	2.73
E0942-UE	DMEPOS	CERVICAL HEAD HARNESS/HALTER	17.22	17.22
E0944-NU	DMEPOS	PELVIC BELT/HARNESS/BOOT	56.83	56.83
E0944-RR	DMEPOS	PELVIC BELT/HARNESS/BOOT	5.71	5.71
E0944-UE	DMEPOS	PELVIC BELT/HARNESS/BOOT	42.59	42.59
E0945-NU	DMEPOS	BELT/HARNESS EXTREMITY	58.45	58.45
E0945-RR	DMEPOS	BELT/HARNESS EXTREMITY	5.85	5.85
E0945-UE	DMEPOS	BELT/HARNESS EXTREMITY	43.85	43.85
E0946-RR	DMEPOS	FRACTURE FRAME DUAL W CROSS	73.38	73.38
E0947-NU	DMEPOS	FRACTURE FRAME ATTACHMNTS PE	720.79	720.79
E0947-RR	DMEPOS	FRACTURE FRAME ATTACHMNTS PE	72.92	72.92
E0947-UE	DMEPOS	FRACTURE FRAME ATTACHMNTS PE	540.57	540.57
E0948-NU	DMEPOS	FRACTURE FRAME ATTACHMNTS CE	720.79	720.79
E0948-RR	DMEPOS	FRACTURE FRAME ATTACHMNTS CE	70.32	70.32
E0948-UE	DMEPOS	FRACTURE FRAME ATTACHMNTS CE	540.57	540.57
E0950-NU	DMEPOS	TRAY	122.26	122.26
E0950-RR	DMEPOS	TRAY	12.25	12.25
E0950-UE	DMEPOS	TRAY	91.69	91.69
E0951-NU	DMEPOS	LOOP HEEL	20.88	20.88
E0951-RR	DMEPOS	LOOP HEEL	2.10	2.10
E0951-UE	DMEPOS	LOOP HEEL	15.67	15.67
E0952-NU	DMEPOS	TOE LOOP/HOLDER, EACH	22.16	22.16
E0952-RR	DMEPOS	TOE LOOP/HOLDER, EACH	2.29	2.29
E0952-UE	DMEPOS	TOE LOOP/HOLDER, EACH	16.63	16.63
E0953-NU	DMEPOS	W/C LATERAL THIGH/KNEE SUP	115.92	115.92
E0953-RR	DMEPOS	W/C LATERAL THIGH/KNEE SUP	11.58	11.58
E0953-UE	DMEPOS	W/C LATERAL THIGH/KNEE SUP	86.94	86.94
E0954-NU	DMEPOS	FOOT BOX, ANY TYPE EACH FOOT	71.59	71.59
E0954-RR	DMEPOS	FOOT BOX, ANY TYPE EACH FOOT	7.23	7.23
E0954-UE	DMEPOS	FOOT BOX, ANY TYPE EACH FOOT	53.69	53.69
E0955-RR	DMEPOS	CUSHIONED HEADREST	23.77	23.77
E0956-NU	DMEPOS	W/C LATERAL TRUNK/HIP SUPPOR	115.92	115.92
E0956-RR	DMEPOS	W/C LATERAL TRUNK/HIP SUPPOR	11.58	11.58
E0956-UE	DMEPOS	W/C LATERAL TRUNK/HIP SUPPOR	86.94	86.94
E0957-NU	DMEPOS	W/C MEDIAL THIGH SUPPORT	162.23	162.23
E0957-RR	DMEPOS	W/C MEDIAL THIGH SUPPORT	16.24	16.24
E0957-UE	DMEPOS	W/C MEDIAL THIGH SUPPORT	121.65	121.65
E0958-RR	DMEPOS	WHLCHR ATT- CONV 1 ARM DRIVE	59.52	59.52
E0959-NU	DMEPOS	AMPUTEE ADAPTER	58.34	58.34
E0959-RR	DMEPOS	AMPUTEE ADAPTER	5.84	5.84
E0959-UE	DMEPOS	AMPUTEE ADAPTER	43.74	43.74
E0960-NU	DMEPOS	W/C SHOULDER HARNESS/STRAPS	107.00	107.00
E0960-RR	DMEPOS	W/C SHOULDER HARNESS/STRAPS	10.73	10.73
E0960-UE	DMEPOS	W/C SHOULDER HARNESS/STRAPS	80.26	80.26
E0961-NU	DMEPOS	WHEELCHAIR BRAKE EXTENSION	34.51	34.51
E0961-RR	DMEPOS	WHEELCHAIR BRAKE EXTENSION	3.60	3.60
E0961-UE	DMEPOS	WHEELCHAIR BRAKE EXTENSION	17.26	17.26
E0966-NU	DMEPOS	WHEELCHAIR HEAD REST EXTENSI	95.55	95.55
E0966-RR	DMEPOS	WHEELCHAIR HEAD REST EXTENSI	9.58	9.58
E0966-UE	DMEPOS	WHEELCHAIR HEAD REST EXTENSI	71.66	71.66
E0967-NU	DMEPOS	MAN WC RIM/PROJECTION REP EA	89.61	89.61
E0967-RR	DMEPOS	MAN WC RIM/PROJECTION REP EA	8.98	8.98
E0967-UE	DMEPOS	MAN WC RIM/PROJECTION REP EA	67.17	67.17
E0968-RR	DMEPOS	WHEELCHAIR COMMODE SEAT	24.45	24.45
E0969-NU	DMEPOS	WHEELCHAIR NARROWING DEVICE	213.71	213.71
E0969-RR	DMEPOS	WHEELCHAIR NARROWING DEVICE	21.16	21.16
E0969-UE	DMEPOS	WHEELCHAIR NARROWING DEVICE	160.29	160.29
E0970	DMEPOS	WHEELCHAIR NO. 2 FOOTPLATES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E0971-NU	DMEPOS	WHEELCHAIR ANTI-TIPPING DEVI	59.20	59.20
E0971-RR	DMEPOS	WHEELCHAIR ANTI-TIPPING DEVI	5.93	5.93
E0971-UE	DMEPOS	WHEELCHAIR ANTI-TIPPING DEVI	44.44	44.44
E0973-NU	DMEPOS	W/CH ACCESS DET ADJ ARMREST	135.22	135.22
E0973-RR	DMEPOS	W/CH ACCESS DET ADJ ARMREST	12.87	12.87
E0973-UE	DMEPOS	W/CH ACCESS DET ADJ ARMREST	101.40	101.40
E0974-NU	DMEPOS	W/CH ACCESS ANTI-ROLLBACK	90.93	90.93
E0974-RR	DMEPOS	W/CH ACCESS ANTI-ROLLBACK	9.64	9.64
E0974-UE	DMEPOS	W/CH ACCESS ANTI-ROLLBACK	68.72	68.72
E0978-NU	DMEPOS	W/C ACC,SAF BELT PELV STRAP	48.77	48.77
E0978-RR	DMEPOS	W/C ACC,SAF BELT PELV STRAP	4.88	4.88
E0978-UE	DMEPOS	W/C ACC,SAF BELT PELV STRAP	36.59	36.59
E0980-NU	DMEPOS	WHEELCHAIR SAFETY VEST	38.34	38.34
E0980-RR	DMEPOS	WHEELCHAIR SAFETY VEST	3.84	3.84
E0980-UE	DMEPOS	WHEELCHAIR SAFETY VEST	28.59	28.59
E0981-NU	DMEPOS	SEAT UPHOLSTERY, REPLACEMENT	52.26	52.26
E0981-RR	DMEPOS	SEAT UPHOLSTERY, REPLACEMENT	5.24	5.24
E0981-UE	DMEPOS	SEAT UPHOLSTERY, REPLACEMENT	39.17	39.17
E0982-NU	DMEPOS	BACK UPHOLSTERY, REPLACEMENT	51.51	51.51
E0982-RR	DMEPOS	BACK UPHOLSTERY, REPLACEMENT	5.15	5.15
E0982-UE	DMEPOS	BACK UPHOLSTERY, REPLACEMENT	38.65	38.65
E0983-RR	DMEPOS	ADD PWR JOYSTICK	341.02	341.02
E0984-RR	DMEPOS	ADD PWR TILLER	260.67	260.67
E0985-RR	DMEPOS	W/C SEAT LIFT MECHANISM	27.71	27.71
E0986-RR	DMEPOS	MAN W/C PUSH-RIM POWR SYSTEM	663.72	663.72
E0988-RR	DMEPOS	LEVER-ACTIVATED WHEEL DRIVE	404.48	404.48
E0990-NU	DMEPOS	WHEELCHAIR ELEVATING LEG RES	129.57	129.57
E0990-RR	DMEPOS	WHEELCHAIR ELEVATING LEG RES	13.23	13.23
E0990-UE	DMEPOS	WHEELCHAIR ELEVATING LEG RES	97.18	97.18
E0992-NU	DMEPOS	WHEELCHAIR SOLID SEAT INSERT	129.85	129.85
E0992-RR	DMEPOS	WHEELCHAIR SOLID SEAT INSERT	12.61	12.61
E0992-UE	DMEPOS	WHEELCHAIR SOLID SEAT INSERT	97.39	97.39
E0994-NU	DMEPOS	WHEELCHAIR ARM REST	22.84	22.84
E0994-RR	DMEPOS	WHEELCHAIR ARM REST	2.28	2.28
E0994-UE	DMEPOS	WHEELCHAIR ARM REST	17.18	17.18
E0995-NU	DMEPOS	WC CALF REST, PAD REPLACEMNT	33.92	33.92
E0995-RR	DMEPOS	WC CALF REST, PAD REPLACEMNT	3.39	3.39
E0995-UE	DMEPOS	WC CALF REST, PAD REPLACEMNT	25.46	25.46
E1002-RR	DMEPOS	PWR SEAT TILT	476.64	476.64
E1003-RR	DMEPOS	PWR SEAT RECLINE	516.44	516.44
E1004-RR	DMEPOS	PWR SEAT RECLINE MECH	572.60	572.60
E1005-RR	DMEPOS	PWR SEAT RECLINE PWR	619.81	619.81
E1006-RR	DMEPOS	PWR SEAT COMBO W/O SHEAR	759.18	759.18
E1007-RR	DMEPOS	PWR SEAT COMBO W/SHEAR	1028.00	1028.00
E1008-RR	DMEPOS	PWR SEAT COMBO PWR SHEAR	1028.07	1028.07
E1009-NU	DMEPOS	ADD MECH LEG ELEVATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1009-RR	DMEPOS	ADD MECH LEG ELEVATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1009-UE	DMEPOS	ADD MECH LEG ELEVATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1010-RR	DMEPOS	ADD PWR LEG ELEVATION	134.51	134.51
E1011-NU	DMEPOS	PED WC MODIFY WIDTH ADJUSTM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1011-RR	DMEPOS	PED WC MODIFY WIDTH ADJUSTM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1011-UE	DMEPOS	PED WC MODIFY WIDTH ADJUSTM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1012-RR	DMEPOS	CTR MOUNT PWR ELEV LEG REST	134.51	134.51
E1014-RR	DMEPOS	RECLINING BACK ADD PED W/C	49.84	49.84
E1015-NU	DMEPOS	SHOCK ABSORBER FOR MAN W/C	156.52	156.52
E1015-RR	DMEPOS	SHOCK ABSORBER FOR MAN W/C	15.65	15.65
E1015-UE	DMEPOS	SHOCK ABSORBER FOR MAN W/C	117.38	117.38
E1016-NU	DMEPOS	SHOCK ABSORBER FOR POWER W/C	154.44	154.44
E1016-RR	DMEPOS	SHOCK ABSORBER FOR POWER W/C	15.47	15.47
E1016-UE	DMEPOS	SHOCK ABSORBER FOR POWER W/C	115.81	115.81
E1017-NU	DMEPOS	HD SHCK ABSRBR FOR HD MAN WC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1017-RR	DMEPOS	HD SHCK ABSRBR FOR HD MAN WC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1017-UE	DMEPOS	HD SHCK ABSRBR FOR HD MAN WC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1018-NU	DMEPOS	HD SHCK ABSRBER FOR HD POWWC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1018-RR	DMEPOS	HD SHCK ABSRBER FOR HD POWWC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1018-UE	DMEPOS	HD SHCK ABSRBER FOR HD POWWC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1020-RR	DMEPOS	RESIDUAL LIMB SUPPORT SYSTEM	28.60	28.60
E1028-RR	DMEPOS	W/C MANUAL SWINGAWAY	24.28	24.28
E1029-RR	DMEPOS	W/C VENT TRAY FIXED	43.44	43.44
E1030-RR	DMEPOS	W/C VENT TRAY GIMBALED	137.04	137.04
E1031-RR	DMEPOS	ROLLABOUT CHAIR WITH CASTERS	49.77	49.77
E1035-RR	DMEPOS	PATIENT TRANSFER SYSTEM <300	693.33	693.33
E1036-RR	DMEPOS	PATIENT TRANSFER SYSTEM >300	986.99	986.99
E1037-RR	DMEPOS	TRANSPORT CHAIR, PED SIZE	122.58	122.58
E1038-RR	DMEPOS	TRANSPORT CHAIR PT WT<=300LB	18.00	18.00
E1039-RR	DMEPOS	TRANSPORT CHAIR PT WT >300LB	38.25	38.25
E1050-RR	DMEPOS	WHELCHR FXD FULL LENGTH ARMS	130.06	130.06
E1060-RR	DMEPOS	WHEELCHAIR DETACHABLE ARMS	151.82	151.82
E1070-RR	DMEPOS	WHEELCHAIR DETACHABLE FOOT R	137.76	137.76
E1083-RR	DMEPOS	HEMI-WHEELCHAIR FIXED ARMS	94.99	94.99
E1084-RR	DMEPOS	HEMI-WHEELCHAIR DETACHABLE A	123.70	123.70
E1085	DMEPOS	HEMI-WHEELCHAIR FIXED ARMS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1086	DMEPOS	HEMI-WHEELCHAIR DETACHABLE A	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1087-RR	DMEPOS	WHEELCHAIR LIGHTWT FIXED ARM	170.84	170.84
E1088-RR	DMEPOS	WHEELCHAIR LIGHTWEIGHT DET A	181.17	181.17
E1089	DMEPOS	WHEELCHAIR LIGHTWT FIXED ARM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1090	DMEPOS	WHEELCHAIR LIGHTWEIGHT DET A	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1092-RR	DMEPOS	WHEELCHAIR WIDE W/ LEG RESTS	175.35	175.35
E1093-RR	DMEPOS	WHEELCHAIR WIDE W/ FOOT REST	150.80	150.80
E1100-RR	DMEPOS	WHCHR S-RECL FXD ARM LEG RES	120.39	120.39
E1110-RR	DMEPOS	WHEELCHAIR SEMI-RECL DETACH	138.69	138.69
E1130	DMEPOS	WHLCHR STAND FXD ARM FT REST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1140	DMEPOS	WHEELCHAIR STANDARD DETACH A	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1150-RR	DMEPOS	WHEELCHAIR STANDARD W/ LEG R	99.07	99.07
E1160-RR	DMEPOS	WHEELCHAIR FIXED ARMS	72.50	72.50
E1161-RR	DMEPOS	MANUAL ADULT WC W TILTINSPAC	322.83	322.83
E1170-RR	DMEPOS	WHLCHR AMPU FXD ARM LEG REST	103.60	103.60
E1171-RR	DMEPOS	WHEELCHAIR AMPUTEE W/O LEG R	92.96	92.96
E1172-RR	DMEPOS	WHEELCHAIR AMPUTEE DETACH AR	115.05	115.05
E1180-RR	DMEPOS	WHEELCHAIR AMPUTEE W/ FOOT R	120.35	120.35
E1190-RR	DMEPOS	WHEELCHAIR AMPUTEE W/ LEG RE	135.78	135.78
E1195-RR	DMEPOS	WHEELCHAIR AMPUTEE HEAVY DUT	145.69	145.69
E1200-RR	DMEPOS	WHEELCHAIR AMPUTEE FIXED ARM	102.17	102.17
E1220	DMEPOS	WHLCHR SPECIAL SIZE/CONSTRC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1221-RR	DMEPOS	WHEELCHAIR SPEC SIZE W FOOT	55.11	55.11
E1222-RR	DMEPOS	WHEELCHAIR SPEC SIZE W/ LEG	78.60	78.60
E1223-RR	DMEPOS	WHEELCHAIR SPEC SIZE W FOOT	85.84	85.84
E1224-RR	DMEPOS	WHEELCHAIR SPEC SIZE W/ LEG	94.12	94.12
E1225-RR	DMEPOS	MANUAL SEMI-RECLINING BACK	52.42	52.42
E1226-NU	DMEPOS	MANUAL FULLY RECLINING BACK	632.83	632.83
E1226-RR	DMEPOS	MANUAL FULLY RECLINING BACK	65.12	65.12
E1226-UE	DMEPOS	MANUAL FULLY RECLINING BACK	474.57	474.57
E1227-NU	DMEPOS	WHEELCHAIR SPEC SZ SPEC HT A	378.64	378.64
E1227-RR	DMEPOS	WHEELCHAIR SPEC SZ SPEC HT A	37.87	37.87
E1227-UE	DMEPOS	WHEELCHAIR SPEC SZ SPEC HT A	284.02	284.02
E1228-RR	DMEPOS	WHEELCHAIR SPEC SZ SPEC HT B	32.50	32.50
E1229	DMEPOS	PEDIATRIC WHEELCHAIR NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1230-NU	DMEPOS	POWER OPERATED VEHICLE	2623.20	2623.20
E1230-RR	DMEPOS	POWER OPERATED VEHICLE	258.00	258.00
E1230-UE	DMEPOS	POWER OPERATED VEHICLE	2074.64	2074.64
E1231-NU	DMEPOS	RIGID PED W/C TILT-IN-SPACE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1231-RR	DMEPOS	RIGID PED W/C TILT-IN-SPACE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1231-UE	DMEPOS	RIGID PED W/C TILT-IN-SPACE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1232-RR	DMEPOS	FOLDING PED WC TILT-IN-SPACE	291.80	291.80
E1233-RR	DMEPOS	RIG PED WC TLTNSPC W/O SEAT	302.31	302.31
E1234-RR	DMEPOS	FLD PED WC TLTNSPC W/O SEAT	263.20	263.20
E1235-RR	DMEPOS	RIGID PED WC ADJUSTABLE	253.45	253.45
E1236-RR	DMEPOS	FOLDING PED WC ADJUSTABLE	223.60	223.60
E1237-RR	DMEPOS	RGD PED WC ADJSTABL W/O SEAT	225.54	225.54
E1238-RR	DMEPOS	FLD PED WC ADJSTABL W/O SEAT	223.60	223.60
E1239	DMEPOS	PED POWER WHEELCHAIR NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1240-RR	DMEPOS	WHCHR LITWT DET ARM LEG REST	123.04	123.04
E1250	DMEPOS	WHEELCHAIR LIGHTWT FIXED ARM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1260	DMEPOS	WHEELCHAIR LIGHTWT FOOT REST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1270-RR	DMEPOS	WHEELCHAIR LIGHTWEIGHT LEG R	97.88	97.88
E1280-RR	DMEPOS	WHCHR H-DUTY DET ARM LEG RES	171.06	171.06
E1285	DMEPOS	WHEELCHAIR HEAVY DUTY FIXED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1290	DMEPOS	WHEELCHAIR HVY DUTY DETACH A	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1295-RR	DMEPOS	WHEELCHAIR HEAVY DUTY FIXED	150.66	150.66
E1296-NU	DMEPOS	WHEELCHAIR SPECIAL SEAT HEIG	626.58	626.58
E1296-RR	DMEPOS	WHEELCHAIR SPECIAL SEAT HEIG	62.69	62.69
E1296-UE	DMEPOS	WHEELCHAIR SPECIAL SEAT HEIG	469.98	469.98
E1297-NU	DMEPOS	WHEELCHAIR SPECIAL SEAT DEPT	128.07	128.07
E1297-RR	DMEPOS	WHEELCHAIR SPECIAL SEAT DEPT	13.48	13.48
E1297-UE	DMEPOS	WHEELCHAIR SPECIAL SEAT DEPT	96.03	96.03
E1298-NU	DMEPOS	WHEELCHAIR SPEC SEAT DEPTH/W	578.06	578.06
E1298-RR	DMEPOS	WHEELCHAIR SPEC SEAT DEPTH/W	59.14	59.14
E1298-UE	DMEPOS	WHEELCHAIR SPEC SEAT DEPTH/W	433.54	433.54
E1300	DMEPOS	WHIRLPOOL PORTABLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1310-NU	DMEPOS	WHIRLPOOL NON-PORTABLE	2930.03	2930.03
E1310-RR	DMEPOS	WHIRLPOOL NON-PORTABLE	250.59	250.59
E1310-UE	DMEPOS	WHIRLPOOL NON-PORTABLE	2197.51	2197.51
E1352	DMEPOS	O2 FLOW REG POS INSPIR PRESS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1353	DMEPOS	OXYGEN SUPPLIES REGULATOR	38.64	38.64
E1354	DMEPOS	WHEELED CART, PORT CYL/CONC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1355	DMEPOS	OXYGEN SUPPLIES STAND/RACK	29.12	29.12
E1356	DMEPOS	BATT PACK/CART, PORT CONC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1357	DMEPOS	BATTERY CHARGER, PORT CONC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1358	DMEPOS	DC POWER ADAPTER, PORT CONC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1372-NU	DMEPOS	OXY SUPPL HEATER FOR NEBULIZ	154.13	154.13
E1372-RR	DMEPOS	OXY SUPPL HEATER FOR NEBULIZ	15.41	15.41
E1372-UE	DMEPOS	OXY SUPPL HEATER FOR NEBULIZ	115.60	115.60
E1390-RR	DMEPOS	OXYGEN CONCENTRATOR	94.73	94.73
E1391-RR	DMEPOS	OXYGEN CONCENTRATOR, DUAL	94.73	94.73
E1392-RR	DMEPOS	PORTABLE OXYGEN CONCENTRATOR	47.37	47.37
E1399	DMEPOS	DURABLE MEDICAL EQUIPMENT MI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1405-RR	DMEPOS	O2/WATER VAPOR ENRICH W/HEAT	129.90	129.90
E1406-RR	DMEPOS	O2/WATER VAPOR ENRICH W/O HE	101.68	101.68
E1500	DMEPOS	CENTRIFUGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1510	DMEPOS	KIDNEY DIALYSATE DELIVRY SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1520	DMEPOS	HEPARIN INFUSION PUMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1530	DMEPOS	REPLACEMENT AIR BUBBLE DETEC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1540	DMEPOS	REPLACEMENT PRESSURE ALARM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1550	DMEPOS	BATH CONDUCTIVITY METER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1560	DMEPOS	REPLACE BLOOD LEAK DETECTOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1570	DMEPOS	ADJUSTABLE CHAIR FOR ESRD PT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1575	DMEPOS	TRANSDUCER PROTECT/FLD BAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1580	DMEPOS	UNIPUNCTURE CONTROL SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1590	DMEPOS	HEMODIALYSIS MACHINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1592	DMEPOS	AUTO INTERM PERITONEAL DIALY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1594	DMEPOS	CYCLER DIALYSIS MACHINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1600	DMEPOS	DELI/INSTALL CHRG HEMO EQUIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1610	DMEPOS	REVERSE OSMOSIS H2O PURI SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1615	DMEPOS	DEIONIZER H2O PURI SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1620	DMEPOS	REPLACEMENT BLOOD PUMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1625	DMEPOS	WATER SOFTENING SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1629	DMEPOS	TABLO FOR DIALYSIS SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1630	DMEPOS	RECIPROCATING PERITONEAL DIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1632	DMEPOS	WEARABLE ARTIFICIAL KIDNEY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1634	DMEPOS	PERITONEAL DIALYSIS CLAMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1635	DMEPOS	COMPACT TRAVEL HEMODIALYZER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1636	DMEPOS	SORBENT CARTRIDGES PER 10	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1637	DMEPOS	HEMOSTATS FOR DIALYSIS, EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1639	DMEPOS	SCALE, EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1699	DMEPOS	DIALYSIS EQUIPMENT NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1700-RR	DMEPOS	JAW MOTION REHAB SYSTEM	47.06	47.06
E1701	DMEPOS	REPL CUSHIONS FOR JAW MOTION	14.46	14.46
E1702	DMEPOS	REPL MEASR SCALES JAW MOTION	30.78	30.78
E1800-RR	DMEPOS	ADJUST ELBOW EXT/FLEX DEVICE	142.08	142.08
E1801-RR	DMEPOS	SPS ELBOW DEVICE	176.03	176.03
E1802-RR	DMEPOS	ADJST FOREARM PRO/SUP DEVICE	445.92	445.92
E1805-RR	DMEPOS	ADJUST WRIST EXT/FLEX DEVICE	146.54	146.54
E1806-RR	DMEPOS	SPS WRIST DEVICE	144.54	144.54
E1810-RR	DMEPOS	ADJUST KNEE EXT/FLEX DEVICE	144.50	144.50
E1811-RR	DMEPOS	SPS KNEE DEVICE	182.99	182.99
E1812-RR	DMEPOS	KNEE EXT/FLEX W ACT RES CTRL	117.33	117.33
E1815-RR	DMEPOS	ADJUST ANKLE EXT/FLEX DEVICE	146.54	146.54
E1816-RR	DMEPOS	SPS ANKLE DEVICE	185.90	185.90
E1818-RR	DMEPOS	SPS FOREARM DEVICE	189.77	189.77
E1820-NU	DMEPOS	SOFT INTERFACE MATERIAL	111.54	111.54
E1820-RR	DMEPOS	SOFT INTERFACE MATERIAL	11.13	11.13
E1820-UE	DMEPOS	SOFT INTERFACE MATERIAL	83.67	83.67
E1821-NU	DMEPOS	REPLACEMENT INTERFACE SPSD	143.59	143.59
E1821-RR	DMEPOS	REPLACEMENT INTERFACE SPSD	14.32	14.32
E1821-UE	DMEPOS	REPLACEMENT INTERFACE SPSD	107.73	107.73
E1825-RR	DMEPOS	ADJUST FINGER EXT/FLEX DEVC	146.54	146.54
E1830-RR	DMEPOS	ADJUST TOE EXT/FLEX DEVICE	146.54	146.54
E1831-RR	DMEPOS	STATIC STR TOE DEV EXT/FLEX	89.26	89.26
E1840-RR	DMEPOS	ADJ SHOULDER EXT/FLEX DEVICE	522.20	522.20
E1841-RR	DMEPOS	STATIC STR SHLDR DEV ROM ADJ	618.08	618.08
E1902	DMEPOS	AAC NON-ELECTRONIC BOARD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E1905-RR	DMEPOS	VR CBT THERAPY	646.04	646.04
E2000-RR	DMEPOS	GASTRIC SUCTION PUMP HME MDL	70.72	70.72
E2001-RR	DMEPOS	SUCT PUM EXT URINE MGMT SYS	62.47	62.47
E2100-NU	DMEPOS	BLD GLUCOSE MONITOR W VOICE	865.47	865.47
E2100-RR	DMEPOS	BLD GLUCOSE MONITOR W VOICE	86.56	86.56
E2100-UE	DMEPOS	BLD GLUCOSE MONITOR W VOICE	649.15	649.15
E2101-NU	DMEPOS	BLD GLUCOSE MONITOR W LANCE	257.27	257.27
E2101-RR	DMEPOS	BLD GLUCOSE MONITOR W LANCE	25.73	25.73
E2101-UE	DMEPOS	BLD GLUCOSE MONITOR W LANCE	192.96	192.96
E2102-NU	DMEPOS	ADJU CGM RECEIVER/MONITOR	213.03	213.03
E2102-RR	DMEPOS	ADJU CGM RECEIVER/MONITOR	21.30	21.30
E2102-UE	DMEPOS	ADJU CGM RECEIVER/MONITOR	159.78	159.78
E2103-NU	DMEPOS	NON-ADJU CGM RECEIVER/MON	304.20	304.20
E2103-RR	DMEPOS	NON-ADJU CGM RECEIVER/MON	30.41	30.41
E2103-UE	DMEPOS	NON-ADJU CGM RECEIVER/MON	228.15	228.15
E2120-RR	DMEPOS	PULSE GEN SYS TX ENDOLYMP FL	386.85	386.85
E2201-NU	DMEPOS	MAN W/CH ACC SEAT W>=20"<24"	509.09	509.09
E2201-RR	DMEPOS	MAN W/CH ACC SEAT W>=20"<24"	50.92	50.92
E2201-UE	DMEPOS	MAN W/CH ACC SEAT W>=20"<24"	381.81	381.81
E2202-NU	DMEPOS	SEAT WIDTH 24-27 IN	646.71	646.71
E2202-RR	DMEPOS	SEAT WIDTH 24-27 IN	64.68	64.68
E2202-UE	DMEPOS	SEAT WIDTH 24-27 IN	485.05	485.05
E2203-NU	DMEPOS	FRAME DEPTH LESS THAN 22 IN	653.64	653.64
E2203-RR	DMEPOS	FRAME DEPTH LESS THAN 22 IN	65.36	65.36
E2203-UE	DMEPOS	FRAME DEPTH LESS THAN 22 IN	490.19	490.19
E2204-NU	DMEPOS	FRAME DEPTH 22 TO 25 IN	1109.85	1109.85
E2204-RR	DMEPOS	FRAME DEPTH 22 TO 25 IN	111.00	111.00
E2204-UE	DMEPOS	FRAME DEPTH 22 TO 25 IN	832.38	832.38
E2205-NU	DMEPOS	MANUAL WC ACCESSORY, HANDRIM	44.58	44.58
E2205-RR	DMEPOS	MANUAL WC ACCESSORY, HANDRIM	4.44	4.44
E2205-UE	DMEPOS	MANUAL WC ACCESSORY, HANDRIM	33.46	33.46
E2206-NU	DMEPOS	MAN WC WHL LOCK COMP REPL EA	55.49	55.49
E2206-RR	DMEPOS	MAN WC WHL LOCK COMP REPL EA	5.52	5.52
E2206-UE	DMEPOS	MAN WC WHL LOCK COMP REPL EA	41.62	41.62
E2207-NU	DMEPOS	CRUTCH AND CANE HOLDER	59.14	59.14
E2207-RR	DMEPOS	CRUTCH AND CANE HOLDER	5.93	5.93
E2207-UE	DMEPOS	CRUTCH AND CANE HOLDER	44.37	44.37
E2208-NU	DMEPOS	CYLINDER TANK CARRIER	139.70	139.70
E2208-RR	DMEPOS	CYLINDER TANK CARRIER	13.96	13.96
E2208-UE	DMEPOS	CYLINDER TANK CARRIER	104.78	104.78
E2209-NU	DMEPOS	ARM TROUGH EACH	126.01	126.01
E2209-RR	DMEPOS	ARM TROUGH EACH	12.62	12.62
E2209-UE	DMEPOS	ARM TROUGH EACH	94.53	94.53
E2210-NU	DMEPOS	WHEELCHAIR BEARINGS	7.68	7.68
E2210-RR	DMEPOS	WHEELCHAIR BEARINGS	0.77	0.77
E2210-UE	DMEPOS	WHEELCHAIR BEARINGS	5.79	5.79
E2211-NU	DMEPOS	PNEUMATIC PROPULSION TIRE	55.83	55.83
E2211-RR	DMEPOS	PNEUMATIC PROPULSION TIRE	5.47	5.47
E2211-UE	DMEPOS	PNEUMATIC PROPULSION TIRE	39.99	39.99
E2212-NU	DMEPOS	PNEUMATIC PROP TIRE TUBE	8.00	8.00
E2212-RR	DMEPOS	PNEUMATIC PROP TIRE TUBE	0.86	0.86
E2212-UE	DMEPOS	PNEUMATIC PROP TIRE TUBE	6.02	6.02
E2213-NU	DMEPOS	PNEUMATIC PROP TIRE INSERT	41.51	41.51
E2213-RR	DMEPOS	PNEUMATIC PROP TIRE INSERT	4.18	4.18
E2213-UE	DMEPOS	PNEUMATIC PROP TIRE INSERT	31.11	31.11
E2214-NU	DMEPOS	PNEUMATIC CASTER TIRE EACH	41.76	41.76
E2214-RR	DMEPOS	PNEUMATIC CASTER TIRE EACH	4.58	4.58
E2214-UE	DMEPOS	PNEUMATIC CASTER TIRE EACH	31.33	31.33
E2215-NU	DMEPOS	PNEUMATIC CASTER TIRE TUBE	13.09	13.09
E2215-RR	DMEPOS	PNEUMATIC CASTER TIRE TUBE	1.30	1.30
E2215-UE	DMEPOS	PNEUMATIC CASTER TIRE TUBE	9.82	9.82
E2216-NU	DMEPOS	FOAM FILLED PROPULSION TIRE	64.53	64.53
E2216-RR	DMEPOS	FOAM FILLED PROPULSION TIRE	7.32	7.32
E2216-UE	DMEPOS	FOAM FILLED PROPULSION TIRE	48.36	48.36
E2217-NU	DMEPOS	FOAM FILLED CASTER TIRE EACH	57.08	57.08
E2217-RR	DMEPOS	FOAM FILLED CASTER TIRE EACH	6.45	6.45
E2217-UE	DMEPOS	FOAM FILLED CASTER TIRE EACH	42.81	42.81
E2218-NU	DMEPOS	FOAM PROPULSION TIRE EACH	64.53	64.53
E2218-RR	DMEPOS	FOAM PROPULSION TIRE EACH	7.32	7.32
E2218-UE	DMEPOS	FOAM PROPULSION TIRE EACH	48.36	48.36
E2219-NU	DMEPOS	FOAM CASTER TIRE ANY SIZE EA	57.08	57.08
E2219-RR	DMEPOS	FOAM CASTER TIRE ANY SIZE EA	6.45	6.45
E2219-UE	DMEPOS	FOAM CASTER TIRE ANY SIZE EA	42.81	42.81
E2220-NU	DMEPOS	SOLID PROPULS TIRE, REPL, EA	38.94	38.94
E2220-RR	DMEPOS	SOLID PROPULS TIRE, REPL, EA	3.76	3.76
E2220-UE	DMEPOS	SOLID PROPULS TIRE, REPL, EA	29.77	29.77
E2221-NU	DMEPOS	SOLID CASTER TIRE REPL, EACH	34.86	34.86
E2221-RR	DMEPOS	SOLID CASTER TIRE REPL, EACH	3.54	3.54
E2221-UE	DMEPOS	SOLID CASTER TIRE REPL, EACH	26.15	26.15
E2222-NU	DMEPOS	SOLID CASTER INTEG WHL, REPL	28.75	28.75
E2222-RR	DMEPOS	SOLID CASTER INTEG WHL, REPL	2.83	2.83
E2222-UE	DMEPOS	SOLID CASTER INTEG WHL, REPL	21.57	21.57
E2224-NU	DMEPOS	PROPULSION WHL EXCL TIRE REP	130.38	130.38
E2224-RR	DMEPOS	PROPULSION WHL EXCL TIRE REP	13.05	13.05
E2224-UE	DMEPOS	PROPULSION WHL EXCL TIRE REP	97.79	97.79
E2225-NU	DMEPOS	CASTER WHEEL EXCLUDES TIRE	23.73	23.73
E2225-RR	DMEPOS	CASTER WHEEL EXCLUDES TIRE	2.35	2.35
E2225-UE	DMEPOS	CASTER WHEEL EXCLUDES TIRE	17.79	17.79
E2226-NU	DMEPOS	CASTER FORK REPLACEMENT ONLY	51.76	51.76
E2226-RR	DMEPOS	CASTER FORK REPLACEMENT ONLY	5.18	5.18
E2226-UE	DMEPOS	CASTER FORK REPLACEMENT ONLY	38.83	38.83
E2227-RR	DMEPOS	GEAR REDUCTION DRIVE WHEEL	252.80	252.80
E2228-RR	DMEPOS	MWC ACC, WHEELCHAIR BRAKE	127.73	127.73
E2230	DMEPOS	MANUAL STANDING SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2231-NU	DMEPOS	SOLID SEAT SUPPORT BASE	209.68	209.68
E2231-RR	DMEPOS	SOLID SEAT SUPPORT BASE	20.98	20.98
E2231-UE	DMEPOS	SOLID SEAT SUPPORT BASE	157.24	157.24
E2291	DMEPOS	PLANAR BACK FOR PED SIZE WC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2292	DMEPOS	PLANAR SEAT FOR PED SIZE WC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2293	DMEPOS	CONTOUR BACK FOR PED SIZE WC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2294	DMEPOS	CONTOUR SEAT FOR PED SIZE WC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2295	DMEPOS	PED DYNAMIC SEATING FRAME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2300	DMEPOS	PWR SEAT ELEVATION SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2301	DMEPOS	PWR STANDING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2310-RR	DMEPOS	ELECTRO CONNECT BTW CONTROL	137.59	137.59
E2311-RR	DMEPOS	ELECTRO CONNECT BTW 2 SYS	278.63	278.63
E2312-RR	DMEPOS	MINI-PROP REMOTE JOYSTICK	347.57	347.57
E2313-RR	DMEPOS	PWC HARNESS, EXPAND CONTROL	43.29	43.29
E2321-RR	DMEPOS	HAND INTERFACE JOYSTICK	304.44	304.44
E2322-RR	DMEPOS	MULT MECH SWITCHES	322.38	322.38
E2323-NU	DMEPOS	SPECIAL JOYSTICK HANDLE	81.35	81.35
E2323-RR	DMEPOS	SPECIAL JOYSTICK HANDLE	8.11	8.11
E2323-UE	DMEPOS	SPECIAL JOYSTICK HANDLE	60.99	60.99
E2324-NU	DMEPOS	CHIN CUP INTERFACE	51.53	51.53
E2324-RR	DMEPOS	CHIN CUP INTERFACE	5.13	5.13
E2324-UE	DMEPOS	CHIN CUP INTERFACE	38.65	38.65
E2325-RR	DMEPOS	SIP AND PUFF INTERFACE	158.40	158.40
E2326-RR	DMEPOS	BREATH TUBE KIT	40.85	40.85
E2327-RR	DMEPOS	HEAD CONTROL INTERFACE MECH	466.74	466.74
E2328-RR	DMEPOS	HEAD/EXTREMITY CONTROL INTER	582.76	582.76
E2329-RR	DMEPOS	HEAD CONTROL NONPROPORTIONAL	207.70	207.70
E2330-RR	DMEPOS	HEAD CONTROL PROXIMITY SWITC	402.43	402.43
E2331	DMEPOS	ATTENDANT CONTROL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2340-NU	DMEPOS	W/C WDTH 20-23 IN SEAT FRAME	488.95	488.95
E2340-RR	DMEPOS	W/C WDTH 20-23 IN SEAT FRAME	48.92	48.92
E2340-UE	DMEPOS	W/C WDTH 20-23 IN SEAT FRAME	366.76	366.76
E2341-NU	DMEPOS	W/C WDTH 24-27 IN SEAT FRAME	733.50	733.50
E2341-RR	DMEPOS	W/C WDTH 24-27 IN SEAT FRAME	73.34	73.34
E2341-UE	DMEPOS	W/C WDTH 24-27 IN SEAT FRAME	550.15	550.15
E2342-NU	DMEPOS	W/C DPTH 20-21 IN SEAT FRAME	611.26	611.26
E2342-RR	DMEPOS	W/C DPTH 20-21 IN SEAT FRAME	61.12	61.12
E2342-UE	DMEPOS	W/C DPTH 20-21 IN SEAT FRAME	458.45	458.45
E2343-NU	DMEPOS	W/C DPTH 22-25 IN SEAT FRAME	978.02	978.02
E2343-RR	DMEPOS	W/C DPTH 22-25 IN SEAT FRAME	97.79	97.79
E2343-UE	DMEPOS	W/C DPTH 22-25 IN SEAT FRAME	733.50	733.50
E2351-NU	DMEPOS	ELECTRONIC SGD INTERFACE	821.90	821.90
E2351-RR	DMEPOS	ELECTRONIC SGD INTERFACE	82.19	82.19
E2351-UE	DMEPOS	ELECTRONIC SGD INTERFACE	616.42	616.42
E2358	DMEPOS	GR 34 NONSEALED LEADACID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2359-NU	DMEPOS	GR34 SEALED LEADACID BATTERY	235.28	235.28
E2359-RR	DMEPOS	GR34 SEALED LEADACID BATTERY	23.54	23.54
E2359-UE	DMEPOS	GR34 SEALED LEADACID BATTERY	176.48	176.48
E2360-NU	DMEPOS	22NF NONSEALED LEADACID	153.29	153.29
E2360-RR	DMEPOS	22NF NONSEALED LEADACID	15.41	15.41
E2360-UE	DMEPOS	22NF NONSEALED LEADACID	114.95	114.95
E2361-NU	DMEPOS	22NF SEALED LEADACID BATTERY	164.03	164.03
E2361-RR	DMEPOS	22NF SEALED LEADACID BATTERY	16.40	16.40
E2361-UE	DMEPOS	22NF SEALED LEADACID BATTERY	123.03	123.03
E2362-NU	DMEPOS	GR24 NONSEALED LEADACID	125.51	125.51
E2362-RR	DMEPOS	GR24 NONSEALED LEADACID	12.56	12.56
E2362-UE	DMEPOS	GR24 NONSEALED LEADACID	94.13	94.13
E2363-NU	DMEPOS	GR24 SEALED LEADACID BATTERY	218.74	218.74
E2363-RR	DMEPOS	GR24 SEALED LEADACID BATTERY	21.87	21.87
E2363-UE	DMEPOS	GR24 SEALED LEADACID BATTERY	164.06	164.06
E2364-NU	DMEPOS	U1NONSEALED LEADACID BATTERY	153.29	153.29
E2364-RR	DMEPOS	U1NONSEALED LEADACID BATTERY	15.41	15.41
E2364-UE	DMEPOS	U1NONSEALED LEADACID BATTERY	114.95	114.95
E2365-NU	DMEPOS	U1 SEALED LEADACID BATTERY	131.90	131.90
E2365-RR	DMEPOS	U1 SEALED LEADACID BATTERY	13.17	13.17
E2365-UE	DMEPOS	U1 SEALED LEADACID BATTERY	98.98	98.98
E2366-NU	DMEPOS	BATTERY CHARGER, SINGLE MODE	263.52	263.52
E2366-RR	DMEPOS	BATTERY CHARGER, SINGLE MODE	26.44	26.44
E2366-UE	DMEPOS	BATTERY CHARGER, SINGLE MODE	197.66	197.66
E2367-NU	DMEPOS	BATTERY CHARGER, DUAL MODE	492.84	492.84
E2367-RR	DMEPOS	BATTERY CHARGER, DUAL MODE	49.26	49.26
E2367-UE	DMEPOS	BATTERY CHARGER, DUAL MODE	369.65	369.65
E2368-RR	DMEPOS	PWR WC DRIVEWHEEL MOTOR REPL	60.74	60.74
E2369-RR	DMEPOS	PWR WC DRIVEWHEEL GEAR REPL	52.93	52.93
E2370-RR	DMEPOS	PWR WC DR WH MOTOR/GEAR COMB	94.43	94.43
E2371-NU	DMEPOS	GR27 SEALED LEADACID BATTERY	177.27	177.27
E2371-RR	DMEPOS	GR27 SEALED LEADACID BATTERY	17.73	17.73
E2371-UE	DMEPOS	GR27 SEALED LEADACID BATTERY	132.97	132.97
E2372-NU	DMEPOS	GR27 NON-SEALED LEADACID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2372-RR	DMEPOS	GR27 NON-SEALED LEADACID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2372-UE	DMEPOS	GR27 NON-SEALED LEADACID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2373-RR	DMEPOS	HAND/CHIN CTRL SPEC JOYSTICK	146.56	146.56
E2374-RR	DMEPOS	HAND/CHIN CTRL STD JOYSTICK	62.82	62.82
E2375-RR	DMEPOS	NON-EXPANDABLE CONTROLLER	100.70	100.70
E2376-RR	DMEPOS	EXPANDABLE CONTROLLER, REPL	157.88	157.88
E2377-RR	DMEPOS	EXPANDABLE CONTROLLER, INITL	57.09	57.09
E2378-RR	DMEPOS	PW ACTUATOR REPLACEMENT	69.83	69.83
E2381-NU	DMEPOS	PNEUM DRIVE WHEEL TIRE	89.58	89.58
E2381-RR	DMEPOS	PNEUM DRIVE WHEEL TIRE	8.99	8.99
E2381-UE	DMEPOS	PNEUM DRIVE WHEEL TIRE	67.17	67.17
E2382-NU	DMEPOS	TUBE, PNEUM WHEEL DRIVE TIRE	24.41	24.41
E2382-RR	DMEPOS	TUBE, PNEUM WHEEL DRIVE TIRE	2.43	2.43
E2382-UE	DMEPOS	TUBE, PNEUM WHEEL DRIVE TIRE	18.32	18.32
E2383-NU	DMEPOS	INSERT, PNEUM WHEEL DRIVE	178.61	178.61
E2383-RR	DMEPOS	INSERT, PNEUM WHEEL DRIVE	17.86	17.86
E2383-UE	DMEPOS	INSERT, PNEUM WHEEL DRIVE	133.95	133.95
E2384-NU	DMEPOS	PNEUMATIC CASTER TIRE	95.15	95.15
E2384-RR	DMEPOS	PNEUMATIC CASTER TIRE	9.54	9.54
E2384-UE	DMEPOS	PNEUMATIC CASTER TIRE	71.38	71.38
E2385-NU	DMEPOS	TUBE, PNEUMATIC CASTER TIRE	58.20	58.20
E2385-RR	DMEPOS	TUBE, PNEUMATIC CASTER TIRE	5.84	5.84
E2385-UE	DMEPOS	TUBE, PNEUMATIC CASTER TIRE	43.64	43.64
E2386-NU	DMEPOS	FOAM FILLED DRIVE WHEEL TIRE	176.99	176.99
E2386-RR	DMEPOS	FOAM FILLED DRIVE WHEEL TIRE	17.70	17.70
E2386-UE	DMEPOS	FOAM FILLED DRIVE WHEEL TIRE	132.76	132.76
E2387-NU	DMEPOS	FOAM FILLED CASTER TIRE	78.65	78.65
E2387-RR	DMEPOS	FOAM FILLED CASTER TIRE	7.83	7.83
E2387-UE	DMEPOS	FOAM FILLED CASTER TIRE	58.98	58.98
E2388-NU	DMEPOS	FOAM DRIVE WHEEL TIRE	59.24	59.24
E2388-RR	DMEPOS	FOAM DRIVE WHEEL TIRE	5.93	5.93
E2388-UE	DMEPOS	FOAM DRIVE WHEEL TIRE	44.46	44.46
E2389-NU	DMEPOS	FOAM CASTER TIRE	32.18	32.18
E2389-RR	DMEPOS	FOAM CASTER TIRE	3.23	3.23
E2389-UE	DMEPOS	FOAM CASTER TIRE	24.11	24.11
E2390-NU	DMEPOS	SOLID DRIVE WHEEL TIRE	50.33	50.33
E2390-RR	DMEPOS	SOLID DRIVE WHEEL TIRE	5.04	5.04
E2390-UE	DMEPOS	SOLID DRIVE WHEEL TIRE	37.72	37.72
E2391-NU	DMEPOS	SOLID CASTER TIRE	24.10	24.10
E2391-RR	DMEPOS	SOLID CASTER TIRE	2.42	2.42
E2391-UE	DMEPOS	SOLID CASTER TIRE	18.08	18.08
E2392-NU	DMEPOS	SOLID CASTER TIRE, INTEGRATE	63.36	63.36
E2392-RR	DMEPOS	SOLID CASTER TIRE, INTEGRATE	6.38	6.38
E2392-UE	DMEPOS	SOLID CASTER TIRE, INTEGRATE	47.53	47.53
E2394-NU	DMEPOS	DRIVE WHEEL EXCLUDES TIRE	90.28	90.28
E2394-RR	DMEPOS	DRIVE WHEEL EXCLUDES TIRE	9.05	9.05
E2394-UE	DMEPOS	DRIVE WHEEL EXCLUDES TIRE	67.71	67.71
E2395-NU	DMEPOS	CASTER WHEEL EXCLUDES TIRE	64.15	64.15
E2395-RR	DMEPOS	CASTER WHEEL EXCLUDES TIRE	6.43	6.43
E2395-UE	DMEPOS	CASTER WHEEL EXCLUDES TIRE	48.11	48.11
E2396-NU	DMEPOS	CASTER FORK	78.19	78.19
E2396-RR	DMEPOS	CASTER FORK	8.36	8.36
E2396-UE	DMEPOS	CASTER FORK	58.68	58.68
E2397-NU	DMEPOS	PWC ACC, LITH-BASED BATTERY	565.06	565.06
E2397-RR	DMEPOS	PWC ACC, LITH-BASED BATTERY	56.52	56.52
E2397-UE	DMEPOS	PWC ACC, LITH-BASED BATTERY	423.77	423.77
E2398-NU	DMEPOS	WC DYNAMIC POS BACK HARDWARE	156.52	156.52
E2398-RR	DMEPOS	WC DYNAMIC POS BACK HARDWARE	15.65	15.65
E2398-UE	DMEPOS	WC DYNAMIC POS BACK HARDWARE	117.38	117.38
E2402-RR	DMEPOS	NEG PRESS WOUND THERAPY PUMP	833.75	833.75
E2500-NU	DMEPOS	SGD DIGITIZED PRE-REC <=8MIN	533.56	533.56
E2500-RR	DMEPOS	SGD DIGITIZED PRE-REC <=8MIN	53.36	53.36
E2500-UE	DMEPOS	SGD DIGITIZED PRE-REC <=8MIN	400.17	400.17
E2502-NU	DMEPOS	SGD PREREC MSG >8MIN <=20MIN	1631.59	1631.59
E2502-RR	DMEPOS	SGD PREREC MSG >8MIN <=20MIN	163.18	163.18
E2502-UE	DMEPOS	SGD PREREC MSG >8MIN <=20MIN	1223.71	1223.71
E2504-NU	DMEPOS	SGD PREREC MSG>20MIN <=40MIN	2152.31	2152.31
E2504-RR	DMEPOS	SGD PREREC MSG>20MIN <=40MIN	215.25	215.25
E2504-UE	DMEPOS	SGD PREREC MSG>20MIN <=40MIN	1614.24	1614.24
E2506-NU	DMEPOS	SGD PREREC MSG > 40 MIN	3155.90	3155.90
E2506-RR	DMEPOS	SGD PREREC MSG > 40 MIN	315.58	315.58
E2506-UE	DMEPOS	SGD PREREC MSG > 40 MIN	2366.88	2366.88
E2508-NU	DMEPOS	SGD SPELLING PHYS CONTACT	4880.09	4880.09
E2508-RR	DMEPOS	SGD SPELLING PHYS CONTACT	488.01	488.01
E2508-UE	DMEPOS	SGD SPELLING PHYS CONTACT	3660.08	3660.08
E2510-NU	DMEPOS	SGD W MULTI METHODS MSG/ACCS	9234.92	9234.92
E2510-RR	DMEPOS	SGD W MULTI METHODS MSG/ACCS	923.49	923.49
E2510-UE	DMEPOS	SGD W MULTI METHODS MSG/ACCS	6926.17	6926.17
E2511-NU	DMEPOS	SGD SFTWRE PRGRM FOR PC/PDA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2511-RR	DMEPOS	SGD SFTWRE PRGRM FOR PC/PDA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2511-UE	DMEPOS	SGD SFTWRE PRGRM FOR PC/PDA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2512-NU	DMEPOS	SGD ACCESSORY, MOUNTING SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2512-RR	DMEPOS	SGD ACCESSORY, MOUNTING SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2512-UE	DMEPOS	SGD ACCESSORY, MOUNTING SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2599	DMEPOS	SGD ACCESSORY NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2601-NU	DMEPOS	GEN W/C CUSHION WDTH < 22 IN	71.92	71.92
E2601-RR	DMEPOS	GEN W/C CUSHION WDTH < 22 IN	7.20	7.20
E2601-UE	DMEPOS	GEN W/C CUSHION WDTH < 22 IN	53.95	53.95
E2602-NU	DMEPOS	GEN W/C CUSHION WDTH >=22 IN	140.41	140.41
E2602-RR	DMEPOS	GEN W/C CUSHION WDTH >=22 IN	14.06	14.06
E2602-UE	DMEPOS	GEN W/C CUSHION WDTH >=22 IN	105.33	105.33
E2603-NU	DMEPOS	SKIN PROTECT WC CUS WD <22IN	178.26	178.26
E2603-RR	DMEPOS	SKIN PROTECT WC CUS WD <22IN	17.84	17.84
E2603-UE	DMEPOS	SKIN PROTECT WC CUS WD <22IN	133.72	133.72
E2604-NU	DMEPOS	SKIN PROTECT WC CUS WD>=22IN	221.59	221.59
E2604-RR	DMEPOS	SKIN PROTECT WC CUS WD>=22IN	22.16	22.16
E2604-UE	DMEPOS	SKIN PROTECT WC CUS WD>=22IN	166.19	166.19
E2605-NU	DMEPOS	POSITION WC CUSH WDTH <22 IN	316.55	316.55
E2605-RR	DMEPOS	POSITION WC CUSH WDTH <22 IN	31.66	31.66
E2605-UE	DMEPOS	POSITION WC CUSH WDTH <22 IN	237.45	237.45
E2606-NU	DMEPOS	POSITION WC CUSH WDTH>=22 IN	493.84	493.84
E2606-RR	DMEPOS	POSITION WC CUSH WDTH>=22 IN	49.39	49.39
E2606-UE	DMEPOS	POSITION WC CUSH WDTH>=22 IN	370.34	370.34
E2607-NU	DMEPOS	SKIN PRO/POS WC CUS WD <22IN	340.87	340.87
E2607-RR	DMEPOS	SKIN PRO/POS WC CUS WD <22IN	34.09	34.09
E2607-UE	DMEPOS	SKIN PRO/POS WC CUS WD <22IN	255.65	255.65
E2608-NU	DMEPOS	SKIN PRO/POS WC CUS WD>=22IN	409.35	409.35
E2608-RR	DMEPOS	SKIN PRO/POS WC CUS WD>=22IN	40.93	40.93
E2608-UE	DMEPOS	SKIN PRO/POS WC CUS WD>=22IN	307.01	307.01
E2609	DMEPOS	CUSTOM FABRICATE W/C CUSHION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2610	DMEPOS	POWERED W/C CUSHION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2611-NU	DMEPOS	GEN USE BACK CUSH WDTH <22IN	367.34	367.34
E2611-RR	DMEPOS	GEN USE BACK CUSH WDTH <22IN	36.72	36.72
E2611-UE	DMEPOS	GEN USE BACK CUSH WDTH <22IN	275.52	275.52
E2612-NU	DMEPOS	GEN USE BACK CUSH WDTH>=22IN	496.91	496.91
E2612-RR	DMEPOS	GEN USE BACK CUSH WDTH>=22IN	49.69	49.69
E2612-UE	DMEPOS	GEN USE BACK CUSH WDTH>=22IN	372.66	372.66
E2613-NU	DMEPOS	POSITION BACK CUSH WD <22IN	462.23	462.23
E2613-RR	DMEPOS	POSITION BACK CUSH WD <22IN	46.23	46.23
E2613-UE	DMEPOS	POSITION BACK CUSH WD <22IN	346.66	346.66
E2614-NU	DMEPOS	POSITION BACK CUSH WD>=22IN	639.69	639.69
E2614-RR	DMEPOS	POSITION BACK CUSH WD>=22IN	63.96	63.96
E2614-UE	DMEPOS	POSITION BACK CUSH WD>=22IN	479.79	479.79
E2615-NU	DMEPOS	POS BACK POST/LAT WDTH <22IN	531.92	531.92
E2615-RR	DMEPOS	POS BACK POST/LAT WDTH <22IN	53.20	53.20
E2615-UE	DMEPOS	POS BACK POST/LAT WDTH <22IN	398.94	398.94
E2616-NU	DMEPOS	POS BACK POST/LAT WDTH>=22IN	715.71	715.71
E2616-RR	DMEPOS	POS BACK POST/LAT WDTH>=22IN	71.56	71.56
E2616-UE	DMEPOS	POS BACK POST/LAT WDTH>=22IN	536.78	536.78
E2617	DMEPOS	CUSTOM FAB W/C BACK CUSHION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E2619-NU	DMEPOS	REPLACE COVER W/C SEAT CUSH	60.33	60.33
E2619-RR	DMEPOS	REPLACE COVER W/C SEAT CUSH	6.02	6.02
E2619-UE	DMEPOS	REPLACE COVER W/C SEAT CUSH	45.30	45.30
E2620-NU	DMEPOS	WC PLANAR BACK CUSH WD <22IN	644.08	644.08
E2620-RR	DMEPOS	WC PLANAR BACK CUSH WD <22IN	64.42	64.42
E2620-UE	DMEPOS	WC PLANAR BACK CUSH WD <22IN	483.10	483.10
E2621-NU	DMEPOS	WC PLANAR BACK CUSH WD>=22IN	675.93	675.93
E2621-RR	DMEPOS	WC PLANAR BACK CUSH WD>=22IN	67.59	67.59
E2621-UE	DMEPOS	WC PLANAR BACK CUSH WD>=22IN	506.96	506.96
E2622-NU	DMEPOS	ADJ SKIN PRO W/C CUS WD<22IN	389.81	389.81
E2622-RR	DMEPOS	ADJ SKIN PRO W/C CUS WD<22IN	39.00	39.00
E2622-UE	DMEPOS	ADJ SKIN PRO W/C CUS WD<22IN	292.36	292.36
E2623-NU	DMEPOS	ADJ SKIN PRO WC CUS WD>=22IN	496.01	496.01
E2623-RR	DMEPOS	ADJ SKIN PRO WC CUS WD>=22IN	49.62	49.62
E2623-UE	DMEPOS	ADJ SKIN PRO WC CUS WD>=22IN	372.01	372.01
E2624-NU	DMEPOS	ADJ SKIN PRO/POS CUS<22IN	393.02	393.02
E2624-RR	DMEPOS	ADJ SKIN PRO/POS CUS<22IN	39.32	39.32
E2624-UE	DMEPOS	ADJ SKIN PRO/POS CUS<22IN	294.79	294.79
E2625-NU	DMEPOS	ADJ SKIN PRO/POS WC CUS>=22	497.54	497.54
E2625-RR	DMEPOS	ADJ SKIN PRO/POS WC CUS>=22	49.73	49.73
E2625-UE	DMEPOS	ADJ SKIN PRO/POS WC CUS>=22	373.16	373.16
E2626-NU	DMEPOS	SEO MOBILE ARM SUP ATT TO WC	847.51	847.51
E2626-RR	DMEPOS	SEO MOBILE ARM SUP ATT TO WC	84.72	84.72
E2626-UE	DMEPOS	SEO MOBILE ARM SUP ATT TO WC	635.55	635.55
E2627-NU	DMEPOS	ARM SUPP ATT TO WC RANCHO TY	1352.33	1352.33
E2627-RR	DMEPOS	ARM SUPP ATT TO WC RANCHO TY	135.28	135.28
E2627-UE	DMEPOS	ARM SUPP ATT TO WC RANCHO TY	1014.23	1014.23
E2628-NU	DMEPOS	MOBILE ARM SUPPORTS RECLININ	1011.09	1011.09
E2628-RR	DMEPOS	MOBILE ARM SUPPORTS RECLININ	101.14	101.14
E2628-UE	DMEPOS	MOBILE ARM SUPPORTS RECLININ	758.37	758.37
E2629-NU	DMEPOS	FRICTION DAMPENING ARM SUPP	1289.22	1289.22
E2629-RR	DMEPOS	FRICTION DAMPENING ARM SUPP	128.92	128.92
E2629-UE	DMEPOS	FRICTION DAMPENING ARM SUPP	966.90	966.90
E2630-NU	DMEPOS	MONOSUSPENSION ARM/HAND SUPP	766.33	766.33
E2630-RR	DMEPOS	MONOSUSPENSION ARM/HAND SUPP	76.62	76.62
E2630-UE	DMEPOS	MONOSUSPENSION ARM/HAND SUPP	574.74	574.74
E2631-NU	DMEPOS	ELEVAT PROXIMAL ARM SUPPORT	360.64	360.64
E2631-RR	DMEPOS	ELEVAT PROXIMAL ARM SUPPORT	36.04	36.04
E2631-UE	DMEPOS	ELEVAT PROXIMAL ARM SUPPORT	270.46	270.46
E2632-NU	DMEPOS	OFFSET/LAT ROCKER ARM W/ELA	218.11	218.11
E2632-RR	DMEPOS	OFFSET/LAT ROCKER ARM W/ELA	21.80	21.80
E2632-UE	DMEPOS	OFFSET/LAT ROCKER ARM W/ELA	163.61	163.61
E2633-NU	DMEPOS	MOBILE ARM SUPPORT SUPINATOR	165.33	165.33
E2633-RR	DMEPOS	MOBILE ARM SUPPORT SUPINATOR	16.54	16.54
E2633-UE	DMEPOS	MOBILE ARM SUPPORT SUPINATOR	124.02	124.02
E3000-RR	DMEPOS	SPEECH VOLUME MODULATION SYS	234.41	234.41
E8000	DMEPOS	POSTERIOR GAIT TRAINER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E8001	DMEPOS	UPRIGHT GAIT TRAINER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
E8002	DMEPOS	ANTERIOR GAIT TRAINER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0008	Other professional services	ADMIN INFLUENZA VIRUS VAC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0009	Other professional services	ADMIN PNEUMOCOCCAL VACCINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0010	Other professional services	ADMIN HEPATITIS B VACCINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0011	Other professional services	HIV PREP COUNSEL, MD 15-30M	37.19	31.73
G0012	Other professional services	INJECTION OF HIV PREP DRUG	20.04	20.04
G0013	Other professional services	HIV PREP COUNSEL, CLIN STAFF	32.37	12.35
G0017	Other professional services	CRISIS PSYCHOTHERAPY 60M	304.88	268.95
G0018	Other professional services	CRISIS PSYCHOTHERAPY ADD 30M	150.36	134.00
G0019	Other professional services	COMM HLTH INTG SVS SDOH 60MN	112.80	70.50
G0022	Other professional services	COMM HLTH INTG SVS ADD 30 M	70.58	49.20
G0023	Other professional services	PIN SERVICE 60M PER MONTH	112.80	70.50
G0024	Other professional services	PIN SRV ADD 30 MIN PR M	70.58	49.20
G0027	Clinical Laboratory	SEMEN ANALYSIS	9.75	9.75
G0029	Other professional services	NO TOB SCR/CESS INT	0.00	0.00
G0030	Other professional services	PT SCR TOB & CESS INT	0.00	0.00
G0031	Other professional services	PALL SERV DURING MEAS	0.00	0.00
G0032	Other professional services	2+ ANTIPSY SCHIZ	0.00	0.00
G0033	Other professional services	2+ BENZO SEIZ	0.00	0.00
G0034	Other professional services	PALL SERV DURING MEAS	0.00	0.00
G0035	Other professional services	PT ED POS 23	0.00	0.00
G0036	Other professional services	PT/PTN DECLN ASSESS	0.00	0.00
G0037	Other professional services	PT NOT ABLE TO PARTICIPATE	0.00	0.00
G0038	Other professional services	CLIN PT NO REF	0.00	0.00
G0039	Other professional services	PT NO REF, RN SPEC	0.00	0.00
G0040	Other professional services	PT PHYS/OCC THERAPY	0.00	0.00
G0041	Other professional services	PT/PTN DECLN REFERRAL	0.00	0.00
G0042	Other professional services	REF TO THERAPY	0.00	0.00
G0043	Other professional services	PT MECH PROS HT VALV	0.00	0.00
G0044	Other professional services	PT MITRAL STENOSIS	0.00	0.00
G0045	Other professional services	MRS 90 DAYS POST STK	0.00	0.00
G0046	Other professional services	NO MRS 90 DAYS POST STK	0.00	0.00
G0047	Other professional services	PED BLUNT HD TRAUM	0.00	0.00
G0048	Other professional services	PALL SERV DURING MEAS	0.00	0.00
G0049	Other professional services	MAIN HEMO IN-CNTR	0.00	0.00
G0050	Other professional services	PT W/ LMTED LIFE EXPEC	0.00	0.00
G0051	Other professional services	PT HOSPICE MNTH	0.00	0.00
G0052	Other professional services	PT PERI DIALYSIS DUR MO	0.00	0.00
G0053	Other professional services	ADV RHEUM PT CARE MVP	0.00	0.00
G0054	Other professional services	STRK CR PREV POS OUTCME MVP	0.00	0.00
G0055	Other professional services	ADV CARE HEART DX MVP	0.00	0.00
G0057	Other professional services	BEST PCT PT SAFETY EM MVP	0.00	0.00
G0058	Other professional services	IMPRV CARE LE JNT REPR MVP	0.00	0.00
G0059	Other professional services	PT SFTY POS EXP W ANETH MVP	0.00	0.00
G0060	Other professional services	ALLERGY/IMMUNOLOGY SS	0.00	0.00
G0061	Other professional services	ANESTHESIOLOGY SS	0.00	0.00
G0062	Other professional services	AUDIOLOGY SS	0.00	0.00
G0063	Other professional services	CARDIOLOGY SS	0.00	0.00
G0064	Other professional services	CERT NURSE MIDWIFE SS	0.00	0.00
G0065	Other professional services	CHIROPRACTIC SS	0.00	0.00
G0066	Other professional services	CLINICAL SOCIAL WORK SS	0.00	0.00
G0067	Other professional services	DENTISTRY SS	0.00	0.00
G0068	DMEPOS	ADM OF INFUSION DRUG IN HOME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0069	DMEPOS	ADM OF IMMUNE DRUG IN HOME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0070	DMEPOS	ADM OF CHEMO DRUG IN HOME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0071	Other professional services	COMM SVCS BY RHC/FQHC 5 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0076	Other professional services	CARE MANAG H VST NEW PT 20 M	70.35	70.35
G0077	Other professional services	CARE MANAG H VST NEW PT 30 M	104.57	104.57
G0078	Other professional services	CARE MANAG H VST NEW PT 45 M	171.84	171.84
G0079	Other professional services	CARE MANAG H VST NEW PT 60 M	225.81	225.81
G0080	Other professional services	CARE MANAG H VST NEW PT 75 M	294.56	294.56
G0081	Other professional services	CARE MAN H V EXT PT 20 MI	68.94	68.94
G0082	Other professional services	CARE MAN H V EXT PT 30 M	111.08	111.08
G0083	Other professional services	CARE MAN H V EXT PT 45 M	173.79	173.79
G0084	Other professional services	CARE MAN H V EXT PT 60 M	245.36	245.36
G0085	Other professional services	CARE MAN H V EXT PT 75 M	294.56	294.56
G0086	Other professional services	CARE MAN HOME CARE PLAN 30 M	104.24	104.24
G0087	Other professional services	CARE MAN HOME CARE PLAN 60 M	146.19	146.19
G0088	Other professional services	ADM IV DRUG 1ST HOME VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0089	Other professional services	ADM SUBQ DRUG 1ST HOME VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0090	Other professional services	ADM IV CHEMO 1ST HOME VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0101	Other professional services	CA SCREEN;PELVIC/BREAST EXAM	54.41	38.04
G0102	Other professional services	PROSTATE CA SCREENING; DRE	32.37	12.35
G0103	Clinical Laboratory	PSA SCREENING	28.97	28.97
G0104	Other professional services	CA SCREEN;FLEXI SIGMOIDSCOPE	255.75	78.38
G0105	Other professional services	COLORECTAL SCRN; HI RISK IND	469.92	254.34
G0105-53	Other professional services	COLORECTAL SCRN; HI RISK IND	234.74	127.40
G0106	Other professional services	COLON CA SCREEN;BARIUM ENEMA	302.49	302.49
G0106-26	Other professional services	COLON CA SCREEN;BARIUM ENEMA	83.87	83.87
G0106-TC	Other professional services	COLON CA SCREEN;BARIUM ENEMA	218.64	218.64
G0108	Other professional services	DIAB MANAGE TRN PER INDIV	76.89	76.89
G0109	Other professional services	DIAB MANAGE TRN IND/GROUP	22.16	22.16
G0117	Other professional services	GLAUCOMA SCRN HGH RISK DIREC	88.25	88.25
G0118	Other professional services	GLAUCOMA SCRN HGH RISK DIREC	57.80	57.80
G0120	Other professional services	COLON CA SCRN; BARIUM ENEMA	302.49	302.49
G0120-26	Other professional services	COLON CA SCRN; BARIUM ENEMA	83.87	83.87
G0120-TC	Other professional services	COLON CA SCRN; BARIUM ENEMA	218.64	218.64
G0121	Other professional services	COLON CA SCRN NOT HI RSK IND	470.25	254.67
G0121-53	Other professional services	COLON CA SCRN NOT HI RSK IND	235.07	127.73
G0122	Other professional services	COLON CA SCRN; BARIUM ENEMA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0122-26	Other professional services	COLON CA SCRN; BARIUM ENEMA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0122-TC	Other professional services	COLON CA SCRN; BARIUM ENEMA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0123	Clinical Laboratory	SCREEN CERV/VAG THIN LAYER	30.39	30.39
G0124	Other professional services	SCREEN C/V THIN LAYER BY MD	33.57	33.57
G0127	Other professional services	TRIM NAIL(S)	33.24	10.50
G0128	Other professional services	CORF SKILLED NURSING SERVICE	13.07	13.07
G0129	Other professional services	PHP/IOP OT SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0130	Other professional services	SINGLE ENERGY X-RAY STUDY	50.58	50.58
G0130-26	Other professional services	SINGLE ENERGY X-RAY STUDY	15.23	15.23
G0130-TC	Other professional services	SINGLE ENERGY X-RAY STUDY	35.36	35.36
G0136	Other professional services	ADM OF SOC DTR ASSESS 5-15 M	26.45	12.81
G0137	Other professional services	INTEN OUTPT SVS,MIN 9 PR 7 D	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0140	Other professional services	NAV SRV PEER SUP 60 MIN PR M	112.80	70.50
G0141	Other professional services	SCR C/V CYTO,AUTOSYS AND MD	33.57	33.57
G0143	Clinical Laboratory	SCR C/V CYTO,THINLAYER,RESCR	40.58	40.58
G0144	Clinical Laboratory	SCR C/V CYTO,THINLAYER,RESCR	65.96	65.96
G0145	Clinical Laboratory	SCR C/V CYTO,THINLAYER,RESCR	39.74	39.74
G0146	Other professional services	NAV SRV PEER SUP ADD 30 PR M	70.58	49.20
G0147	Clinical Laboratory	SCR C/V CYTO, AUTOMATED SYS	26.64	26.64
G0148	Clinical Laboratory	SCR C/V CYTO, AUTOSYS, RESCR	47.91	47.91
G0151	Other professional services	HHCP-SERV OF PT,EA 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0152	Other professional services	HHCP-SERV OF OT,EA 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0153	Other professional services	HHCP-SVS OF S/L PATH,EA 15MN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0155	Other professional services	HHCP-SVS OF CSW,EA 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0156	Other professional services	HHCP-SVS OF AIDE,EA 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0157	Other professional services	HHC PT ASSISTANT EA 15	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0158	Other professional services	HHC OT ASSISTANT EA 15	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0159	Other professional services	HHC PT MAINT EA 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0160	Other professional services	HHC OCCUP THERAPY EA 15	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0161	Other professional services	HHC SLP EA 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0162	Other professional services	HHC RN E&M PLAN SVS, 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0166	Other professional services	EXTRNL COUNTERPULSE, PER TX	139.58	139.58
G0168	Other professional services	WOUND CLOSURE BY ADHESIVE	166.82	20.37
G0175	Other professional services	OPPS SERVICE,SCHED TEAM CONF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0176	Other professional services	OPPS/PHP/IOP; ACTIVITY THRPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0177	Other professional services	OPPS/PHP/IOP; TRAIN & EDUC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0179	Other professional services	MD RECERTIFICATION HHA PT	58.56	58.56
G0180	Other professional services	MD CERTIFICATION HHA PATIENT	75.02	75.02
G0181	Other professional services	HOME HEALTH CARE SUPERVISION	147.56	147.56
G0182	Other professional services	HOSPICE CARE SUPERVISION	147.24	147.24
G0186	Other professional services	DSTRY EYE LESN,FDR VSSL TECH	687.65	660.50
G0219	Other professional services	PET IMG WHOLBOD MELANO NONCO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0219-26	Other professional services	PET IMG WHOLBOD MELANO NONCO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0219-TC	Other professional services	PET IMG WHOLBOD MELANO NONCO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0235	Other professional services	PET NOT OTHERWISE SPECIFIED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0235-26	Other professional services	PET NOT OTHERWISE SPECIFIED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0235-TC	Other professional services	PET NOT OTHERWISE SPECIFIED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0237	Other professional services	THERAPEUTIC PROCD STRG ENDUR	15.33	15.33
G0238	Other professional services	OTH RESP PROC, INDIV	13.97	13.97
G0239	Other professional services	OTH RESP PROC, GROUP	17.61	17.61
G0245	Other professional services	INITIAL FOOT EXAM PT LOPS	90.92	56.36
G0246	Other professional services	FOLLOWUP EVAL OF FOOT PT LOP	54.60	28.22
G0247	Other professional services	ROUTINE FOOTCARE PT W LOPS	116.63	30.68
G0248	Other professional services	DEMONSTRATE USE HOME INR MON	135.93	135.93
G0249	Other professional services	PROVIDE INR TEST MATER/EQUIP	89.48	89.48
G0250	Other professional services	MD INR TEST REVIE INTER MGMT	12.35	12.35
G0252	Other professional services	PET IMAGING INITIAL DX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0252-26	Other professional services	PET IMAGING INITIAL DX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0252-TC	Other professional services	PET IMAGING INITIAL DX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0255	Other professional services	CURRENT PERCEP THRESHOLD TST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0255-26	Other professional services	CURRENT PERCEP THRESHOLD TST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0255-TC	Other professional services	CURRENT PERCEP THRESHOLD TST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0257	Other professional services	UNSCHED DIALYSIS ESRD PT HOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0259	Other professional services	INJECT FOR SACROILIAC JOINT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0260	Other professional services	INJ FOR SACROILIAC JT ANESTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0268	Other professional services	REMOVAL OF IMPACTED WAX MD	72.47	46.10
G0269	Other professional services	OCCLUSIVE DEVICE IN VEIN ART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0270	Other professional services	MNT SUBS TX FOR CHANGE DX	44.72	38.36
G0271	Other professional services	GROUP MNT 2 OR MORE 30 MINS	23.52	21.71
G0276	Other professional services	PILD/PLACEBO CONTROL CLIN TR	514.47	514.47
G0277	Other professional services	HBOT, FULL BODY CHAMBER, 30M	248.27	248.27
G0278	Other professional services	ILIAC ART ANGIO,CARDIAC CATH	18.33	18.33
G0279	Other professional services	TOMOSYNTHESIS, MAMMO	66.38	66.38
G0279-26	Other professional services	TOMOSYNTHESIS, MAMMO	40.01	40.01
G0279-TC	Other professional services	TOMOSYNTHESIS, MAMMO	26.39	26.39
G0281	Other professional services	ELEC STIM UNATTEND FOR PRESS	16.44	16.44
G0282	Other professional services	ELECT STIM WOUND CARE NOT PD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0283	Other professional services	ELEC STIM OTHER THAN WOUND	16.44	16.44
G0288	Other professional services	RECON, CTA FOR SURG PLAN	58.43	58.43
G0289	Other professional services	ARTHRO, LOOSE BODY + CHONDRO	117.06	117.06
G0293	Other professional services	NON-COV SURG PROC,CLIN TRIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0294	Other professional services	NON-COV PROC, CLINICAL TRIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0295	Other professional services	ELECTROMAGNETIC THERAPY ONC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0296	Other professional services	VISIT TO DETERM LDCT ELIG	39.26	35.61
G0299	Other professional services	HHS/HOSPICE OF RN EA 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0300	Other professional services	HHS/HOSPICE OF LPN EA 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0302	Other professional services	PRE-OP SERVICE LVRS COMPLETE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0303	Other professional services	PRE-OP SERVICE LVRS 10-15DOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0304	Other professional services	PRE-OP SERVICE LVRS 1-9 DOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0305	Other professional services	POST OP SERVICE LVRS MIN 6	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0306	Clinical Laboratory	CBC/DIFFWBC W/O PLATELET	11.66	11.66
G0307	Clinical Laboratory	CBC WITHOUT PLATELET	9.71	9.71
G0310	Other professional services	IMMUNIZE COUNSEL 5-15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0311	Other professional services	IMMUNIZE COUNSEL 16-30 MINS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0312	Other professional services	IMMUNIZE COUNS < 21YR 5-15 M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0313	Other professional services	IMMUNIZE COUNS < 21YR 6-30 M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0314	Other professional services	COUNSEL IMMUNE <21 16-30 M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0315	Other professional services	COUNSEL IMMUNE <21 5-15 M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0316	Evaluation & Management	PROLONG INPT EVAL ADD15 M	41.92	39.80
G0317	Evaluation & Management	PROLONG NURSIN FAC EVAL 15M	41.92	39.80
G0318	Evaluation & Management	PROLONG HOME EVAL ADD 15M	40.95	39.26
G0320	Evaluation & Management	TWO-WAY AUDIO AND VIDEO HHS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0321	Evaluation & Management	AUDIO-ONLY HHS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0322	Other professional services	HOME H PHYSIO DATA COLLEC TR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0323	Other professional services	CARE MANAGE BEH SVS 20MINS	77.66	61.74
G0327	Clinical Laboratory	COLON CA SCRN;BLD-BSD BIOMRK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0328	Clinical Laboratory	FECAL BLOOD SCRN IMMUNOASSAY	27.08	27.08
G0329	Other professional services	ELECTROMAGNTIC TX FOR ULCERS	14.64	14.64
G0330	Other professional services	FACILITY SVS DENTAL REHAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0333	Other professional services	DISPENSE FEE INITIAL 30 DAY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0337	Other professional services	HOSPICE EVALUATION PREELECTI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0339	Other professional services	ROBOT LIN-RADSURG COM, FIRST	4103.22	4103.22
G0340	Other professional services	ROBT LIN-RADSURG FRACTX 2-5	3207.48	3207.48
G0341	Other professional services	PERCUTANEOUS ISLET CELLTRANS	2171.87	429.92
G0342	Major surgery	LAPAROSCOPY ISLET CELL TRANS	1346.90	1346.90
G0343	Major surgery	LAPAROTOMY ISLET CELL TRANSP	2201.63	2201.63
G0372	Other professional services	MD SERVICE REQUIRED FOR PMD	12.32	12.32
G0378	Other professional services	HOSPITAL OBSERVATION PER HR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0379	Other professional services	DIRECT REFER HOSPITAL OBSERV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0380	Other professional services	LEV 1 HOSP TYPE B ED VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0381	Other professional services	LEV 2 HOSP TYPE B ED VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0382	Other professional services	LEV 3 HOSP TYPE B ED VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0383	Other professional services	LEV 4 HOSP TYPE B ED VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0384	Other professional services	LEV 5 HOSP TYPE B ED VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0390	Other professional services	TRAUMA RESPONS W/HOSP CRITI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0396	Other professional services	ALCOHOL/SUBS INTERV 15-30MN	48.57	44.48
G0397	Other professional services	ALCOHOL/SUBS INTERV >30 MIN	94.16	90.06
G0398	Other professional services	HOME SLEEP TEST/TYPE 2 PORTA	203.58	0.00
G0398-26	Other professional services	HOME SLEEP TEST/TYPE 2 PORTA	54.29	0.00
G0398-TC	Other professional services	HOME SLEEP TEST/TYPE 2 PORTA	149.30	0.00
G0399	Other professional services	HOME SLEEP TEST/TYPE 3 PORTA	122.15	0.00
G0399-26	Other professional services	HOME SLEEP TEST/TYPE 3 PORTA	54.29	0.00
G0399-TC	Other professional services	HOME SLEEP TEST/TYPE 3 PORTA	67.86	0.00
G0400	Other professional services	HOME SLEEP TEST/TYPE 4 PORTA	123.96	0.00
G0400-26	Other professional services	HOME SLEEP TEST/TYPE 4 PORTA	58.37	0.00
G0400-TC	Other professional services	HOME SLEEP TEST/TYPE 4 PORTA	65.60	0.00
G0402	Other professional services	INITIAL PREVENTIVE EXAM	233.78	184.65
G0403	Other professional services	EKG FOR INITIAL PREVENT EXAM	19.92	19.92
G0404	Other professional services	EKG TRACING FOR INITIAL PREV	8.52	8.52
G0405	Other professional services	EKG INTERPRET & REPORT PREVE	11.40	11.40
G0406	Other professional services	INPT/TELE FOLLOW UP 15	57.56	57.56
G0407	Other professional services	INPT/TELE FOLLOW UP 25	100.85	100.85
G0408	Other professional services	INPT/TELE FOLLOW UP 35	146.87	146.87
G0409	Other professional services	CORF RELATED SERV 15 MINS EA	32.16	32.16
G0410	Other professional services	GRP PSYCH PHP/IOP 45-50	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0411	Other professional services	INTERACTIVE GRP PSYC PHP/IOP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0412	Major surgery	OPEN TX ILIAC SPINE UNI/BIL	1310.01	1310.01
G0413	Major surgery	PELVIC RING FRACTURE UNI/BIL	1919.79	1919.79
G0414	Major surgery	PELVIC RING FX TREAT INT FIX	1811.34	1811.34
G0415	Major surgery	OPEN TX POST PELVIC FXCTURE	2459.89	2459.89
G0416	Other professional services	PROSTATE BIOPSY, ANY MTHD	506.97	506.97
G0416-26	Other professional services	PROSTATE BIOPSY, ANY MTHD	246.09	246.09
G0416-TC	Other professional services	PROSTATE BIOPSY, ANY MTHD	260.88	260.88
G0420	Other professional services	ED SVC CKD IND PER SESSION	153.41	153.41
G0421	Other professional services	ED SVC CKD GRP PER SESSION	38.28	38.28
G0422	Other professional services	INTENS CARDIAC REHAB W/EXERC	180.54	180.54
G0423	Other professional services	INTENS CARDIAC REHAB NO EXER	180.54	180.54
G0425	Other professional services	INPT/ED TELECONSULT30	129.75	129.75
G0426	Other professional services	INPT/ED TELECONSULT50	183.47	183.47
G0427	Other professional services	INPT/ED TELECONSULT70	260.85	260.85
G0428	Other professional services	COLLAGEN MENISCUS IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0429	Other professional services	DERMAL FILLER INJECTION(S)	138.53	95.31
G0432	Clinical Laboratory	EIA HIV-1/HIV-2 SCREEN	29.36	29.36
G0433	Clinical Laboratory	ELISA HIV-1/HIV-2 SCREEN	27.44	27.44
G0435	Clinical Laboratory	ORAL HIV-1/HIV-2 SCREEN	17.97	17.97
G0438	Other professional services	PPPS, INITIAL VISIT	233.31	233.31
G0439	Other professional services	PPPS, SUBSEQ VISIT	183.15	183.15
G0442	Other professional services	ANNUAL ALCOHOL SCREEN 15 MIN	26.45	12.81
G0443	Other professional services	BRIEF ALCOHOL MISUSE COUNSEL	35.36	31.73
G0444	Other professional services	DEPRESSION SCREEN ANNUAL	26.45	12.81
G0445	Other professional services	HIGH INTEN BEH COUNS STD 30M	37.19	31.73
G0446	Other professional services	INTENS BEHAVE THER CARDIO DX	35.82	32.18
G0447	Other professional services	BEHAVIOR COUNSEL OBESITY 15M	35.82	31.73
G0448	Other professional services	PLACE PERM PACING CARDIOVERT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0451	Other professional services	DEVLOPMENT TEST INTERPT&REP	15.80	15.80
G0452	Other professional services	MOLECULAR PATHOLOGY INTERPR	69.86	69.86
G0452-26	Other professional services	MOLECULAR PATHOLOGY INTERPR	65.43	65.43
G0452-TC	Other professional services	MOLECULAR PATHOLOGY INTERPR	4.43	4.43
G0453	Other professional services	CONT INTRAOP NEURO MONITOR	44.75	44.75
G0454	Other professional services	MD DOCUMENT VISIT BY NPP	12.35	12.35
G0455	Other professional services	FECAL MICROBIOTA PREP INSTIL	181.70	98.01
G0458	Other professional services	LDR PROSTATE BRACHY COMP RAT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0459	Other professional services	TELEHEALTH INPT PHARM MGMT	60.12	60.12
G0460	Other professional services	AUTOLOG PRP NOT DIAB ULCER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0463	Other professional services	HOSPITAL OUTPT CLINIC VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0465	Other professional services	AUTOLOG PRP DIAB WOUND ULCER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0466	Other professional services	FQHC VISIT NEW PATIENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0467	Other professional services	FQHC VISIT, ESTAB PT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0468	Other professional services	FQHC VISIT, IPPE OR AWV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0469	Other professional services	FQHC VISIT, MH NEW PT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0470	Other professional services	FQHC VISIT, MH ESTAB PT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0471	Clinical Laboratory	VEN BLOOD COLL SNF/HHA	16.25	16.25
G0472	Clinical Laboratory	HEP C SCREEN HIGH RISK/OTHER	69.53	69.53
G0473	Other professional services	GROUP BEHAVE COUNS 2-10	17.54	16.17
G0475	Clinical Laboratory	HIV COMBINATION ASSAY	36.12	36.12
G0476	Clinical Laboratory	HPV COMBO ASSAY CA SCREEN	52.64	52.64
G0480	Clinical Laboratory	DRUG TEST DEF 1-7 CLASSES	171.65	171.65
G0481	Clinical Laboratory	DRUG TEST DEF 8-14 CLASSES	234.89	234.89
G0482	Clinical Laboratory	DRUG TEST DEF 15-21 CLASSES	298.11	298.11
G0483	Clinical Laboratory	DRUG TEST DEF 22+ CLASSES	370.38	370.38
G0490	Other professional services	HOME VISIT RN, LPN BY RHC/FQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0491	Other professional services	DIALYSIS ACU KIDNEY NO ESRD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0492	Other professional services	MD/OTH EVAL ACUT KID NO ESRD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0493	Other professional services	RN CARE EA 15 MIN HH/HOSPICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0494	Other professional services	LPN CARE EA 15MIN HH/HOSPICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0495	Other professional services	RN CARE TRAIN/EDU IN HH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0496	Other professional services	LPN CARE TRAIN/EDU IN HH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0498	Other professional services	CHEMO EXTEND IV INFUS W/PUMP	317.39	297.93
G0499	Clinical Laboratory	HEPB SCREEN HIGH RISK INDIV	42.41	42.41
G0500	Other professional services	MOD SEDAT ENDO SERVICE >5YRS	78.21	7.71
G0501	Other professional services	RESOURCE-INTEN SVC DURING OV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0506	Other professional services	COMP ASSES CARE PLAN CCM SVC	87.90	61.98
G0508	Other professional services	CRIT CARE TELEHEA CONSULT 60	288.53	288.53
G0509	Other professional services	CRIT CARE TELEHEA CONSULT 50	266.31	266.31
G0511	Other professional services	CCM/BHI BY RHC/FQHC 20MIN MO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0512	Other professional services	COCM BY RHC/FQHC 60 MIN MO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G0513	Other professional services	PROLONG PREV SVCS, FIRST 30M	89.19	83.28
G0514	Other professional services	PROLONG PREV SVCS, ADDL 30M	89.64	83.73
G0516	Other professional services	INSERT DRUG DEL IMPLANT, >=4	273.54	135.74
G0517	Other professional services	REMOVE DRUG IMPLANT	304.01	154.82
G0518	Other professional services	REMOVE W INSERT DRUG IMPLANT	531.44	254.00
G0659	Clinical Laboratory	DRUG TEST DEF SIMPLE ALL CL	93.21	93.21
G0913	Other professional services	IMPROVE VISUAL FUNCT	0.00	0.00
G0914	Other professional services	SURVEY NOT COMPLETE	0.00	0.00
G0915	Other professional services	NO IMPROVE VISUAL FUNCT	0.00	0.00
G0916	Other professional services	SATISFY WITH CARE	0.00	0.00
G0917	Other professional services	CARE SURVEY NOT COMPLETE	0.00	0.00
G0918	Other professional services	NO SATISFY WITH CARE	0.00	0.00
G1001	Other professional services	CDSM EVICORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1002	Other professional services	CDSM MEDCURRENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1003	Other professional services	CDSM MEDICALIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1004	Other professional services	CDSM NDSC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1007	Other professional services	CDSM AIM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1008	Other professional services	CDSM CRANBERRY PK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1010	Other professional services	CDSM STANSON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1011	Other professional services	CDSM QUALIFIED NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1012	Other professional services	CDSM AGILEMD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1013	Other professional services	CDSM EVIDENCECARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1014	Other professional services	CDSM INVENIQA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1015	Other professional services	CDSM RELIANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1016	Other professional services	CDSM SPEED OF CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1017	Other professional services	CDSM HEALTHHELP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1018	Other professional services	CDSM INFINX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1019	Other professional services	CDSM LOGICNETS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1020	Other professional services	CDSM CURBSIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1021	Other professional services	CDSM EHEALTHLINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1022	Other professional services	CDSM INTERMOUNTAIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1023	Other professional services	CDSM PERSIVIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1024	Other professional services	CDSM RADRITE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G1025	Other professional services	PT MNTH 1 MCP PROV	0.00	0.00
G1026	Other professional services	PT HEMO > 3MO	0.00	0.00
G1027	Other professional services	PT HEMO < 3MO	0.00	0.00
G1028	Other professional services	TAKE HOME SUPPLY 8MG PER 0.1	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2000	Other professional services	BLINDED CONV. TX MDD CLIN TR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2001	Other professional services	POST D/C H VST NEW PT 20 M	70.35	70.35
G2002	Other professional services	POST-D/C H VST NEW PT 30 M	104.57	104.57
G2003	Other professional services	POST-D/C H VST NEW PT 45 M	171.84	171.84
G2004	Other professional services	POST-D/C H VST NEW PT 60 M	225.81	225.81
G2005	Other professional services	POST-D/C H VST NEW PT 75 M	294.56	294.56
G2006	Other professional services	POST-D/C H VST EXT PT 20 M	68.94	68.94
G2007	Other professional services	POST-D/C H VST EXT PT 30 M	111.08	111.08
G2008	Other professional services	POST-D/C H VST EXT PT 45 M	173.79	173.79
G2009	Other professional services	POST-D/C H VST EXT PT 60 M	245.36	245.36
G2010	Other professional services	REMOT IMAGE SUBMIT BY PT	17.36	12.81
G2011	Other professional services	ALCOHOL/SUB ABUSE ASSESS	23.55	23.55
G2012	Other professional services	BRIEF CHECK IN BY MD/QHP	19.76	17.94
G2013	Other professional services	POST-D/C H VST EXT PT 75 M	294.56	294.56
G2014	Other professional services	POST-D/C CARE PLAN OVERS 30M	104.24	104.24
G2015	Other professional services	POST-D/C CARE PLAN OVERS 60M	146.19	146.19
G2020	Other professional services	HI INTEN SERV FOR SIP MODEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2021	Other professional services	HEA CARE PRACT TX IN PLACE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2022	Other professional services	BENEF REFUSES SERVICE, MOD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2025	Other professional services	DIS SITE TELE SVCS RHC/FQHC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2067	Other professional services	MED ASSIST TX METH WK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2068	Other professional services	MED ASSIST TX BUPRE ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2069	Other professional services	MED ASSIST TX INJECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2070	Other professional services	MED ASSIST TX IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2071	Other professional services	MED TX REMOVE IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2072	Other professional services	MED TX INSERT/REMOVE IMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2073	Other professional services	MED TX NALTREXONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2074	Other professional services	MED ASSIST TX NO DRUG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2075	Other professional services	MED TX MEDS NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2076	Other professional services	INTAKE ACT W/MED EXAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2077	Other professional services	PERIODIC ASSESSMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2078	Other professional services	TAKE-HOME METH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2079	Other professional services	TAKE-HOM BUPRENORPHINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2080	Other professional services	ADD 30 MINS COUNSEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2081	Other professional services	PT 66+ SNP OR LTC POS > 90D	0.00	0.00
G2082	Other professional services	VISIT ESKETAMINE 56M OR LESS	1167.68	49.28
G2083	Other professional services	VISIT ESKETAMINE, > 56M	1657.05	49.28
G2086	Other professional services	OFF BASE OPIOID TX 70MIN	655.53	568.67
G2087	Other professional services	OFF BASE OPIOID TX, 60 M	606.45	548.69
G2088	Other professional services	OFF BASE OPIOID TX, ADD30	82.38	54.20
G2090	Other professional services	PT 66+ FRAILTY AND MED DEM	0.00	0.00
G2091	Other professional services	PT 66+ FRAILTY AND ADV ILL	0.00	0.00
G2092	Other professional services	ACE ARB ARNI	0.00	0.00
G2093	Other professional services	MED DOC RSN NO ACE ARN ARNI	0.00	0.00
G2094	Other professional services	PT RSN NO ACE ARN ARNI	0.00	0.00
G2096	Other professional services	NO RSN ACE ARB ARNI	0.00	0.00
G2097	Other professional services	DX URI 3D AFTER OTHER DX	0.00	0.00
G2098	Other professional services	PT 66+ FRAILTY AND MED DEM	0.00	0.00
G2099	Other professional services	PT 66+ FRAILTY AND ADV ILL	0.00	0.00
G2100	Other professional services	PT 66+ FRAILTY AND MED DEM	0.00	0.00
G2101	Other professional services	PT 66+ FRAILTY AND ADV ILL	0.00	0.00
G2105	Other professional services	PT 66+ SNP OR LTC POS > 90D	0.00	0.00
G2106	Other professional services	PT 66+ FRAILTY AND MED DEM	0.00	0.00
G2107	Other professional services	PT 66+ FRAILTY AND ADV ILL	0.00	0.00
G2112	Other professional services	PRED<=5 MG RA GLU <6M	0.00	0.00
G2113	Other professional services	PRED>5 MG >6M, NO CHG DA	0.00	0.00
G2115	Other professional services	PT 66-80 FRAILTY AND MED DEM	0.00	0.00
G2116	Other professional services	PT 66-80 FRAILTY AND ADV ILL	0.00	0.00
G2118	Other professional services	PT 81+ FRAILTY	0.00	0.00
G2121	Other professional services	PSY DEP ANX AP AND ICD ASSE	0.00	0.00
G2122	Other professional services	PSY/DEP/ANX/APANDICD NOASSE	0.00	0.00
G2125	Other professional services	PT 81+ FRAILTY	0.00	0.00
G2126	Other professional services	PT 66-80 FRAILTY AND ADV ILL	0.00	0.00
G2127	Other professional services	PT 66-80 FRAILTY AND MED DEM	0.00	0.00
G2128	Other professional services	NO ASPIRIN MED RSN	0.00	0.00
G2129	Other professional services	NO BP OUTPT	0.00	0.00
G2136	Other professional services	BK PAIN VAS 6-20WK <= 3	0.00	0.00
G2137	Other professional services	BK PAIN VAS 6-20WK > 3	0.00	0.00
G2138	Other professional services	BK PAIN VAS 9-15MO <= 3	0.00	0.00
G2139	Other professional services	BK PAIN VAS 9-15MO > 3	0.00	0.00
G2140	Other professional services	LEG PAIN VAS 6-20WK <= 3	0.00	0.00
G2141	Other professional services	LEG PAIN VAS 6-20WK > 3	0.00	0.00
G2142	Other professional services	FS ODI 9-15MO POSTOP<= 22	0.00	0.00
G2143	Other professional services	FS ODI 9-15MO > 22	0.00	0.00
G2144	Other professional services	FS ODI 6-20WK POSTOP <= 22	0.00	0.00
G2145	Other professional services	FSODI 6-20WK >22 OR CHG 30PT	0.00	0.00
G2146	Other professional services	LEG PAIN VAS 9-15MO <= 3	0.00	0.00
G2147	Other professional services	LEG PAIN VAS 9-15MO > 3	0.00	0.00
G2148	Other professional services	MPM USED	0.00	0.00
G2149	Other professional services	NO MPM MED RSN	0.00	0.00
G2150	Other professional services	NO MPM	0.00	0.00
G2151	Other professional services	DX DEGEN NEURO	0.00	0.00
G2152	Other professional services	RES CHANGE SC >=0	0.00	0.00
G2167	Other professional services	RES CHANGE SC < 0	0.00	0.00
G2168	Other professional services	SVS BY PT IN HOME HEALTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2169	Other professional services	SVS BY OT IN HOME HEALTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2172	Other professional services	TX FOR OPIOID USE DEMO PROJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2173	Other professional services	URI W COMORB 12M OTH DX	0.00	0.00
G2174	Other professional services	URI NEW RX ANTIBIOTIC 30D	0.00	0.00
G2175	Other professional services	PT COMORB DX 12M OF EPI	0.00	0.00
G2176	Other professional services	OUTPT ED OBS W INPT ADMIT	0.00	0.00
G2177	Other professional services	BRONCH W RX ANTIBX 30D	0.00	0.00
G2178	Other professional services	PT NOT ELIG LOW NEURO EX	0.00	0.00
G2179	Other professional services	MED DOC RSN NO LOW EX	0.00	0.00
G2180	Other professional services	INELIG FOOTWR EVAL	0.00	0.00
G2181	Other professional services	BMI NOT DOC MEDRSN PTREF	0.00	0.00
G2182	Other professional services	PT 1ST BIOLOG ANTIRHEUM	0.00	0.00
G2183	Other professional services	DOC PT UNABLE COMM	0.00	0.00
G2184	Other professional services	NO CAREGIVER	0.00	0.00
G2185	Other professional services	CAREGIVER DEM TRAINED	0.00	0.00
G2186	Other professional services	PT REF APP RSRCS	0.00	0.00
G2187	Other professional services	CLIN IND IMG HD TRAUMA	0.00	0.00
G2188	Other professional services	PT 50 YRS W/CLIN IND HD	0.00	0.00
G2189	Other professional services	IMG HD ABNML NEURO EXAM	0.00	0.00
G2190	Other professional services	IND IMG HD RAD NECK	0.00	0.00
G2191	Other professional services	IND IMG HD POS HD ACHE	0.00	0.00
G2192	Other professional services	>55 YRS TEMP HD ACHE	0.00	0.00
G2193	Other professional services	<6YR NEW ONSET HD ACHE	0.00	0.00
G2194	Other professional services	NEW HDACHE PED PT DIS	0.00	0.00
G2195	Other professional services	OCCIP HDACHE CHILD	0.00	0.00
G2196	Other professional services	SCREEN UNHLTHY ETOH USE	0.00	0.00
G2197	Other professional services	SCREEN HLTHY ETOH USE	0.00	0.00
G2199	Other professional services	NOT SCRN ETOH NO RSN	0.00	0.00
G2200	Other professional services	UNHLTHY ETOH RCVD COUNS	0.00	0.00
G2202	Other professional services	NO RSN NO BRIEF COUNS	0.00	0.00
G2204	Other professional services	PT 45-85 W/ SCOPE	0.00	0.00
G2205	Other professional services	PREG DRNG ADJV TRTMT	0.00	0.00
G2206	Other professional services	ADJV TRTMT CHEMO HER2	0.00	0.00
G2207	Other professional services	RSN NO TRTMT CHEM HER2	0.00	0.00
G2208	Other professional services	NO TRTMT CHEMO AND HER2	0.00	0.00
G2209	Other professional services	REFUSED TO PARTICIPATE	0.00	0.00
G2210	Other professional services	NO NECK FS PROM NO RSN	0.00	0.00
G2211	Other professional services	COMPLEX E/M VISIT ADD ON	23.24	23.24
G2212	Other professional services	PROLONG OUTPT/OFFICE VIS	45.69	43.88
G2213	Other professional services	INITIAT MED ASSIST TX IN ER	90.18	85.19
G2214	Other professional services	INIT/SUB PSYCH CARE M 1ST 30	80.39	54.00
G2215	Other professional services	HOME SUPPLY NASAL NALOXONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2216	Other professional services	HOME SUPPLY INJECT NALOXON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G2250	Other professional services	REMOT IMG SUB BY PT, NON E/M	17.36	12.81
G2251	Other professional services	BRIEF CHKIN, 5-10, NON-E/M	19.76	17.94
G2252	Other professional services	BRIEF CHKIN BY MD/QHP, 11-20	37.37	35.09
G3002	Pain management	CHRONIC PAIN MGMT 30 MINS	126.77	113.42
G3003	Pain management	CHRONIC PAIN MGMT ADDL 15M	46.39	39.48
G4000	Other professional services	DERMATOLOGY SS	0.00	0.00
G4001	Other professional services	DIAGNOSTIC RAD SS	0.00	0.00
G4002	Other professional services	EP CARDIO SS	0.00	0.00
G4003	Other professional services	EMERGENCY MED SS	0.00	0.00
G4004	Other professional services	ENDOCRINOLOGY SS	0.00	0.00
G4005	Other professional services	FAMILY MEDICINE SS	0.00	0.00
G4006	Other professional services	GASTROENTEROLOGY SS	0.00	0.00
G4007	Other professional services	GENERAL SURGERY SS	0.00	0.00
G4008	Other professional services	GERIATRICS SS	0.00	0.00
G4009	Other professional services	HOSPITALISTS SS	0.00	0.00
G4010	Other professional services	INFECTIOUS DISEASE SS	0.00	0.00
G4011	Other professional services	INTERNAL MEDICINE SS	0.00	0.00
G4012	Other professional services	INTERVENTIONAL RAD SS	0.00	0.00
G4013	Other professional services	MNTAL/BEHAV/PSYCH HLTH SS	0.00	0.00
G4014	Other professional services	NEPHROLOGY SS	0.00	0.00
G4015	Other professional services	NEUROLOGY SS	0.00	0.00
G4016	Other professional services	NEUROSURGICAL SS	0.00	0.00
G4017	Other professional services	NUTRITION/DIETICIAN SS	0.00	0.00
G4018	Other professional services	OB/GYN SS	0.00	0.00
G4019	Other professional services	ONCOLOGY/HEMA SS	0.00	0.00
G4020	Other professional services	OPHTHALMOLOGY/OPTOMETRY SS	0.00	0.00
G4021	Other professional services	ORTHOPEDIC SURGERY SS	0.00	0.00
G4022	Other professional services	OTOLARYNGOLOGY SS	0.00	0.00
G4023	Other professional services	PATHOLOGY SS	0.00	0.00
G4024	Other professional services	PEDIATRIC SS	0.00	0.00
G4025	Other professional services	PHYSICAL MEDICINE SS	0.00	0.00
G4026	Other professional services	PHYS/OCC THERAPY SS	0.00	0.00
G4027	Other professional services	PLASTIC SURGERY SS	0.00	0.00
G4028	Other professional services	PODIATRY SS	0.00	0.00
G4029	Other professional services	PREVENTIVE MEDICINE SS	0.00	0.00
G4030	Other professional services	PULMONOLOGY SS	0.00	0.00
G4031	Other professional services	RADIATION ONCOLOGY SS	0.00	0.00
G4032	Other professional services	RHEUMATOLOGY SS	0.00	0.00
G4033	Other professional services	SKILLED NURSING FACILITY SS	0.00	0.00
G4034	Other professional services	SPEECH LANGUAGE PATH SS	0.00	0.00
G4035	Other professional services	THORACIC SURGERY SS	0.00	0.00
G4036	Other professional services	URGENT CARE SS	0.00	0.00
G4037	Other professional services	UROLOGY SS	0.00	0.00
G4038	Other professional services	VASCULAR SURGERY SS	0.00	0.00
G6001	Other professional services	ECHO GUIDANCE RADIOTHERAPY	247.32	247.32
G6001-26	Other professional services	ECHO GUIDANCE RADIOTHERAPY	44.61	44.61
G6001-TC	Other professional services	ECHO GUIDANCE RADIOTHERAPY	202.73	202.73
G6002	Other professional services	STEREOSCOPIC X-RAY GUIDANCE	103.82	103.82
G6002-26	Other professional services	STEREOSCOPIC X-RAY GUIDANCE	28.91	28.91
G6002-TC	Other professional services	STEREOSCOPIC X-RAY GUIDANCE	74.91	74.91
G6003	Other professional services	RADIATION TREATMENT DELIVERY	210.00	210.00
G6004	Other professional services	RADIATION TREATMENT DELIVERY	172.25	172.25
G6005	Other professional services	RADIATION TREATMENT DELIVERY	172.70	172.70
G6006	Other professional services	RADIATION TREATMENT DELIVERY	171.35	171.35
G6007	Other professional services	RADIATION TREATMENT DELIVERY	313.70	313.70
G6008	Other professional services	RADIATION TREATMENT DELIVERY	237.62	237.62
G6009	Other professional services	RADIATION TREATMENT DELIVERY	237.17	237.17
G6010	Other professional services	RADIATION TREATMENT DELIVERY	235.34	235.34
G6011	Other professional services	RADIATION TREATMENT DELIVERY	312.66	312.66
G6012	Other professional services	RADIATION TREATMENT DELIVERY	313.11	313.11
G6013	Other professional services	RADIATION TREATMENT DELIVERY	314.48	314.48
G6014	Other professional services	RADIATION TREATMENT DELIVERY	312.21	312.21
G6015	Other professional services	RADIATION TX DELIVERY IMRT	484.98	484.98
G6016	Other professional services	DELIVERY COMP IMRT	483.35	483.35
G6017	Other professional services	INTRAFRACTION TRACK MOTION	144.32	144.32
G8395	Other professional services	LVEF>=40% DOC NORMAL OR MILD	0.00	0.00
G8396	Other professional services	LVEF NOT PERFORMED	0.00	0.00
G8397	Other professional services	DIL MACULA/FUNDUS EXAM/W DOC	0.00	0.00
G8399	Other professional services	PT W/DXA RESULTS DOCUMENT	0.00	0.00
G8400	Other professional services	PT W/DXA NO RESULTS DOC	0.00	0.00
G8404	Other professional services	LOW EXTEMITY NEUR EXAM DOCUM	0.00	0.00
G8405	Other professional services	LOW EXTEMITY NEUR NOT PERFOR	0.00	0.00
G8410	Other professional services	EVAL ON FOOT DOCUMENTED	0.00	0.00
G8415	Other professional services	EVAL ON FOOT NOT PERFORMED	0.00	0.00
G8416	Other professional services	PT INELIG FOOTWEAR EVALUATIO	0.00	0.00
G8417	Other professional services	CALC BMI ABV UP PARAM F/U	0.00	0.00
G8418	Other professional services	CALC BMI BLW LOW PARAM F/U	0.00	0.00
G8419	Other professional services	CALC BMI OUT NRM PARAM NOF/U	0.00	0.00
G8420	Other professional services	CALC BMI NORM PARAMETERS	0.00	0.00
G8421	Other professional services	BMI NOT CALCULATED	0.00	0.00
G8427	Other professional services	DOCREV CUR MEDS BY ELIG CLIN	0.00	0.00
G8428	Other professional services	CUR MEDS NOT DOCUMENT	0.00	0.00
G8430	Other professional services	DOC MED RSN NO MEDREC	0.00	0.00
G8431	Other professional services	POS CLIN DEPRES SCRN F/U DOC	0.00	0.00
G8432	Other professional services	DEP SCR NOT DOC, RNG	0.00	0.00
G8433	Other professional services	SCR FOR DEP NOT CPT DOC RSN	0.00	0.00
G8450	Other professional services	BETA-BLOC RX PT W/ABN LVEF	0.00	0.00
G8451	Other professional services	PT W/ABN LVEF INELIG B-BLOC	0.00	0.00
G8452	Other professional services	PT W/ABN LVEF B-BLOC NO RX	0.00	0.00
G8465	Other professional services	HIGH RISK RECURRENCE PRO CA	0.00	0.00
G8473	Other professional services	ACE/ARB THXPY RX'D	0.00	0.00
G8474	Other professional services	ACE/ARB NOT RX'D; DOC REAS	0.00	0.00
G8475	Other professional services	ACE/ARB THXPY NOT RX'D	0.00	0.00
G8476	Other professional services	BP SYS <140 AND DIAS <90	0.00	0.00
G8477	Other professional services	BP SYS>=140 AND/OR DIAS >=90	0.00	0.00
G8478	Other professional services	BP NOT PERFORMED/DOC	0.00	0.00
G8482	Other professional services	FLU IMMUNIZE ORDER/ADMIN	0.00	0.00
G8483	Other professional services	FLU IMM NO ADMIN DOC REA	0.00	0.00
G8484	Other professional services	FLU IMMUNIZE NO ADMIN	0.00	0.00
G8510	Other professional services	SCR DEP NEG, NO PLAN REQD	0.00	0.00
G8511	Other professional services	SCR DEP POS, NO PLAN DOC RNG	0.00	0.00
G8535	Other professional services	ELD MALTREATMENT NOT DOC	0.00	0.00
G8536	Other professional services	NO DOC ELDER MAL SCRN	0.00	0.00
G8539	Other professional services	DOC FUNCT AND CARE PLAN	0.00	0.00
G8540	Other professional services	FOA NOT DOC AS BEING PERF	0.00	0.00
G8541	Other professional services	NO DOC CUR FUNCT ASSESS	0.00	0.00
G8542	Other professional services	DOC FUNCT NO DEFICIENCIES	0.00	0.00
G8543	Other professional services	CUR FUNCT ASSES; NO CARE PLN	0.00	0.00
G8559	Other professional services	PT REF DOC OTO EVAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8560	Other professional services	PT HX ACT DRAIN PREV 90 DAYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8561	Other professional services	PT INELIG FOR REF OTO EVAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8562	Other professional services	PT NO HX ACT DRAIN 90 D	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8563	Other professional services	PT NO REF OTO REAS NO SPEC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8564	Other professional services	PT REF OTO EVAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8565	Other professional services	VER DOC HEAR LOSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8566	Other professional services	PT INELIG REF OTO EVAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8567	Other professional services	PT NO DOC HEAR LOSS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8568	Other professional services	PT NO REF OTOLO NO SPEC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8569	Other professional services	PROL INTUBATION REQ	0.00	0.00
G8570	Other professional services	NO PROL INTUB REQ	0.00	0.00
G8575	Other professional services	POSTOP REN FAIL	0.00	0.00
G8576	Other professional services	NO POSTOP REN FAIL	0.00	0.00
G8577	Other professional services	REOP REQ BLD GRFT OTH	0.00	0.00
G8578	Other professional services	NO REOP REQ BLD GRFT OTH	0.00	0.00
G8598	Other professional services	ASA/ANTIPLAT THER USED	0.00	0.00
G8599	Other professional services	NO ASA/ANTIPLAT THER USE RNG	0.00	0.00
G8600	Other professional services	TPA INITI W/IN 4.5 HR	0.00	0.00
G8601	Other professional services	NO ELIG TPA INIT W/IN 4.5 HR	0.00	0.00
G8602	Other professional services	NO TPA INIT W/IN 4.5 HR	0.00	0.00
G8633	Other professional services	PHARM THER OSTEO RX	0.00	0.00
G8635	Other professional services	NO PHARM THER OSTEO RX	0.00	0.00
G8647	Other professional services	RAFSCRS KI SCOR >= 0	0.00	0.00
G8648	Other professional services	RAFSCRS KI SCOR < 0	0.00	0.00
G8650	Other professional services	RAFS CRS KI NO SCOR NO RSN	0.00	0.00
G8651	Other professional services	RAFSCRS HI SCOR >=0	0.00	0.00
G8652	Other professional services	RAFSCRS HI SCOR < 0	0.00	0.00
G8654	Other professional services	RAFS CRS HI NO SCOR NO SURV	0.00	0.00
G8655	Other professional services	RAFSCRS LLFAI SCOR >= 0	0.00	0.00
G8656	Other professional services	RAFSCRS LLFAI SCOR < 0	0.00	0.00
G8658	Other professional services	RAFSCRS LLFAI NO SCOR + SURV	0.00	0.00
G8659	Other professional services	RAFSCRS LBI SCOR >= 0	0.00	0.00
G8660	Other professional services	RAFSCRS LBI SCOR < 0	0.00	0.00
G8661	Other professional services	RAFSCRS LBI NO SCOR	0.00	0.00
G8662	Other professional services	RAFS CRS LBI NO SCOR NO SURV	0.00	0.00
G8663	Other professional services	RAFSCRS SI SCOR >= 0	0.00	0.00
G8664	Other professional services	RAFSCRS SI SCOR < 0	0.00	0.00
G8666	Other professional services	RAFS CRS SI NO SCOR NO SURV	0.00	0.00
G8667	Other professional services	RAFSCRS EWH SCOR >= 0	0.00	0.00
G8668	Other professional services	RAFSCRS EWH SCOR < 0	0.00	0.00
G8670	Other professional services	RAFS CRS EWH NO SCOR NO SURV	0.00	0.00
G8694	Other professional services	LVEF <=40%	0.00	0.00
G8708	Other professional services	ANTIBIOTIC NOT PRES	0.00	0.00
G8709	Other professional services	URI EP COMPETE DIAG	0.00	0.00
G8710	Other professional services	PT PRES ANTIBIOTIC	0.00	0.00
G8711	Other professional services	PRES ANTIBX ON/WITHIN 3 DAY	0.00	0.00
G8712	Other professional services	NOT PRES ANTIBIOTIC	0.00	0.00
G8721	Other professional services	PT, PN, HIST GRADE DOC	0.00	0.00
G8722	Other professional services	MED REAS PT, PN, NOT DOC	0.00	0.00
G8723	Other professional services	SPEC SIT NOT PRIM TUMOR	0.00	0.00
G8724	Other professional services	PT, PN, HIST GRADE NOT DOC	0.00	0.00
G8733	Other professional services	DOC POS ELDER MAL SCRN PLAN	0.00	0.00
G8734	Other professional services	DOC NEG ELD REQ	0.00	0.00
G8735	Other professional services	ELD MAL SCRN POS NO PLAN	0.00	0.00
G8749	Other professional services	NO SIGNS MELANOMA	0.00	0.00
G8752	Other professional services	SYS BP LESS 140	0.00	0.00
G8753	Other professional services	SYS BP > OR = 140	0.00	0.00
G8754	Other professional services	DIAS BP LESS 90	0.00	0.00
G8755	Other professional services	DIAS BP > OR = 90	0.00	0.00
G8756	Other professional services	NO BP MEASURE DOC	0.00	0.00
G8783	Other professional services	BP SCRN PERF REC INTERVAL	0.00	0.00
G8785	Other professional services	BP SCRN NO PERF AT INTERVAL	0.00	0.00
G8797	Other professional services	SPECIMEN SITE NOT ESOPHAGUS	0.00	0.00
G8798	Other professional services	SPECIMEN SITE NOT PROSTATE	0.00	0.00
G8806	Other professional services	PERF ULTRSND TO LCT PREG DOC	0.00	0.00
G8807	Other professional services	NO TA TV ULTRASND	0.00	0.00
G8808	Other professional services	ULTRASOUND NOT PERF, RNG	0.00	0.00
G8815	Other professional services	DOC REAS NO STATIN THERAPY	0.00	0.00
G8816	Other professional services	STATIN MED PRES AT DISCH	0.00	0.00
G8817	Other professional services	DOC REAS NO STATIN MED DISCH	0.00	0.00
G8826	Other professional services	PT DISCH HOME DAY #2 EVAR	0.00	0.00
G8833	Other professional services	PT NOT DISCH HOME DAY#2 EVAR	0.00	0.00
G8834	Other professional services	PT DISCH HOME DAY #2 CEA	0.00	0.00
G8838	Other professional services	NOT DISCH HOME BY DAY #2	0.00	0.00
G8839	Other professional services	SLEEP APNEA ASSESS	0.00	0.00
G8840	Other professional services	DOC REAS NO SLEEP APNEA	0.00	0.00
G8841	Other professional services	NO SLEEP APNEA ASSESS	0.00	0.00
G8842	Other professional services	AHI OR RDI INITIAL DX	0.00	0.00
G8843	Other professional services	DOC REAS NO AHI OR RDI	0.00	0.00
G8844	Other professional services	NO AHI OR RDI INITIAL DX	0.00	0.00
G8845	Other professional services	POS AIRWAY PRESS PRESCRIBED	0.00	0.00
G8846	Other professional services	MOD OR SEVERE OSA	0.00	0.00
G8849	Other professional services	DOC REAS NO POS AIR PRESS	0.00	0.00
G8850	Other professional services	NO PAP PRESCRIBED	0.00	0.00
G8851	Other professional services	ADHERE TX ASSESS AT LST ANN	0.00	0.00
G8854	Other professional services	REAS NO ADHERE THERAPY	0.00	0.00
G8855	Other professional services	THER NOT ASSESSED ANNUALLY	0.00	0.00
G8856	Other professional services	REF FOR OTO EVAL	0.00	0.00
G8857	Other professional services	NO ELIG REF FOR OTO EVAL	0.00	0.00
G8858	Other professional services	NOT REF FOR OTO EVAL	0.00	0.00
G8863	Other professional services	NO ASSESS BONE LOSS	0.00	0.00
G8864	Other professional services	PNEUMOCOCCAL VACCINE ADMIN	0.00	0.00
G8865	Other professional services	DOC MED REAS NO PNEUMOCOCCAL	0.00	0.00
G8866	Other professional services	DOC PT REAS NO PNEUMOCOCCAL	0.00	0.00
G8867	Other professional services	NO PNEUMOCOCCAL ADMIN	0.00	0.00
G8869	Other professional services	DOC IMMUNE HEP B ANTITNF	0.00	0.00
G8875	Other professional services	BREAST CANCER DX MIN INVSIVE	0.00	0.00
G8876	Other professional services	DOC REAS NO MIN INV DX	0.00	0.00
G8877	Other professional services	NO BRST CNCR DX MIN INVASIVE	0.00	0.00
G8878	Other professional services	SENT LYMPH NODE BIOPSY	0.00	0.00
G8880	Other professional services	SEN LYM P NODE BIOP NOT PERF	0.00	0.00
G8881	Other professional services	BRST CNCR STAGE > T1N0M0	0.00	0.00
G8882	Other professional services	NO SENT LYMPH NODE BIOPSY	0.00	0.00
G8907	Other professional services	PT DOC NO EVENTS ON DISCHARG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8908	Other professional services	PT DOC W BURN PRIOR TO D/C	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8909	Other professional services	PT DOC NO BURN PRIOR TO D/C	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8910	Other professional services	PT DOC TO HAVE FALL IN ASC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8911	Other professional services	PT DOC NO FALL IN ASC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8912	Other professional services	PT DOC WITH WRONG EVENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8913	Other professional services	PT DOC NO WRONG EVENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8914	Other professional services	PT TRANS TO HOSP POST D/C	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8915	Other professional services	PT NOT TRANS TO HOSP AT D/C	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8916	Other professional services	PT W IV AB GIVEN ON TIME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8917	Other professional services	PT W IV AB NOT GIVEN ON TIME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8918	Other professional services	PT W/O PREOP ORDER IV AB PRO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G8923	Other professional services	LVEF <= 40% OR LVSD	0.00	0.00
G8924	Other professional services	SPIR RES DOC FEV1/FVC<70%	0.00	0.00
G8934	Other professional services	LVEF <=40% OR DEP LV SYS FCN	0.00	0.00
G8935	Other professional services	RX ACE OR ARB THERAPY	0.00	0.00
G8936	Other professional services	PT NOT ELIGIBLE ACE/ARB	0.00	0.00
G8937	Other professional services	NO RX ACE/ARB THERAPY	0.00	0.00
G8942	Other professional services	DOC FCN/CARE PLAN W/30 DAYS	0.00	0.00
G8944	Other professional services	AJCC MEL CNR STG 0 - IIC	0.00	0.00
G8946	Other professional services	MIBM BUT NO DX OF BREAST CA	0.00	0.00
G8950	Other professional services	PRE-HTN OR HTN DOC, F/U INDC	0.00	0.00
G8952	Other professional services	PRE-HTN/HTN, NO F/U, NOT GVN	0.00	0.00
G8955	Other professional services	MOST RECENT ASSESS VOL MGMT	0.00	0.00
G8956	Other professional services	PT RCV HEDIA OUTPT DYLS FAC	0.00	0.00
G8958	Other professional services	ASSESS VOL MGMT NOT DOC	0.00	0.00
G8961	Other professional services	CSIT LOWRISK SURG PTS PREOP	0.00	0.00
G8962	Other professional services	CSIT ON PT ANY REAS 30 DAYS	0.00	0.00
G8965	Other professional services	CSIT PERF ON LOW CHD RSK	0.00	0.00
G8966	Other professional services	CSIT PERF SX OR HIGH CHD RSK	0.00	0.00
G8967	Other professional services	WARF OR OTHER FDA DRUG PRESC	0.00	0.00
G8968	Other professional services	DOC MED NOT PRESB	0.00	0.00
G8969	Other professional services	DOC PT RSN NO PRESC WARF/FDA	0.00	0.00
G8970	Other professional services	NO RSK FAC OR 1 MOD RISK TE	0.00	0.00
G9001	Other professional services	MCCD, INITIAL RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9002	Other professional services	MCCD,MAINTENANCE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9003	Other professional services	MCCD, RISK ADJ HI, INITIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9004	Other professional services	MCCD, RISK ADJ LO, INITIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9005	Other professional services	MCCD, RISK ADJ, MAINTENANCE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9006	Other professional services	MCCD, HOME MONITORING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9007	Other professional services	MCCD, SCH TEAM CONF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9008	Other professional services	MCCD,PHYS COOR-CARE OVRSGHT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9009	Other professional services	MCCD, RISK ADJ, LEVEL 3	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9010	Other professional services	MCCD, RISK ADJ, LEVEL 4	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9011	Other professional services	MCCD, RISK ADJ, LEVEL 5	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9012	Other professional services	OTHER SPECIFIED CASE MGMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9013	Other professional services	ESRD DEMO BUNDLE LEVEL I	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9014	Other professional services	ESRD DEMO BUNDLE-LEVEL II	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9016	Other professional services	DEMO-SMOKING CESSATION COUN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9050	Other professional services	ONCOLOGY WORK-UP EVALUATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9051	Other professional services	ONCOLOGY TX DECISION-MGMT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9052	Other professional services	ONC SURVEILLANCE FOR DISEASE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9053	Other professional services	ONC EXPECTANT MANAGEMENT PT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9054	Other professional services	ONC SUPERVISION PALLIATIVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9055	Other professional services	ONC VISIT UNSPECIFIED NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9056	Other professional services	ONC PRAC MGMT ADHERES GUIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9057	Other professional services	ONC PRACT MGMT DIFFERS TRIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9058	Other professional services	ONC PRAC MGMT DISAGREE W/GUI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9059	Other professional services	ONC PRAC MGMT PT OPT ALTERNA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9060	Other professional services	ONC PRAC MGMT DIF PT COMORB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9061	Other professional services	ONC PRAC COND NOADD BY GUIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9062	Other professional services	ONC PRAC GUIDE DIFFERS NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9063	Other professional services	ONC DX NSCLC STGI NO PROGRES	0.00	0.00
G9064	Other professional services	ONC DX NSCLC STG2 NO PROGRES	0.00	0.00
G9065	Other professional services	ONC DX NSCLC STG3A NO PROGRE	0.00	0.00
G9066	Other professional services	ONC DX NSCLC STG3B-4 METASTA	0.00	0.00
G9067	Other professional services	ONC DX NSCLC DX UNKNOWN NOS	0.00	0.00
G9068	Other professional services	ONC DX SCLC/NSCLC LIMITED	0.00	0.00
G9069	Other professional services	ONC DX SCLC/NSCLC EXT AT DX	0.00	0.00
G9070	Other professional services	ONC DX SCLC/NSCLC EXT UNKNWN	0.00	0.00
G9071	Other professional services	ONC DX BRST STG1-2B HR,NOPRO	0.00	0.00
G9072	Other professional services	ONC DX BRST STG1-2 NOPROGRES	0.00	0.00
G9073	Other professional services	ONC DX BRST STG3-HR, NO PRO	0.00	0.00
G9074	Other professional services	ONC DX BRST STG3-NOPROGRESS	0.00	0.00
G9075	Other professional services	ONC DX BRST METASTIC/ RECUR	0.00	0.00
G9077	Other professional services	ONC DX PROSTATE T1NO PROGRES	0.00	0.00
G9078	Other professional services	ONC DX PROSTATE T2NO PROGRES	0.00	0.00
G9079	Other professional services	ONC DX PROSTATE T3B-T4NOPROG	0.00	0.00
G9080	Other professional services	ONC DX PROSTATE W/RISE PSA	0.00	0.00
G9083	Other professional services	ONC DX PROSTATE UNKNWN NOS	0.00	0.00
G9084	Other professional services	ONC DX COLON T1-3,N1-2,NO PR	0.00	0.00
G9085	Other professional services	ONC DX COLON T4, N0 W/O PROG	0.00	0.00
G9086	Other professional services	ONC DX COLON T1-4 NO DX PROG	0.00	0.00
G9087	Other professional services	ONC DX COLON METAS EVID DX	0.00	0.00
G9088	Other professional services	ONC DX COLON METAS NOEVID DX	0.00	0.00
G9089	Other professional services	ONC DX COLON EXTENT UNKNOWN	0.00	0.00
G9090	Other professional services	ONC DX RECTAL T1-2 NO PROGR	0.00	0.00
G9091	Other professional services	ONC DX RECTAL T3 N0 NO PROG	0.00	0.00
G9092	Other professional services	ONC DX RECTAL T1-3,N1-2NOPRG	0.00	0.00
G9093	Other professional services	ONC DX RECTAL T4,N,M0 NO PRG	0.00	0.00
G9094	Other professional services	ONC DX RECTAL M1 W/METS PROG	0.00	0.00
G9095	Other professional services	ONC DX RECTAL EXTENT UNKNWN	0.00	0.00
G9096	Other professional services	ONC DX ESOPHAG T1-T3 NOPROG	0.00	0.00
G9097	Other professional services	ONC DX ESOPHAGEAL T4 NO PROG	0.00	0.00
G9098	Other professional services	ONC DX ESOPHAGEAL METS RECUR	0.00	0.00
G9099	Other professional services	ONC DX ESOPHAGEAL UNKNOWN	0.00	0.00
G9100	Other professional services	ONC DX GASTRIC NO RECURRENCE	0.00	0.00
G9101	Other professional services	ONC DX GASTRIC P R1-R2NOPROG	0.00	0.00
G9102	Other professional services	ONC DX GASTRIC UNRESECTABLE	0.00	0.00
G9103	Other professional services	ONC DX GASTRIC RECURRENT	0.00	0.00
G9104	Other professional services	ONC DX GASTRIC UNKNOWN NOS	0.00	0.00
G9105	Other professional services	ONC DX PANCREATC P R0 RES NO	0.00	0.00
G9106	Other professional services	ONC DX PANCREATC P R1/R2 NO	0.00	0.00
G9107	Other professional services	ONC DX PANCREATIC UNRESECTAB	0.00	0.00
G9108	Other professional services	ONC DX PANCREATIC UNKNWN NOS	0.00	0.00
G9109	Other professional services	ONC DX HEAD/NECK T1-T2NO PRG	0.00	0.00
G9110	Other professional services	ONC DX HEAD/NECK T3-4 NOPROG	0.00	0.00
G9111	Other professional services	ONC DX HEAD/NECK M1 METS REC	0.00	0.00
G9112	Other professional services	ONC DX HEAD/NECK EXT UNKNOWN	0.00	0.00
G9113	Other professional services	ONC DX OVARIAN STG1A-B NO PR	0.00	0.00
G9114	Other professional services	ONC DX OVARIAN STG1A-B OR 2	0.00	0.00
G9115	Other professional services	ONC DX OVARIAN STG3/4 NOPROG	0.00	0.00
G9116	Other professional services	ONC DX OVARIAN RECURRENCE	0.00	0.00
G9117	Other professional services	ONC DX OVARIAN UNKNOWN NOS	0.00	0.00
G9123	Other professional services	ONC DX CML CHRONIC PHASE	0.00	0.00
G9124	Other professional services	ONC DX CML ACCELER PHASE	0.00	0.00
G9125	Other professional services	ONC DX CML BLAST PHASE	0.00	0.00
G9126	Other professional services	ONC DX CML REMISSION	0.00	0.00
G9128	Other professional services	ONC DX MULTI MYELOMA STAGE I	0.00	0.00
G9129	Other professional services	ONC DX MULT MYELOMA STG2 HIG	0.00	0.00
G9130	Other professional services	ONC DX MULTI MYELOMA UNKNOWN	0.00	0.00
G9131	Other professional services	ONC DX BRST UNKNOWN NOS	0.00	0.00
G9132	Other professional services	ONC DX PROSTATE METS NO CAST	0.00	0.00
G9133	Other professional services	ONC DX PROSTATE CLINICAL MET	0.00	0.00
G9134	Other professional services	ONC NHLSTG 1-2 NO RELAP NO	0.00	0.00
G9135	Other professional services	ONC DX NHL STG 3-4 NOT RELAP	0.00	0.00
G9136	Other professional services	ONC DX NHL TRANS TO LG BCELL	0.00	0.00
G9137	Other professional services	ONC DX NHL RELAPSE/REFRACTOR	0.00	0.00
G9138	Other professional services	ONC DX NHL STG UNKNOWN	0.00	0.00
G9139	Other professional services	ONC DX CML DX STATUS UNKNOWN	0.00	0.00
G9140	Other professional services	FRONTIER EXTENDED STAY DEMO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9143	Clinical Laboratory	WARFARIN RESPON GENETIC TEST	181.08	181.08
G9147	Other professional services	OUTPT IV INSULIN TX ANY MEA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9148	Other professional services	MEDICAL HOME LEVEL 1	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9149	Other professional services	MEDICAL HOME LEVEL II	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9150	Other professional services	MEDICAL HOME LEVEL III	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9151	Other professional services	MAPCP DEMO STATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9152	Other professional services	MAPCP DEMO COMMUNITY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9153	Other professional services	MAPCP DEMO PHYSICIAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9156	Other professional services	EVALUATION FOR WHEELCHAIR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9157	Other professional services	TRANSESOPH DOPPL CARDIAC MON	132.14	132.14
G9187	Other professional services	BPCI HOME VISIT	65.31	65.31
G9188	Other professional services	BETA NOT GIVEN NO REASON	0.00	0.00
G9189	Other professional services	BETA PRES OR ALREADY TAKING	0.00	0.00
G9190	Other professional services	MEDICAL REASON FOR NO BETA	0.00	0.00
G9191	Other professional services	PT REASON FOR NO BETA	0.00	0.00
G9212	Other professional services	DOC OF DSM-IV INIT EVAL	0.00	0.00
G9213	Other professional services	NO DOC OF DSM-IV	0.00	0.00
G9223	Other professional services	PJP PROPH ORDERED CD4 LOW	0.00	0.00
G9225	Other professional services	NORSN NO FOOT EXAM	0.00	0.00
G9226	Other professional services	3 COMP FOOT EXAM COMPLETED	0.00	0.00
G9227	Other professional services	FOA DOC, CARE PLAN NOT DOC	0.00	0.00
G9228	Other professional services	GC CHL SYP DOCUMENTED	0.00	0.00
G9230	Other professional services	NORSN FOR GC CHL SYP TEST	0.00	0.00
G9231	Other professional services	DOC ESRD DIA TRANS PREG	0.00	0.00
G9242	Other professional services	DOC VIRAL LOAD >=200	0.00	0.00
G9243	Other professional services	DOC VIRAL LOAD <200	0.00	0.00
G9246	Other professional services	NO MED VISIT IN 24MO	0.00	0.00
G9247	Other professional services	1 MED VISIT IN 24MO	0.00	0.00
G9254	Other professional services	DOC PT DISCHG >2D	0.00	0.00
G9255	Other professional services	DOC PT DISCHG <=2D	0.00	0.00
G9273	Other professional services	SYS<140 AND DIA<90	0.00	0.00
G9274	Other professional services	BP OUT OF NRML LIMITS	0.00	0.00
G9275	Other professional services	DOC OF NON TOBACCO USER	0.00	0.00
G9276	Other professional services	DOC OF TOBACCO USER	0.00	0.00
G9277	Other professional services	DOC DAILY ASPIRIN OR CONTRA	0.00	0.00
G9278	Other professional services	DOC NO DAILY ASPIRIN	0.00	0.00
G9279	Other professional services	PNE SCRN DONE DOC VAC DONE	0.00	0.00
G9280	Other professional services	PNE NOT GIVEN NORSN	0.00	0.00
G9281	Other professional services	PNE SCRN DONE DOC NOT IND	0.00	0.00
G9282	Other professional services	DOC MEDRSN NO HISTO TYPE	0.00	0.00
G9283	Other professional services	HIST TYPE DOC ON REPORT	0.00	0.00
G9284	Other professional services	NO HIST TYPE DOC ON REPORT	0.00	0.00
G9285	Other professional services	SITE NOT SMALL CELL LUNG CA	0.00	0.00
G9286	Other professional services	ANTIBIO RX W IN 10D OF SYMPT	0.00	0.00
G9287	Other professional services	NO ANTIBIO W IN 10D OF SYMPT	0.00	0.00
G9288	Other professional services	DOC MEDRSN NO HIST TYPE RPT	0.00	0.00
G9289	Other professional services	DOC TYPE NSM LUNG CA	0.00	0.00
G9290	Other professional services	NO DOC TYPE NSM LUNG CA	0.00	0.00
G9291	Other professional services	NOT NSM LUNG CA	0.00	0.00
G9292	Other professional services	MEDRSN NO PT CATEGORY	0.00	0.00
G9293	Other professional services	NO PT CATEGORY ON REPORT	0.00	0.00
G9294	Other professional services	PT CAT AND THCK ON REPORT	0.00	0.00
G9295	Other professional services	NON CUTANEOUS LOC	0.00	0.00
G9296	Other professional services	DOC SHARE DEC PRIOR PROC	0.00	0.00
G9297	Other professional services	NO DOC SHARE DEC PRIOR PROC	0.00	0.00
G9298	Other professional services	EVAL RISK VTE CARD 30D PRIOR	0.00	0.00
G9299	Other professional services	NO EVAL RISK VTE CARD PRIOR	0.00	0.00
G9305	Other professional services	NO INTERV REQ FOR LEAK	0.00	0.00
G9306	Other professional services	INTERV REQ FOR LEAK	0.00	0.00
G9307	Other professional services	NO RET FOR SURG W IN 30D	0.00	0.00
G9308	Other professional services	UNPL RET OR W/COMPL W/IN 30D	0.00	0.00
G9309	Other professional services	NO UNPLND HOSP READM IN 30D	0.00	0.00
G9310	Other professional services	UNPLND HOSP READM IN 30D	0.00	0.00
G9311	Other professional services	NO SURG SITE INFECTION	0.00	0.00
G9312	Other professional services	SURGICAL SITE INFECTION	0.00	0.00
G9313	Other professional services	AMOXIC NOT PRESC AS 1ST LINE	0.00	0.00
G9314	Other professional services	NORSN NOT FIRST LINE AMOX	0.00	0.00
G9315	Other professional services	AMOX W/WO CLAV RX	0.00	0.00
G9316	Other professional services	DOC COMM RISK CALC	0.00	0.00
G9317	Other professional services	NO DOC COMM RISK CALC	0.00	0.00
G9318	Other professional services	IMAGE STD NOMENCLATURE	0.00	0.00
G9319	Other professional services	IMAGE NOT STD NOMENCLATURE	0.00	0.00
G9321	Other professional services	DOC COUNT OF CT IN 12MO	0.00	0.00
G9322	Other professional services	NO DOC COUNT OF CT IN 12MO	0.00	0.00
G9341	Other professional services	SRCH FOR CT W IN 12 MOS	0.00	0.00
G9342	Other professional services	NO SRCH FOR CT IN 12MO NORSN	0.00	0.00
G9344	Other professional services	SYSRSN NO DICOM SRCH	0.00	0.00
G9345	Other professional services	FOLLOW UP PULM NOD	0.00	0.00
G9347	Other professional services	NO FOLLOW UP PULM NOD NORSN	0.00	0.00
G9351	Other professional services	DOC >1 SINUS CT W 90D DX	0.00	0.00
G9352	Other professional services	NOT >1 SINUS CT W 90D DX	0.00	0.00
G9353	Other professional services	MEDRSN >1 SINUS CT W 90D DX	0.00	0.00
G9354	Other professional services	1 OR NO CT SINUS W/IN 90D DX	0.00	0.00
G9355	Other professional services	NO EARLY IND/DELIVERY	0.00	0.00
G9356	Other professional services	EARLY IND/DELIVERY	0.00	0.00
G9357	Other professional services	PP EVAL/EDU PERF	0.00	0.00
G9358	Other professional services	PP EVAL/EDU NOT PERF	0.00	0.00
G9361	Other professional services	DOC RSN ELECT C-SEC/INDUCT	0.00	0.00
G9364	Other professional services	SINUS CAUS BAC INX	0.00	0.00
G9367	Other professional services	>= 2 SAME HI-RSK MED ORD	0.00	0.00
G9368	Other professional services	>= 2 SAME HI-RSK MED NOT ORD	0.00	0.00
G9380	Other professional services	OFF ASSIS EOL ISS	0.00	0.00
G9382	Other professional services	NO OFF ASSIS EOL	0.00	0.00
G9383	Other professional services	RECD SCRN HCV INFEC	0.00	0.00
G9384	Other professional services	DOC MED RSN NO HCV SCRN	0.00	0.00
G9385	Other professional services	DOC PT REAS NOT REC HCV SRN	0.00	0.00
G9386	Other professional services	SCRN HCV INFEC NOT RECD	0.00	0.00
G9393	Other professional services	INI PHQ9 >9 REMISS <5	0.00	0.00
G9394	Other professional services	DX BIPOL, DEATH, NHRES, HOSP	0.00	0.00
G9395	Other professional services	INI PHQ9 >9 NO REMISS >=5	0.00	0.00
G9396	Other professional services	INI PHQ9 >9 NOT ASSESS	0.00	0.00
G9402	Other professional services	RECD F/U W/IN 30D DISCH	0.00	0.00
G9403	Other professional services	DOC REAS NO 30 DAY F/U	0.00	0.00
G9404	Other professional services	NO 30 DAY F/U	0.00	0.00
G9405	Other professional services	RECD F/U W/IN 7D DC	0.00	0.00
G9406	Other professional services	DOC REAS NO 7D F/U	0.00	0.00
G9407	Other professional services	NO 7D F/U	0.00	0.00
G9408	Other professional services	CARD TAMP W/IN 30D	0.00	0.00
G9409	Other professional services	NO CARD TAMP E/IN 30D	0.00	0.00
G9410	Other professional services	ADMIT W/IN 180D REQ REMOV	0.00	0.00
G9411	Other professional services	NO ADMIT W/IN 180D REQ REMOV	0.00	0.00
G9412	Other professional services	ADMIT W/IN 180D REQ SURG REV	0.00	0.00
G9413	Other professional services	NO ADMIT REQ SURG REV	0.00	0.00
G9414	Other professional services	1DOSE MENIG VAC BTWN 11 & 13	0.00	0.00
G9415	Other professional services	NO 1DOSE MENI VAC BTWN 11&13	0.00	0.00
G9416	Other professional services	PT 1 TDAP BETW 10-13 YRS	0.00	0.00
G9417	Other professional services	PT NOT 1 TDAP BETW 10-13 YRS	0.00	0.00
G9418	Other professional services	LUNGCX BX RPT DOCS CLASS	0.00	0.00
G9419	Other professional services	MED REAS NOT INCL HISTO TYPE	0.00	0.00
G9420	Other professional services	SPEC SITE NO LUNG	0.00	0.00
G9421	Other professional services	LUNG CX BX RPT NO DOC CLASS	0.00	0.00
G9422	Other professional services	RPT DOC CLASS HISTO TYPE	0.00	0.00
G9423	Other professional services	MED REAS RPT NO HISTO TYPE	0.00	0.00
G9424	Other professional services	SITE NO LUNG OR LUNG CX	0.00	0.00
G9425	Other professional services	SPEC RPT NO DOC CLASS HISTO	0.00	0.00
G9426	Other professional services	IMPR MED TIME EDARR PAIN MED	0.00	0.00
G9427	Other professional services	NO IMPRO MED TIME PAIN MED	0.00	0.00
G9428	Other professional services	PATHO RPT INCL PT CTG	0.00	0.00
G9429	Other professional services	DOC MED RSN NO PT CAT	0.00	0.00
G9430	Other professional services	SPEC SITE NO CUTANEOUS	0.00	0.00
G9431	Other professional services	PATHO RPT NO PT CTG	0.00	0.00
G9432	Other professional services	ASTH CONTROLLED	0.00	0.00
G9434	Other professional services	ASTH NOT CONTROLLED	0.00	0.00
G9452	Other professional services	DOC MED REAS NO HCV TEST	0.00	0.00
G9455	Other professional services	ABD IMAG W/US, CT OR MRI	0.00	0.00
G9456	Other professional services	DOC MED PT REAS NO HCC SCRN	0.00	0.00
G9457	Other professional services	PT NO ABD IMG NO DOC RSN	0.00	0.00
G9458	Other professional services	TOB USER RECD CESS INTERV	0.00	0.00
G9459	Other professional services	TOB NON-USER	0.00	0.00
G9460	Other professional services	NO TOB ASSESS OR CESS INTER	0.00	0.00
G9468	Other professional services	NO RECD CORTICO>=10MG/D >60D	0.00	0.00
G9470	Other professional services	NO REC CORTICO>60D 1RX 600MG	0.00	0.00
G9471	Other professional services	W/IN 2YR DXA NOT ORDER	0.00	0.00
G9473	Other professional services	CHAP SERVICES AT HOSPICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9474	Other professional services	DIET COUNSEL AT HOSPICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9475	Other professional services	OTHER COUNSELOR AT HOSPICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9476	Other professional services	VOLUN SERVICE AT HOSPICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9477	Other professional services	CARE COORD AT HOSPICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9478	Other professional services	OTHE THERAPIST AT HOSPICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9479	Other professional services	PHARMACIST AT HOSPICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9480	Other professional services	ADMISSION TO MCCM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9481	Other professional services	REMOTE E/M NEW PT 10MINS	25.53	25.53
G9482	Other professional services	REMOTE E/M NEW PT 20MINS	48.29	48.29
G9483	Other professional services	REMOTE E/M NEW PT 30MINS	74.97	74.97
G9484	Other professional services	REMOTE E/M NEW PT 45MINS	127.19	127.19
G9485	Other professional services	REMOTE E/M NEW PT 60MINS	166.47	166.47
G9486	Other professional services	REMOTE E/M EST. PT 10MINS	25.53	25.53
G9487	Other professional services	REMOTE E/M EST. PT 15MINS	50.91	50.91
G9488	Other professional services	REMOTE E/M EST. PT 25MINS	78.24	78.24
G9489	Other professional services	REMOTE E/M EST. PT 40MINS	110.82	110.82
G9490	Other professional services	CMMI MOD HOME VISIT	65.31	65.31
G9497	Other professional services	REC INST NO SMOKE DAY SURG	0.00	0.00
G9498	Other professional services	ABX REG PRESCRIBED	0.00	0.00
G9500	Other professional services	RAD EXPOS IND/EXP TM DOC	0.00	0.00
G9501	Other professional services	RAD EXPOS IND/EXP TM NO DOC	0.00	0.00
G9502	Other professional services	MED REAS NO PERF FOOT EXAM	0.00	0.00
G9504	Other professional services	DOC RSN HEP B STAT NOT ASSES	0.00	0.00
G9505	Other professional services	ABX PRES W/IN 10 DYS OF SYMP	0.00	0.00
G9507	Other professional services	DOC REAS ON STATIN OR CONTRA	0.00	0.00
G9508	Other professional services	DOC PT NOT ON STATIN	0.00	0.00
G9509	Other professional services	ADIT MDD DYS REM 12 MNTHS	0.00	0.00
G9510	Other professional services	REMIS12M NOT PHQ-9 SCORE <5	0.00	0.00
G9511	Other professional services	IDX EVT DTE PHQ>9 DOC 12 MO	0.00	0.00
G9512	Other professional services	INDIV PDC > 0.8	0.00	0.00
G9513	Other professional services	INDIV PDC NOT > 0.8	0.00	0.00
G9514	Other professional services	REQ RET OR W/IN 90D OF SURG	0.00	0.00
G9515	Other professional services	NO REAS, NO RET OR W/IN 90D	0.00	0.00
G9516	Other professional services	IMPR VIS ACUIT W/IN 90D	0.00	0.00
G9517	Other professional services	NO IMPR VIS ACUIT W/IN 90D	0.00	0.00
G9518	Other professional services	DOC ACTIVE INJ DRUG USE	0.00	0.00
G9519	Other professional services	FINAL REF +/- 1.0 W/IN 90D	0.00	0.00
G9520	Other professional services	REFRACT NOT +/- 1.0 W/IN 90D	0.00	0.00
G9521	Other professional services	ER AND IP HOSP <2 IN 12 MOS	0.00	0.00
G9522	Other professional services	ER/IP HOSP =/>2 IN 12 MOS	0.00	0.00
G9529	Other professional services	MINOR BLUNT TRAUMA W/HEAD CT	0.00	0.00
G9530	Other professional services	PT MBHT HD CT ORD EC PROV	0.00	0.00
G9531	Other professional services	PT DOC	0.00	0.00
G9533	Other professional services	INDIC FOR HEAD CT NOT VALID	0.00	0.00
G9537	Other professional services	IMG HD CLIN TRIAL	0.00	0.00
G9539	Other professional services	INTENT POT REMV TIME PLACEMT	0.00	0.00
G9540	Other professional services	PT ALIVE 3 MOS POST PROC	0.00	0.00
G9541	Other professional services	FILTER REM 3 MON PLMT	0.00	0.00
G9542	Other professional services	DOC REASS APPR REMO FILT 3MS	0.00	0.00
G9543	Other professional services	DOC 2X RE-ASSESS FILT REMOV	0.00	0.00
G9544	Other professional services	NO FILT REMOV W/IN 3MOS PLCM	0.00	0.00
G9547	Other professional services	CYS REN LES OR ADREN	0.00	0.00
G9548	Other professional services	NO F/U REC IMAGE STUDY	0.00	0.00
G9549	Other professional services	DOC MED RSN FOR F/U IMAG	0.00	0.00
G9550	Other professional services	IMAG REC	0.00	0.00
G9551	Other professional services	IMAG NO LES	0.00	0.00
G9552	Other professional services	INC THYR NODE <1.0 IN RPT	0.00	0.00
G9553	Other professional services	PRIOR THYROID DISE DX	0.00	0.00
G9554	Other professional services	CT/CTA/MRI/A CHST FOLL REC	0.00	0.00
G9555	Other professional services	DOC MED RSN FOR FOLLUP IMAGE	0.00	0.00
G9556	Other professional services	CT/CTA/MRI/A NO FOLLUP IMAG	0.00	0.00
G9557	Other professional services	CT/CTA/MRI/A NO THYR <1.0CM	0.00	0.00
G9580	Other professional services	DOOR TO PUNC TIME <2HRS	0.00	0.00
G9582	Other professional services	DOOR TO PUNC TIME >2HR, NRG	0.00	0.00
G9593	Other professional services	LOW PECARN PED HEAD TRAUMA	0.00	0.00
G9594	Other professional services	PT MBHT HD CT ORD EC PROV	0.00	0.00
G9595	Other professional services	DOC SHNT/TUM/COAG	0.00	0.00
G9597	Other professional services	NO LOW PECARN PED HEAD TRAUM	0.00	0.00
G9598	Other professional services	AOR ANE 5.5-5.9 CM MAX DIAM	0.00	0.00
G9599	Other professional services	AOR ANE >=6.0 CM MAX DIAM	0.00	0.00
G9603	Other professional services	PT SURV IMPROV BSLINE TX	0.00	0.00
G9604	Other professional services	PT SURV RESULTS NOT AVAIL	0.00	0.00
G9605	Other professional services	SURV SCORE NO IMPROV W/TX	0.00	0.00
G9606	Other professional services	INTRAOP CYST EVAL TRAC INJ	0.00	0.00
G9607	Other professional services	DOC MED RSN NOT PERF CYSTOSC	0.00	0.00
G9608	Other professional services	INTRAOP CYST EVAL NOT DONE	0.00	0.00
G9609	Other professional services	DOC ORDER ANTI-PLAT	0.00	0.00
G9610	Other professional services	DOC MD RSN NO ANTIPLA	0.00	0.00
G9611	Other professional services	NO DOC ORDER ANTI-PLAT RNG	0.00	0.00
G9621	Other professional services	SCR UNHEAL ETOH W/COUNSEL	0.00	0.00
G9622	Other professional services	NO UNHEAL ETOH USER	0.00	0.00
G9624	Other professional services	PT NOT SCRN OR NO COUNSELING	0.00	0.00
G9625	Other professional services	PT BL SRG 30 DAY PST SRG	0.00	0.00
G9626	Other professional services	MED RSN NO RPT BLADDER INJ	0.00	0.00
G9627	Other professional services	PT NO BL SRG 30 DAY PST SRG	0.00	0.00
G9628	Other professional services	PT BWLI SRG 30 DAY PST SRG	0.00	0.00
G9629	Other professional services	MED RSN NO RPT BOWEL INJ	0.00	0.00
G9630	Other professional services	PT NO BWLI SRG 30 DAY SRG	0.00	0.00
G9637	Other professional services	DOC >1 DOSE REDUC TECH	0.00	0.00
G9638	Other professional services	NO DOC >1 DOSE REDUC TECH	0.00	0.00
G9642	Other professional services	CURRENT SMOKER	0.00	0.00
G9643	Other professional services	ELECTIVE SURGERY	0.00	0.00
G9644	Other professional services	NO SMOK B/4 ANES DAY OF SURG	0.00	0.00
G9645	Other professional services	HAD SMOKE B/4 ANES DAY SURG	0.00	0.00
G9646	Other professional services	PT W/90D MRS 0-2	0.00	0.00
G9648	Other professional services	PT W/90D MRS >2	0.00	0.00
G9649	Other professional services	PSOR AS DOC SPC BM	0.00	0.00
G9651	Other professional services	PSOR AS DOC NO SPC BM	0.00	0.00
G9654	Other professional services	MON ANESTH CARE	0.00	0.00
G9655	Other professional services	TOC TOOL INCL KEY ELEM	0.00	0.00
G9656	Other professional services	PT TRANS FROM ANEST TO PACU	0.00	0.00
G9658	Other professional services	TOC TOOL INCL ELEM NOT USED	0.00	0.00
G9659	Other professional services	>=86Y NO HX COLO CA/RSN SCOP	0.00	0.00
G9660	Other professional services	DOC MED RSN SCOPE PT >= 86Y	0.00	0.00
G9661	Other professional services	PT >= 86 W/ HI RISK	0.00	0.00
G9662	Other professional services	PRIOR DX/ACTIVE CLIN ASCVD	0.00	0.00
G9663	Other professional services	FAST/DIR LDL >= 190 MG/DL	0.00	0.00
G9664	Other professional services	TAKING STATIN OR REC'D ORDER	0.00	0.00
G9665	Other professional services	NO STATIN/NO ORDER STATIN	0.00	0.00
G9674	Other professional services	PT W/CLIN ASCVD DX	0.00	0.00
G9675	Other professional services	PT W/FAST/DIR LAB LDL-C >190	0.00	0.00
G9676	Other professional services	40-75Y W/TYPE 1/2 W/LDL-C RS	0.00	0.00
G9679	Other professional services	ACUTE CARE PNEUMONIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9680	Other professional services	ACUTE CARE CONGESTIVE HEART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9681	Other professional services	ACUTE CARE CHRONIC OBSTRUCT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9682	Other professional services	ACUTE CARE SKIN INFECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9683	Other professional services	ACUTE FLUID/ELECTRO DISORDER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9684	Other professional services	ACUTE CARE URINARY TRACT INF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9685	Other professional services	ACUTE NURSING FACILITY CARE	261.83	261.83
G9687	Other professional services	HOSPICE ANYTIME MSMT PER	0.00	0.00
G9688	Other professional services	PT W/HOSP ANYTIME MSMT PER	0.00	0.00
G9689	Other professional services	INPT ELECT CAROTID INTERVENT	0.00	0.00
G9690	Other professional services	PT IN HOS	0.00	0.00
G9691	Other professional services	PT HOSP DUR MSMT PERIOD	0.00	0.00
G9692	Other professional services	HOSP RECD BY PT DUR MSMT PER	0.00	0.00
G9693	Other professional services	PT USE HOSP DURING MSMT PER	0.00	0.00
G9694	Other professional services	HOSP SRV USED PT IN MSMT PER	0.00	0.00
G9695	Other professional services	LONG ACT INHAL BRONCHDIL PRE	0.00	0.00
G9696	Other professional services	MED RSN NO PRESC BRONCHDIL	0.00	0.00
G9698	Other professional services	SYS RSN NO PRESC BRONCHDIL	0.00	0.00
G9699	Other professional services	LONG INHAL BRONCHDIL NO PRES	0.00	0.00
G9700	Other professional services	PT IS W/HOSP DURING MSMT PER	0.00	0.00
G9702	Other professional services	PT USE HOSP DURING MSMT PER	0.00	0.00
G9703	Other professional services	ANBX 30 PRIOR TO EPISODE	0.00	0.00
G9704	Other professional services	AJCC BR CA STG I: T1 MIC/T1A	0.00	0.00
G9705	Other professional services	AJCC BR CA STG IB	0.00	0.00
G9706	Other professional services	LOW RECUR PROST CA	0.00	0.00
G9707	Other professional services	PT HAD HOSP DUR MSMT PER	0.00	0.00
G9708	Other professional services	BILAT MAST/HX BI /UNILAT MAS	0.00	0.00
G9709	Other professional services	HOSP SRV USED PT IN MSMT PER	0.00	0.00
G9710	Other professional services	PT PROV HOSP SRV MSMT PER	0.00	0.00
G9711	Other professional services	PT HX TOT COL OR COLON CA	0.00	0.00
G9712	Other professional services	DOC MED RSN PRESC ANBX	0.00	0.00
G9713	Other professional services	PT USE HOSP DURING MSMT PER	0.00	0.00
G9714	Other professional services	PT IS W/HOSP DURING MSMT PER	0.00	0.00
G9716	Other professional services	BMI DOC ONL FUP NOT CMPLTD	0.00	0.00
G9717	Other professional services	DOC PT DX BIPOL	0.00	0.00
G9719	Other professional services	PT NOT AMBUL/IMMOB/WC	0.00	0.00
G9720	Other professional services	HOSPICE ANYTIME MSMT PER	0.00	0.00
G9721	Other professional services	PT NOT AMBUL/IMMOB/WC	0.00	0.00
G9722	Other professional services	DOC HX RENAL FAIL OR CR+ >=4	0.00	0.00
G9723	Other professional services	HOSP RECD BY PT DUR MSMT PER	0.00	0.00
G9724	Other professional services	PT W/DOC USE ANTICOAG MST YR	0.00	0.00
G9726	Other professional services	REFUSED TO PARTICIPATE	0.00	0.00
G9727	Other professional services	PT UNABLE CMPLT LEPF PROM	0.00	0.00
G9728	Other professional services	REFUSED TO PARTICIPATE	0.00	0.00
G9729	Other professional services	PT UNBL CMPLT LEPF PROM	0.00	0.00
G9730	Other professional services	REFUSED TO PARTICIPATE	0.00	0.00
G9731	Other professional services	PT UNBL CMPLT LEPF PROM	0.00	0.00
G9732	Other professional services	REFUSED TO PARTICIPATE	0.00	0.00
G9733	Other professional services	PT UNBL CMPLT LB FS PROM	0.00	0.00
G9734	Other professional services	REFUSED TO PARTICIPATE	0.00	0.00
G9735	Other professional services	PT UNBL CMPLT SHLD FS PROM	0.00	0.00
G9736	Other professional services	REFUSED TO PARTICIPATE	0.00	0.00
G9737	Other professional services	PT UNBL CMPLT EWH FS PROM	0.00	0.00
G9740	Other professional services	HOSP SRV TO PT DUR MSMT PER	0.00	0.00
G9741	Other professional services	PT W/HOSP ANYTIME MSMT PER	0.00	0.00
G9744	Other professional services	PT NOT ELI D/T ACT DIG HTN	0.00	0.00
G9745	Other professional services	DOC RSN NO HBP SCRN OR F/U	0.00	0.00
G9746	Other professional services	MIT STEN, VALVE OR TRANS AF	0.00	0.00
G9751	Other professional services	PT DIED W/IN 24 MOS RPT TIME	0.00	0.00
G9752	Other professional services	URGENT SURGERY	0.00	0.00
G9753	Other professional services	DOC NO DICOM, CT OTHER FAC	0.00	0.00
G9754	Other professional services	INCID PULM NODULE	0.00	0.00
G9755	Other professional services	DOC MED RSN NO FLLW UP	0.00	0.00
G9756	Other professional services	SURG PROC W/SILICONE OIL	0.00	0.00
G9757	Other professional services	SURG PROC W/SILICONE OIL	0.00	0.00
G9758	Other professional services	PT IN HOS	0.00	0.00
G9760	Other professional services	PT W/HOSP ANYTIME MSMT PER	0.00	0.00
G9761	Other professional services	PT W/HOSP ANYTIME MSMT PER	0.00	0.00
G9762	Other professional services	PT HAD >= 2-3 HPV VACCINES	0.00	0.00
G9763	Other professional services	PT NOT HAVE 2-3 HPV VACCINES	0.00	0.00
G9764	Other professional services	PT TREATD W/ORAL SYST OR BIO	0.00	0.00
G9765	Other professional services	DOC PAT DECLINED THERAPY	0.00	0.00
G9766	Other professional services	CVA STROKE DX TX TRANSF FAC	0.00	0.00
G9767	Other professional services	HOSP NEW DX CVA CONSID EVST	0.00	0.00
G9768	Other professional services	PT W/HOSP ANYTIME MSMT PER	0.00	0.00
G9769	Other professional services	BN DEN 2YR/GOT OST MED/THER	0.00	0.00
G9770	Other professional services	PERIP NERVE BLOCK	0.00	0.00
G9771	Other professional services	ANES END, 1 TEMP >35.5(95.9)	0.00	0.00
G9772	Other professional services	DOC MED RSN NO TEMP >= 35.5	0.00	0.00
G9773	Other professional services	1 BOD TEMP >=35.5	0.00	0.00
G9775	Other professional services	RECD 2 ANTI-EMET PRE/INTRAOP	0.00	0.00
G9776	Other professional services	DOC MED RSN NO PROPH ANTIEM	0.00	0.00
G9777	Other professional services	PT NO ANTIEMET PRE/INTRAOP	0.00	0.00
G9779	Other professional services	PTS BREASTFEEDING	0.00	0.00
G9780	Other professional services	PTS DX W/RHABDOMYOLYSIS	0.00	0.00
G9781	Other professional services	DOC RSN NO STATIN	0.00	0.00
G9782	Other professional services	HX DX FAM/PURE HYPERCHOLES	0.00	0.00
G9784	Other professional services	PATH/DERM PROV 2ND BIOP OPIN	0.00	0.00
G9785	Other professional services	PATH REPORT SENT	0.00	0.00
G9786	Other professional services	PATH REPORT NOT SENT	0.00	0.00
G9787	Other professional services	PT ALIVE	0.00	0.00
G9788	Other professional services	MOST RCT BP	0.00	0.00
G9789	Other professional services	RECORD BP IP, ER, URG/SELF	0.00	0.00
G9790	Other professional services	MOST RCT BP >/= 140/90	0.00	0.00
G9791	Other professional services	MOST RCT TOB STAT FREE	0.00	0.00
G9792	Other professional services	MOST RCT TOB STAT NOT FREE	0.00	0.00
G9793	Other professional services	PT ON DAILY ASA/ANTIPLAT	0.00	0.00
G9794	Other professional services	DOC MED RSN NO DAILY ASPIRIN	0.00	0.00
G9795	Other professional services	PT NO DAILY ASA/ANTIPLAT	0.00	0.00
G9796	Other professional services	PT NOT CURRENTLY ON STATIN	0.00	0.00
G9797	Other professional services	PT CURRENTLY ON STATIN	0.00	0.00
G9805	Other professional services	PT W/HOSP ANYTIME MSMT PER	0.00	0.00
G9806	Other professional services	PT RECD CERV CYTO/HPV	0.00	0.00
G9807	Other professional services	PT NO RECD CERV CYTO/HPV	0.00	0.00
G9812	Other professional services	PT DIED DURING INPT/30D AFT	0.00	0.00
G9813	Other professional services	PT NOT DIED W/IN 30D OF PROC	0.00	0.00
G9818	Other professional services	DOC SEX ACTIVITY	0.00	0.00
G9819	Other professional services	PT W/HOSP ANYTIME MSMT PER	0.00	0.00
G9820	Other professional services	DOC CHLAM SCR TEST W/FOLLOW	0.00	0.00
G9821	Other professional services	NO DOC CHLAM SCR TS W/FOLLOW	0.00	0.00
G9822	Other professional services	ENDO ABL PROC YR PREV IND DT	0.00	0.00
G9823	Other professional services	ENDO SMPL/HYST BX RES DOC	0.00	0.00
G9824	Other professional services	ENDO SMPL/HYST BX RES NO DOC	0.00	0.00
G9830	Other professional services	HER-2 POS	0.00	0.00
G9831	Other professional services	AJCC STG BRT CA DX II OR III	0.00	0.00
G9832	Other professional services	BRT CA DX I, NO T1/T1A/T1B	0.00	0.00
G9838	Other professional services	PT MET DIS AT DX	0.00	0.00
G9839	Other professional services	ANTI-EGFR MON ANTI THER	0.00	0.00
G9840	Other professional services	GENE TESTING PERFORMED	0.00	0.00
G9841	Other professional services	GENE TESTING NOT PERFORMED	0.00	0.00
G9842	Other professional services	PT MET DIS AT DX	0.00	0.00
G9843	Other professional services	KRAS OR NRAS GENE MUTATION	0.00	0.00
G9844	Other professional services	PT NO RECD ANTI-EGFR THER	0.00	0.00
G9845	Other professional services	PT RECD ANTI-EGFR THER	0.00	0.00
G9846	Other professional services	PT DIED FROM CANCER	0.00	0.00
G9847	Other professional services	PT RECD CHEMO LAST 14D LIFE	0.00	0.00
G9848	Other professional services	PT NO CHEMO LAST 14D LIFE	0.00	0.00
G9858	Other professional services	PT ENROLL HOSPICE	0.00	0.00
G9859	Other professional services	PT DIED FROM CANCER	0.00	0.00
G9860	Other professional services	PT LESS 3D HOSPICE	0.00	0.00
G9861	Other professional services	PT MORE THAN 3D HOSPICE	0.00	0.00
G9862	Other professional services	DOC RSN NO 10 YR FOLLOW	0.00	0.00
G9868	Other professional services	CMMI ASYNTELEHEALTH <10MIN	39.30	39.30
G9869	Other professional services	CMMI ASYNTELEHEALTH 10-20MIN	52.56	52.56
G9870	Other professional services	CMMI ASYNTELEHEALTH >20MIN	65.82	65.82
G9873	Other professional services	1 EM CORE SESSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9874	Other professional services	4 EM CORE SESSIONS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9875	Other professional services	9 EM CORE SESSIONS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9876	Other professional services	2 EM CORE MS MO 7-9 NO WL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9877	Other professional services	2 EM CORE MS MO 10-12 NO WL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9878	Other professional services	2 EM CORE MS MO 7-9 WL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9879	Other professional services	2 EM CORE MS MO 10-12 WL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9880	Other professional services	EM 5 PERCENT WL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9881	Other professional services	EM 9 PERCENT WL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9882	Other professional services	2 EM ONGOING MS MO 13-15 WL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9883	Other professional services	2 EM ONGOING MS MO 16-18 WL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9884	Other professional services	2 EM ONGOING MS MO 19-21 WL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9885	Other professional services	2 EM ONGOING MS MO 22-24 WL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9886	Other professional services	IN-PERSON ATTENDANCE G CODE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9887	Other professional services	DISTANCE LEARNING ATTENDANCE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9888	Other professional services	5% WL MAINTND FROM BSLINE WT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9890	Other professional services	EM BRIDGE PAYMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9891	Other professional services	EM SESSION REPORTING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
G9892	Other professional services	DOC PT RSN NO DIL MAC EXAM	0.00	0.00
G9893	Other professional services	NO MAC EXAM	0.00	0.00
G9894	Other professional services	ADR DEP THRPY PRESCRIBED	0.00	0.00
G9895	Other professional services	DOC MED RSN NO ADR DEP THRPY	0.00	0.00
G9896	Other professional services	DOC PT RSN NO ADR DEP THRPY	0.00	0.00
G9897	Other professional services	PT NT PRSC ADR DEP THRPY RNG	0.00	0.00
G9898	Other professional services	PT 66+ SNP OR LTC POS > 90D	0.00	0.00
G9899	Other professional services	SCRN MAM PERF RSLTS DOC	0.00	0.00
G9900	Other professional services	SCRN MAM PERF RSLTS NOT DOC	0.00	0.00
G9901	Other professional services	PT 66+ SNP OR LTC POS > 90D	0.00	0.00
G9902	Other professional services	PT SCRN TBCO AND ID AS USER	0.00	0.00
G9903	Other professional services	PT SCRN TBCO ID AS NON USER	0.00	0.00
G9905	Other professional services	NO PT TBCO SCRN RNG	0.00	0.00
G9906	Other professional services	PT RECV TBCO CESS INTERV	0.00	0.00
G9908	Other professional services	NO PT TBCO CESS INTERV RNG	0.00	0.00
G9910	Other professional services	PT 66+ SNP OR LTC POS > 90D	0.00	0.00
G9911	Other professional services	NODE NEG PRE/POST SYST THER	0.00	0.00
G9912	Other professional services	HBV STATUS ASSESED AND INT	0.00	0.00
G9913	Other professional services	NO HBV STATUS ASSESD AND INT	0.00	0.00
G9914	Other professional services	PT INITIATED ANTI-TNF AGENT	0.00	0.00
G9915	Other professional services	NO DOCUMNTD HBV RESULTS RCD	0.00	0.00
G9916	Other professional services	FUNCT STATUS PAST 12 MONTHS	0.00	0.00
G9917	Other professional services	ADV DEM CRGVR LIMITED	0.00	0.00
G9918	Other professional services	NO FUNCT STAT PERF, RSN NOS	0.00	0.00
G9919	Other professional services	SCRN ND POS ND PROV OF REC	0.00	0.00
G9920	Other professional services	SCRNING PERF AND NEGATIVE	0.00	0.00
G9921	Other professional services	NO OR PART SCRN ND RNG OR OS	0.00	0.00
G9922	Other professional services	SFTY CNCRNS SCRN ND MIT RECS	0.00	0.00
G9923	Other professional services	SAFTY CNCRNS SCRN AND NEG	0.00	0.00
G9925	Other professional services	NO SCRN PROV RSN NOS	0.00	0.00
G9926	Other professional services	SFTY CNCRNS SCRN BUT NO RECS	0.00	0.00
G9928	Other professional services	NO WARF OR FDA DRUG PRESC	0.00	0.00
G9929	Other professional services	TRS/REV AF	0.00	0.00
G9930	Other professional services	COM CARE	0.00	0.00
G9931	Other professional services	NO CHAD OR CHAD SCR 0 OR 1	0.00	0.00
G9938	Other professional services	PT 66+ SNP OR LTC POS > 90D	0.00	0.00
G9939	Other professional services	SAME PATH/DERM PERF BIOPSY	0.00	0.00
G9940	Other professional services	DOC REAS NO STATIN THERAPY	0.00	0.00
G9943	Other professional services	BK PN NT MSR VAS SCL PRE/PST	0.00	0.00
G9945	Other professional services	PT W/CANCER SCOLIOSIS	0.00	0.00
G9946	Other professional services	BK PAIN NO VAS	0.00	0.00
G9949	Other professional services	LEG PAIN NO VAS	0.00	0.00
G9954	Other professional services	PT >2 RSK FAC POST-OP VOMIT	0.00	0.00
G9955	Other professional services	INHLNT ANESTH ONLY FOR INDUC	0.00	0.00
G9956	Other professional services	COMBO THRPY OF >= 2 PROPHLY	0.00	0.00
G9957	Other professional services	DOC MED RSN NO COMBO THRPY	0.00	0.00
G9958	Other professional services	NO COMBO PROHPYL THRP FOR PT	0.00	0.00
G9959	Other professional services	SYSTEMIC ANTIMICRO NOT PRESC	0.00	0.00
G9960	Other professional services	MED RSN SYS ANTIMI NT RX	0.00	0.00
G9961	Other professional services	SYSTEMIC ANTIMICRO PRESC	0.00	0.00
G9962	Other professional services	EMBOLIZATION DOC SEPARATLY	0.00	0.00
G9963	Other professional services	EMBOLIZATION NOT DOC SEPARAT	0.00	0.00
G9964	Other professional services	PT RECV >=1 WELL-CHLD VISIT	0.00	0.00
G9965	Other professional services	NO WELL-CHLD VIST RECV BY PT	0.00	0.00
G9968	Other professional services	PT REFRD 2 PVDR/SPCLST IN PP	0.00	0.00
G9969	Other professional services	PVDR RFRD PT RPRT RCVD	0.00	0.00
G9970	Other professional services	PVDR RFRD PT NO RPRT RCVD	0.00	0.00
G9974	Other professional services	MAC EXAM PERF	0.00	0.00
G9975	Other professional services	DOC MED RSN NO DIL MAC EXAM	0.00	0.00
G9978	Other professional services	REMOTE E/M NEW PT 10MINS	68.30	38.73
G9979	Other professional services	REMOTE E/M NEW PT 20MINS	101.06	66.48
G9980	Other professional services	REMOTE E/M NEW PT 30 MINS	147.29	105.90
G9981	Other professional services	REMOTE E/M NEW PT 45MINS	226.34	178.59
G9982	Other professional services	REMOTE E/M NEW PT 60MINS	293.37	237.89
G9983	Other professional services	REMOTE E/M EST. PT 10MINS	68.30	38.73
G9984	Other professional services	REMOTE E/M EST. PT 15MINS	111.41	76.38
G9985	Other professional services	REMOTE E/M EST. PT 25MINS	159.66	116.00
G9986	Other professional services	REMOTE E/M EST. PT 40MINS	219.98	168.59
G9987	Other professional services	BPCI ADVANCED IN HOME VISIT	65.31	65.31
G9988	Other professional services	PALL SERV DURING MEAS	0.00	0.00
G9990	Other professional services	NO PNEUM VAX ADMIN 19+	0.00	0.00
G9991	Other professional services	PNEUM VAX ADMIN 19+	0.00	0.00
G9992	Other professional services	PALL SERV DURING MEAS	0.00	0.00
G9993	Other professional services	PALL SERV DURING MEAS	0.00	0.00
G9994	Other professional services	PALL SERV DURING MEAS	0.00	0.00
G9996	Other professional services	DOC PT PAL OR HOSPICE	0.00	0.00
G9997	Other professional services	DOC PT PREG DUR MSRMT PD	0.00	0.00
G9998	Other professional services	DOC MED RSN <3 COLON	0.00	0.00
G9999	Other professional services	DOC SYS RSN <3 COLON	0.00	0.00
H0001	Other professional services	ALCOHOL AND/OR DRUG ASSESS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0002	Other professional services	ALCOHOL AND/OR DRUG SCREENIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0003	Other professional services	ALCOHOL AND/OR DRUG SCREENIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0004	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0005	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0006	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0007	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0008	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0009	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0010	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0011	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0012	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0013	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0014	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0015	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0016	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0017	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0018	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0019	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0020	Other professional services	ALCOHOL AND/OR DRUG SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0021	Other professional services	ALCOHOL AND/OR DRUG TRAINING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0022	Other professional services	ALCOHOL AND/OR DRUG INTERVEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0023	Other professional services	ALCOHOL AND/OR DRUG OUTREACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0024	Other professional services	ALCOHOL AND/OR DRUG PREVENTI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0025	Other professional services	ALCOHOL AND/OR DRUG PREVENTI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0026	Other professional services	ALCOHOL AND/OR DRUG PREVENTI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0027	Other professional services	ALCOHOL AND/OR DRUG PREVENTI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0028	Other professional services	ALCOHOL AND/OR DRUG PREVENTI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0029	Other professional services	ALCOHOL AND/OR DRUG PREVENTI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0030	Other professional services	ALCOHOL AND/OR DRUG HOTLINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0031	Other professional services	MH HEALTH ASSESS BY NON-MD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0032	Other professional services	MH SVC PLAN DEV BY NON-MD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0033	Other professional services	ORAL MED ADM DIRECT OBSERVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0034	Other professional services	MED TRNG & SUPPORT PER 15MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0035	Other professional services	MH PARTIAL HOSP TX UNDER 24H	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0036	Other professional services	COMM PSY FACE-FACE PER 15MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0037	Other professional services	COMM PSY SUP TX PGM PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0038	Other professional services	SELF-HELP/PEER SVC PER 15MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0039	Other professional services	ASSER COM TX FACE-FACE/15MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0040	Other professional services	ASSERT COMM TX PGM PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0041	Other professional services	FOS C CHLD NON-THER PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0042	Other professional services	FOS C CHLD NON-THER PER MON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0043	Other professional services	SUPPORTED HOUSING, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0044	Other professional services	SUPPORTED HOUSING, PER MONTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0045	Other professional services	RESPITE NOT-IN-HOME PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0046	Other professional services	MENTAL HEALTH SERVICE, NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0047	Other professional services	ALCOHOL/DRUG ABUSE SVC NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0048	Other professional services	SPEC COLL NON-BLOOD:A/D TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0049	Other professional services	ALCOHOL/DRUG SCREENING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H0050	Other professional services	ALCOHOL/DRUG SERVICE 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H1000	Other professional services	PRENATAL CARE ATRISK ASSESSM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H1001	Other professional services	ANTEPARTUM MANAGEMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H1002	Other professional services	CARECOORDINATION PRENATAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H1003	Other professional services	PRENATAL AT RISK EDUCATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H1004	Other professional services	FOLLOW UP HOME VISIT/PRENTAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H1005	Other professional services	PRENATALCARE ENHANCED SRV PK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H1010	Other professional services	NONMED FAMILY PLANNING ED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H1011	Other professional services	FAMILY ASSESSMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2000	Other professional services	COMP MULTIDISIPLN EVALUATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2001	Other professional services	REHABILITATION PROGRAM 1/2 D	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2010	Other professional services	COMPREHENSIVE MED SVC 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2011	Other professional services	CRISIS INTERVEN SVC, 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2012	Other professional services	BEHAV HLTH DAY TREAT, PER HR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2013	Other professional services	PSYCH HLTH FAC SVC, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2014	Other professional services	SKILLS TRAIN AND DEV, 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2015	Other professional services	COMP COMM SUPP SVC, 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2016	Other professional services	COMP COMM SUPP SVC, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2017	Other professional services	PSYSOC REHAB SVC, PER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2018	Other professional services	PSYSOC REHAB SVC, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2019	Other professional services	THER BEHAV SVC, PER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2020	Other professional services	THER BEHAV SVC, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2021	Other professional services	COM WRAP-AROUND SV, 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2022	Other professional services	COM WRAP-AROUND SV, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2023	Other professional services	SUPPORTED EMPLOY, PER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2024	Other professional services	SUPPORTED EMPLOY, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2025	Other professional services	SUPP MAINT EMPLOY, 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2026	Other professional services	SUPP MAINT EMPLOY, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2027	Other professional services	PSYCHOED SVC, PER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2028	Other professional services	SEX OFFEND TX SVC, 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2029	Other professional services	SEX OFFEND TX SVC, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2030	Other professional services	MH CLUBHOUSE SVC, PER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2031	Other professional services	MH CLUBHOUSE SVC, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2032	Other professional services	ACTIVITY THERAPY, PER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2033	Other professional services	MULTISYS THER/JUVENILE 15MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2034	Other professional services	A/D HALFWAY HOUSE, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2035	Other professional services	A/D TX PROGRAM, PER HOUR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2036	Other professional services	A/D TX PROGRAM, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2037	Other professional services	DEV DELAY PREV DP CH, 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2038	Other professional services	SKILL TRAIN AND DEV/DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2040	Other professional services	COORD SPECIALTY CARE, MONTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
H2041	Other professional services	COORD SPECIAL CARE ENCOUNTER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0120	Other professional services	TETRACYCLIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0121	Other professional services	INJ., OMADACYCLINE, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0122	Other professional services	INJ., ERAVACYCLINE, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0129	Other professional services	ABATACEPT INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0130	Other professional services	ABCIXIMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0131	Other professional services	INJ, ACETAMINOPHEN (NOS)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0132	Other professional services	ACETYLCYSTEINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0133	Other professional services	ACYCLOVIR INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0134	Other professional services	INJ ACETAMINOPHEN -FRESENIUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0135	Other professional services	ADALIMUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0136	Other professional services	INJ, ACETAMINOPHEN (B BRAUN)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0137	Other professional services	INJ, ACETAMINOPHEN (HIKMA)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0153	Other professional services	ADENOSINE INJ 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0171	Other professional services	ADRENALIN EPINEPHRINE INJECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0172	Other professional services	INJ, ADUCANUMAB-AVWA, 2 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0173	Other professional services	INJ, EPINEPHRINE (BELCHER)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0174	Other professional services	INJ, LECANEMAB-IRMB, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0178	Other professional services	AFLIBERCEPT INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0179	Other professional services	INJ, BROLUCIZUMAB-DBLL, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0180	Other professional services	AGALSIDASE BETA INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0184	Other professional services	INJ, AMISULPRIDE, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0185	Other professional services	INJ., APREPITANT, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0190	Other professional services	INJ BIPERIDEN LACTATE/5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0200	Other professional services	ALATROFLOXACIN MESYLATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0202	Other professional services	INJECTION, ALEMTUZUMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0205	Other professional services	ALGLUCERASE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0206	Other professional services	INJ ALLOPURINOL SODIUM 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0207	Other professional services	AMIFOSTINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0208	Other professional services	INJ SODIUM THIOSULFATE 100MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0210	Other professional services	METHYLDOPATE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0215	Other professional services	ALEFACEPT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0216	Other professional services	INJ, ALFENTANIL HCL, 500MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0217	Other professional services	INJ VELMANASE ALFA-TYCV 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0218	Other professional services	INJ OLIPUDASE ALFA-RPCP 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0219	Other professional services	INJ AVAL ALFA-NQPT 4MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0220	Other professional services	ALGLUCOSIDASE ALFA INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0221	Other professional services	LUMIZYME INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0222	Other professional services	INJ., PATISIRAN, 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0223	Other professional services	INJ GIVOSIRAN 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0224	Other professional services	INJ. LUMASIRAN, 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0225	Other professional services	INJ, VUTRISIRAN, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0248	Other professional services	INJ, REMDESIVIR, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0256	Other professional services	ALPHA 1 PROTEINASE INHIBITOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0257	Other professional services	GLASSIA INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0270	Other professional services	ALPROSTADIL FOR INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0275	Other professional services	ALPROSTADIL URETHRAL SUPPOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0278	Other professional services	AMIKACIN SULFATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0280	Other professional services	AMINOPHYLLIN 250 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0282	Other professional services	AMIODARONE HCL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0283	Other professional services	INJ, AMIODARONE (NEXTERONE)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0285	Other professional services	AMPHOTERICIN B	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0287	Other professional services	AMPHOTERICIN B LIPID COMPLEX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0288	Other professional services	AMPHO B CHOLESTERYL SULFATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0289	Other professional services	AMPHOTERICIN B LIPOSOME INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0290	Other professional services	AMPICILLIN 500 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0291	Other professional services	INJ., PLAZOMICIN, 5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0295	Other professional services	AMPICILLIN SULBACTAM 1.5 GM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0300	Other professional services	AMOBARBITAL 125 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0330	Other professional services	SUCCINYCHOLINE CHLORIDE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0348	Other professional services	ANIDULAFUNGIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0349	Other professional services	INJ, REZAFUNGIN, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0350	Other professional services	INJECTION ANISTREPLASE 30 U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0360	Other professional services	HYDRALAZINE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0364	Other professional services	APOMORPHINE HYDROCHLORIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0365	Other professional services	APROTONIN, 10,000 KIU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0380	Other professional services	INJ METARAMINOL BITARTRATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0390	Other professional services	CHLOROQUINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0391	Other professional services	INJ, ARTESUNATE, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0395	Other professional services	ARBUTAMINE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0400	Other professional services	ARIPIPRAZOLE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0401	Other professional services	INJ ARIPIPRAZOLE EXT REL 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0402	Other professional services	INJ, ABILIFY ASIMTUFII, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0456	Other professional services	AZITHROMYCIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0457	Other professional services	INJECTION, AZTREONAM, 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0461	Other professional services	ATROPINE SULFATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0470	Other professional services	DIMECAPROL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0475	Other professional services	BACLOFEN 10 MG INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0476	Other professional services	BACLOFEN INTRATHECAL TRIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0480	Other professional services	BASILIXIMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0485	Other professional services	BELATACEPT INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0490	Other professional services	BELIMUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0491	Other professional services	INJ ANIFROLUMAB-FNIA 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0500	Other professional services	DICYCLOMINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0515	Other professional services	INJ BENZTROPINE MESYLATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0517	Other professional services	INJ., BENRALIZUMAB, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0520	Other professional services	BETHANECHOL CHLORIDE INJECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0558	Other professional services	PENG BENZATHINE/PROCAINE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0561	Other professional services	PENICILLIN G BENZATHINE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0565	Other professional services	INJ, BEZLOTOXUMAB, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0567	Other professional services	INJ., CERLIPONASE ALFA 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0570	Other professional services	BUPRENORPHINE IMPLANT 74.2MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0571	Other professional services	BUPRENORPHINE ORAL 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0572	Other professional services	BUPREN/NAL UP TO 3MG BUPRENO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0573	Other professional services	BUPREN/NAL 3.1 TO 6MG BUPREN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0574	Other professional services	BUPREN/NAL 6.1 TO 10MG BUPRE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0575	Other professional services	BUPREN/NAL OVER 10MG BUPRENO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0576	Other professional services	INJ BUPRENORPH (BRIXADI) 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0583	Other professional services	BIVALIRUDIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0584	Other professional services	INJECTION, BUROSUMAB-TWZA 1M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0585	Other professional services	INJECTION,ONABOTULINUMTOXINA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0586	Other professional services	ABOBOTULINUMTOXINA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0587	Other professional services	INJ, RIMABOTULINUMTOXINB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0588	Other professional services	INCOBOTULINUMTOXIN A	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0591	Other professional services	INJ DEOXYCHOLIC ACID, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0592	Other professional services	BUPRENORPHINE HYDROCHLORIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0593	Other professional services	INJ., LANADELUMAB-FLYO, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0594	Other professional services	BUSULFAN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0595	Other professional services	BUTORPHANOL TARTRATE 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0596	Other professional services	INJECTION, RUCONEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0597	Other professional services	C-1 ESTERASE, BERINERT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0598	Other professional services	C-1 ESTERASE, CINRYZE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0599	Other professional services	INJ., HAEGARDA 10 UNITS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0600	Other professional services	EDETATE CALCIUM DISODIUM INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0604	Other professional services	CINACALCET, ESRD ON DIALYSIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0606	Other professional services	INJ, ETELCALCETIDE, 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0612	Other professional services	CALCIUM GLUCON (FRESENIUS)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0613	Other professional services	CALCIUM GLUCON (WG CRITICAL)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0620	Other professional services	CALCIUM GLYCER & LACT/10 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0630	Other professional services	CALCITONIN SALMON INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0636	Other professional services	INJ CALCITRIOL PER 0.1 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0637	Other professional services	CASPOFUNGIN ACETATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0638	Other professional services	CANAKINUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0640	Other professional services	LEUCOVORIN CALCIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0641	Other professional services	INJ LEVOLEUCOVORIN NOS 0.5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0642	Other professional services	INJECTION, KHAPZORY, 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0665	Other professional services	INJ, BUPIVACAINE, NOS, 0.5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0670	Other professional services	INJ MEPIVACAINE HCL/10 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0688	Other professional services	INJ CEFAZOLIN SODIUM, HIKMA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0689	Other professional services	INJ CEFAZOLIN SODIUM, BAXTER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0690	Other professional services	CEFAZOLIN SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0691	Other professional services	INJ LEFAMULIN 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0692	Other professional services	CEFEPIME HCL FOR INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0694	Other professional services	CEFOXITIN SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0695	Other professional services	INJ CEFTOLOZANE TAZOBACTAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0696	Other professional services	CEFTRIAXONE SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0697	Other professional services	STERILE CEFUROXIME INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0698	Other professional services	CEFOTAXIME SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0699	Other professional services	INJ, CEFIDEROCOL, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0701	Other professional services	INJ. CEFEPIME HCL (BAXTER)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0702	Other professional services	BETAMETHASONE ACET&SOD PHOSP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0703	Other professional services	INJ, CEFEPIME HCL (B BRAUN)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0706	Other professional services	CAFFEINE CITRATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0710	Other professional services	CEPHAPIRIN SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0712	Other professional services	CEFTAROLINE FOSAMIL INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0713	Other professional services	INJ CEFTAZIDIME PER 500 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0714	Other professional services	CEFTAZIDIME AND AVIBACTAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0715	Other professional services	CEFTIZOXIME SODIUM / 500 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0716	Other professional services	CENTRUROIDES IMMUNE F(AB)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0717	Other professional services	CERTOLIZUMAB PEGOL INJ 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0720	Other professional services	CHLORAMPHENICOL SODIUM INJEC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0725	Other professional services	CHORIONIC GONADOTROPIN/1000U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0735	Other professional services	CLONIDINE HYDROCHLORIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0736	Other professional services	INJ, CLINDAMYCIN PHOSP 300MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0737	Other professional services	INJ, CLINDAMYCIN (BAXTER)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0739	Other professional services	INJECTION, CABOTEGRAVIR 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0740	Other professional services	CIDOFOVIR INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0741	Other professional services	INJ, CABOTE RILPIVIR 2MG 3MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0742	Other professional services	INJ IMIP 4 CILAS 4 RELEB 2MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0743	Other professional services	CILASTATIN SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0744	Other professional services	CIPROFLOXACIN IV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0745	Other professional services	INJ CODEINE PHOSPHATE /30 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0750	Other professional services	HIV PREP, FTC/TDF 200/300MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0751	Other professional services	HIV PREP, FTC/TAF 200/25MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0770	Other professional services	COLISTIMETHATE SODIUM INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0775	Other professional services	COLLAGENASE, CLOST HIST INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0780	Other professional services	PROCHLORPERAZINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0791	Other professional services	INJ CRIZANLIZUMAB-TMCA 5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0795	Other professional services	CORTICORELIN OVINE TRIFLUTAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0799	Other professional services	HIV PREP, FDA APPROVED, NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0801	Other professional services	INJ. ACTHAR GEL TO 40 UNITS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0802	Other professional services	INJ. (ANI), UP TO 40 UNITS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0834	Other professional services	INJ., COSYNTROPIN, 0.25 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0840	Other professional services	CROTALIDAE POLY IMMUNE FAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0841	Other professional services	INJ CROTALIDAE IM F(AB')2 EQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0850	Other professional services	CYTOMEGALOVIRUS IMM IV /VIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0873	Other professional services	INJ, DAPTOMYCIN (XELLIA)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0874	Other professional services	INJ, DAPTOMYCIN (BAXTER)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0875	Other professional services	INJECTION, DALBAVANCIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0877	Other professional services	INJ, DAPTOMYCIN (HOSPIRA)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0878	Other professional services	DAPTOMYCIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0879	Other professional services	DIFELIKEFALIN, ESRD ON DIALY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0881	Other professional services	DARBEPOETIN ALFA, NON-ESRD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0882	Other professional services	DARBEPOETIN ALFA, ESRD USE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0883	Other professional services	ARGATROBAN NONESRD USE 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0884	Other professional services	ARGATROBAN ESRD DIALYSIS 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0885	Other professional services	EPOETIN ALFA, NON-ESRD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0887	Other professional services	EPOETIN BETA ESRD USE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0888	Other professional services	EPOETIN BETA NON ESRD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0889	Other professional services	DAPRODUSTAT ORAL 1MG ESRD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0890	Other professional services	PEGINESATIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0891	Other professional services	ARGATROBAN NONESRD (ACCORD)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0892	Other professional services	ARGATROBAN DIALYSIS (ACCORD)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0893	Other professional services	INJ, DECITABINE (SUN PHARMA)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0894	Other professional services	DECITABINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0895	Other professional services	DEFEROXAMINE MESYLATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0896	Other professional services	INJ LUSPATERCEPT-AAMT 0.25MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0897	Other professional services	DENOSUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0898	Other professional services	ARGATROBAN NONESRD (AUROMED)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0899	Other professional services	ARGATROBAN DIALYSIS, AUROMED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J0945	Other professional services	BROMPHENIRAMINE MALEATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1000	Other professional services	DEPO-ESTRADIOL CYPIONATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1020	Other professional services	METHYLPREDNISOLONE 20 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1030	Other professional services	METHYLPREDNISOLONE 40 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1040	Other professional services	METHYLPREDNISOLONE 80 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1050	Other professional services	MEDROXYPROGESTERONE ACETATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1071	Other professional services	INJ TESTOSTERONE CYPIONATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1094	Other professional services	INJ DEXAMETHASONE ACETATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1095	Other professional services	INJECTION, DEXAMETHASONE 9%	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1096	Other professional services	DEXAMETHA OPTH INSERT 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1097	Other professional services	PHENYLEP KETOROLAC OPTH SOLN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1100	Other professional services	DEXAMETHASONE SODIUM PHOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1105	Other professional services	DEXMEDETOMIDINE FILM, 1 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1110	Other professional services	INJ DIHYDROERGOTAMINE MESYLT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1120	Other professional services	ACETAZOLAMID SODIUM INJECTIO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1130	Other professional services	INJ DICLOFENAC SODIUM 0.5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1160	Other professional services	DIGOXIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1162	Other professional services	DIGOXIN IMMUNE FAB (OVINE)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1165	Other professional services	PHENYTOIN SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1170	Other professional services	HYDROMORPHONE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1180	Other professional services	DYPHYLLINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1190	Other professional services	DEXRAZOXANE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1200	Other professional services	DIPHENHYDRAMINE HCL INJECTIO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1201	Other professional services	INJ. CETIRIZINE HCL 0.5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1205	Other professional services	CHLOROTHIAZIDE SODIUM INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1212	Other professional services	DIMETHYL SULFOXIDE 50% 50 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1230	Other professional services	METHADONE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1240	Other professional services	DIMENHYDRINATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1245	Other professional services	DIPYRIDAMOLE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1250	Other professional services	INJ DOBUTAMINE HCL/250 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1260	Other professional services	DOLASETRON MESYLATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1265	Other professional services	DOPAMINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1267	Other professional services	DORIPENEM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1270	Other professional services	INJECTION, DOXERCALCIFEROL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1290	Other professional services	ECALLANTIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1300	Other professional services	ECULIZUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1301	Other professional services	INJECTION, EDARAVONE, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1302	Other professional services	INJ, SUTIMLIMAB-JOME, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1303	Other professional services	INJ., RAVULIZUMAB-CWVZ 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1304	Other professional services	INJ TOFERSEN INTRATHEC 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1305	Other professional services	INJ, EVINACUMAB-DGNB, 5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1306	Other professional services	INJECTION, INCLISIRAN, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1320	Other professional services	AMITRIPTYLINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1322	Other professional services	ELOSULFASE ALFA, INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1324	Other professional services	ENFUVIRTIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1325	Other professional services	EPOPROSTENOL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1327	Other professional services	EPTIFIBATIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1330	Other professional services	ERGONOVINE MALEATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1335	Other professional services	ERTAPENEM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1364	Other professional services	ERYTHRO LACTOBIONATE /500 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1380	Other professional services	ESTRADIOL VALERATE 10 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1410	Other professional services	INJ ESTROGEN CONJUGATE 25 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1411	Other professional services	INJ, HEMGENIX, PER TX DOSE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1412	Other professional services	INJ ROCTAVIAN ML 2X10^13VC G	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1413	Other professional services	INJ DELANDISTROGENE MOX ROKL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1426	Other professional services	INJECTION, CASIMERSEN, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1427	Other professional services	INJ. VILTOLARSEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1428	Other professional services	INJ, ETEPLIRSEN, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1429	Other professional services	INJ GOLODIRSEN 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1430	Other professional services	ETHANOLAMINE OLEATE 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1435	Other professional services	INJECTION ESTRONE PER 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1436	Other professional services	ETIDRONATE DISODIUM INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1437	Other professional services	INJ. FE DERISOMALTOSE 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1438	Other professional services	ETANERCEPT INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1439	Other professional services	INJ FERRIC CARBOXYMALTOS 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1440	Other professional services	FECAL MICROBIOTA JSLM 1 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1442	Other professional services	INJ FILGRASTIM EXCL BIOSIMIL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1443	Other professional services	INJ FERRIC PYROPHOSPHATE CIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1444	Other professional services	FE PYRO CIT POW 0.1 MG IRON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1445	Other professional services	INJ TRIFERIC AVNU 0.1MG IRON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1447	Other professional services	INJ TBO FILGRASTIM 1 MICROG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1448	Other professional services	INJECTION, TRILACICLIB, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1449	Other professional services	INJ EFLAPEGRASTIM-XNST 0.1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1450	Other professional services	FLUCONAZOLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1451	Other professional services	FOMEPIZOLE, 15 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1452	Other professional services	INTRAOCULAR FOMIVIRSEN NA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1453	Other professional services	FOSAPREPITANT INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1454	Other professional services	INJ FOSNETUPITANT, PALONOSET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1455	Other professional services	FOSCARNET SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1456	Other professional services	INJ, FOSAPREPITANT (TEVA)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1457	Other professional services	GALLIUM NITRATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1458	Other professional services	GALSULFASE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1459	Other professional services	INJ IVIG PRIVIGEN 500 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1460	Other professional services	GAMMA GLOBULIN 1 CC INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1551	Other professional services	INJ CUTAQUIG 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1554	Other professional services	INJ. ASCENIV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1555	Other professional services	INJ CUVITRU, 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1556	Other professional services	INJ, IMM GLOB BIVIGAM, 500MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1557	Other professional services	GAMMAPLEX INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1558	Other professional services	INJ. XEMBIFY, 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1559	Other professional services	HIZENTRA INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1560	Other professional services	GAMMA GLOBULIN > 10 CC INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1561	Other professional services	GAMUNEX-C/GAMMAKED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1562	Other professional services	VIVAGLOBIN, INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1566	Other professional services	IMMUNE GLOBULIN, POWDER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1568	Other professional services	OCTAGAM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1569	Other professional services	GAMMAGARD LIQUID INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1570	Other professional services	GANCICLOVIR SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1571	Other professional services	HEPAGAM B IM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1572	Other professional services	FLEBOGAMMA INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1573	Other professional services	HEPAGAM B INTRAVENOUS, INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1574	Other professional services	INJ, GANCICLOVIR (EXELA)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1575	Other professional services	HYQVIA 100MG IMMUNEGLOBULIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1576	Other professional services	INJ, PANZYGA, 500 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1580	Other professional services	GARAMYCIN GENTAMICIN INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1595	Other professional services	INJECTION GLATIRAMER ACETATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1596	Other professional services	INJ, GLYCOPYRROLATE, 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1599	Other professional services	IVIG NON-LYOPHILIZED, NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1600	Other professional services	GOLD SODIUM THIOMALEATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1602	Other professional services	GOLIMUMAB FOR IV USE 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1610	Other professional services	GLUCAGON HYDROCHLORIDE/1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1611	Other professional services	INJ GLUCAGON HCL, FRESENIUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1620	Other professional services	GONADORELIN HYDROCH/ 100 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1626	Other professional services	GRANISETRON HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1627	Other professional services	INJ, GRANISETRON, XR, 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1628	Other professional services	INJ., GUSELKUMAB, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1630	Other professional services	HALOPERIDOL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1631	Other professional services	HALOPERIDOL DECANOATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1632	Other professional services	INJ., BREXANOLONE, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1640	Other professional services	HEMIN, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1642	Other professional services	INJ HEPARIN SODIUM PER 10 U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1643	Other professional services	INJ HEPARIN, PFIZER, 1000U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1644	Other professional services	INJ HEPARIN SODIUM PER 1000U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1645	Other professional services	DALTEPARIN SODIUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1650	Other professional services	INJ ENOXAPARIN SODIUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1652	Other professional services	FONDAPARINUX SODIUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1655	Other professional services	TINZAPARIN SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1670	Other professional services	TETANUS IMMUNE GLOBULIN INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1675	Other professional services	HISTRELIN ACETATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1700	Other professional services	HYDROCORTISONE ACETATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1710	Other professional services	HYDROCORTISONE SODIUM PH INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1720	Other professional services	HYDROCORTISONE SODIUM SUCC I	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1726	Other professional services	MAKENA, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1729	Other professional services	INJ HYDROXYPROGST CAPOAT NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1730	Other professional services	DIAZOXIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1738	Other professional services	INJ. MELOXICAM 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1740	Other professional services	IBANDRONATE SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1741	Other professional services	IBUPROFEN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1742	Other professional services	IBUTILIDE FUMARATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1743	Other professional services	IDURSULFASE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1744	Other professional services	ICATIBANT INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1745	Other professional services	INFLIXIMAB NOT BIOSIMIL 10MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1746	Other professional services	INJ., IBALIZUMAB-UIYK, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1747	Other professional services	INJ, SPESOLIMAB-SBZO, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1750	Other professional services	INJ IRON DEXTRAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1756	Other professional services	IRON SUCROSE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1786	Other professional services	IMUGLUCERASE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1790	Other professional services	DROPERIDOL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1800	Other professional services	PROPRANOLOL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1805	Other professional services	INJ, ESMOLOL HCL, 10MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1806	Other professional services	INJ ESMOLOL HCL WG CRIT CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1810	Other professional services	DROPERIDOL/FENTANYL INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1811	Other professional services	FIASP FOR INSULIN PUMP USE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1812	Other professional services	INJ. INSULIN (FIASP)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1813	Other professional services	LYUMJEV FOR INSULIN PUMP USE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1814	Other professional services	INJ. INSULIN (LYUMJEV)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1815	Other professional services	INSULIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1817	Other professional services	INSULIN FOR INSULIN PUMP USE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1823	Other professional services	INJ. INEBILIZUMAB-CDON, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1826	Other professional services	INTERFERON BETA-1A INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1830	Other professional services	INTERFERON BETA-1B / .25 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1833	Other professional services	INJECTION, ISAVUCONAZONIUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1835	Other professional services	ITRACONAZOLE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1836	Other professional services	INJ, METRONIDAZOLE, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1840	Other professional services	KANAMYCIN SULFATE 500 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1850	Other professional services	KANAMYCIN SULFATE 75 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1885	Other professional services	KETOROLAC TROMETHAMINE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1890	Other professional services	CEPHALOTHIN SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1920	Other professional services	INJ, LABETALOL HCL, 5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1921	Other professional services	INJ LABETALOL HCL HIKMA, 5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1930	Other professional services	LANREOTIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1931	Other professional services	LARONIDASE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1932	Other professional services	INJ, LANREOTIDE, (CIPLA) 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1939	Other professional services	INJ, BUMETANIDE, 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1940	Other professional services	FUROSEMIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1941	Other professional services	INJ, FUROSCIX, 20 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1943	Other professional services	INJ., ARISTADA INITIO, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1944	Other professional services	ARIPIRAZOLE LAUROXIL 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1945	Other professional services	LEPIRUDIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1950	Other professional services	LEUPROLIDE ACETATE /3.75 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1951	Other professional services	INJ FENSOLVI 0.25 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1952	Other professional services	LEUPROLIDE INJ, CAMCEVI, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1953	Other professional services	LEVETIRACETAM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1954	Other professional services	LEUPROLIDE DEPOT CIPLA 7.5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1955	Other professional services	INJ LEVOCARNITINE PER 1 GM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1956	Other professional services	LEVOFLOXACIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1960	Other professional services	LEVORPHANOL TARTRATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1961	Other professional services	INJ, LENACAPAVIR, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1980	Other professional services	HYOSCYAMINE SULFATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J1990	Other professional services	CHLORDIAZEPOXIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2001	Other professional services	LIDOCAINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2010	Other professional services	LINCOMYCIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2020	Other professional services	LINEZOLID INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2021	Other professional services	INJ, LINEZOLID (HOSPIRA)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2060	Other professional services	LORAZEPAM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2062	Other professional services	LOXAPINE FOR INHALATION 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2150	Other professional services	MANNITOL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2170	Other professional services	MECASERMIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2175	Other professional services	MEPERIDINE HYDROCHL /100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2180	Other professional services	MEPERIDINE/PROMETHAZINE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2182	Other professional services	INJECTION, MEPOLIZUMAB, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2184	Other professional services	INJ, MEROPENEM (B. BRAUN)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2185	Other professional services	MEROPENEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2186	Other professional services	INJ., MEROPENEM, VABORBACTAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2210	Other professional services	METHYLERGONOVIN MALEATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2212	Other professional services	METHYLNALTREXONE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2247	Other professional services	INJ, MICAFUNGIN (PAR PHARM)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2248	Other professional services	MICAFUNGIN SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2249	Other professional services	INJ, REMIMAZOLAM, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2250	Other professional services	INJ MIDAZOLAM HYDROCHLORIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2251	Other professional services	INJ MIDAZOLAM (WG CRIT CARE)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2260	Other professional services	INJ MILRINONE LACTATE / 5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2265	Other professional services	MINOCYCLINE HYDROCHLORIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2270	Other professional services	MORPHINE SULFATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2272	Other professional services	INJ, MORPHINE (FRESENIUS)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2274	Other professional services	INJ MORPHINE PF EPID ITHC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2278	Other professional services	ZICONOTIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2280	Other professional services	INJ, MOXIFLOXACIN 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2281	Other professional services	INJ MOXIFLOXACIN (FRES KABI)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2300	Other professional services	INJ NALBUPHINE HYDROCHLORIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2305	Other professional services	INJ, NITROGLYCERIN, 5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2310	Other professional services	INJ NALOXONE HYDROCHLORIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2311	Other professional services	INJ, NALOXONE HCL (ZIMHI)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2315	Other professional services	NALTREXONE, DEPOT FORM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2320	Other professional services	NANDROLONE DECANOATE 50 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2323	Other professional services	NATALIZUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2325	Other professional services	NESIRITIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2326	Other professional services	INJ, NUSINERSEN, 0.1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2327	Other professional services	INJ RISANKIZUMAB-RZAA 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2329	Other professional services	INJ UBLITUXIMAB-XIIY, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2350	Other professional services	INJECTION, OCRELIZUMAB, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2353	Other professional services	OCTREOTIDE INJECTION, DEPOT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2354	Other professional services	OCTREOTIDE INJ, NON-DEPOT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2355	Other professional services	OPRELVEKIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2356	Other professional services	INJ TEZEPELUMAB-EKKO, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2357	Other professional services	OMALIZUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2358	Other professional services	OLANZAPINE LONG-ACTING INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2359	Other professional services	INJ. OLANZAPINE, 0.5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2360	Other professional services	ORPHENADRINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2371	Other professional services	INJ PHENYLEPHRINE HCL 20 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2372	Other professional services	INJ, BIORPHEN, 20 MICROGRAMS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2401	Other professional services	CHLOROPROCAINE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2402	Other professional services	CHLOROPROCAINE (CLOROTEKAL)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2403	Other professional services	CHLOROPROCAINE OPHT GEL, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2404	Other professional services	INJ, NICARDIPINE 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2405	Other professional services	ONDANSETRON HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2406	Other professional services	INJECTION, ORITAVANCIN 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2407	Other professional services	INJECTION, ORITAVANCIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2410	Other professional services	OXYMORPHONE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2425	Other professional services	PALIFERMIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2426	Other professional services	INJ, INVEGA SUSTENNA, 1 MGJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2427	Other professional services	INJ, INVEGA HAFYERA/TRINZA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2430	Other professional services	PAMIDRONATE DISODIUM /30 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2440	Other professional services	PAPAVERIN HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2460	Other professional services	OXYTETRACYCLINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2469	Other professional services	PALONOSETRON HCL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2501	Other professional services	PARICALCITOL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2502	Other professional services	INJ, PASIREOTIDE LONG ACTING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2503	Other professional services	PEGAPTANIB SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2504	Other professional services	PEGADEMASE BOVINE, 25 IU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2506	Other professional services	INJ PEGFILGRAST EX BIO 0.5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2507	Other professional services	PEGLOTICASE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2508	Other professional services	PEGUNIGALSIDASE ALFA-IWXJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2510	Other professional services	PENICILLIN G PROCAINE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2513	Other professional services	PENTASTARCH 10% SOLUTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2515	Other professional services	PENTOBARBITAL SODIUM INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2540	Other professional services	PENICILLIN G POTASSIUM INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2543	Other professional services	PIPERACILLIN/TAZOBACTAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2545	Other professional services	PENTAMIDINE NON-COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2547	Other professional services	INJECTION, PERAMIVIR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2550	Other professional services	PROMETHAZINE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2560	Other professional services	PHENOBARBITAL SODIUM INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2561	Other professional services	INJ, SEZABY, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2562	Other professional services	PLERIXAFOR INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2590	Other professional services	OXYTOCIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2597	Other professional services	INJ DESMOPRESSIN ACETATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2598	Other professional services	INJ, VASOPRESSIN, 1 UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2599	Other professional services	INJ VASOPRESSIN (AM REG) 1 U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2650	Other professional services	PREDNISOLONE ACETATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2670	Other professional services	TOTAZOLINE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2675	Other professional services	INJ PROGESTERONE PER 50 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2679	Other professional services	INJ FLUPHENAZINE HCL 1.25 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2680	Other professional services	FLUPHENAZINE DECANOATE 25 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2690	Other professional services	PROCAINAMIDE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2700	Other professional services	OXACILLIN SODIUM INJECITON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2704	Other professional services	INJ, PROPOFOL, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2710	Other professional services	NEOSTIGMINE METHYLSLFTE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2720	Other professional services	INJ PROTAMINE SULFATE/10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2724	Other professional services	PROTEIN C CONCENTRATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2725	Other professional services	INJ PROTIRELIN PER 250 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2730	Other professional services	PRALIDOXIME CHLORIDE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2760	Other professional services	PHENTOLAINE MESYLATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2765	Other professional services	METOCLOPRAMIDE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2770	Other professional services	QUINUPRISTIN/DALFOPRISTIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2777	Other professional services	INJ, FARICIMAB-SVOA, 0.1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2778	Other professional services	RANIBIZUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2779	Other professional services	INJ, SUSVIMO 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2780	Other professional services	RANITIDINE HYDROCHLORIDE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2781	Other professional services	INJ, PEGCETACOPLAN, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2783	Other professional services	RASBURICASE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2785	Other professional services	REGADENOSON INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2786	Other professional services	INJECTION, RESLIZUMAB, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2787	Other professional services	RIBOFLAVIN 5'PHOS OPTH<=3ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2788	Other professional services	RHO D IMMUNE GLOBULIN 50 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2790	Other professional services	RHO D IMMUNE GLOBULIN INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2791	Other professional services	RHOPHYLAC INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2792	Other professional services	RHO(D) IMMUNE GLOBULIN H, SD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2793	Other professional services	RILONACEPT INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2794	Other professional services	INJ RISPERDAL CONSTA, 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2795	Other professional services	ROPIVACAINE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2796	Other professional services	ROMIPLOSTIM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2797	Other professional services	INJ., ROLAPITANT, 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2798	Other professional services	INJ., PERSERIS, 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2799	Other professional services	INJ, UZEDY, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2800	Other professional services	METHOCARBAMOL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2805	Other professional services	SINCALIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2806	Other professional services	INJ SINCALIDE, MAIA, 5 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2810	Other professional services	INJ THEOPHYLLINE PER 40 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2820	Other professional services	SARGRAMOSTIM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2840	Other professional services	INJ SEBELIPASE ALFA 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2850	Other professional services	INJ SECRETIN SYNTHETIC HUMAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2860	Other professional services	INJECTION, SILTUXIMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2910	Other professional services	AUROTHIOGLUCOSE INJECITON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2916	Other professional services	NA FERRIC GLUCONATE COMPLEX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2920	Other professional services	METHYLPREDNISOLONE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2930	Other professional services	METHYLPREDNISOLONE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2940	Other professional services	SOMATREM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2941	Other professional services	SOMATROPIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2950	Other professional services	PROMAZINE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2993	Other professional services	RETEPLASE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2995	Other professional services	INJ STREPTOKINASE /250000 IU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2997	Other professional services	ALTEPLASE RECOMBINANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J2998	Other professional services	INJ PLASMINOGEN TVMH 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3000	Other professional services	STREPTOMYCIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3010	Other professional services	FENTANYL CITRATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3030	Other professional services	SUMATRIPTAN SUCCINATE / 6 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3031	Other professional services	INJ., FREMANEZUMAB-VFRM 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3032	Other professional services	INJ. EPTINEZUMAB-JJMR 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3060	Other professional services	INJ, TALIGLUCERASE ALFA 10 U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3070	Other professional services	PENTAZOCINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3090	Other professional services	INJ TEDIZOLID PHOSPHATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3095	Other professional services	TELAVANCIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3101	Other professional services	TENECTEPLASE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3105	Other professional services	TERBUTALINE SULFATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3110	Other professional services	TERIPARATIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3111	Other professional services	INJ. ROMOSOZUMAB-AQQG 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3121	Other professional services	INJ TESTOSTERO ENANTHATE 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3145	Other professional services	TESTOSTERONE UNDECANOATE 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3230	Other professional services	CHLORPROMAZINE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3240	Other professional services	THYROTROPIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3241	Other professional services	INJ. TEPROTUMUMAB-TRBW 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3243	Other professional services	TIGECYCLINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3244	Other professional services	INJ. TIGECYCLINE (ACCORD)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3245	Other professional services	INJ., TILDRAKIZUMAB, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3246	Other professional services	TIROFIBAN HCL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3250	Other professional services	TRIMETHOBENZAMIDE HCL INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3260	Other professional services	TOBRAMYCIN SULFATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3262	Other professional services	TOCILIZUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3265	Other professional services	INJECTION TORSEMIDE 10 MG/ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3280	Other professional services	THIETHYLPERAZINE MALEATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3285	Other professional services	TREPROSTINIL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3299	Other professional services	INJ XIPERE 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3300	Other professional services	TRIAMCINOLONE A INJ PRS-FREE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3301	Other professional services	TRIAMCINOLONE ACET INJ NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3302	Other professional services	TRIAMCINOLONE DIACETATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3303	Other professional services	TRIAMCINOLONE HEXACETONL INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3304	Other professional services	INJ TRIAMCINOLONE ACE XR 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3305	Other professional services	INJ TRIMETREXATE GLUCORONATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3310	Other professional services	PERPHENAZINE INJECITON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3315	Other professional services	TRIPTORELIN PAMOATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3316	Other professional services	INJ., TRIPTORELIN XR 3.75 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3320	Other professional services	SPECTINOMYCN DI-HCL INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3350	Other professional services	UREA INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3355	Other professional services	UROFOLLITROPIN, 75 IU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3357	Other professional services	USTEKINUMAB SUB CU INJ, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3358	Other professional services	USTEKINUMAB, IV INJECT, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3360	Other professional services	DIAZEPAM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3364	Other professional services	UROKINASE 5000 IU INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3365	Other professional services	UROKINASE 250,000 IU INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3370	Other professional services	VANCOMYCIN HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3371	Other professional services	INJ, VANCOMYCIN HCL (MYLAN)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3372	Other professional services	INJ, VANCOMYCIN HCL (XELLIA)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3380	Other professional services	INJECTION, VEDOLIZUMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3385	Other professional services	VELAGLUCERASE ALFA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3396	Other professional services	VERTEPORFIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3397	Other professional services	INJ., VESTRONIDASE ALFA-VJBK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3398	Other professional services	INJ LUXTURNA 1 BILLION VEC G	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3399	Other professional services	INJ ONASE ABEPAR-XIOI TREAT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3400	Other professional services	TRIFLUPROMAZINE HCL INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3401	Other professional services	VYJUVEK 5X10^9PFU/ML, 0.1 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3410	Other professional services	HYDROXYZINE HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3411	Other professional services	THIAMINE HCL 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3415	Other professional services	PYRIDOXINE HCL 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3420	Other professional services	VITAMIN B12 INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3425	Other professional services	INJ, HYDROXOCOBALAMIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3430	Other professional services	VITAMIN K PHYTONADIONE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3465	Other professional services	INJECTION, VORICONAZOLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3470	Other professional services	HYALURONIDASE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3471	Other professional services	OVINE, UP TO 999 USP UNITS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3472	Other professional services	OVINE, 1000 USP UNITS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3473	Other professional services	HYALURONIDASE RECOMBINANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3475	Other professional services	INJ MAGNESIUM SULFATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3480	Other professional services	INJ POTASSIUM CHLORIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3485	Other professional services	ZIDOVUDINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3486	Other professional services	ZIPRASIDONE MESYLATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3489	Other professional services	ZOLEDRONIC ACID 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3490	Other professional services	DRUGS UNCLASSIFIED INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3520	Other professional services	EDETATE DISODIUM PER 150 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3530	Other professional services	NASAL VACCINE INHALATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3535	Other professional services	METERED DOSE INHALER DRUG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3570	Other professional services	LAETRILE AMYGDALIN VIT B17	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3590	Other professional services	UNCLASSIFIED BIOLOGICS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J3591	Other professional services	ESRD ON DIALYSI DRUG/BIO NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7030	Other professional services	NORMAL SALINE SOLUTION INFUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7040	Other professional services	NORMAL SALINE SOLUTION INFUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7042	Other professional services	5% DEXTROSE/NORMAL SALINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7050	Other professional services	NORMAL SALINE SOLUTION INFUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7060	Other professional services	5% DEXTROSE/WATER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7070	Other professional services	D5W INFUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7100	Other professional services	DEXTRAN 40 INFUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7110	Other professional services	DEXTRAN 75 INFUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7120	Other professional services	RINGERS LACTATE INFUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7121	Other professional services	5% DEXTROSE IN LAC RINGERS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7131	Other professional services	HYPERTONIC SALINE SOL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7168	Other professional services	PROTHROMBIN COMPLEX KCENTRA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7169	Other professional services	INJ ANDEXXA, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7170	Other professional services	INJ., EMICIZUMAB-KXWH 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7175	Other professional services	INJ, FACTOR X, (HUMAN), 1IU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7177	Other professional services	INJ., FIBRYGA, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7178	Other professional services	INJ HUMAN FIBRINOGEN CON NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7179	Other professional services	VONVENDI INJ 1 IU VWF:RCO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7180	Other professional services	FACTOR XIII ANTI-HEM FACTOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7181	Other professional services	FACTOR XIII RECOMB A-SUBUNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7182	Other professional services	FACTOR VIII RECOMB NOVOEIGHT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7183	Other professional services	WILATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7185	Other professional services	XYNTHA INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7186	Other professional services	ANTIHEMOPHILIC VIII/VWF COMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7187	Other professional services	HUMATE-P, INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7188	Other professional services	FACTOR VIII RECOMB OBIZUR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7189	Other professional services	FACTOR VIIA RECOMB NOVOSEVEN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7190	Other professional services	FACTOR VIII	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7191	Other professional services	FACTOR VIII (PORCINE)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7192	Other professional services	FACTOR VIII RECOMBINANT NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7193	Other professional services	FACTOR IX NON-RECOMBINANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7194	Other professional services	FACTOR IX COMPLEX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7195	Other professional services	FACTOR IX RECOMBINANT NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7196	Other professional services	ANTITHROMBIN RECOMBINANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7197	Other professional services	ANTITHROMBIN III INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7198	Other professional services	ANTI-INHIBITOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7199	Other professional services	HEMOPHILIA CLOT FACTOR NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7200	Other professional services	FACTOR IX RECOMBINAN RIXUBIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7201	Other professional services	FACTOR IX ALPROLIX RECOMB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7202	Other professional services	FACTOR IX IDELVION INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7203	Other professional services	FACTOR IX RECOMB GLY REBINYN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7204	Other professional services	INJ RECOMBIN ESPEROCT PER IU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7205	Other professional services	FACTOR VIII FC FUSION RECOMB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7207	Other professional services	FACTOR VIII PEGYLATED RECOMB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7208	Other professional services	INJ. JIVI 1 IU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7209	Other professional services	FACTOR VIII NUWIQ RECOMB 1IU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7210	Other professional services	INJ, AFSTYLA, 1 I.U.	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7211	Other professional services	INJ, KOVALTRY, 1 I.U.	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7212	Other professional services	FACTOR VIIA RECOMB SEVENFACT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7213	Other professional services	INJ, IXINITY, 1 I.U.	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7214	Other professional services	ALTUVIIIO PER FACTOR VIII IU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7294	Other professional services	SEG ACET AND ETH ESTR YEARLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7295	Other professional services	ETH ESTR AND ETON MONTHLY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7296	Other professional services	KYLEENA, 19.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7297	Other professional services	LILETTA, 52 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7298	Other professional services	MIRENA, 52 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7300	Other professional services	INTRAUT COPPER CONTRACEPTIVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7301	Other professional services	SKYLA, 13.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7304	Other professional services	CONTRACEPTIVE HORMONE PATCH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7306	Other professional services	LEVONORGESTREL IMPLANT SYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7307	Other professional services	ETONOGESTREL IMPLANT SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7308	Other professional services	AMINOLEVULINIC ACID HCL TOP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7309	Other professional services	METHYL AMINOLEVULINATE, TOP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7310	Other professional services	GANCICLOVIR LONG ACT IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7311	Other professional services	INJ., RETISERT, 0.01 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7312	Other professional services	DEXAMETHASONE INTRA IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7313	Other professional services	INJ., ILUVIEN, 0.01 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7314	Other professional services	INJ., YUTIQ, 0.01 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7315	Other professional services	OPHTHALMIC MITOMYCIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7316	Other professional services	INJ, OCRIPLASMIN, 0.125 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7318	Other professional services	INJ, DUROLANE 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7320	Other professional services	GENVISC 850, INJ, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7321	Other professional services	HYALGAN SUPARTZ VISCO-3 DOSE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7322	Other professional services	HYMOVIS INJECTION 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7323	Other professional services	EUFLEXXA INJ PER DOSE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7324	Other professional services	ORTHOVISC INJ PER DOSE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7325	Other professional services	SYNVISC OR SYNVISC-ONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7326	Other professional services	GEL-ONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7327	Other professional services	MONOVISC INJ PER DOSE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7328	Other professional services	GELSYN-3 INJECTION 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7329	Other professional services	INJ, TRIVISC 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7330	Other professional services	CULTURED CHONDROCYTES IMPLNT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7331	Other professional services	SYNOJOYNT, INJ., 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7332	Other professional services	INJ., TRILURON, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7336	Other professional services	CAPSAICIN 8% PATCH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7340	Other professional services	CARBIDOPA LEVODOPA ENT 100ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7342	Other professional services	CIPROFLOXACIN OTIC SUSP 6 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7345	Other professional services	AMINOLEVULINIC ACID, 10% GEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7351	Other professional services	INJ BIMATOPROST ITC IMP1MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7352	Other professional services	AFAMELANOTIDE IMPLANT, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7353	Other professional services	ANACAULASE-BCDB 8.8% GEL 1 G	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7402	Other professional services	MOMETASONE SINUS SINUVA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7500	Other professional services	AZATHIOPRINE ORAL 50MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7501	Other professional services	AZATHIOPRINE PARENTERAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7502	Other professional services	CYCLOSPORINE ORAL 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7503	Other professional services	TACROL ENVARSUS EX REL ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7504	Other professional services	LYMPHOCYTE IMMUNE GLOBULIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7505	Other professional services	MONOCLONAL ANTIBODIES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7507	Other professional services	TACROLIMUS IMME REL ORAL 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7508	Other professional services	TACROL ASTAGRAF EX REL ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7509	Other professional services	METHYLPREDNISOLONE ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7510	Other professional services	PREDNISOLONE ORAL PER 5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7511	Other professional services	ANTITHYMOCYTE GLOBULN RABBIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7512	Other professional services	PREDNISONE IR OR DR ORAL 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7513	Other professional services	DACLIZUMAB, PARENTERAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7515	Other professional services	CYCLOSPORINE ORAL 25 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7516	Other professional services	CYCLOSPORIN PARENTERAL 250MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7517	Other professional services	MYCOPHENOLATE MOFETIL ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7518	Other professional services	MYCOPHENOLIC ACID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7519	Other professional services	INJ. MYCOPHENOLATE MOFETIL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7520	Other professional services	SIROLIMUS, ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7525	Other professional services	TACROLIMUS INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7527	Other professional services	ORAL EVEROLIMUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7599	Other professional services	IMMUNOSUPPRESSIVE DRUG NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7604	Other professional services	ACETYLCYSTEINE COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7605	Other professional services	ARFORMOTEROL NON-COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7606	Other professional services	FORMOTEROL FUMARATE, INH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7607	Other professional services	LEVALBUTEROL COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7608	Other professional services	ACETYLCYSTEINE NON-COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7609	Other professional services	ALBUTEROL COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7610	Other professional services	ALBUTEROL COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7611	Other professional services	ALBUTEROL NON-COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7612	Other professional services	LEVALBUTEROL NON-COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7613	Other professional services	ALBUTEROL NON-COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7614	Other professional services	LEVALBUTEROL NON-COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7615	Other professional services	LEVALBUTEROL COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7620	Other professional services	ALBUTEROL IPRATROP NON-COMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7622	Other professional services	BECLOMETHASONE COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7624	Other professional services	BETAMETHASONE COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7626	Other professional services	BUDESONIDE NON-COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7627	Other professional services	BUDESONIDE COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7628	Other professional services	BITOLTEROL MESYLATE COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7629	Other professional services	BITOLTEROL MESYLATE COMP UNT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7631	Other professional services	CROMOLYN SODIUM NONCOMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7632	Other professional services	CROMOLYN SODIUM COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7633	Other professional services	BUDESONIDE NON-COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7634	Other professional services	BUDESONIDE COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7635	Other professional services	ATROPINE COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7636	Other professional services	ATROPINE COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7637	Other professional services	DEXAMETHASONE COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7638	Other professional services	DEXAMETHASONE COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7639	Other professional services	DORNASE ALFA NON-COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7640	Other professional services	FORMOTEROL COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7641	Other professional services	FLUNISOLIDE COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7642	Other professional services	GLYCOPYRROLATE COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7643	Other professional services	GLYCOPYRROLATE COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7644	Other professional services	IPRATROPIUM BROMIDE NON-COMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7645	Other professional services	IPRATROPIUM BROMIDE COMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7647	Other professional services	ISOETHARINE COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7648	Other professional services	ISOETHARINE NON-COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7649	Other professional services	ISOETHARINE NON-COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7650	Other professional services	ISOETHARINE COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7657	Other professional services	ISOPROTERENOL COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7658	Other professional services	ISOPROTERENOL NON-COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7659	Other professional services	ISOPROTERENOL NON-COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7660	Other professional services	ISOPROTERENOL COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7665	Other professional services	MANNITOL FOR INHALER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7667	Other professional services	METAPROTERENOL COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7668	Other professional services	METAPROTERENOL NON-COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7669	Other professional services	METAPROTERENOL NON-COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7670	Other professional services	METAPROTERENOL COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7674	Other professional services	METHACHOLINE CHLORIDE, NEB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7676	Other professional services	PENTAMIDINE COMP UNIT DOSE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7677	Other professional services	REVEFENACIN INH NON-COM 1MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7680	Other professional services	TERBUTALINE SULF COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7681	Other professional services	TERBUTALINE SULF COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7682	Other professional services	TOBRAMYCIN NON-COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7683	Other professional services	TRIAMCINOLONE COMP CON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7684	Other professional services	TRIAMCINOLONE COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7685	Other professional services	TOBRAMYCIN COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7686	Other professional services	TREPROSTINIL, NON-COMP UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7699	Other professional services	INHALATION SOLUTION FOR DME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7799	Other professional services	NON-INHALATION DRUG FOR DME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J7999	Other professional services	COMPOUNDED DRUG, NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8498	Other professional services	ANTIEMETIC RECTAL/SUPP NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8499	Other professional services	ORAL PRESCRIP DRUG NON CHEMO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8501	Other professional services	ORAL APREPITANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8510	Other professional services	ORAL BUSULFAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8515	Other professional services	CABERGOLINE, ORAL 0.25MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8520	Other professional services	CAPECITABINE, ORAL, 150 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8521	Other professional services	CAPECITABINE, ORAL, 500 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8530	Other professional services	CYCLOPHOSPHAMIDE ORAL 25 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8540	Other professional services	ORAL DEXAMETHASONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8560	Other professional services	ETOPOSIDE ORAL 50 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8562	Other professional services	ORAL FLUDARABINE PHOSPHATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8565	Other professional services	GEFITINIB ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8597	Other professional services	ANTIEMETIC DRUG ORAL NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8600	Other professional services	MELPHALAN ORAL 2 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8610	Other professional services	METHOTREXATE ORAL 2.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8650	Other professional services	NABILONE ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8655	Other professional services	ORAL NETUPITANT, PALONOSETRO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8670	Other professional services	ROLAPITANT, ORAL, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8700	Other professional services	TEMOZOLOMIDE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8705	Other professional services	TOPOTECAN ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J8999	Other professional services	ORAL PRESCRIPTION DRUG CHEMO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9000	Other professional services	DOXORUBICIN HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9015	Other professional services	ALDESLEUKIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9017	Other professional services	ARSENIC TRIOXIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9019	Other professional services	ERWINAZE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9020	Other professional services	ASPARAGINASE, NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9021	Other professional services	INJ, ASPARA, RYLAZE, 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9022	Other professional services	INJ, ATEZOLIZUMAB,10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9023	Other professional services	INJECTION, AVELUMAB, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9025	Other professional services	AZACITIDINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9027	Other professional services	CLOFARABINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9029	Other professional services	INJ, ADSTILADRIN, PER TX DOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9030	Other professional services	BCG LIVE INTRAVESICAL 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9032	Other professional services	INJECTION, BELINOSTAT, 10MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9033	Other professional services	INJ., TREANDA 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9034	Other professional services	INJ., BENDEKA 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9035	Other professional services	BEVACIZUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9036	Other professional services	INJ. BELRAPZO/BENDAMUSTINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9037	Other professional services	INJ BELANTAMAB MAFODONT BLMF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9039	Other professional services	INJECTION, BLINATUMOMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9040	Other professional services	BLEOMYCIN SULFATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9041	Other professional services	INJECTION, BORTEZOMIB, 0.1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9042	Other professional services	BRENTUXIMAB VEDOTIN INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9043	Other professional services	CABAZITAXEL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9045	Other professional services	CARBOPLATIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9046	Other professional services	INJ, BORTEZOMIB, DR. REDDY'S	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9047	Other professional services	INJECTION, CARFILZOMIB, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9048	Other professional services	INJ, BORTEZOMIB FRESENIUSKAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9049	Other professional services	INJ, BORTEZOMIB, HOSPIRA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9050	Other professional services	CARMUSTINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9051	Other professional services	INJ, BORTEZOMIB (MAIA)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9052	Other professional services	INJ, CARMUSTINE (ACCORD)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9055	Other professional services	CETUXIMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9056	Other professional services	INJ, BENDAMUSTINE, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9057	Other professional services	INJ., COPANLISIB, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9058	Other professional services	INJ APOTEX/BENDAMUSTINE 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9059	Other professional services	INJ BENDAMUSTINE, BAXTER 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9060	Other professional services	CISPLATIN 10 MG INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9061	Other professional services	INJ, AMIVANTAMAB-VMJW	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9063	Other professional services	INJ, ELAHERE, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9064	Other professional services	INJ, CABAZITAXEL (SANDOZ)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9065	Other professional services	INJ CLADRIBINE PER 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9070	Other professional services	CYCLOPHOSPHAMIDE 100 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9071	Other professional services	INJ CYCLOPHOSPHAMD AUROMEDIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9072	Other professional services	INJ CYCLOPHOS DR.REDDY'S 5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9098	Other professional services	CYTARABINE LIPOSOME INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9100	Other professional services	CYTARABINE HCL 100 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9118	Other professional services	INJ. CALASPARGASE PEGOL-MKNL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9119	Other professional services	INJ., CEMIPLIMAB-RWLC, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9120	Other professional services	DACTINOMYCIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9130	Other professional services	DACARBAZINE 100 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9144	Other professional services	DARATUMUMAB, HYALURONIDASE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9145	Other professional services	INJECTION, DARATUMUMAB 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9150	Other professional services	DAUNORUBICIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9151	Other professional services	DAUNORUBICIN CITRATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9153	Other professional services	INJ DAUNORUBICIN, CYTARABINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9155	Other professional services	DEGARELIX INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9165	Other professional services	DIETHYLSTILBESTROL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9171	Other professional services	DOCETAXEL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9172	Other professional services	DOCETAXEL (INGENUS), 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9173	Other professional services	INJ., DURVALUMAB, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9175	Other professional services	ELLIOTTS B SOLUTION PER ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9176	Other professional services	INJECTION, ELOTUZUMAB, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9177	Other professional services	INJ ENFORT VEDO-EJFV 0.25MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9178	Other professional services	INJ, EPIRUBICIN HCL, 2 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9179	Other professional services	ERIBULIN MESYLATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9181	Other professional services	ETOPOSIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9185	Other professional services	FLUDARABINE PHOSPHATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9190	Other professional services	FLUOROURACIL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9196	Other professional services	INJ GEMCITABINE HCL (ACCORD)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9198	Other professional services	INJ. INFUGEM, 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9200	Other professional services	FLOXURIDINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9201	Other professional services	IN GEMCITABINE HCL NOS 200MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9202	Other professional services	GOSERELIN ACETATE IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9203	Other professional services	GEMTUZUMAB OZOGAMICIN 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9204	Other professional services	INJ MOGAMULIZUMAB-KPKC, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9205	Other professional services	INJ IRINOTECAN LIPOSOME 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9206	Other professional services	IRINOTECAN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9207	Other professional services	IXABEPILONE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9208	Other professional services	IFOSFAMIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9209	Other professional services	MESNA INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9210	Other professional services	INJ., EMAPALUMAB-LZSG, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9211	Other professional services	IDARUBICIN HCL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9212	Other professional services	INTERFERON ALFACON-1 INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9213	Other professional services	INTERFERON ALFA-2A INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9214	Other professional services	INTERFERON ALFA-2B INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9215	Other professional services	INTERFERON ALFA-N3 INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9216	Other professional services	INTERFERON GAMMA 1-B INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9217	Other professional services	LEUPROLIDE ACETATE SUSPNSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9218	Other professional services	LEUPROLIDE ACETATE INJECITON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9219	Other professional services	LEUPROLIDE ACETATE IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9223	Other professional services	INJ. LURBINECTEDIN, 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9225	Other professional services	VANTAS IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9226	Other professional services	SUPPRELIN LA IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9227	Other professional services	INJ. ISATUXIMAB-IRFC 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9228	Other professional services	IPILIMUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9229	Other professional services	INJ INOTUZUMAB OZOGAM 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9230	Other professional services	MECHLORETHAMINE HCL INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9245	Other professional services	INJ MELPHALAN HYDROCHL 50 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9246	Other professional services	INJ., EVOMELA, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9247	Other professional services	INJ, MELPHALAN FLUFENAMI 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9250	Other professional services	METHOTREXATE SODIUM INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9255	Other professional services	INJ, METHOTREXATE (ACCORD)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9258	Other professional services	PACLITAXEL (TEVA)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9259	Other professional services	PACLITAXEL (AMERICAN REGENT)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9260	Other professional services	METHOTREXATE SODIUM INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9261	Other professional services	NELARABINE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9262	Other professional services	INJ, OMACETAXINE MEP, 0.01MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9263	Other professional services	OXALIPLATIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9264	Other professional services	PACLITAXEL PROTEIN BOUND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9266	Other professional services	PEGASPARGASE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9267	Other professional services	PACLITAXEL INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9268	Other professional services	PENTOSTATIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9269	Other professional services	INJ. TAGRAXOFUSP-ERZS 10 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9270	Other professional services	PLICAMYCIN (MITHRAMYCIN) INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9271	Other professional services	INJ PEMBROLIZUMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9272	Other professional services	INJ, DOSTARLIMAB-GXLY, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9273	Other professional services	INJ TISOTU VEDOTIN-TFTV, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9274	Other professional services	INJ, TEBENTAFUSP-TEBN, 1 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9280	Other professional services	MITOMYCIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9281	Other professional services	MITOMYCIN INSTILLATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9285	Other professional services	INJ, OLARATUMAB, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9286	Other professional services	INJ GLOFITAMAB GXBM, 2.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9293	Other professional services	MITOXANTRONE HYDROCHL / 5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9294	Other professional services	INJ PEMETREXED, HOSPIRA 10MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9295	Other professional services	INJECTION, NECITUMUMAB, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9296	Other professional services	INJ PEMETREXED (ACCORD) 10MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9297	Other professional services	INJ PEMETREXED (SANDOZ) 10MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9298	Other professional services	INJ NIVOL RELATLIMAB 3MG/1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9299	Other professional services	INJECTION, NIVOLUMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9301	Other professional services	OBINUTUZUMAB INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9302	Other professional services	OFATUMUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9303	Other professional services	PANITUMUMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9304	Other professional services	INJ. PEMETREXED, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9305	Other professional services	PEMETREXED INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9306	Other professional services	INJECTION, PERTUZUMAB, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9307	Other professional services	PRALATREXATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9308	Other professional services	INJECTION, RAMUCIRUMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9309	Other professional services	INJ, POLATUZUMAB VEDOTIN 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9311	Other professional services	INJ RITUXIMAB, HYALURONIDASE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9312	Other professional services	INJ., RITUXIMAB, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9313	Other professional services	INJ., LUMOXITI, 0.01 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9314	Other professional services	INJ PEMETREXED (TEVA) 10MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9316	Other professional services	PERTUZU, TRASTUZU, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9317	Other professional services	SACITUZUMAB GOVITECAN-HZIY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9318	Other professional services	INJ ROMIDEPSIN NON-LYO 0.1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9319	Other professional services	INJ ROMIDEPSIN LYOPHIL 0.1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9320	Other professional services	STREPTOZOCIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9321	Other professional services	INJ EPCORITAMAB-BYSP 0.16 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9322	Other professional services	INJ PEMETREXED (BLUEPOINT)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9323	Other professional services	INJ PEMETREXED DITROMETHAMIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9324	Other professional services	INJ, PEMRYDI RTU, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9325	Other professional services	INJ TALIMOGENE LAHERPAREPVEC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9328	Other professional services	TEMOZOLOMIDE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9330	Other professional services	TEMSIROLIMUS INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9331	Other professional services	INJ SIROLIMUS PROT PART 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9332	Other professional services	INJ EFGARTIGIMOD 2MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9333	Other professional services	INJ RONZANOLIXIZUM-NOLI 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9334	Other professional services	INJ EFGART-ALFA 2MG HYA-QVFC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9340	Other professional services	THIOTEPA INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9345	Other professional services	INJ, RETIFANLIMAB-DLWR, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9347	Other professional services	INJ, TREMELIMUMAB-ACTL, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9348	Other professional services	INJ. NAXITAMAB-GQGK, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9349	Other professional services	INJ., TAFASITAMAB-CXIX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9350	Other professional services	INJ MOSUNETUZUMAB-AXGB, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9351	Other professional services	TOPOTECAN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9352	Other professional services	INJECTION TRABECTEDIN 0.1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9353	Other professional services	INJ. MARGETUXIMAB-CMKB, 5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9354	Other professional services	INJ, ADO-TRASTUZUMAB EMT 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9355	Other professional services	INJ TRASTUZUMAB EXCL BIOSIMI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9356	Other professional services	INJ. HERCEPTIN HYLECTA, 10MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9357	Other professional services	VALRUBICIN INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9358	Other professional services	INJ FAM-TRASTU DERU-NXKI 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9359	Other professional services	INJ LON TESIRIN-LPYL 0.075MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9360	Other professional services	VINBLASTINE SULFATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9370	Other professional services	VINCRISTINE SULFATE 1 MG INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9371	Other professional services	INJ, VINCRISTINE SUL LIP 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9380	Other professional services	INJ TECLISTAMAB CQYV 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9381	Other professional services	INJ TEPLIZUMAB MZWV 5 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9390	Other professional services	VINORELBINE TARTRATE INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9393	Other professional services	INJ, FULVESTRANT (TEVA)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9394	Other professional services	INJ, FULVESTRANT (FRESENIUS)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9395	Other professional services	INJECTION, FULVESTRANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9400	Other professional services	INJ, ZIV-AFLIBERCEPT, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9600	Other professional services	PORFIMER SODIUM INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
J9999	Other professional services	CHEMOTHERAPY DRUG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0001-RR	DMEPOS	STANDARD WHEELCHAIR	29.37	29.37
K0002-RR	DMEPOS	STND HEMI (LOW SEAT) WHLCHR	51.17	51.17
K0003-RR	DMEPOS	LIGHTWEIGHT WHEELCHAIR	44.43	44.43
K0004-RR	DMEPOS	HIGH STRENGTH LTWT WHLCHR	54.78	54.78
K0005-NU	DMEPOS	ULTRALIGHTWEIGHT WHEELCHAIR	2522.56	2522.56
K0005-RR	DMEPOS	ULTRALIGHTWEIGHT WHEELCHAIR	252.23	252.23
K0005-UE	DMEPOS	ULTRALIGHTWEIGHT WHEELCHAIR	1891.86	1891.86
K0006-RR	DMEPOS	HEAVY DUTY WHEELCHAIR	81.00	81.00
K0007-RR	DMEPOS	EXTRA HEAVY DUTY WHEELCHAIR	114.18	114.18
K0008	DMEPOS	CSTM MANUAL WHEELCHAIR/BASE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0009-RR	DMEPOS	OTHER MANUAL WHEELCHAIR/BASE	100.46	100.46
K0010-RR	DMEPOS	STND WT FRAME POWER WHLCHR	494.05	494.05
K0011-RR	DMEPOS	STND WT PWR WHLCHR W CONTROL	776.02	776.02
K0012-RR	DMEPOS	LTWT PORTBL POWER WHLCHR	443.33	443.33
K0013	DMEPOS	CUSTOM POWER WHLCHR BASE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0014	DMEPOS	OTHER POWER WHLCHR BASE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0015-RR	DMEPOS	DETACH NON-ADJ HT ARMRST REP	21.37	21.37
K0017-NU	DMEPOS	DETACH ADJUST ARMREST BASE	60.09	60.09
K0017-RR	DMEPOS	DETACH ADJUST ARMREST BASE	6.00	6.00
K0017-UE	DMEPOS	DETACH ADJUST ARMREST BASE	45.08	45.08
K0018-NU	DMEPOS	DETACH ADJUST ARMRST UPPER	33.57	33.57
K0018-RR	DMEPOS	DETACH ADJUST ARMRST UPPER	3.36	3.36
K0018-UE	DMEPOS	DETACH ADJUST ARMRST UPPER	25.20	25.20
K0019-NU	DMEPOS	ARM PAD REPL, EACH	19.81	19.81
K0019-RR	DMEPOS	ARM PAD REPL, EACH	2.00	2.00
K0019-UE	DMEPOS	ARM PAD REPL, EACH	14.85	14.85
K0020-NU	DMEPOS	FIXED ADJUST ARMREST PAIR	54.64	54.64
K0020-RR	DMEPOS	FIXED ADJUST ARMREST PAIR	5.47	5.47
K0020-UE	DMEPOS	FIXED ADJUST ARMREST PAIR	40.98	40.98
K0037-NU	DMEPOS	HI MOUNT FLIP-UP FOOTREST EA	48.14	48.14
K0037-RR	DMEPOS	HI MOUNT FLIP-UP FOOTREST EA	4.30	4.30
K0037-UE	DMEPOS	HI MOUNT FLIP-UP FOOTREST EA	36.12	36.12
K0038-NU	DMEPOS	LEG STRAP EACH	28.55	28.55
K0038-RR	DMEPOS	LEG STRAP EACH	2.84	2.84
K0038-UE	DMEPOS	LEG STRAP EACH	21.39	21.39
K0039-NU	DMEPOS	LEG STRAP H STYLE EACH	63.36	63.36
K0039-RR	DMEPOS	LEG STRAP H STYLE EACH	6.38	6.38
K0039-UE	DMEPOS	LEG STRAP H STYLE EACH	47.53	47.53
K0040-NU	DMEPOS	ADJUSTABLE ANGLE FOOTPLATE	87.83	87.83
K0040-RR	DMEPOS	ADJUSTABLE ANGLE FOOTPLATE	8.76	8.76
K0040-UE	DMEPOS	ADJUSTABLE ANGLE FOOTPLATE	65.82	65.82
K0041-NU	DMEPOS	LARGE SIZE FOOTPLATE EACH	62.23	62.23
K0041-RR	DMEPOS	LARGE SIZE FOOTPLATE EACH	6.28	6.28
K0041-UE	DMEPOS	LARGE SIZE FOOTPLATE EACH	46.66	46.66
K0042-NU	DMEPOS	STANDARD SIZE FTPLATE REP EA	36.42	36.42
K0042-RR	DMEPOS	STANDARD SIZE FTPLATE REP EA	3.64	3.64
K0042-UE	DMEPOS	STANDARD SIZE FTPLATE REP EA	27.30	27.30
K0043-NU	DMEPOS	FTRST LOWR EXTEN TUBE REP EA	22.96	22.96
K0043-RR	DMEPOS	FTRST LOWR EXTEN TUBE REP EA	2.28	2.28
K0043-UE	DMEPOS	FTRST LOWR EXTEN TUBE REP EA	17.26	17.26
K0044-NU	DMEPOS	FTRST UPR HANGER BRAC REP EA	19.58	19.58
K0044-RR	DMEPOS	FTRST UPR HANGER BRAC REP EA	1.97	1.97
K0044-UE	DMEPOS	FTRST UPR HANGER BRAC REP EA	14.68	14.68
K0045-NU	DMEPOS	FTRST COMPL ASSEMBLY REPL EA	66.59	66.59
K0045-RR	DMEPOS	FTRST COMPL ASSEMBLY REPL EA	6.86	6.86
K0045-UE	DMEPOS	FTRST COMPL ASSEMBLY REPL EA	49.96	49.96
K0046-NU	DMEPOS	ELEV LGRST LWR EXTEN REPL EA	22.96	22.96
K0046-RR	DMEPOS	ELEV LGRST LWR EXTEN REPL EA	2.28	2.28
K0046-UE	DMEPOS	ELEV LGRST LWR EXTEN REPL EA	17.26	17.26
K0047-NU	DMEPOS	ELEV LEGRST UPR HANGR REP EA	89.94	89.94
K0047-RR	DMEPOS	ELEV LEGRST UPR HANGR REP EA	9.02	9.02
K0047-UE	DMEPOS	ELEV LEGRST UPR HANGR REP EA	67.42	67.42
K0050-NU	DMEPOS	RATCHET ASSEMBLY REPLACEMENT	38.23	38.23
K0050-RR	DMEPOS	RATCHET ASSEMBLY REPLACEMENT	3.82	3.82
K0050-UE	DMEPOS	RATCHET ASSEMBLY REPLACEMENT	28.69	28.69
K0051-NU	DMEPOS	CAM REL ASM FT/LEGRST REP EA	61.87	61.87
K0051-RR	DMEPOS	CAM REL ASM FT/LEGRST REP EA	6.24	6.24
K0051-UE	DMEPOS	CAM REL ASM FT/LEGRST REP EA	46.39	46.39
K0052-NU	DMEPOS	SWINGAWAY DETACH FTREST REPL	108.74	108.74
K0052-RR	DMEPOS	SWINGAWAY DETACH FTREST REPL	10.87	10.87
K0052-UE	DMEPOS	SWINGAWAY DETACH FTREST REPL	81.52	81.52
K0053-NU	DMEPOS	ELEVATE FOOTREST ARTICULATE	119.97	119.97
K0053-RR	DMEPOS	ELEVATE FOOTREST ARTICULATE	11.99	11.99
K0053-UE	DMEPOS	ELEVATE FOOTREST ARTICULATE	89.97	89.97
K0056-NU	DMEPOS	SEAT HT <17 OR >=21 LTWT WC	129.77	129.77
K0056-RR	DMEPOS	SEAT HT <17 OR >=21 LTWT WC	12.99	12.99
K0056-UE	DMEPOS	SEAT HT <17 OR >=21 LTWT WC	97.35	97.35
K0065-NU	DMEPOS	SPOKE PROTECTORS	60.64	60.64
K0065-RR	DMEPOS	SPOKE PROTECTORS	6.06	6.06
K0065-UE	DMEPOS	SPOKE PROTECTORS	45.50	45.50
K0069-NU	DMEPOS	RR WHL COMPL SOL TIRE REP EA	136.36	136.36
K0069-RR	DMEPOS	RR WHL COMPL SOL TIRE REP EA	14.03	14.03
K0069-UE	DMEPOS	RR WHL COMPL SOL TIRE REP EA	102.26	102.26
K0070-RR	DMEPOS	RR WHL COMPL PNE TIRE REP EA	25.00	25.00
K0071-NU	DMEPOS	FR CSTR COMP PNE TIRE REP EA	149.07	149.07
K0071-RR	DMEPOS	FR CSTR COMP PNE TIRE REP EA	14.91	14.91
K0071-UE	DMEPOS	FR CSTR COMP PNE TIRE REP EA	111.76	111.76
K0072-NU	DMEPOS	FR CSTR SEMI-PNE TIRE REP EA	89.73	89.73
K0072-RR	DMEPOS	FR CSTR SEMI-PNE TIRE REP EA	8.98	8.98
K0072-UE	DMEPOS	FR CSTR SEMI-PNE TIRE REP EA	67.29	67.29
K0073-NU	DMEPOS	CASTER PIN LOCK EACH	47.05	47.05
K0073-RR	DMEPOS	CASTER PIN LOCK EACH	4.73	4.73
K0073-UE	DMEPOS	CASTER PIN LOCK EACH	35.26	35.26
K0077-NU	DMEPOS	FR CSTR ASMB SOL TIRE REP EA	80.31	80.31
K0077-RR	DMEPOS	FR CSTR ASMB SOL TIRE REP EA	8.00	8.00
K0077-UE	DMEPOS	FR CSTR ASMB SOL TIRE REP EA	60.21	60.21
K0098-NU	DMEPOS	DRIVE BELT FOR PWC, REPL	32.00	32.00
K0098-RR	DMEPOS	DRIVE BELT FOR PWC, REPL	3.21	3.21
K0098-UE	DMEPOS	DRIVE BELT FOR PWC, REPL	23.97	23.97
K0105-NU	DMEPOS	IV HANGER	135.66	135.66
K0105-RR	DMEPOS	IV HANGER	13.56	13.56
K0105-UE	DMEPOS	IV HANGER	101.75	101.75
K0108	DMEPOS	W/C COMPONENT-ACCESSORY NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0195-RR	DMEPOS	ELEVATING WHLCHAIR LEG RESTS	24.79	24.79
K0455-RR	DMEPOS	PUMP UNINTERRUPTED INFUSION	361.39	361.39
K0462	DMEPOS	TEMPORARY REPLACEMENT EQPMNT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0552	DMEPOS	SUP/EXT NON-INS INF PUMP SYR	3.28	3.28
K0601-NU	DMEPOS	REPL BATT SILVER OXIDE 1.5 V	1.49	1.49
K0602-NU	DMEPOS	REPL BATT SILVER OXIDE 3 V	8.39	8.39
K0603-NU	DMEPOS	REPL BATT ALKALINE 1.5 V	0.75	0.75
K0604-NU	DMEPOS	REPL BATT LITHIUM 3.6 V	8.09	8.09
K0605-NU	DMEPOS	REPL BATT LITHIUM 4.5 V	19.33	19.33
K0606-RR	DMEPOS	AED GARMENT W ELEC ANALYSIS	3436.06	3436.06
K0607-RR	DMEPOS	REPL BATT FOR AED	29.43	29.43
K0608-NU	DMEPOS	REPL GARMENT FOR AED	183.62	183.62
K0608-RR	DMEPOS	REPL GARMENT FOR AED	18.39	18.39
K0608-UE	DMEPOS	REPL GARMENT FOR AED	137.71	137.71
K0609	DMEPOS	REPL ELECTRODE FOR AED	1221.13	1221.13
K0669	DMEPOS	SEAT/BACK CUS NO DMEPDAC VER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0672	DMEPOS	REMOVABLE SOFT INTERFACE LE	100.30	100.30
K0730-RR	DMEPOS	CTRL DOSE INH DRUG DELIV SYS	235.22	235.22
K0733-NU	DMEPOS	12-24HR SEALED LEAD ACID	35.52	35.52
K0733-RR	DMEPOS	12-24HR SEALED LEAD ACID	3.59	3.59
K0733-UE	DMEPOS	12-24HR SEALED LEAD ACID	26.67	26.67
K0738-RR	DMEPOS	PORTABLE GAS OXYGEN SYSTEM	47.37	47.37
K0739	DMEPOS	REPAIR/SVC DME NON-OXYGEN EQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0740	DMEPOS	REPAIR/SVC OXYGEN EQUIPMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0743	DMEPOS	PORTABLE HOME SUCTION PUMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0744	DMEPOS	ABSORP DRG <= 16 SUC PUMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0745	DMEPOS	ABSORP DRG >16<=48 SUC PUMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0746	DMEPOS	ABSORP DRG >48 SUC PUMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0800-NU	DMEPOS	POV GROUP 1 STD UP TO 300LBS	1000.42	1000.42
K0800-RR	DMEPOS	POV GROUP 1 STD UP TO 300LBS	100.04	100.04
K0800-UE	DMEPOS	POV GROUP 1 STD UP TO 300LBS	750.31	750.31
K0801-NU	DMEPOS	POV GROUP 1 HD 301-450 LBS	1798.05	1798.05
K0801-RR	DMEPOS	POV GROUP 1 HD 301-450 LBS	179.81	179.81
K0801-UE	DMEPOS	POV GROUP 1 HD 301-450 LBS	1348.54	1348.54
K0802-NU	DMEPOS	POV GROUP 1 VHD 451-600 LBS	2378.92	2378.92
K0802-RR	DMEPOS	POV GROUP 1 VHD 451-600 LBS	237.89	237.89
K0802-UE	DMEPOS	POV GROUP 1 VHD 451-600 LBS	1784.19	1784.19
K0806-NU	DMEPOS	POV GROUP 2 STD UP TO 300LBS	1653.26	1653.26
K0806-RR	DMEPOS	POV GROUP 2 STD UP TO 300LBS	165.33	165.33
K0806-UE	DMEPOS	POV GROUP 2 STD UP TO 300LBS	1239.95	1239.95
K0807-NU	DMEPOS	POV GROUP 2 HD 301-450 LBS	2562.14	2562.14
K0807-RR	DMEPOS	POV GROUP 2 HD 301-450 LBS	256.21	256.21
K0807-UE	DMEPOS	POV GROUP 2 HD 301-450 LBS	1921.61	1921.61
K0808-NU	DMEPOS	POV GROUP 2 VHD 451-600 LBS	3960.65	3960.65
K0808-RR	DMEPOS	POV GROUP 2 VHD 451-600 LBS	396.07	396.07
K0808-UE	DMEPOS	POV GROUP 2 VHD 451-600 LBS	2970.49	2970.49
K0812	DMEPOS	POWER OPERATED VEHICLE NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0813-RR	DMEPOS	PWC GP 1 STD PORT SEAT/BACK	304.08	304.08
K0814-RR	DMEPOS	PWC GP 1 STD PORT CAP CHAIR	318.69	318.69
K0815-RR	DMEPOS	PWC GP 1 STD SEAT/BACK	354.10	354.10
K0816-RR	DMEPOS	PWC GP 1 STD CAP CHAIR	330.69	330.69
K0820-RR	DMEPOS	PWC GP 2 STD PORT SEAT/BACK	311.01	311.01
K0821-RR	DMEPOS	PWC GP 2 STD PORT CAP CHAIR	331.00	331.00
K0822-RR	DMEPOS	PWC GP 2 STD SEAT/BACK	354.45	354.45
K0823-RR	DMEPOS	PWC GP 2 STD CAP CHAIR	331.17	331.17
K0824-RR	DMEPOS	PWC GP 2 HD SEAT/BACK	516.39	516.39
K0825-RR	DMEPOS	PWC GP 2 HD CAP CHAIR	467.59	467.59
K0826-RR	DMEPOS	PWC GP 2 VHD SEAT/BACK	863.02	863.02
K0827-RR	DMEPOS	PWC GP VHD CAP CHAIR	759.77	759.77
K0828-RR	DMEPOS	PWC GP 2 XTRA HD SEAT/BACK	1006.06	1006.06
K0829-RR	DMEPOS	PWC GP 2 XTRA HD CAP CHAIR	1009.13	1009.13
K0830	DMEPOS	PWC GP2 STD SEAT ELEVATE S/B	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0831	DMEPOS	PWC GP2 STD SEAT ELEVATE CAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0835-RR	DMEPOS	PWC GP2 STD SING POW OPT S/B	424.79	424.79
K0836-RR	DMEPOS	PWC GP2 STD SING POW OPT CAP	440.60	440.60
K0837-RR	DMEPOS	PWC GP 2 HD SING POW OPT S/B	544.85	544.85
K0838-RR	DMEPOS	PWC GP 2 HD SING POW OPT CAP	482.92	482.92
K0839-RR	DMEPOS	PWC GP2 VHD SING POW OPT S/B	723.74	723.74
K0840-RR	DMEPOS	PWC GP2 XHD SING POW OPT S/B	1111.17	1111.17
K0841-RR	DMEPOS	PWC GP2 STD MULT POW OPT S/B	478.70	478.70
K0842-RR	DMEPOS	PWC GP2 STD MULT POW OPT CAP	478.01	478.01
K0843-RR	DMEPOS	PWC GP2 HD MULT POW OPT S/B	567.46	567.46
K0848-RR	DMEPOS	PWC GP 3 STD SEAT/BACK	932.20	932.20
K0849-RR	DMEPOS	PWC GP 3 STD CAP CHAIR	896.24	896.24
K0850-RR	DMEPOS	PWC GP 3 HD SEAT/BACK	1081.29	1081.29
K0851-RR	DMEPOS	PWC GP 3 HD CAP CHAIR	1039.68	1039.68
K0852-RR	DMEPOS	PWC GP 3 VHD SEAT/BACK	1249.37	1249.37
K0853-RR	DMEPOS	PWC GP 3 VHD CAP CHAIR	1283.43	1283.43
K0854-RR	DMEPOS	PWC GP 3 XHD SEAT/BACK	1700.26	1700.26
K0855-RR	DMEPOS	PWC GP 3 XHD CAP CHAIR	1606.14	1606.14
K0856-RR	DMEPOS	PWC GP3 STD SING POW OPT S/B	1000.59	1000.59
K0857-RR	DMEPOS	PWC GP3 STD SING POW OPT CAP	1020.65	1020.65
K0858-RR	DMEPOS	PWC GP3 HD SING POW OPT S/B	1241.45	1241.45
K0859-RR	DMEPOS	PWC GP3 HD SING POW OPT CAP	1183.96	1183.96
K0860-RR	DMEPOS	PWC GP3 VHD SING POW OPT S/B	1773.57	1773.57
K0861-RR	DMEPOS	PWC GP3 STD MULT POW OPT S/B	1002.20	1002.20
K0862-RR	DMEPOS	PWC GP3 HD MULT POW OPT S/B	1241.45	1241.45
K0863-RR	DMEPOS	PWC GP3 VHD MULT POW OPT S/B	1773.57	1773.57
K0864-RR	DMEPOS	PWC GP3 XHD MULT POW OPT S/B	2110.55	2110.55
K0868	DMEPOS	PWC GP 4 STD SEAT/BACK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0869	DMEPOS	PWC GP 4 STD CAP CHAIR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0870	DMEPOS	PWC GP 4 HD SEAT/BACK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0871	DMEPOS	PWC GP 4 VHD SEAT/BACK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0877	DMEPOS	PWC GP4 STD SING POW OPT S/B	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0878	DMEPOS	PWC GP4 STD SING POW OPT CAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0879	DMEPOS	PWC GP4 HD SING POW OPT S/B	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0880	DMEPOS	PWC GP4 VHD SING POW OPT S/B	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0884	DMEPOS	PWC GP4 STD MULT POW OPT S/B	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0885	DMEPOS	PWC GP4 STD MULT POW OPT CAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0886	DMEPOS	PWC GP4 HD MULT POW S/B	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0890	DMEPOS	PWC GP5 PED SING POW OPT S/B	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0891	DMEPOS	PWC GP5 PED MULT POW OPT S/B	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0898	DMEPOS	POWER WHEELCHAIR NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0899	DMEPOS	POW MOBIL DEV NO DMEPDAC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K0900	DMEPOS	CSTM DME OTHER THAN WHEELCHR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K1004	Other professional services	LO FREQ US DIATHERMY DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K1007	DMEPOS	BIL HKAF PC S/D MICRO SENSOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
K1027	Other professional services	ORAL DEV WITHOUT FIX MECH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L0112	DMEPOS	CRANIAL CERVICAL ORTHOSIS	1655.74	1655.74
L0113	DMEPOS	CRANIAL CERVICAL TORTICOLLIS	337.37	337.37
L0120	DMEPOS	CERV FLEX N/ADJ FOAM PRE OTS	33.10	33.10
L0130	DMEPOS	FLEX THERMOPLASTIC COLLAR MO	239.33	239.33
L0140	DMEPOS	CERVICAL SEMI-RIGID ADJUSTAB	82.58	82.58
L0150	DMEPOS	CERV SEMI-RIG ADJ MOLDED CHN	137.71	137.71
L0160	DMEPOS	CERV SR WIRE OCC/MAN PRE OTS	196.08	196.08
L0170	DMEPOS	CERVICAL COLLAR MOLDED TO PT	829.75	829.75
L0172	DMEPOS	CERV COL SR FOAM 2PC PRE OTS	168.23	168.23
L0174	DMEPOS	CERV SR 2PC THOR EXT PRE OTS	302.22	302.22
L0180	DMEPOS	CER POST COL OCC/MAN SUP ADJ	411.02	411.02
L0190	DMEPOS	CERV COLLAR SUPP ADJ CERV BA	618.74	618.74
L0200	DMEPOS	CERV COL SUPP ADJ BAR & THOR	568.14	568.14
L0220	DMEPOS	THOR RIB BELT CUSTOM FABRICA	134.74	134.74
L0450	DMEPOS	TLSO FLEX TRUNK/THOR PRE OTS	137.17	137.17
L0452	DMEPOS	TLSO FLEX CUSTOM FAB THORACI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L0454	DMEPOS	TLSO TRNK SJ-T9 PRE CST	410.29	410.29
L0455	DMEPOS	TLSO FLEX TRNK SJ-T9 PRE OTS	254.65	254.65
L0456	DMEPOS	TLSO FLEX TRNK SJ-SS PRE CST	1176.58	1176.58
L0457	DMEPOS	TLSO FLEX TRNK SJ-SS PRE OTS	730.24	730.24
L0458	DMEPOS	TLSO 2MOD SYMPHIS-XIPHO PRE	1055.05	1055.05
L0460	DMEPOS	TLSO 2 SHL SYMPHYS-STERN CST	1187.55	1187.55
L0462	DMEPOS	TLSO 3MOD SACRO-SCAP PRE	1477.10	1477.10
L0464	DMEPOS	TLSO 4MOD SACRO-SCAP PRE	1758.43	1758.43
L0466	DMEPOS	TLSO R FRAM SOFT ANT PRE CST	452.16	452.16
L0467	DMEPOS	TLSO R FRAM SOFT PRE OTS	285.59	285.59
L0468	DMEPOS	TLSO RIG FRAM PELVIC PRE CST	566.94	566.94
L0469	DMEPOS	TLSO RIG FRAM PELVIC PRE OTS	363.89	363.89
L0470	DMEPOS	TLSO RIGID FRAME PRE SUBCLAV	807.10	807.10
L0472	DMEPOS	TLSO RIGID FRAME HYPEREX PRE	506.62	506.62
L0480	DMEPOS	TLSO RIGID PLASTIC CUSTOM FA	1566.59	1566.59
L0482	DMEPOS	TLSO RIGID LINED CUSTOM FAB	1795.91	1795.91
L0484	DMEPOS	TLSO RIGID PLASTIC CUST FAB	2093.98	2093.98
L0486	DMEPOS	TLSO RIGIDLINED CUST FAB TWO	2074.34	2074.34
L0488	DMEPOS	TLSO RIGID LINED PRE ONE PIE	1187.55	1187.55
L0490	DMEPOS	TLSO RIGID PLASTIC PRE ONE	334.63	334.63
L0491	DMEPOS	TLSO 2 PIECE RIGID SHELL	908.51	908.51
L0492	DMEPOS	TLSO 3 PIECE RIGID SHELL	588.80	588.80
L0621	DMEPOS	SIO FLEX PELVIC/SACR PRE OTS	72.32	72.32
L0622	DMEPOS	SIO FLEX PELVISACRAL CUSTOM	286.04	286.04
L0623	DMEPOS	SIO RIG PNL PELV/SAC PRE OTS	129.64	129.64
L0624	DMEPOS	SIO PANEL CUSTOM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L0625	DMEPOS	LO FLEX L1-BELOW L5 PRE OTS	40.46	40.46
L0626	DMEPOS	LO SAG RIG PNL STAYS PRE CST	92.22	92.22
L0627	DMEPOS	LO SAG RI AN/POS PNL PRE CST	486.30	486.30
L0628	DMEPOS	LSO FLEX NO RI STAYS PRE OTS	61.60	61.60
L0629	DMEPOS	LSO FLEX W/RIGID STAYS CUST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L0630	DMEPOS	LSO R POST PNL SJ-T9 PRE CST	191.55	191.55
L0631	DMEPOS	LSO SAG R AN/POS PNL PRE CST	1214.45	1214.45
L0632	DMEPOS	LSO SAG RIGID FRAME CUST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L0633	DMEPOS	LSO SC R POS/LAT PNL PRE CST	339.24	339.24
L0634	DMEPOS	LSO FLEXION CONTROL CUSTOM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L0635	DMEPOS	LSO SAGIT RIGID PANEL PREFAB	1257.95	1257.95
L0636	DMEPOS	LSO SAGITTAL RIGID PANEL CUS	1856.20	1856.20
L0637	DMEPOS	LSO SC R ANT/POS PNL PRE CST	1610.47	1610.47
L0638	DMEPOS	LSO SAG-CORONAL PANEL CUSTOM	1560.27	1560.27
L0639	DMEPOS	LSO S/C SHELL/PANEL PREFAB	1610.47	1610.47
L0640	DMEPOS	LSO S/C SHELL/PANEL CUSTOM	1237.90	1237.90
L0641	DMEPOS	LO RIG POS PNL L1-L5 PRE OTS	57.24	57.24
L0642	DMEPOS	LO SAG RI AN/POS PNL PRE OTS	301.88	301.88
L0643	DMEPOS	LSO SAG CTR RIGI POS PRE OTS	118.93	118.93
L0648	DMEPOS	LSO SAG R AN/POS PNL PRE OTS	753.91	753.91
L0649	DMEPOS	LSO SC R POS/LAT PNL PRE OTS	210.59	210.59
L0650	DMEPOS	LSO SC R ANT/POS PNL PRE OTS	872.32	872.32
L0651	DMEPOS	LSO SAG-CO SHELL PNL PRE OTS	872.32	872.32
L0700	DMEPOS	CTLSO A-P-L CONTROL MOLDED	2547.02	2547.02
L0710	DMEPOS	CTLSO A-P-L CONTROL W/ INTER	2780.23	2780.23
L0810	DMEPOS	HALO CERVICAL INTO JCKT VEST	2953.61	2953.61
L0820	DMEPOS	HALO CERVICAL INTO BODY JACK	2389.34	2389.34
L0830	DMEPOS	HALO CERV INTO MILWAUKEE TYP	3449.94	3449.94
L0859	DMEPOS	MRI COMPATIBLE SYSTEM	1340.28	1340.28
L0861	DMEPOS	HALO REPL LINER/INTERFACE	254.98	254.98
L0970	DMEPOS	TLSO CORSET FRONT	125.74	125.74
L0972	DMEPOS	LSO CORSET FRONT	128.54	128.54
L0974	DMEPOS	TLSO FULL CORSET	262.63	262.63
L0976	DMEPOS	LSO FULL CORSET	234.56	234.56
L0978	DMEPOS	AXILLARY CRUTCH EXTENSION	211.78	211.78
L0980	DMEPOS	PERONEAL STRAPS PAIR PRE OTS	19.21	19.21
L0982	DMEPOS	STOCKING SUP GRIPS 4 PRE OTS	20.94	20.94
L0984	DMEPOS	PROTECT BODY SOCK EA PRE OTS	66.80	66.80
L0999	DMEPOS	ADD TO SPINAL ORTHOSIS NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L1000	DMEPOS	CTLSO MILWAUKE INITIAL MODEL	2233.62	2233.62
L1001	DMEPOS	CTLSO INFANT IMMOBILIZER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L1005	DMEPOS	TENSION BASED SCOLIOSIS ORTH	3786.39	3786.39
L1010	DMEPOS	CTLSO AXILLA SLING	89.95	89.95
L1020	DMEPOS	KYPHOSIS PAD	122.90	122.90
L1025	DMEPOS	KYPHOSIS PAD FLOATING	139.69	139.69
L1030	DMEPOS	LUMBAR BOLSTER PAD	93.31	93.31
L1040	DMEPOS	LUMBAR OR LUMBAR RIB PAD	112.32	112.32
L1050	DMEPOS	STERNAL PAD	97.24	97.24
L1060	DMEPOS	THORACIC PAD	109.69	109.69
L1070	DMEPOS	TRAPEZIUS SLING	112.16	112.16
L1080	DMEPOS	OUTRIGGER	77.71	77.71
L1085	DMEPOS	OUTRIGGER BIL W/ VERT EXTENS	215.89	215.89
L1090	DMEPOS	LUMBAR SLING	100.85	100.85
L1100	DMEPOS	RING FLANGE PLASTIC/LEATHER	178.02	178.02
L1110	DMEPOS	RING FLANGE PLAS/LEATHER MOL	301.52	301.52
L1120	DMEPOS	COVERS FOR UPRIGHT EACH	48.03	48.03
L1200	DMEPOS	FURNSH INITIAL ORTHOSIS ONLY	1911.98	1911.98
L1210	DMEPOS	LATERAL THORACIC EXTENSION	287.87	287.87
L1220	DMEPOS	ANTERIOR THORACIC EXTENSION	243.74	243.74
L1230	DMEPOS	MILWAUKEE TYPE SUPERSTRUCTUR	625.40	625.40
L1240	DMEPOS	LUMBAR DEROTATION PAD	107.63	107.63
L1250	DMEPOS	ANTERIOR ASIS PAD	105.98	105.98
L1260	DMEPOS	ANTERIOR THORACIC DEROTATION	108.93	108.93
L1270	DMEPOS	ABDOMINAL PAD	108.80	108.80
L1280	DMEPOS	RIB GUSSET (ELASTIC) EACH	96.97	96.97
L1290	DMEPOS	LATERAL TROCHANTERIC PAD	109.94	109.94
L1300	DMEPOS	BODY JACKET MOLD TO PATIENT	1837.78	1837.78
L1310	DMEPOS	POST-OPERATIVE BODY JACKET	1891.08	1891.08
L1499	DMEPOS	SPINAL ORTHOSIS NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L1600	DMEPOS	HO FLEX FREJKA W/COV PRE CST	141.77	141.77
L1610	DMEPOS	HO FREJKA COV ONLY PRE CST	48.30	48.30
L1620	DMEPOS	HO FLEX PAVLIK HARNS PRE CST	159.05	159.05
L1630	DMEPOS	ABDUCT CONTROL HIP SEMI-FLEX	189.80	189.80
L1640	DMEPOS	PELV BAND/SPREAD BAR THIGH C	507.66	507.66
L1650	DMEPOS	HO ABDUCTION HIP ADJUSTABLE	269.22	269.22
L1652	DMEPOS	HO BI THIGHCUFFS W SPRDR BAR	421.72	421.72
L1660	DMEPOS	HO ABDUCTION STATIC PLASTIC	188.28	188.28
L1680	DMEPOS	PELVIC & HIP CONTROL THIGH C	1547.95	1547.95
L1681	DMEPOS	HO BILATERAL HIP ABDUCTION	2191.52	2191.52
L1685	DMEPOS	POST-OP HIP ABDUCT CUSTOM FA	1633.34	1633.34
L1686	DMEPOS	HO POST-OP HIP ABDUCTION	1095.76	1095.76
L1690	DMEPOS	COMBINATION BILATERAL HO	2287.64	2287.64
L1700	DMEPOS	LEG PERTHES ORTH TORONTO TYP	1903.16	1903.16
L1710	DMEPOS	LEGG PERTHES ORTH NEWINGTON	2237.05	2237.05
L1720	DMEPOS	LEGG PERTHES ORTHOSIS TRILAT	1652.51	1652.51
L1730	DMEPOS	LEGG PERTHES ORTH SCOTTISH R	1246.77	1246.77
L1755	DMEPOS	LEGG PERTHES PATTEN BOTTOM T	1814.72	1814.72
L1810	DMEPOS	KO ELASTIC WITH JOINTS	143.22	143.22
L1812	DMEPOS	KO ELASTIC W/JOINTS PRE OTS	81.02	81.02
L1820	DMEPOS	KO ELAS W/ CONDYLE PADS & JO	142.65	142.65
L1830	DMEPOS	KO IMMOB CANVAS LONG PRE OTS	73.01	73.01
L1831	DMEPOS	KNEE ORTH POS LOCKING JOINT	348.15	348.15
L1832	DMEPOS	KO ADJ JNT POS R SUP PRE CST	891.83	891.83
L1833	DMEPOS	KO ADJ JNT POS R SUP PRE OTS	525.91	525.91
L1834	DMEPOS	KO W/0 JOINT RIGID MOLDED TO	1049.24	1049.24
L1836	DMEPOS	KO RIGID W/O JOINTS PRE OTS	103.23	103.23
L1840	DMEPOS	KO DEROT ANT CRUCIATE CUSTOM	1102.93	1102.93
L1843	DMEPOS	KO SINGLE UPRIGHT PRE CST	1061.45	1061.45
L1844	DMEPOS	KO W/ADJ JT ROT CNTRL MOLDED	1839.26	1839.26
L1845	DMEPOS	KO DOUBLE UPRIGHT PRE CST	1108.06	1108.06
L1846	DMEPOS	KO W ADJ FLEX/EXT ROTAT MOLD	1405.93	1405.93
L1847	DMEPOS	KO DBL UPRIGHT W/AIR PRE CST	680.45	680.45
L1848	DMEPOS	KO DBL UPRIGHT W/AIR PRE OTS	680.45	680.45
L1850	DMEPOS	KO SWEDISH TYPE PRE OTS	237.76	237.76
L1851	DMEPOS	KO SINGLE UPRIGHT PREFAB OTS	694.15	694.15
L1852	DMEPOS	KO DOUBLE UPRIGHT PREFAB OTS	662.21	662.21
L1860	DMEPOS	KO SUPRACONDYLAR SOCKET MOLD	1228.28	1228.28
L1900	DMEPOS	AFO SPRNG WIR DRSFLX CALF BD	332.76	332.76
L1902	DMEPOS	AFO ANKLE GAUNTLET PRE OTS	90.37	90.37
L1904	DMEPOS	AFO MOLDED ANKLE GAUNTLET	517.35	517.35
L1906	DMEPOS	AFO MULTILIG ANK SUP PRE OTS	151.19	151.19
L1907	DMEPOS	AFO SUPRAMALLEOLAR CUSTOM	665.66	665.66
L1910	DMEPOS	AFO SING BAR CLASP ATTACH SH	294.21	294.21
L1920	DMEPOS	AFO SING UPRIGHT W/ ADJUST S	384.62	384.62
L1930	DMEPOS	AFO PLASTIC	260.26	260.26
L1932	DMEPOS	AFO RIG ANT TIB PREFAB TCF/=	1055.66	1055.66
L1940	DMEPOS	AFO MOLDED TO PATIENT PLASTI	588.16	588.16
L1945	DMEPOS	AFO MOLDED PLAS RIG ANT TIB	1080.11	1080.11
L1950	DMEPOS	AFO SPIRAL MOLDED TO PT PLAS	819.47	819.47
L1951	DMEPOS	AFO SPIRAL PREFABRICATED	993.52	993.52
L1960	DMEPOS	AFO POS SOLID ANK PLASTIC MO	609.82	609.82
L1970	DMEPOS	AFO PLASTIC MOLDED W/ANKLE J	901.98	901.98
L1971	DMEPOS	AFO W/ANKLE JOINT, PREFAB	554.50	554.50
L1980	DMEPOS	AFO SING SOLID STIRRUP CALF	403.77	403.77
L1990	DMEPOS	AFO DOUB SOLID STIRRUP CALF	518.79	518.79
L2000	DMEPOS	KAFO SING FRE STIRR THI/CALF	1115.91	1115.91
L2005	DMEPOS	KAFO SNG/DBL MECHANICAL ACT	4847.62	4847.62
L2006	DMEPOS	KAF SNG/DBL SWG/STN MCPR CUS	37701.48	37701.48
L2010	DMEPOS	KAFO SNG SOLID STIRRUP W/O J	1017.25	1017.25
L2020	DMEPOS	KAFO DBL SOLID STIRRUP BAND/	1284.63	1284.63
L2030	DMEPOS	KAFO DBL SOLID STIRRUP W/O J	1114.53	1114.53
L2034	DMEPOS	KAFO PLA SIN UP W/WO K/A CUS	2429.08	2429.08
L2035	DMEPOS	KAFO PLASTIC PEDIATRIC SIZE	204.94	204.94
L2036	DMEPOS	KAFO PLAS DOUB FREE KNEE MOL	2041.20	2041.20
L2037	DMEPOS	KAFO PLAS SING FREE KNEE MOL	1881.09	1881.09
L2038	DMEPOS	KAFO W/O JOINT MULTI-AXIS AN	1572.97	1572.97
L2040	DMEPOS	HKAFO TORSION BIL ROT STRAPS	200.92	200.92
L2050	DMEPOS	HKAFO TORSION CABLE HIP PELV	535.07	535.07
L2060	DMEPOS	HKAFO TORSION BALL BEARING J	686.74	686.74
L2070	DMEPOS	HKAFO TORSION UNILAT ROT STR	197.28	197.28
L2080	DMEPOS	HKAFO UNILAT TORSION CABLE	420.73	420.73
L2090	DMEPOS	HKAFO UNILAT TORSION BALL BR	518.56	518.56
L2106	DMEPOS	AFO TIB FX CAST PLASTER MOLD	748.04	748.04
L2108	DMEPOS	AFO TIB FX CAST MOLDED TO PT	1175.49	1175.49
L2112	DMEPOS	AFO TIBIAL FRACTURE SOFT	558.15	558.15
L2114	DMEPOS	AFO TIB FX SEMI-RIGID	638.58	638.58
L2116	DMEPOS	AFO TIBIAL FRACTURE RIGID	841.34	841.34
L2126	DMEPOS	KAFO FEM FX CAST THERMOPLAS	1496.99	1496.99
L2128	DMEPOS	KAFO FEM FX CAST MOLDED TO P	1886.53	1886.53
L2132	DMEPOS	KAFO FEMORAL FX CAST SOFT	887.51	887.51
L2134	DMEPOS	KAFO FEM FX CAST SEMI-RIGID	1064.08	1064.08
L2136	DMEPOS	KAFO FEMORAL FX CAST RIGID	1301.08	1301.08
L2180	DMEPOS	PLAS SHOE INSERT W ANK JOINT	128.84	128.84
L2182	DMEPOS	DROP LOCK KNEE	100.84	100.84
L2184	DMEPOS	LIMITED MOTION KNEE JOINT	181.71	181.71
L2186	DMEPOS	ADJ MOTION KNEE JNT LERMAN T	201.36	201.36
L2188	DMEPOS	QUADRILATERAL BRIM	439.33	439.33
L2190	DMEPOS	WAIST BELT	114.10	114.10
L2192	DMEPOS	PELVIC BAND & BELT THIGH FLA	392.28	392.28
L2200	DMEPOS	LIMITED ANKLE MOTION EA JNT	52.30	52.30
L2210	DMEPOS	DORSIFLEXION ASSIST EACH JOI	84.86	84.86
L2220	DMEPOS	DORSI & PLANTAR FLEX ASS/RES	97.45	97.45
L2230	DMEPOS	SPLIT FLAT CALIPER STIRR & P	84.42	84.42
L2232	DMEPOS	ROCKER BOTTOM, CONTACT AFO	114.30	114.30
L2240	DMEPOS	ROUND CALIPER AND PLATE ATTA	92.02	92.02
L2250	DMEPOS	FOOT PLATE MOLDED STIRRUP AT	390.93	390.93
L2260	DMEPOS	REINFORCED SOLID STIRRUP	220.54	220.54
L2265	DMEPOS	LONG TONGUE STIRRUP	129.57	129.57
L2270	DMEPOS	VARUS/VALGUS STRAP PADDED/LI	59.08	59.08
L2275	DMEPOS	PLASTIC MOD LOW EXT PAD/LINE	143.77	143.77
L2280	DMEPOS	MOLDED INNER BOOT	534.07	534.07
L2300	DMEPOS	ABDUCTION BAR JOINTED ADJUST	301.48	301.48
L2310	DMEPOS	ABDUCTION BAR-STRAIGHT	135.35	135.35
L2320	DMEPOS	NON-MOLDED LACER	226.37	226.37
L2330	DMEPOS	LACER MOLDED TO PATIENT MODE	432.00	432.00
L2335	DMEPOS	ANTERIOR SWING BAND	254.13	254.13
L2340	DMEPOS	PRE-TIBIAL SHELL MOLDED TO P	599.69	599.69
L2350	DMEPOS	PROSTHETIC TYPE SOCKET MOLDE	980.32	980.32
L2360	DMEPOS	EXTENDED STEEL SHANK	56.92	56.92
L2370	DMEPOS	PATTEN BOTTOM	282.42	282.42
L2375	DMEPOS	TORSION ANK & HALF SOLID STI	124.31	124.31
L2380	DMEPOS	TORSION STRAIGHT KNEE JOINT	135.45	135.45
L2385	DMEPOS	STRAIGHT KNEE JOINT HEAVY DU	147.36	147.36
L2387	DMEPOS	ADD LE POLY KNEE CUSTOM KAFO	199.98	199.98
L2390	DMEPOS	OFFSET KNEE JOINT EACH	120.43	120.43
L2395	DMEPOS	OFFSET KNEE JOINT HEAVY DUTY	183.87	183.87
L2397	DMEPOS	SUSPENSION SLEEVE LOWER EXT	128.95	128.95
L2405	DMEPOS	KNEE JOINT DROP LOCK EA JNT	103.15	103.15
L2415	DMEPOS	KNEE JOINT CAM LOCK EACH JOI	143.71	143.71
L2425	DMEPOS	KNEE DISC/DIAL LOCK/ADJ FLEX	169.58	169.58
L2430	DMEPOS	KNEE JNT RATCHET LOCK EA JNT	169.58	169.58
L2492	DMEPOS	KNEE LIFT LOOP DROP LOCK RIN	112.19	112.19
L2500	DMEPOS	THI/GLUT/ISCHIA WGT BEARING	347.09	347.09
L2510	DMEPOS	TH/WGHT BEAR QUAD-LAT BRIM M	929.27	929.27
L2520	DMEPOS	TH/WGHT BEAR QUAD-LAT BRIM C	506.83	506.83
L2525	DMEPOS	TH/WGHT BEAR NAR M-L BRIM MO	1738.83	1738.83
L2526	DMEPOS	TH/WGHT BEAR NAR M-L BRIM CU	937.25	937.25
L2530	DMEPOS	THIGH/WGHT BEAR LACER NON-MO	258.50	258.50
L2540	DMEPOS	THIGH/WGHT BEAR LACER MOLDED	465.14	465.14
L2550	DMEPOS	THIGH/WGHT BEAR HIGH ROLL CU	315.98	315.98
L2570	DMEPOS	HIP CLEVIS TYPE 2 POSIT JNT	698.70	698.70
L2580	DMEPOS	PELVIC CONTROL PELVIC SLING	662.33	662.33
L2600	DMEPOS	HIP CLEVIS/THRUST BEARING FR	225.96	225.96
L2610	DMEPOS	HIP CLEVIS/THRUST BEARING LO	267.19	267.19
L2620	DMEPOS	PELVIC CONTROL HIP HEAVY DUT	294.16	294.16
L2622	DMEPOS	HIP JOINT ADJUSTABLE FLEXION	337.38	337.38
L2624	DMEPOS	HIP ADJ FLEX EXT ABDUCT CONT	458.66	458.66
L2627	DMEPOS	PLASTIC MOLD RECIPRO HIP & C	1889.67	1889.67
L2628	DMEPOS	METAL FRAME RECIPRO HIP & CA	2219.75	2219.75
L2630	DMEPOS	PELVIC CONTROL BAND & BELT U	272.43	272.43
L2640	DMEPOS	PELVIC CONTROL BAND & BELT B	369.72	369.72
L2650	DMEPOS	PELV & THOR CONTROL GLUTEAL	132.03	132.03
L2660	DMEPOS	THORACIC CONTROL THORACIC BA	205.05	205.05
L2670	DMEPOS	THORAC CONT PARASPINAL UPRIG	187.67	187.67
L2680	DMEPOS	THORAC CONT LAT SUPPORT UPRI	172.16	172.16
L2750	DMEPOS	PLATING CHROME/NICKEL PR BAR	91.95	91.95
L2755	DMEPOS	CARBON GRAPHITE LAMINATION	154.61	154.61
L2760	DMEPOS	EXTENSION PER EXTENSION PER	66.85	66.85
L2768	DMEPOS	ORTHO SIDEBAR DISCONNECT	154.14	154.14
L2780	DMEPOS	NON-CORROSIVE FINISH	79.07	79.07
L2785	DMEPOS	DROP LOCK RETAINER EACH	46.49	46.49
L2795	DMEPOS	KNEE CONTROL FULL KNEECAP	93.49	93.49
L2800	DMEPOS	KNEE CAP MEDIAL OR LATERAL P	117.35	117.35
L2810	DMEPOS	KNEE CONTROL CONDYLAR PAD	85.93	85.93
L2820	DMEPOS	SOFT INTERFACE BELOW KNEE SE	95.54	95.54
L2830	DMEPOS	SOFT INTERFACE ABOVE KNEE SE	107.43	107.43
L2840	DMEPOS	TIBIAL LENGTH SOCK FX OR EQU	59.97	59.97
L2850	DMEPOS	FEMORAL LGTH SOCK FX OR EQUA	68.12	68.12
L2861	DMEPOS	TORSION MECHANISM KNEE/ANKLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L2999	DMEPOS	LOWER EXTREMITY ORTHOSIS NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3000	DMEPOS	FT INSERT UCB BERKELEY SHELL	371.63	371.63
L3001	DMEPOS	FOOT INSERT REMOV MOLDED SPE	156.47	156.47
L3002	DMEPOS	FOOT INSERT PLASTAZOTE OR EQ	191.05	191.05
L3003	DMEPOS	FOOT INSERT SILICONE GEL EAC	206.12	206.12
L3010	DMEPOS	FOOT LONGITUDINAL ARCH SUPPO	206.12	206.12
L3020	DMEPOS	FOOT LONGITUD/METATARSAL SUP	234.71	234.71
L3030	DMEPOS	FOOT ARCH SUPPORT REMOV PREM	90.29	90.29
L3031	DMEPOS	FOOT LAMIN/PREPREG COMPOSITE	144.87	144.87
L3040	DMEPOS	FT ARCH SUPRT PREMOLD LONGIT	55.67	55.67
L3050	DMEPOS	FOOT ARCH SUPP PREMOLD METAT	55.67	55.67
L3060	DMEPOS	FOOT ARCH SUPP LONGITUD/META	87.26	87.26
L3070	DMEPOS	ARCH SUPRT ATT TO SHO LONGIT	37.61	37.61
L3080	DMEPOS	ARCH SUPP ATT TO SHOE METATA	37.61	37.61
L3090	DMEPOS	ARCH SUPP ATT TO SHOE LONG/M	48.16	48.16
L3100	DMEPOS	HALLUS-VALGUS NT DYN PRE OTS	51.13	51.13
L3140	DMEPOS	ABDUCTION ROTATION BAR SHOE	105.34	105.34
L3150	DMEPOS	ABDUCT ROTATION BAR W/O SHOE	96.30	96.30
L3160	DMEPOS	SHOE STYLED POSITIONING DEV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3170	DMEPOS	FOOT PLAS HEEL STABI PRE OTS	60.20	60.20
L3201	DMEPOS	OXFORD W SUPINAT/PRONAT INF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3202	DMEPOS	OXFORD W/ SUPINAT/PRONATOR C	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3203	DMEPOS	OXFORD W/ SUPINATOR/PRONATOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3204	DMEPOS	HIGHTOP W/ SUPP/PRONATOR INF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3206	DMEPOS	HIGHTOP W/ SUPP/PRONATOR CHI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3207	DMEPOS	HIGHTOP W/ SUPP/PRONATOR JUN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3208	DMEPOS	SURGICAL BOOT EACH INFANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3209	DMEPOS	SURGICAL BOOT EACH CHILD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3211	DMEPOS	SURGICAL BOOT EACH JUNIOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3212	DMEPOS	BENESCH BOOT PAIR INFANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3213	DMEPOS	BENESCH BOOT PAIR CHILD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3214	DMEPOS	BENESCH BOOT PAIR JUNIOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3215	DMEPOS	ORTHOPEDIC FTWEAR LADIES OXF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3216	DMEPOS	ORTHOPED LADIES SHOES DPTH I	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3217	DMEPOS	LADIES SHOES HIGHTOP DEPTH I	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3219	DMEPOS	ORTHOPEDIC MENS SHOES OXFORD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3221	DMEPOS	ORTHOPEDIC MENS SHOES DPTH I	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3222	DMEPOS	MENS SHOES HIGHTOP DEPTH INL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3224	DMEPOS	WOMAN'S SHOE OXFORD BRACE	64.69	64.69
L3225	DMEPOS	MAN'S SHOE OXFORD BRACE	74.42	74.42
L3230	DMEPOS	CUSTOM SHOES DEPTH INLAY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3250	DMEPOS	CUSTOM MOLD SHOE REMOV PROST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3251	DMEPOS	SHOE MOLDED TO PT SILICONE S	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3252	DMEPOS	SHOE MOLDED PLASTAZOTE CUST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3253	DMEPOS	SHOE MOLDED PLASTAZOTE CUST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3254	DMEPOS	ORTH FOOT NON-STNDARD SIZE/W	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3255	DMEPOS	ORTH FOOT NON-STANDARD SIZE/	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3257	DMEPOS	ORTH FOOT ADD CHARGE SPLIT S	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3260	DMEPOS	AMBULATORY SURGICAL BOOT EAC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3265	DMEPOS	PLASTAZOTE SANDAL EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3300	DMEPOS	SHO LIFT TAPER TO METATARSAL	61.67	61.67
L3310	DMEPOS	SHOE LIFT ELEV HEEL/SOLE NEO	96.30	96.30
L3320	DMEPOS	SHOE LIFT ELEV HEEL/SOLE COR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3330	DMEPOS	LIFTS ELEVATION METAL EXTENS	669.50	669.50
L3332	DMEPOS	SHOE LIFTS TAPERED TO ONE-HA	87.26	87.26
L3334	DMEPOS	SHOE LIFTS ELEVATION HEEL /I	45.13	45.13
L3340	DMEPOS	SHOE WEDGE SACH	100.84	100.84
L3350	DMEPOS	SHOE HEEL WEDGE	27.06	27.06
L3360	DMEPOS	SHOE SOLE WEDGE OUTSIDE SOLE	42.13	42.13
L3370	DMEPOS	SHOE SOLE WEDGE BETWEEN SOLE	58.69	58.69
L3380	DMEPOS	SHOE CLUBFOOT WEDGE	58.69	58.69
L3390	DMEPOS	SHOE OUTFLARE WEDGE	58.69	58.69
L3400	DMEPOS	SHOE METATARSAL BAR WEDGE RO	48.16	48.16
L3410	DMEPOS	SHOE METATARSAL BAR BETWEEN	109.85	109.85
L3420	DMEPOS	FULL SOLE/HEEL WEDGE BTWEEN	64.68	64.68
L3430	DMEPOS	SHO HEEL COUNT PLAST REINFOR	189.57	189.57
L3440	DMEPOS	HEEL LEATHER REINFORCED	90.29	90.29
L3450	DMEPOS	SHOE HEEL SACH CUSHION TYPE	124.84	124.84
L3455	DMEPOS	SHOE HEEL NEW LEATHER STANDA	48.16	48.16
L3460	DMEPOS	SHOE HEEL NEW RUBBER STANDAR	40.61	40.61
L3465	DMEPOS	SHOE HEEL THOMAS WITH WEDGE	69.20	69.20
L3470	DMEPOS	SHOE HEEL THOMAS EXTEND TO B	73.71	73.71
L3480	DMEPOS	SHOE HEEL PAD & DEPRESS FOR	73.71	73.71
L3485	DMEPOS	SHOE HEEL PAD REMOVABLE FOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3500	DMEPOS	ORTHO SHOE ADD LEATHER INSOL	34.64	34.64
L3510	DMEPOS	ORTHOPEDIC SHOE ADD RUB INSL	34.64	34.64
L3520	DMEPOS	O SHOE ADD FELT W LEATH INSL	37.61	37.61
L3530	DMEPOS	ORTHO SHOE ADD HALF SOLE	37.61	37.61
L3540	DMEPOS	ORTHO SHOE ADD FULL SOLE	60.20	60.20
L3550	DMEPOS	O SHOE ADD STANDARD TOE TAP	10.55	10.55
L3560	DMEPOS	O SHOE ADD HORSESHOE TOE TAP	27.06	27.06
L3570	DMEPOS	O SHOE ADD INSTEP EXTENSION	100.84	100.84
L3580	DMEPOS	O SHOE ADD INSTEP VELCRO CLO	76.73	76.73
L3590	DMEPOS	O SHOE CONVERT TO SOF COUNTE	63.20	63.20
L3595	DMEPOS	ORTHO SHOE ADD MARCH BAR	49.64	49.64
L3600	DMEPOS	TRANS SHOE CALIP PLATE EXIST	90.29	90.29
L3610	DMEPOS	TRANS SHOE CALIPER PLATE NEW	118.84	118.84
L3620	DMEPOS	TRANS SHOE SOLID STIRRUP EXI	90.29	90.29
L3630	DMEPOS	TRANS SHOE SOLID STIRRUP NEW	118.84	118.84
L3640	DMEPOS	SHOE DENNIS BROWNE SPLINT BO	51.13	51.13
L3649	DMEPOS	ORTHOPEDIC SHOE MODIFICA NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3650	DMEPOS	SO 8 ABD RESTRAINT PRE OTS	64.44	64.44
L3660	DMEPOS	SO 8 AB RSTR CAN/WEB PRE OTS	110.65	110.65
L3670	DMEPOS	SO ACRO/CLAV CAN WEB PRE OTS	154.22	154.22
L3671	DMEPOS	SO CAP DESIGN W/O JNTS CF	970.09	970.09
L3674	DMEPOS	SO AIRPLANE W/WO JOINT CF	1272.63	1272.63
L3675	DMEPOS	SO VEST CANVAS/WEB PRE OTS	188.94	188.94
L3677	DMEPOS	SO HARD PLAS STABILI PRE CST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3678	DMEPOS	SO HARD PLAS STABILI PRE OTS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3702	DMEPOS	EO W/O JOINTS CF	310.89	310.89
L3710	DMEPOS	EO ELAS W/METAL JNTS PRE OTS	156.11	156.11
L3720	DMEPOS	FOREARM/ARM CUFFS FREE MOTIO	778.76	778.76
L3730	DMEPOS	FOREARM/ARM CUFFS EXT/FLEX A	1025.15	1025.15
L3740	DMEPOS	CUFFS ADJ LOCK W/ ACTIVE CON	1152.11	1152.11
L3760	DMEPOS	EO ADJ JT PREFAB CUSTOM FIT	538.40	538.40
L3761	DMEPOS	EO, ADJ LOCK JOINT PREFAB OT	538.40	538.40
L3762	DMEPOS	EO RIGID W/O JOINTS PRE OTS	115.78	115.78
L3763	DMEPOS	EWHO RIGID W/O JNTS CF	854.79	854.79
L3764	DMEPOS	EWHO W/JOINT(S) CF	852.46	852.46
L3765	DMEPOS	EWHFO RIGID W/O JNTS CF	1380.50	1380.50
L3766	DMEPOS	EWHFO W/JOINT(S) CF	1461.87	1461.87
L3806	DMEPOS	WHFO W/JOINT(S) CUSTOM FAB	489.04	489.04
L3807	DMEPOS	WHFO W/O JOINTS PRE CST	269.22	269.22
L3808	DMEPOS	WHFO, RIGID W/O JOINTS	359.60	359.60
L3809	DMEPOS	WHFO W/O JOINTS PRE OTS	269.22	269.22
L3891	DMEPOS	TORSION MECHANISM WRIST/ELBO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3900	DMEPOS	HINGE EXTENSION/FLEX WRIST/F	1681.88	1681.88
L3901	DMEPOS	HINGE EXT/FLEX WRIST FINGER	1885.84	1885.84
L3904	DMEPOS	WHFO ELECTRIC CUSTOM FITTED	3839.05	3839.05
L3905	DMEPOS	WHO W/NONTORSION JNT(S) CF	1067.71	1067.71
L3906	DMEPOS	WHO W/O JOINTS CF	454.18	454.18
L3908	DMEPOS	WHO COCK-UP NONMOLDE PRE OTS	64.50	64.50
L3912	DMEPOS	HFO FLEXION GLOVE PRE OTS	103.47	103.47
L3913	DMEPOS	HFO W/O JOINTS CF	291.61	291.61
L3915	DMEPOS	WHO NONTORSION JNTS PRE CST	572.32	572.32
L3916	DMEPOS	WHO NONTORSION JNTS PRE OTS	572.32	572.32
L3917	DMEPOS	METACARP FX ORTHOSIS PRE CST	113.73	113.73
L3918	DMEPOS	METACARP FX ORTHOSIS PRE OTS	113.73	113.73
L3919	DMEPOS	HO W/O JOINTS CF	291.61	291.61
L3921	DMEPOS	HFO W/JOINT(S) CF	345.80	345.80
L3923	DMEPOS	HFO WITHOUT JOINTS PRE CST	93.65	93.65
L3924	DMEPOS	HFO WITHOUT JOINTS PRE OTS	93.65	93.65
L3925	DMEPOS	FO PIP DIP JNT/SPRNG PRE OTS	56.87	56.87
L3927	DMEPOS	FO PIP DIP NO JT SPR PRE OTS	37.67	37.67
L3929	DMEPOS	HFO NONTORSION JNTS PRE CST	90.63	90.63
L3930	DMEPOS	HFO NONTORSION JNTS PRE OTS	90.63	90.63
L3931	DMEPOS	WHFO NONTORSION JOINT PREFAB	219.26	219.26
L3933	DMEPOS	FO W/O JOINTS CF	229.71	229.71
L3935	DMEPOS	FO NONTORSION JOINT CF	237.89	237.89
L3956	DMEPOS	ADD JOINT UPPER EXT ORTHOSIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L3960	DMEPOS	SEWHO AIRPLAN DESIG ABDU POS	887.44	887.44
L3961	DMEPOS	SEWHO CAP DESIGN W/O JNTS CF	1808.87	1808.87
L3962	DMEPOS	SEWHO ERBS PALSEY DESIGN ABD	924.02	924.02
L3967	DMEPOS	SEWHO AIRPLANE W/O JNTS CF	2135.66	2135.66
L3971	DMEPOS	SEWHO CAP DESIGN W/JNT(S) CF	2027.20	2027.20
L3973	DMEPOS	SEWHO AIRPLANE W/JNT(S) CF	2135.66	2135.66
L3975	DMEPOS	SEWHFO CAP DESIGN W/O JNT CF	1808.87	1808.87
L3976	DMEPOS	SEWHFO AIRPLANE W/O JNTS CF	1808.87	1808.87
L3977	DMEPOS	SEWHFO CAP DESGN W/JNT(S) CF	2027.20	2027.20
L3978	DMEPOS	SEWHFO AIRPLANE W/JNT(S) CF	2135.66	2135.66
L3980	DMEPOS	UP EXT FX ORTHOS HUMERAL NOS	332.82	332.82
L3981	DMEPOS	UE FX ORTH SHOUL CAP FOREARM	1083.70	1083.70
L3982	DMEPOS	UPPER EXT FX ORTHOSIS RAD/UL	411.19	411.19
L3984	DMEPOS	UPPER EXT FX ORTHOSIS WRIST	438.92	438.92
L3995	DMEPOS	SOCK FRACTURE OR EQUAL EACH	36.82	36.82
L3999	DMEPOS	UPPER LIMB ORTHOSIS NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L4000	DMEPOS	REPL GIRDLE MILWAUKEE ORTH	1435.23	1435.23
L4002	DMEPOS	REPLACE STRAP, ANY ORTHOSIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L4010	DMEPOS	REPLACE TRILATERAL SOCKET BR	807.66	807.66
L4020	DMEPOS	REPLACE QUADLAT SOCKET BRIM	1008.84	1008.84
L4030	DMEPOS	REPLACE SOCKET BRIM CUST FIT	555.47	555.47
L4040	DMEPOS	REPLACE MOLDED THIGH LACER	449.09	449.09
L4045	DMEPOS	REPLACE NON-MOLDED THIGH LAC	360.89	360.89
L4050	DMEPOS	REPLACE MOLDED CALF LACER	454.20	454.20
L4055	DMEPOS	REPLACE NON-MOLDED CALF LACE	294.11	294.11
L4060	DMEPOS	REPLACE HIGH ROLL CUFF	349.64	349.64
L4070	DMEPOS	REPLACE PROX & DIST UPRIGHT	333.56	333.56
L4080	DMEPOS	REPL MET BAND KAFO-AFO PROX	117.60	117.60
L4090	DMEPOS	REPL MET BAND KAFO-AFO CALF/	104.09	104.09
L4100	DMEPOS	REPL LEATH CUFF KAFO PROX TH	117.41	117.41
L4110	DMEPOS	REPL LEATH CUFF KAFO-AFO CAL	93.30	93.30
L4130	DMEPOS	REPLACE PRETIBIAL SHELL	642.12	642.12
L4205	DMEPOS	ORTHO DVC REPAIR PER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L4210	DMEPOS	ORTH DEV REPAIR/REPL MINOR P	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L4350	DMEPOS	ANKLE CONTROL ORTHO PRE OTS	115.68	115.68
L4360	DMEPOS	PNEUMAT WALKING BOOT PRE CST	323.66	323.66
L4361	DMEPOS	PNEUMA/VAC WALK BOOT PRE OTS	323.66	323.66
L4370	DMEPOS	PNEUM FULL LEG SPLNT PRE OTS	207.70	207.70
L4386	DMEPOS	NON-PNEUM WALK BOOT PRE CST	187.55	187.55
L4387	DMEPOS	NON-PNEUM WALK BOOT PRE OTS	187.55	187.55
L4392	DMEPOS	REPLACE AFO SOFT INTERFACE	27.86	27.86
L4394	DMEPOS	REPLACE FOOT DROP SPINT	20.33	20.33
L4396	DMEPOS	STATIC OR DYNAMI AFO PRE CST	198.57	198.57
L4397	DMEPOS	STATIC OR DYNAMI AFO PRE OTS	198.57	198.57
L4398	DMEPOS	FOOT DROP SPLINT PRE OTS	91.39	91.39
L4631	DMEPOS	AFO, WALK BOOT TYPE, CUS FAB	1765.41	1765.41
L5000	DMEPOS	SHO INSERT W ARCH TOE FILLER	620.31	620.31
L5010	DMEPOS	MOLD SOCKET ANK HGT W/ TOE F	1498.19	1498.19
L5020	DMEPOS	TIBIAL TUBERCLE HGT W/ TOE F	2544.23	2544.23
L5050	DMEPOS	ANK SYMES MOLD SCKT SACH FT	2814.38	2814.38
L5060	DMEPOS	SYMES MET FR LEATH SOCKET AR	3237.38	3237.38
L5100	DMEPOS	MOLDED SOCKET SHIN SACH FOOT	2820.60	2820.60
L5105	DMEPOS	PLAST SOCKET JTS/THGH LACER	4071.86	4071.86
L5150	DMEPOS	MOLD SCKT EXT KNEE SHIN SACH	4116.09	4116.09
L5160	DMEPOS	MOLD SOCKET BENT KNEE SHIN S	4476.99	4476.99
L5200	DMEPOS	KNE SING AXIS FRIC SHIN SACH	4287.35	4287.35
L5210	DMEPOS	NO KNEE/ANKLE JOINTS W/ FT B	2844.22	2844.22
L5220	DMEPOS	NO KNEE JOINT WITH ARTIC ALI	3232.98	3232.98
L5230	DMEPOS	FEM FOCAL DEFIC CONSTANT FRI	4458.91	4458.91
L5250	DMEPOS	HIP CANAD SING AXI CONS FRIC	6081.56	6081.56
L5270	DMEPOS	TILT TABLE LOCKING HIP SING	6054.58	6054.58
L5280	DMEPOS	HEMIPELVECT CANAD SING AXIS	6008.21	6008.21
L5301	DMEPOS	BK MOLD SOCKET SACH FT ENDO	3224.14	3224.14
L5312	DMEPOS	KNEE DISART, SACH FT, ENDO	4615.14	4615.14
L5321	DMEPOS	AK OPEN END SACH	4673.47	4673.47
L5331	DMEPOS	HIP DISART CANADIAN SACH FT	5954.95	5954.95
L5341	DMEPOS	HEMIPELVECTOMY CANADIAN SACH	6199.14	6199.14
L5400	DMEPOS	POSTOP DRESS & 1 CAST CHG BK	1596.22	1596.22
L5410	DMEPOS	POSTOP DSG BK EA ADD CAST CH	489.72	489.72
L5420	DMEPOS	POSTOP DSG & 1 CAST CHG AK/D	1956.11	1956.11
L5430	DMEPOS	POSTOP DSG AK EA ADD CAST CH	589.83	589.83
L5450	DMEPOS	POSTOP APP NON-WGT BEAR DSG	479.84	479.84
L5460	DMEPOS	POSTOP APP NON-WGT BEAR DSG	639.32	639.32
L5500	DMEPOS	INIT BK PTB PLASTER DIRECT	1505.37	1505.37
L5505	DMEPOS	INIT AK ISCHAL PLSTR DIRECT	2081.99	2081.99
L5510	DMEPOS	PREP BK PTB PLASTER MOLDED	1706.44	1706.44
L5520	DMEPOS	PERP BK PTB THERMOPLS DIRECT	1685.55	1685.55
L5530	DMEPOS	PREP BK PTB THERMOPLS MOLDED	2024.51	2024.51
L5535	DMEPOS	PREP BK PTB OPEN END SOCKET	1987.68	1987.68
L5540	DMEPOS	PREP BK PTB LAMINATED SOCKET	2121.47	2121.47
L5560	DMEPOS	PREP AK ISCHIAL PLAST MOLDED	2278.09	2278.09
L5570	DMEPOS	PREP AK ISCHIAL DIRECT FORM	2368.41	2368.41
L5580	DMEPOS	PREP AK ISCHIAL THERMO MOLD	2764.96	2764.96
L5585	DMEPOS	PREP AK ISCHIAL OPEN END	3402.72	3402.72
L5590	DMEPOS	PREP AK ISCHIAL LAMINATED	2817.68	2817.68
L5595	DMEPOS	HIP DISARTIC SACH THERMOPLS	4977.81	4977.81
L5600	DMEPOS	HIP DISART SACH LAMINAT MOLD	5350.92	5350.92
L5610	DMEPOS	ABOVE KNEE HYDRACADENCE	2426.72	2426.72
L5611	DMEPOS	AK 4 BAR LINK W/FRIC SWING	1888.48	1888.48
L5613	DMEPOS	AK 4 BAR LING W/HYDRAUL SWIG	2952.58	2952.58
L5614	DMEPOS	4-BAR LINK ABOVE KNEE W/SWNG	2000.17	2000.17
L5615	DMEPOS	AK 4 BAR LINK HYDL SWG/STANC	6550.59	6550.59
L5616	DMEPOS	AK UNIV MULTIPLEX SYS FRICT	1595.55	1595.55
L5617	DMEPOS	AK/BK SELF-ALIGNING UNIT EA	663.19	663.19
L5618	DMEPOS	TEST SOCKET SYMES	350.85	350.85
L5620	DMEPOS	TEST SOCKET BELOW KNEE	325.86	325.86
L5622	DMEPOS	TEST SOCKET KNEE DISARTICULA	424.92	424.92
L5624	DMEPOS	TEST SOCKET ABOVE KNEE	426.13	426.13
L5626	DMEPOS	TEST SOCKET HIP DISARTICULAT	558.84	558.84
L5628	DMEPOS	TEST SOCKET HEMIPELVECTOMY	597.55	597.55
L5629	DMEPOS	BELOW KNEE ACRYLIC SOCKET	372.49	372.49
L5630	DMEPOS	SYME TYP EXPANDABL WALL SCKT	526.04	526.04
L5631	DMEPOS	AK/KNEE DISARTIC ACRYLIC SOC	515.00	515.00
L5632	DMEPOS	SYMES TYPE PTB BRIM DESIGN S	287.42	287.42
L5634	DMEPOS	SYMES TYPE POSTER OPENING SO	356.54	356.54
L5636	DMEPOS	SYMES TYPE MEDIAL OPENING SO	298.65	298.65
L5637	DMEPOS	BELOW KNEE TOTAL CONTACT	338.61	338.61
L5638	DMEPOS	BELOW KNEE LEATHER SOCKET	589.84	589.84
L5639	DMEPOS	BELOW KNEE WOOD SOCKET	1314.14	1314.14
L5640	DMEPOS	KNEE DISARTICULAT LEATHER SO	749.49	749.49
L5642	DMEPOS	ABOVE KNEE LEATHER SOCKET	726.20	726.20
L5643	DMEPOS	HIP FLEX INNER SOCKET EXT FR	1824.32	1824.32
L5644	DMEPOS	ABOVE KNEE WOOD SOCKET	692.30	692.30
L5645	DMEPOS	BK FLEX INNER SOCKET EXT FRA	935.22	935.22
L5646	DMEPOS	BELOW KNEE CUSHION SOCKET	642.21	642.21
L5647	DMEPOS	BELOW KNEE SUCTION SOCKET	932.37	932.37
L5648	DMEPOS	ABOVE KNEE CUSHION SOCKET	771.69	771.69
L5649	DMEPOS	ISCH CONTAINMT/NARROW M-L SO	2796.27	2796.27
L5650	DMEPOS	TOT CONTACT AK/KNEE DISART S	572.21	572.21
L5651	DMEPOS	AK FLEX INNER SOCKET EXT FRA	1407.61	1407.61
L5652	DMEPOS	SUCTION SUSP AK/KNEE DISART	511.02	511.02
L5653	DMEPOS	KNEE DISART EXPAND WALL SOCK	682.17	682.17
L5654	DMEPOS	SOCKET INSERT SYMES	388.73	388.73
L5655	DMEPOS	SOCKET INSERT BELOW KNEE	329.42	329.42
L5656	DMEPOS	SOCKET INSERT KNEE ARTICULAT	441.91	441.91
L5658	DMEPOS	SOCKET INSERT ABOVE KNEE	426.17	426.17
L5661	DMEPOS	MULTI-DUROMETER SYMES	713.29	713.29
L5665	DMEPOS	MULTI-DUROMETER BELOW KNEE	600.15	600.15
L5666	DMEPOS	BELOW KNEE CUFF SUSPENSION	82.04	82.04
L5668	DMEPOS	BK MOLDED DISTAL CUSHION	132.34	132.34
L5670	DMEPOS	BK MOLDED SUPRACONDYLAR SUSP	318.05	318.05
L5671	DMEPOS	BK/AK LOCKING MECHANISM	674.00	674.00
L5672	DMEPOS	BK REMOVABLE MEDIAL BRIM SUS	349.51	349.51
L5673	DMEPOS	SOCKET INSERT W LOCK MECH	833.44	833.44
L5676	DMEPOS	BK KNEE JOINTS SINGLE AXIS P	424.74	424.74
L5677	DMEPOS	BK KNEE JOINTS POLYCENTRIC P	577.91	577.91
L5678	DMEPOS	BK JOINT COVERS PAIR	46.54	46.54
L5679	DMEPOS	SOCKET INSERT W/O LOCK MECH	694.50	694.50
L5680	DMEPOS	BK THIGH LACER NON-MOLDED	388.49	388.49
L5681	DMEPOS	INTL CUSTM CONG/LATYP INSERT	1559.16	1559.16
L5682	DMEPOS	BK THIGH LACER GLUT/ISCHIA M	733.02	733.02
L5683	DMEPOS	INITIAL CUSTOM SOCKET INSERT	1559.16	1559.16
L5684	DMEPOS	BK FORK STRAP	56.42	56.42
L5685	DMEPOS	BELOW KNEE SUS/SEAL SLEEVE	151.82	151.82
L5686	DMEPOS	BK BACK CHECK	59.88	59.88
L5688	DMEPOS	BK WAIST BELT WEBBING	71.60	71.60
L5690	DMEPOS	BK WAIST BELT PADDED AND LIN	114.69	114.69
L5692	DMEPOS	AK PELVIC CONTROL BELT LIGHT	155.75	155.75
L5694	DMEPOS	AK PELVIC CONTROL BELT PAD/L	212.64	212.64
L5695	DMEPOS	AK SLEEVE SUSP NEOPRENE/EQUA	196.28	196.28
L5696	DMEPOS	AK/KNEE DISARTIC PELVIC JOIN	216.86	216.86
L5697	DMEPOS	AK/KNEE DISARTIC PELVIC BAND	94.09	94.09
L5698	DMEPOS	AK/KNEE DISARTIC SILESIAN BA	153.86	153.86
L5699	DMEPOS	SHOULDER HARNESS	277.18	277.18
L5700	DMEPOS	REPLACE SOCKET BELOW KNEE	3358.32	3358.32
L5701	DMEPOS	REPLACE SOCKET ABOVE KNEE	4033.10	4033.10
L5702	DMEPOS	REPLACE SOCKET HIP	5102.44	5102.44
L5703	DMEPOS	SYMES ANKLE W/O (SACH) FOOT	2640.58	2640.58
L5704	DMEPOS	CUSTOM SHAPE COVER BK	628.27	628.27
L5705	DMEPOS	CUSTOM SHAPE COVER AK	1122.62	1122.62
L5706	DMEPOS	CUSTOM SHAPE CVR KNEE DISART	1100.44	1100.44
L5707	DMEPOS	CUSTOM SHAPE CVR HIP DISART	1450.75	1450.75
L5710	DMEPOS	KNE-SHIN EXO SNG AXI MNL LOC	438.36	438.36
L5711	DMEPOS	KNEE-SHIN EXO MNL LOCK ULTRA	612.63	612.63
L5712	DMEPOS	KNEE-SHIN EXO FRICT SWG & ST	513.32	513.32
L5714	DMEPOS	KNEE-SHIN EXO VARIABLE FRICT	527.26	527.26
L5716	DMEPOS	KNEE-SHIN EXO MECH STANCE PH	854.28	854.28
L5718	DMEPOS	KNEE-SHIN EXO FRCT SWG & STA	1067.76	1067.76
L5722	DMEPOS	KNEE-SHIN PNEUM SWG FRCT EXO	1128.05	1128.05
L5724	DMEPOS	KNEE-SHIN EXO FLUID SWING PH	1769.20	1769.20
L5726	DMEPOS	KNEE-SHIN EXT JNTS FLD SWG E	2038.96	2038.96
L5728	DMEPOS	KNEE-SHIN FLUID SWG & STANCE	2789.04	2789.04
L5780	DMEPOS	KNEE-SHIN PNEUM/HYDRA PNEUM	1341.96	1341.96
L5781	DMEPOS	LOWER LIMB PROS VACUUM PUMP	4742.63	4742.63
L5782	DMEPOS	HD LOW LIMB PROS VACUUM PUMP	4999.81	4999.81
L5785	DMEPOS	EXOSKELETAL BK ULTRALT MATER	754.35	754.35
L5790	DMEPOS	EXOSKELETAL AK ULTRA-LIGHT M	842.77	842.77
L5795	DMEPOS	EXOSKEL HIP ULTRA-LIGHT MATE	1677.98	1677.98
L5810	DMEPOS	ENDOSKEL KNEE-SHIN MNL LOCK	570.66	570.66
L5811	DMEPOS	ENDO KNEE-SHIN MNL LCK ULTRA	854.84	854.84
L5812	DMEPOS	ENDO KNEE-SHIN FRCT SWG & ST	662.59	662.59
L5814	DMEPOS	ENDO KNEE-SHIN HYDRAL SWG PH	4402.09	4402.09
L5816	DMEPOS	ENDO KNEE-SHIN POLYC MCH STA	1002.83	1002.83
L5818	DMEPOS	ENDO KNEE-SHIN FRCT SWG & ST	1125.61	1125.61
L5822	DMEPOS	ENDO KNEE-SHIN PNEUM SWG FRC	1995.99	1995.99
L5824	DMEPOS	ENDO KNEE-SHIN FLUID SWING P	1797.50	1797.50
L5826	DMEPOS	MINIATURE KNEE JOINT	3701.57	3701.57
L5828	DMEPOS	ENDO KNEE-SHIN FLUID SWG/STA	3309.97	3309.97
L5830	DMEPOS	ENDO KNEE-SHIN PNEUM/SWG PHA	2224.12	2224.12
L5840	DMEPOS	MULTI-AXIAL KNEE/SHIN SYSTEM	4112.40	4112.40
L5845	DMEPOS	KNEE-SHIN SYS STANCE FLEXION	2124.55	2124.55
L5848	DMEPOS	KNEE-SHIN SYS HYDRAUL STANCE	1274.57	1274.57
L5850	DMEPOS	ENDO AK/HIP KNEE EXTENS ASSI	149.94	149.94
L5855	DMEPOS	MECH HIP EXTENSION ASSIST	402.91	402.91
L5856	DMEPOS	ELEC KNEE-SHIN SWING/STANCE	28454.32	28454.32
L5857	DMEPOS	ELEC KNEE-SHIN SWING ONLY	10096.63	10096.63
L5858	DMEPOS	STANCE PHASE ONLY	22029.19	22029.19
L5859	DMEPOS	KNEE-SHIN PRO FLEX/EXT CONT	17198.02	17198.02
L5910	DMEPOS	ENDO BELOW KNEE ALIGNABLE SY	424.51	424.51
L5920	DMEPOS	ENDO AK/HIP ALIGNABLE SYSTEM	621.92	621.92
L5925	DMEPOS	ABOVE KNEE MANUAL LOCK	525.12	525.12
L5926	DMEPOS	ENDOSKEL POSIT ROTAT UNIT	667.72	667.72
L5930	DMEPOS	HIGH ACTIVITY KNEE FRAME	3989.61	3989.61
L5940	DMEPOS	ENDO BK ULTRA-LIGHT MATERIAL	587.94	587.94
L5950	DMEPOS	ENDO AK ULTRA-LIGHT MATERIAL	919.29	919.29
L5960	DMEPOS	ENDO HIP ULTRA-LIGHT MATERIA	1129.96	1129.96
L5961	DMEPOS	ENDO POLY HIP, PNEU/HYD/ROT	5388.13	5388.13
L5962	DMEPOS	BELOW KNEE FLEX COVER SYSTEM	743.64	743.64
L5964	DMEPOS	ABOVE KNEE FLEX COVER SYSTEM	1097.71	1097.71
L5966	DMEPOS	HIP FLEXIBLE COVER SYSTEM	1398.75	1398.75
L5968	DMEPOS	MULTIAXIAL ANKLE W DORSIFLEX	4307.32	4307.32
L5969	DMEPOS	AK/FT POWER ASST INCL MOTORS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L5970	DMEPOS	FOOT EXTERNAL KEEL SACH FOOT	238.05	238.05
L5971	DMEPOS	SACH FOOT, REPLACEMENT	238.05	238.05
L5972	DMEPOS	FLEXIBLE KEEL FOOT	444.66	444.66
L5973	DMEPOS	ANK-FOOT SYS DORS-PLANT FLEX	20392.86	20392.86
L5974	DMEPOS	FOOT SINGLE AXIS ANKLE/FOOT	273.14	273.14
L5975	DMEPOS	COMBO ANKLE/FOOT PROSTHESIS	549.54	549.54
L5976	DMEPOS	ENERGY STORING FOOT	656.42	656.42
L5978	DMEPOS	FT PROSTH MULTIAXIAL ANKL/FT	342.05	342.05
L5979	DMEPOS	MULTI-AXIAL ANKLE/FT PROSTH	2674.48	2674.48
L5980	DMEPOS	FLEX FOOT SYSTEM	4345.85	4345.85
L5981	DMEPOS	FLEX-WALK SYS LOW EXT PROSTH	3510.86	3510.86
L5982	DMEPOS	EXOSKELETAL AXIAL ROTATION U	677.61	677.61
L5984	DMEPOS	ENDOSKELETAL AXIAL ROTATION	667.72	667.72
L5985	DMEPOS	LWR EXT DYNAMIC PROSTH PYLON	334.70	334.70
L5986	DMEPOS	MULTI-AXIAL ROTATION UNIT	742.75	742.75
L5987	DMEPOS	SHANK FT W VERT LOAD PYLON	8526.80	8526.80
L5988	DMEPOS	VERTICAL SHOCK REDUCING PYLO	2367.87	2367.87
L5990	DMEPOS	USER ADJUSTABLE HEEL HEIGHT	2150.39	2150.39
L5991	DMEPOS	LOW PROS EXT OSSEO CONNECTOR	11254.44	11254.44
L5999	DMEPOS	LOWR EXTREMITY PROSTHES NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L6000	DMEPOS	PART HAND THUMB REM	1557.38	1557.38
L6010	DMEPOS	PART HAND LITTLE/RING	1733.10	1733.10
L6020	DMEPOS	PART HAND NO FINGERS	1615.84	1615.84
L6026	DMEPOS	PART HAND MYO EXCLU TERM DEV	5859.30	5859.30
L6050	DMEPOS	WRST MLD SCK FLX HNG TRI PAD	2226.56	2226.56
L6055	DMEPOS	WRST MOLD SOCK W/EXP INTERFA	3103.27	3103.27
L6100	DMEPOS	ELB MOLD SOCK FLEX HINGE PAD	2255.85	2255.85
L6110	DMEPOS	ELBOW MOLD SOCK SUSPENSION T	2392.71	2392.71
L6120	DMEPOS	ELBOW MOLD DOUB SPLT SOC STE	2788.37	2788.37
L6130	DMEPOS	ELBOW STUMP ACTIVATED LOCK H	3034.26	3034.26
L6200	DMEPOS	ELBOW MOLD OUTSID LOCK HINGE	3197.61	3197.61
L6205	DMEPOS	ELBOW MOLDED W/ EXPAND INTER	4268.32	4268.32
L6250	DMEPOS	ELBOW INTER LOC ELBOW FORARM	3350.36	3350.36
L6300	DMEPOS	SHLDER DISART INT LOCK ELBOW	4366.85	4366.85
L6310	DMEPOS	SHOULDER PASSIVE RESTOR COMP	3770.59	3770.59
L6320	DMEPOS	SHOULDER PASSIVE RESTOR CAP	2059.78	2059.78
L6350	DMEPOS	THORACIC INTERN LOCK ELBOW	4591.07	4591.07
L6360	DMEPOS	THORACIC PASSIVE RESTOR COMP	4128.94	4128.94
L6370	DMEPOS	THORACIC PASSIVE RESTOR CAP	2470.63	2470.63
L6380	DMEPOS	POSTOP DSG CAST CHG WRST/ELB	1431.67	1431.67
L6382	DMEPOS	POSTOP DSG CAST CHG ELB DIS/	2153.89	2153.89
L6384	DMEPOS	POSTOP DSG CAST CHG SHLDER/T	2979.68	2979.68
L6386	DMEPOS	POSTOP EA CAST CHG & REALIGN	470.70	470.70
L6388	DMEPOS	POSTOP APPLICAT RIGID DSG ON	515.29	515.29
L6400	DMEPOS	BELOW ELBOW PROSTH TISS SHAP	2719.76	2719.76
L6450	DMEPOS	ELB DISART PROSTH TISS SHAP	3633.55	3633.55
L6500	DMEPOS	ABOVE ELBOW PROSTH TISS SHAP	3801.42	3801.42
L6550	DMEPOS	SHLDR DISAR PROSTH TISS SHAP	4569.37	4569.37
L6570	DMEPOS	SCAP THORAC PROSTH TISS SHAP	5130.18	5130.18
L6580	DMEPOS	WRIST/ELBOW BOWDEN CABLE MOL	1958.60	1958.60
L6582	DMEPOS	WRIST/ELBOW BOWDEN CBL DIR F	1773.96	1773.96
L6584	DMEPOS	ELBOW FAIR LEAD CABLE MOLDED	2782.04	2782.04
L6586	DMEPOS	ELBOW FAIR LEAD CABLE DIR FO	2603.54	2603.54
L6588	DMEPOS	SHDR FAIR LEAD CABLE MOLDED	3420.99	3420.99
L6590	DMEPOS	SHDR FAIR LEAD CABLE DIRECT	3249.39	3249.39
L6600	DMEPOS	POLYCENTRIC HINGE PAIR	219.86	219.86
L6605	DMEPOS	SINGLE PIVOT HINGE PAIR	217.09	217.09
L6610	DMEPOS	FLEXIBLE METAL HINGE PAIR	208.47	208.47
L6611	DMEPOS	ADDITIONAL SWITCH, EXT POWER	488.00	488.00
L6615	DMEPOS	DISCONNECT LOCKING WRIST UNI	224.62	224.62
L6616	DMEPOS	DISCONNECT INSERT LOCKING WR	83.23	83.23
L6620	DMEPOS	FLEXION/EXTENSION WRIST UNIT	359.40	359.40
L6621	DMEPOS	FLEX/EXT WRIST W/WO FRICTION	2711.12	2711.12
L6623	DMEPOS	SPRING-ASS ROT WRST W/ LATCH	1002.49	1002.49
L6624	DMEPOS	FLEX/EXT/ROTATION WRIST UNIT	4463.94	4463.94
L6625	DMEPOS	ROTATION WRST W/ CABLE LOCK	712.27	712.27
L6628	DMEPOS	QUICK DISCONN HOOK ADAPTER O	561.50	561.50
L6629	DMEPOS	LAMINATION COLLAR W/ COUPLIN	171.48	171.48
L6630	DMEPOS	STAINLESS STEEL ANY WRIST	252.61	252.61
L6632	DMEPOS	LATEX SUSPENSION SLEEVE EACH	87.73	87.73
L6635	DMEPOS	LIFT ASSIST FOR ELBOW	206.45	206.45
L6637	DMEPOS	NUDGE CONTROL ELBOW LOCK	440.33	440.33
L6638	DMEPOS	ELEC LOCK ON MANUAL PW ELBOW	2964.13	2964.13
L6640	DMEPOS	SHOULDER ABDUCTION JOINT PAI	391.19	391.19
L6641	DMEPOS	EXCURSION AMPLIFIER PULLEY T	188.03	188.03
L6642	DMEPOS	EXCURSION AMPLIFIER LEVER TY	254.87	254.87
L6645	DMEPOS	SHOULDER FLEXION-ABDUCTION J	470.45	470.45
L6646	DMEPOS	MULTIPO LOCKING SHOULDER JNT	3738.46	3738.46
L6647	DMEPOS	SHOULDER LOCK ACTUATOR	615.46	615.46
L6648	DMEPOS	EXT PWRD SHLDER LOCK/UNLOCK	3855.66	3855.66
L6650	DMEPOS	SHOULDER UNIVERSAL JOINT	488.44	488.44
L6655	DMEPOS	STANDARD CONTROL CABLE EXTRA	95.99	95.99
L6660	DMEPOS	HEAVY DUTY CONTROL CABLE	107.59	107.59
L6665	DMEPOS	TEFLON OR EQUAL CABLE LINING	53.98	53.98
L6670	DMEPOS	HOOK TO HAND CABLE ADAPTER	59.69	59.69
L6672	DMEPOS	HARNESS CHEST/SHLDER SADDLE	236.86	236.86
L6675	DMEPOS	HARNESS FIGURE OF 8 SING CON	140.76	140.76
L6676	DMEPOS	HARNESS FIGURE OF 8 DUAL CON	162.71	162.71
L6677	DMEPOS	UE TRIPLE CONTROL HARNESS	351.66	351.66
L6680	DMEPOS	TEST SOCK WRIST DISART/BEL E	271.93	271.93
L6682	DMEPOS	TEST SOCK ELBW DISART/ABOVE	300.66	300.66
L6684	DMEPOS	TEST SOCKET SHLDR DISART/THO	408.56	408.56
L6686	DMEPOS	SUCTION SOCKET	922.63	922.63
L6687	DMEPOS	FRAME TYP SOCKET BEL ELBOW/W	676.09	676.09
L6688	DMEPOS	FRAME TYP SOCK ABOVE ELB/DIS	672.00	672.00
L6689	DMEPOS	FRAME TYP SOCKET SHOULDER DI	805.15	805.15
L6690	DMEPOS	FRAME TYP SOCK INTERSCAP-THO	877.38	877.38
L6691	DMEPOS	REMOVABLE INSERT EACH	406.08	406.08
L6692	DMEPOS	SILICONE GEL INSERT OR EQUAL	655.48	655.48
L6693	DMEPOS	LOCKINGELBOW FOREARM CNTRBAL	3365.05	3365.05
L6694	DMEPOS	ELBOW SOCKET INS USE W/LOCK	833.44	833.44
L6695	DMEPOS	ELBOW SOCKET INS USE W/O LCK	694.50	694.50
L6696	DMEPOS	CUS ELBO SKT IN FOR CON/ATYP	1559.16	1559.16
L6697	DMEPOS	CUS ELBO SKT IN NOT CON/ATYP	1559.16	1559.16
L6698	DMEPOS	BELOW/ABOVE ELBOW LOCK MECH	674.00	674.00
L6703	DMEPOS	TERM DEV, PASSIVE HAND MITT	426.11	426.11
L6704	DMEPOS	TERM DEV, SPORT/REC/WORK ATT	686.43	686.43
L6706	DMEPOS	TERM DEV MECH HOOK VOL OPEN	408.97	408.97
L6707	DMEPOS	TERM DEV MECH HOOK VOL CLOSE	1507.42	1507.42
L6708	DMEPOS	TERM DEV MECH HAND VOL OPEN	985.44	985.44
L6709	DMEPOS	TERM DEV MECH HAND VOL CLOSE	1420.05	1420.05
L6711	DMEPOS	PED TERM DEV, HOOK, VOL OPEN	796.88	796.88
L6712	DMEPOS	PED TERM DEV, HOOK, VOL CLOS	1467.26	1467.26
L6713	DMEPOS	PED TERM DEV, HAND, VOL OPEN	1851.77	1851.77
L6714	DMEPOS	PED TERM DEV, HAND, VOL CLOS	1568.51	1568.51
L6715	DMEPOS	TERM DEVICE, MULTI ART DIGIT	3742.19	3742.19
L6721	DMEPOS	HOOK/HAND, HVY DTY, VOL OPEN	2787.82	2787.82
L6722	DMEPOS	HOOK/HAND, HVY DTY, VOL CLOS	2403.29	2403.29
L6805	DMEPOS	TERM DEV MODIFIER WRIST UNIT	398.79	398.79
L6810	DMEPOS	TERM DEV PRECISION PINCH DEV	226.03	226.03
L6880	DMEPOS	ELEC HAND IND ART DIGITS	28320.00	28320.00
L6881	DMEPOS	TERM DEV AUTO GRASP FEATURE	4845.79	4845.79
L6882	DMEPOS	MICROPROCESSOR CONTROL UPLMB	3675.83	3675.83
L6883	DMEPOS	REPLC SOCKT BELOW E/W DISA	1860.00	1860.00
L6884	DMEPOS	REPLC SOCKT ABOVE ELBOW DISA	2760.64	2760.64
L6885	DMEPOS	REPLC SOCKT SHLDR DIS/INTERC	4128.94	4128.94
L6890	DMEPOS	PREFAB GLOVE FOR TERM DEVICE	199.36	199.36
L6895	DMEPOS	CUSTOM GLOVE FOR TERM DEVICE	733.40	733.40
L6900	DMEPOS	HAND RESTORAT THUMB/1 FINGER	2092.93	2092.93
L6905	DMEPOS	HAND RESTORATION MULTIPLE FI	2081.04	2081.04
L6910	DMEPOS	HAND RESTORATION NO FINGERS	1779.49	1779.49
L6915	DMEPOS	HAND RESTORATION REPLACMNT G	897.20	897.20
L6920	DMEPOS	WRIST DISARTICUL SWITCH CTRL	7822.35	7822.35
L6925	DMEPOS	WRIST DISART MYOELECTRONIC C	10530.24	10530.24
L6930	DMEPOS	BELOW ELBOW SWITCH CONTROL	7870.86	7870.86
L6935	DMEPOS	BELOW ELBOW MYOELECTRONIC CT	10693.65	10693.65
L6940	DMEPOS	ELBOW DISARTICULATION SWITCH	10283.79	10283.79
L6945	DMEPOS	ELBOW DISART MYOELECTRONIC C	12565.56	12565.56
L6950	DMEPOS	ABOVE ELBOW SWITCH CONTROL	11688.98	11688.98
L6955	DMEPOS	ABOVE ELBOW MYOELECTRONIC CT	13999.14	13999.14
L6960	DMEPOS	SHLDR DISARTIC SWITCH CONTRO	15857.53	15857.53
L6965	DMEPOS	SHLDR DISARTIC MYOELECTRONIC	16912.64	16912.64
L6970	DMEPOS	INTERSCAPULAR-THOR SWITCH CT	17623.24	17623.24
L6975	DMEPOS	INTERSCAP-THOR MYOELECTRONIC	19274.14	19274.14
L7007	DMEPOS	ADULT ELECTRIC HAND	4033.31	4033.31
L7008	DMEPOS	PEDIATRIC ELECTRIC HAND	6348.01	6348.01
L7009	DMEPOS	ADULT ELECTRIC HOOK	4115.25	4115.25
L7040	DMEPOS	PREHENSILE ACTUATOR	3304.39	3304.39
L7045	DMEPOS	PEDIATRIC ELECTRIC HOOK	1894.52	1894.52
L7170	DMEPOS	ELECTRONIC ELBOW HOSMER SWIT	8723.07	8723.07
L7180	DMEPOS	ELECTRONIC ELBOW SEQUENTIAL	38289.48	38289.48
L7181	DMEPOS	ELECTRONIC ELBO SIMULTANEOUS	47492.96	47492.96
L7185	DMEPOS	ELECTRON ELBOW ADOLESCENT SW	8614.16	8614.16
L7186	DMEPOS	ELECTRON ELBOW CHILD SWITCH	10367.98	10367.98
L7190	DMEPOS	ELBOW ADOLESCENT MYOELECTRON	9047.81	9047.81
L7191	DMEPOS	ELBOW CHILD MYOELECTRONIC CT	10833.92	10833.92
L7259	DMEPOS	ELECTRONIC WRIST ROTATOR ANY	3745.97	3745.97
L7360	DMEPOS	SIX VOLT BAT OTTO BOCK/EQ EA	279.69	279.69
L7362	DMEPOS	BATTERY CHRGR SIX VOLT OTTO	293.67	293.67
L7364	DMEPOS	TWELVE VOLT BATTERY UTAH/EQU	467.06	467.06
L7366	DMEPOS	BATTERY CHRGR 12 VOLT UTAH/E	629.15	629.15
L7367	DMEPOS	REPLACEMNT LITHIUM IONBATTER	461.45	461.45
L7368	DMEPOS	LITHIUM ION BATTERY CHARGER	598.22	598.22
L7400	DMEPOS	ADD UE PROST BE/WD, ULTLITE	363.30	363.30
L7401	DMEPOS	ADD UE PROST A/E ULTLITE MAT	406.72	406.72
L7402	DMEPOS	ADD UE PROST S/D ULTLITE MAT	439.17	439.17
L7403	DMEPOS	ADD UE PROST B/E ACRYLIC	436.52	436.52
L7404	DMEPOS	ADD UE PROST A/E ACRYLIC	658.77	658.77
L7405	DMEPOS	ADD UE PROST S/D ACRYLIC	861.61	861.61
L7499	DMEPOS	UPPER EXTREMITY PROSTHES NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L7510	DMEPOS	PROSTHETIC DEVICE REPAIR REP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L7520	DMEPOS	REPAIR PROSTHESIS PER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L7600	DMEPOS	PROSTHETIC DONNING SLEEVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L7700	DMEPOS	PROS SOC INSERT GASKET/SEAL	132.29	132.29
L7900	DMEPOS	MALE VACUUM ERECTION SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L7902	DMEPOS	TENSION RING, VAC ERECT DEV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8000	DMEPOS	MASTECTOMY BRA	51.55	51.55
L8001	DMEPOS	BREAST PROSTHESIS BRA & FORM	148.67	148.67
L8002	DMEPOS	BRST PRSTH BRA & BILAT FORM	195.58	195.58
L8010	DMEPOS	MASTECTOMY SLEEVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8015	DMEPOS	EXT BREASTPROSTHESIS GARMENT	71.04	71.04
L8020	DMEPOS	MASTECTOMY FORM	267.23	267.23
L8030	DMEPOS	BREAST PROSTHES W/O ADHESIVE	386.52	386.52
L8031	DMEPOS	BREAST PROSTHESIS W ADHESIVE	386.52	386.52
L8032	DMEPOS	REUSABLE NIPPLE PROSTHESIS	46.43	46.43
L8033	Other professional services	NIPPLE PROSTHESIS CUSTOM, EA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8035	DMEPOS	CUSTOM BREAST PROSTHESIS	4342.51	4342.51
L8039	DMEPOS	BREAST PROSTHESIS NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8040	DMEPOS	NASAL PROSTHESIS	2865.09	2865.09
L8041	DMEPOS	MIDFACIAL PROSTHESIS	3453.34	3453.34
L8042	DMEPOS	ORBITAL PROSTHESIS	3880.12	3880.12
L8043	DMEPOS	UPPER FACIAL PROSTHESIS	4345.75	4345.75
L8044	DMEPOS	HEMI-FACIAL PROSTHESIS	4811.34	4811.34
L8045	DMEPOS	AURICULAR PROSTHESIS	3013.00	3013.00
L8046	DMEPOS	PARTIAL FACIAL PROSTHESIS	3104.11	3104.11
L8047	DMEPOS	NASAL SEPTAL PROSTHESIS	1590.83	1590.83
L8048	DMEPOS	UNSPEC MAXILLOFACIAL PROSTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8049	DMEPOS	REPAIR MAXILLOFACIAL PROSTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8300	DMEPOS	TRUSS SINGLE W/ STANDARD PAD	114.16	114.16
L8310	DMEPOS	TRUSS DOUBLE W/ STANDARD PAD	175.53	175.53
L8320	DMEPOS	TRUSS ADDITION TO STD PAD WA	76.66	76.66
L8330	DMEPOS	TRUSS ADD TO STD PAD SCROTAL	76.00	76.00
L8400	DMEPOS	SHEATH BELOW KNEE	22.22	22.22
L8410	DMEPOS	SHEATH ABOVE KNEE	25.27	25.27
L8415	DMEPOS	SHEATH UPPER LIMB	25.13	25.13
L8417	DMEPOS	PROS SHEATH/SOCK W GEL CUSHN	89.13	89.13
L8420	DMEPOS	PROSTHETIC SOCK MULTI PLY BK	29.37	29.37
L8430	DMEPOS	PROSTHETIC SOCK MULTI PLY AK	32.31	32.31
L8435	DMEPOS	PROS SOCK MULTI PLY UPPER LM	28.98	28.98
L8440	DMEPOS	SHRINKER BELOW KNEE	61.45	61.45
L8460	DMEPOS	SHRINKER ABOVE KNEE	85.53	85.53
L8465	DMEPOS	SHRINKER UPPER LIMB	76.23	76.23
L8470	DMEPOS	PROS SOCK SINGLE PLY BK	7.82	7.82
L8480	DMEPOS	PROS SOCK SINGLE PLY AK	10.79	10.79
L8485	DMEPOS	PROS SOCK SINGLE PLY UPPER L	13.04	13.04
L8499	DMEPOS	UNLISTED MISC PROSTHETIC SER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8500	DMEPOS	ARTIFICIAL LARYNX	773.54	773.54
L8501	DMEPOS	TRACHEOSTOMY SPEAKING VALVE	171.78	171.78
L8505	DMEPOS	ARTIFICIAL LARYNX, ACCESSORY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8507	DMEPOS	TRACH-ESOPH VOICE PROS PT IN	49.65	49.65
L8509	DMEPOS	TRACH-ESOPH VOICE PROS MD IN	129.46	129.46
L8510	DMEPOS	VOICE AMPLIFIER	299.54	299.54
L8511	DMEPOS	INDWELLING TRACH INSERT	86.21	86.21
L8512	DMEPOS	GEL CAP FOR TRACH VOICE PROS	2.59	2.59
L8513	DMEPOS	TRACH PROS CLEANING DEVICE	6.19	6.19
L8514	DMEPOS	REPL TRACH PUNCTURE DILATOR	111.77	111.77
L8515	DMEPOS	GEL CAP APP DEVICE FOR TRACH	74.81	74.81
L8600	DMEPOS	IMPLANT BREAST SILICONE/EQ	731.92	731.92
L8603	DMEPOS	COLLAGEN IMP URINARY 2.5 ML	514.04	514.04
L8604	DMEPOS	DEXTRANOMER/HYALURONIC ACID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8605	DMEPOS	INJ BULKING AGENT ANAL CANAL	848.97	848.97
L8606	DMEPOS	SYNTHETIC IMPLNT URINARY 1ML	269.83	269.83
L8607	DMEPOS	INJ VOCAL CORD BULKING AGENT	50.86	50.86
L8608	Other professional services	ARG II EXT COM/SUP/ACC MISC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8609	DMEPOS	ARTIFICIAL CORNEA	7722.81	7722.81
L8610	DMEPOS	OCULAR IMPLANT	750.79	750.79
L8612	DMEPOS	AQUEOUS SHUNT PROSTHESIS	791.84	791.84
L8613	DMEPOS	OSSICULAR IMPLANT	354.50	354.50
L8614	DMEPOS	COCHLEAR DEVICE	22439.75	22439.75
L8615	DMEPOS	COCH IMPLANT HEADSET REPLACE	534.59	534.59
L8616	DMEPOS	COCH IMPLANT MICROPHONE REPL	124.52	124.52
L8617	DMEPOS	COCH IMPLANT TRANS COIL REPL	108.80	108.80
L8618	DMEPOS	COCH IMPLANT TRAN CABLE REPL	31.07	31.07
L8619	DMEPOS	COCH IMP EXT PROC/CONTR RPLC	9625.81	9625.81
L8621	DMEPOS	REPL ZINC AIR BATTERY	0.73	0.73
L8622	DMEPOS	REPL ALKALINE BATTERY	0.38	0.38
L8623	DMEPOS	LITH ION BATT CID,NON-EARLVL	76.66	76.66
L8624	DMEPOS	LITH ION BATT CID, EAR LEVEL	191.12	191.12
L8625	DMEPOS	CHARGER COCH IMPL/AOI BATTRY	223.86	223.86
L8627	DMEPOS	CID EXT SPEECH PROCESS REPL	8159.49	8159.49
L8628	DMEPOS	CID EXT CONTROLLER REPL	1466.35	1466.35
L8629	DMEPOS	CID TRANSMIT COIL AND CABLE	212.23	212.23
L8630	DMEPOS	METACARPOPHALANGEAL IMPLANT	394.89	394.89
L8631	DMEPOS	MCP JOINT REPL 2 PC OR MORE	2650.14	2650.14
L8641	DMEPOS	METATARSAL JOINT IMPLANT	428.60	428.60
L8642	DMEPOS	HALLUX IMPLANT	351.83	351.83
L8658	DMEPOS	INTERPHALANGEAL JOINT SPACER	367.69	367.69
L8659	DMEPOS	INTERPHALANGEAL JOINT REPL	2287.24	2287.24
L8670	DMEPOS	VASCULAR GRAFT, SYNTHETIC	652.47	652.47
L8678	DMEPOS	EXT SPLY IMPLT NEUROSTIM	12.52	12.52
L8679	DMEPOS	IMP NEUROSTI PLS GN ANY TYPE	9890.28	9890.28
L8680	DMEPOS	IMPLT NEUROSTIM ELCTR EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8681	DMEPOS	PT PRGRM FOR IMPLT NEUROSTIM	1338.78	1338.78
L8682	DMEPOS	IMPLT NEUROSTIM RADIOFQ REC	7066.41	7066.41
L8683	DMEPOS	RADIOFQ TRSMTR FOR IMPLT NEU	6220.03	6220.03
L8684	DMEPOS	RADIOF TRSMTR IMPLT SCRL NEU	816.81	816.81
L8685	DMEPOS	IMPLT NROSTM PLS GEN SNG REC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8686	DMEPOS	IMPLT NROSTM PLS GEN SNG NON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8687	DMEPOS	IMPLT NROSTM PLS GEN DUA REC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8688	DMEPOS	IMPLT NROSTM PLS GEN DUA NON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8689	DMEPOS	EXTERNAL RECHARG SYS INTERN	2044.57	2044.57
L8690	DMEPOS	AUD OSSEO DEV, INT/EXT COMP	5638.70	5638.70
L8691	DMEPOS	AOI SND PROC REPL EXCL ACTUA	2041.29	2041.29
L8692	DMEPOS	NON-OSSEOINTEGRATED SND PROC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8693	DMEPOS	AUD OSSEO DEV, ABUTMENT	1797.32	1797.32
L8694	DMEPOS	AOI TRANSDUCER/ACTUATOR REPL	1119.41	1119.41
L8695	DMEPOS	EXTERNAL RECHARG SYS EXTERN	19.74	19.74
L8696	DMEPOS	EXT ANTENNA PHREN NERVE STIM	256.93	256.93
L8698	Other professional services	MISC USED WITH TOT ART HEART	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8699	DMEPOS	PROSTHETIC IMPLANT NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8701	Other professional services	POW UE ROM DEV EWH UPRT CUST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L8702	Other professional services	POW UE ROM DEV EWHF UPRT CUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
L9900	DMEPOS	O&P SUPPLY/ACCESSORY/SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0001	Other professional services	ADVANCING CANCER CARE MVP	0.00	0.00
M0002	Other professional services	OPT CARE KIDNEY HLTH MVP	0.00	0.00
M0003	Other professional services	OPT CARE EPISOD NEURO MVP	0.00	0.00
M0004	Other professional services	SUPPORT CARE NEUR COND MVP	0.00	0.00
M0005	Other professional services	VALUE IN PRIMARY CARE MVP	0.00	0.00
M0010	Other professional services	EOM MEOS PAYMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0075	Other professional services	CELLULAR THERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0076	Other professional services	PROLOTHERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0100	Other professional services	INTRAGASTRIC HYPOTHERMIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0201	Other professional services	PNE FLU HEPB COV HOME ADMIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0220	DMEPOS	TIXAGEV AND CILGAV INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0221	DMEPOS	TIXAGEV AND CILGAV INJ HM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0222	Other professional services	BEBTELOVIMAB INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0223	Other professional services	BEBTELOVIMAB INJECTION HOME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0240	Other professional services	CASIRI AND IMDEV REPEAT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0241	Other professional services	CASIRI AND IMDEV REPEAT HM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0243	DMEPOS	CASIRIVI AND IMDEVI INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0244	Other professional services	CASIRIVI AND IMDEVI INJ HM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0245	Other professional services	BAMLAN AND ETESEV INFUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0246	Other professional services	BAMLAN AND ETESEV INFUS HOME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0247	Other professional services	SOTROVIMAB INFUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0248	Other professional services	SOTROVIMAB INF, HOME ADMIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0249	Other professional services	ADM TOCILIZU COVID-19 1ST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0250	Other professional services	ADM TOCILIZU COVID-19 2ND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0300	Other professional services	IV CHELATIONTHERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M0301	Other professional services	FABRIC WRAPPING OF ANEURYSM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
M1003	Other professional services	TB SCR 12 MO PRI FST BIO DZ	0.00	0.00
M1004	Other professional services	DOC MED RSN NO SRN TB	0.00	0.00
M1005	Other professional services	TB SCR NO PERF	0.00	0.00
M1006	Other professional services	DZ NOT ASES, NO RSN	0.00	0.00
M1007	Other professional services	>=50% TOTAL PT OUTPT RA ENCT	0.00	0.00
M1008	Other professional services	<50% TOTAL PT OUTPT RA ENCTS	0.00	0.00
M1009	Other professional services	DC EOC DOC MED REC	0.00	0.00
M1010	Other professional services	DC EOC DOC MED REC	0.00	0.00
M1011	Other professional services	DC EOC DOC MED REC	0.00	0.00
M1012	Other professional services	DC EOC DOC MED REC	0.00	0.00
M1013	Other professional services	DC EOC DOC MED REC	0.00	0.00
M1014	Other professional services	DC EPI CARE DOC MEDREC	0.00	0.00
M1016	Other professional services	PT DX MEOP OR SUR STERI	0.00	0.00
M1018	Other professional services	PT DX HST CR PT SK LG CR SCR	0.00	0.00
M1019	Other professional services	ADL PT MJ DEP DS RS 12 PHQ<5	0.00	0.00
M1020	Other professional services	ADL PT MJ DEP DS NO RS 12 MO	0.00	0.00
M1021	Other professional services	PT UC IN PP	0.00	0.00
M1027	Other professional services	IMG HEAD (CT OR MRI) OBTND	0.00	0.00
M1028	Other professional services	DOC OF PT PRM HDA DX AND OTR	0.00	0.00
M1029	Other professional services	DOC SYSM RSN IMG HD	0.00	0.00
M1032	Other professional services	ADT TKNG PHARMTHRY FOR OUD	0.00	0.00
M1034	Other professional services	ADT 180 DYS PHARMTHRY OUD	0.00	0.00
M1035	Other professional services	ADT PD OUT MAT PR 180 DYS TX	0.00	0.00
M1036	Other professional services	ADT NO 180 DYS PHARMTHRY OUD	0.00	0.00
M1037	Other professional services	PT DX LUM SP REG CACR	0.00	0.00
M1038	Other professional services	PT DX LUM SP REG FRACT	0.00	0.00
M1039	Other professional services	PT DX LUM SP REG INF	0.00	0.00
M1040	Other professional services	PT DX LUM IDI OR CONG SCOL	0.00	0.00
M1041	Other professional services	PT CR FT INF LM OR PT ID SL	0.00	0.00
M1043	Other professional services	FS NO ODI 9-15MO	0.00	0.00
M1045	Other professional services	FS OKS 9-15MO >= 37 >= 71	0.00	0.00
M1046	Other professional services	FS OKS 9-15MO < 37 < 71	0.00	0.00
M1049	Other professional services	FS WTH SCR NO ODI PRE AND P	0.00	0.00
M1051	Other professional services	PT W/CANCER SCOLIOSIS	0.00	0.00
M1052	Other professional services	LG PN NOT MEAS W/ VAS 1YR PO	0.00	0.00
M1054	Other professional services	PT UC IN PP	0.00	0.00
M1055	Other professional services	ASPIRIN USED	0.00	0.00
M1056	Other professional services	PRESC ANTICO MED IN PP	0.00	0.00
M1057	Other professional services	ASPIRIN NOT USED, NO RSN	0.00	0.00
M1058	Other professional services	PT PRM NURS HM RES IN PP	0.00	0.00
M1059	Other professional services	PT NO PRM NURS HM RES IN PP	0.00	0.00
M1060	Other professional services	PT DIED IN PP	0.00	0.00
M1067	Other professional services	HSPC PT PRV TIME MEAM PER	0.00	0.00
M1068	Other professional services	PT NOT AMBULATORY	0.00	0.00
M1069	Other professional services	PT SCR FT FALL RSK	0.00	0.00
M1070	Other professional services	PT NOT SCRN FUT FALL NO RSN	0.00	0.00
M1106	Other professional services	START EOC DOC MED REC	0.00	0.00
M1107	Other professional services	DOCU DX DEGEN NEURO	0.00	0.00
M1108	Other professional services	OC NI PT HOME PROG	0.00	0.00
M1109	Other professional services	OC NI PT DC	0.00	0.00
M1110	Other professional services	OC NOT P PT SELFDC	0.00	0.00
M1111	Other professional services	START EOC DOC MED REC	0.00	0.00
M1112	Other professional services	DOCU DX DEGEN NEURO	0.00	0.00
M1113	Other professional services	OC NI PT HOME PROG	0.00	0.00
M1114	Other professional services	OC NI PT DC	0.00	0.00
M1115	Other professional services	OC NI PT SELFDC	0.00	0.00
M1116	Other professional services	START EOC DOC MED REC	0.00	0.00
M1117	Other professional services	DOCU DX DEGEN NEURO	0.00	0.00
M1118	Other professional services	OC NI PT HOME PROG	0.00	0.00
M1119	Other professional services	OC NI PT DC	0.00	0.00
M1120	Other professional services	OC NI PT SELFDC	0.00	0.00
M1121	Other professional services	START EOC DOC MED REC	0.00	0.00
M1122	Other professional services	DOCU DX DEGEN NEURO	0.00	0.00
M1123	Other professional services	OC NI PT HOME PROG	0.00	0.00
M1124	Other professional services	OC NI PT DC 1-2 VIS	0.00	0.00
M1125	Other professional services	OC NI PT SELFDC 1-2 VIS	0.00	0.00
M1126	Other professional services	START EOC DOC MED REC	0.00	0.00
M1127	Other professional services	DOCU DX DEGEN NEURO	0.00	0.00
M1128	Other professional services	OC NI PT HOME PROG	0.00	0.00
M1129	Other professional services	OC NI PT DC	0.00	0.00
M1130	Other professional services	OC NI PT SELFDC	0.00	0.00
M1131	Other professional services	DOCU DX DEGEN NEURO	0.00	0.00
M1132	Other professional services	OC NI PT HOME PROG	0.00	0.00
M1133	Other professional services	OC NI PT DC	0.00	0.00
M1134	Other professional services	OC NI PT SELFDC	0.00	0.00
M1135	Other professional services	START EOC DOC MED REC	0.00	0.00
M1141	Other professional services	FS NO OKS	0.00	0.00
M1142	Other professional services	EMERGE CASES	0.00	0.00
M1143	Other professional services	NI REHAB MED CHIRO	0.00	0.00
M1146	Other professional services	ONGOING CARE NOT IND	0.00	0.00
M1147	Other professional services	CARE NOT POSS MED RSN	0.00	0.00
M1148	Other professional services	PT SELF DSCHG	0.00	0.00
M1149	Other professional services	NO NECK FS PROM INCAP	0.00	0.00
M1150	Other professional services	LVEF <=40% OR MOD/SEV L VSF	0.00	0.00
M1151	Other professional services	PT W/ HX TRNSPLT OR LVAD	0.00	0.00
M1152	Other professional services	PT W/ HX TRNSPLT OR LVAD	0.00	0.00
M1153	Other professional services	PT W/ DX OSTEO DOE	0.00	0.00
M1154	Other professional services	HOSPC SERV DUR MEAS PD	0.00	0.00
M1155	Other professional services	PT ANPHX DUE TO PNEUM	0.00	0.00
M1159	Other professional services	HOSPC SERV DUR MEAS PD	0.00	0.00
M1160	Other professional services	PT ANPHX DUE TO MENGB BEF 13	0.00	0.00
M1161	Other professional services	PT ANPHX DUE TO DTP BEF 13	0.00	0.00
M1162	Other professional services	PT ENCEPH DUE TO DTP BEF 13	0.00	0.00
M1163	Other professional services	PT ANPHX DUE TO HPV BEF 13	0.00	0.00
M1164	Other professional services	PT W/ DEMENTIA ANY TIME	0.00	0.00
M1165	Other professional services	PT USE HSPC DUR MEAS PD	0.00	0.00
M1166	Other professional services	PATH RPT TIS SPEC WLE/REEXC	0.00	0.00
M1167	Other professional services	HSPC DUR MEAS PD	0.00	0.00
M1168	Other professional services	PT RECD FLU VAX 7/1-6/30	0.00	0.00
M1169	Other professional services	DOC MED RSN NO FLU VAX	0.00	0.00
M1170	Other professional services	PT W/O FLU VAX 7/1-6/30	0.00	0.00
M1171	Other professional services	PT RECD 1 TD/TDAP 9YRS PRIOR	0.00	0.00
M1172	Other professional services	DOC MED RSN NO TD/TDAP	0.00	0.00
M1173	Other professional services	PT NO REC TD/TDAP 9YRS PRIOR	0.00	0.00
M1174	Other professional services	PT W 2 HZV ON/AFT 50	0.00	0.00
M1175	Other professional services	DOC MED RSN NO HZV	0.00	0.00
M1176	Other professional services	PT W/O HZV ON/AFT AGE 50	0.00	0.00
M1177	Other professional services	PT RECD PCV ON/AFT 60	0.00	0.00
M1178	Other professional services	DOC MED RSN NO PCV	0.00	0.00
M1179	Other professional services	NO PCV RECD	0.00	0.00
M1180	Other professional services	PT IMM CKPT INHIB THERAPY	0.00	0.00
M1181	Other professional services	GR 2 OR> DIA OR GR2 OR> COL	0.00	0.00
M1182	Other professional services	NOT ELG PRE EX IBD/UC/CROHN	0.00	0.00
M1183	Other professional services	DOC IMM CKPT INHIB HLD	0.00	0.00
M1184	Other professional services	DOC MED RSN NO CST/IST RX	0.00	0.00
M1185	Other professional services	IMM CKPT INHIB NOT HLD NO RX	0.00	0.00
M1186	Other professional services	PT W/ RX FOR HSPC/PLLTV CARE	0.00	0.00
M1187	Other professional services	PT W/ ESRD	0.00	0.00
M1188	Other professional services	PT W/ CKD STG 5	0.00	0.00
M1189	Other professional services	DOC KHE PEF W/EFGR/UACR	0.00	0.00
M1190	Other professional services	DOC KHE NOT PEF W/EFGR/UACR	0.00	0.00
M1191	Other professional services	HSPC SVC ANY TIME IN MEAS PD	0.00	0.00
M1192	Other professional services	PT W/ DX SQ CELL CA OF ESOPH	0.00	0.00
M1193	Other professional services	RPTS W/ IMP/CON MMR/MSI	0.00	0.00
M1194	Other professional services	MED RSN NO IMP/CON MMR/MSI	0.00	0.00
M1195	Other professional services	RPT WO IMP/CON MMR/MSI	0.00	0.00
M1196	Other professional services	IXV NRS VRS IQA >=4	0.00	0.00
M1197	Other professional services	ISA REDUCED >=3 FR IXV	0.00	0.00
M1198	Other professional services	ISA NOT RED 3PTS /NO ASSESS	0.00	0.00
M1199	Other professional services	PT REC'G RRT	0.00	0.00
M1200	Other professional services	ACE-I/ARB RX	0.00	0.00
M1201	Other professional services	MED RSN NO ACE-I/ARB RX	0.00	0.00
M1202	Other professional services	PT RSN NO ACE-I/ARB RX	0.00	0.00
M1203	Other professional services	NO RSN ACE-I/ARB RX	0.00	0.00
M1204	Other professional services	IXV NRS VRS IQA >=4	0.00	0.00
M1205	Other professional services	ISA REDUCED >=3	0.00	0.00
M1206	Other professional services	ISA NOT RED 3PTS/NO ASSESS	0.00	0.00
M1207	Other professional services	PT SCRN SDOH	0.00	0.00
M1208	Other professional services	PT NO SCRN SDOH	0.00	0.00
M1209	Other professional services	>=2 SAME HI-RSK MED W/O DIAG	0.00	0.00
M1210	Other professional services	>=2 SAME MEDS TBL4 NOT ORD	0.00	0.00
M1211	Other professional services	HEMOGLOBIN A1C LEVEL >9.0%	0.00	0.00
M1212	Other professional services	MISSING HB A1C LEVEL	0.00	0.00
M1213	Other professional services	NO HX SPIRO PRS SPIRO>=70%	0.00	0.00
M1214	Other professional services	SPIRO RESULTS WTH OBS DOC	0.00	0.00
M1215	Other professional services	MED RSN FOR NO DOC SPIRO	0.00	0.00
M1216	Other professional services	NO SPIRO DOC NO RES DOC	0.00	0.00
M1217	Other professional services	SYS RSN NO DOC SPIRO	0.00	0.00
M1218	Other professional services	PT COPD SYMPTOMS	0.00	0.00
M1219	Other professional services	ANPHX DUE TO VAX	0.00	0.00
M1220	Other professional services	DRE WTH INTERP RTNOPTHY	0.00	0.00
M1221	Other professional services	DRE W/O RTNOPTHY	0.00	0.00
M1222	Other professional services	GLAUCOMA PLN OF CARE NOT DOC	0.00	0.00
M1223	Other professional services	GLAUCOMA PLAN OF CARE DOC	0.00	0.00
M1224	Other professional services	IOP DEC <20% FROM BASE	0.00	0.00
M1225	Other professional services	IOP DEC>=20% FROM BASE	0.00	0.00
M1226	Other professional services	IOP NOT DOC	0.00	0.00
M1227	Other professional services	EB THERAPY PRESCRIBED	0.00	0.00
M1228	Other professional services	PT + HCV ABY +VIR W/ RX 3 MO	0.00	0.00
M1229	Other professional services	PT W/ +HCV +VIR REF WIN 1 MO	0.00	0.00
M1230	Other professional services	PT HCV RCTV ABY NO F/U TST	0.00	0.00
M1231	Other professional services	PT HCV TST NO REACTIVE RES	0.00	0.00
M1232	Other professional services	PT HCV TST REACTIVE RESULT	0.00	0.00
M1233	Other professional services	PT NO HCV ABY OR RESULT	0.00	0.00
M1234	Other professional services	PT HCV RCTV ABY F/U NEG	0.00	0.00
M1235	Other professional services	DOC PT HCV ABY RNA TST	0.00	0.00
M1236	Other professional services	BASELINE MRS > 2	0.00	0.00
M1237	Other professional services	PT RSN NO SCRN	0.00	0.00
M1238	Other professional services	DOC 2ND RECOM HZV 2-6 MO INT	0.00	0.00
M1239	Other professional services	PT NO RESP HEARD	0.00	0.00
M1240	Other professional services	PT NO RESP BEST INT	0.00	0.00
M1241	Other professional services	PT NO RESP SEEN AS PERSON	0.00	0.00
M1242	Other professional services	PT NO RESP IMPRT TO ME	0.00	0.00
M1243	Other professional services	PT OTHR THN TRUE HEARD	0.00	0.00
M1244	Other professional services	PT OTHR THN TRUE BEST INT	0.00	0.00
M1245	Other professional services	PT OTHR THN TRUE PERSON	0.00	0.00
M1246	Other professional services	PT OTHR THN TRUE IMPRT TO ME	0.00	0.00
M1247	Other professional services	PT RESP TRUE BEST INT	0.00	0.00
M1248	Other professional services	PT RESP TRUE SEEN AS PERSON	0.00	0.00
M1249	Other professional services	PT RESP TRUE IMPRT TO ME	0.00	0.00
M1250	Other professional services	PT RESP TRUE HEARD	0.00	0.00
M1251	Other professional services	PTS PROXY CMPLT HU SURV	0.00	0.00
M1252	Other professional services	PTS NO CMPLT HU SURVEY	0.00	0.00
M1253	Other professional services	PTS HU SURV NO AMB PLLTV	0.00	0.00
M1254	Other professional services	PTS DECEASED PRIOR HU SURV	0.00	0.00
M1255	Other professional services	PTS W/ OTHR RSN VST,+PRG TST	0.00	0.00
M1256	Other professional services	PRIOR HISTORY OF KNOWN CVD	0.00	0.00
M1257	Other professional services	CVD RISK ASSESS NOT PERF	0.00	0.00
M1258	Other professional services	CVD RISK ASSESS PERF	0.00	0.00
M1259	Other professional services	PT KID TRANSPLT WTLST LV DON	0.00	0.00
M1260	Other professional services	PT NO KD TRNSPLT WTLST LV DO	0.00	0.00
M1261	Other professional services	PTS ON WTLIST BEF DIALYSIS	0.00	0.00
M1262	Other professional services	PTS TRANSPLT BEF DIALYSIS	0.00	0.00
M1263	Other professional services	PTS HOSP DIALYSIS DT	0.00	0.00
M1264	Other professional services	PTS 75+ DIALYSIS DT	0.00	0.00
M1265	Other professional services	CMS 2728 COMPLETED	0.00	0.00
M1266	Other professional services	PTS ADMIT SNF	0.00	0.00
M1267	Other professional services	PT NO ACT KID TRANSPLT WTLST	0.00	0.00
M1268	Other professional services	PT AC STAT KID TRNSPLT WTLST	0.00	0.00
M1269	Other professional services	REC'D ESRD MCP LST DAY OF MO	0.00	0.00
M1270	Other professional services	PTS NO KID TRANSPLT WTLST	0.00	0.00
M1271	Other professional services	PTS DEM ANY TIME/DUR MO	0.00	0.00
M1272	Other professional services	PTS KID TRANSPLT WTLST	0.00	0.00
M1273	Other professional services	PTS SNF 1 YR DIALYSIS	0.00	0.00
M1274	Other professional services	PTS SNF EXL MO	0.00	0.00
M1275	Other professional services	PTS HOSP EXL	0.00	0.00
M1276	Other professional services	CALC BMI OUT NRM PARAM NOF/U	0.00	0.00
M1277	Other professional services	COLORECTAL CA SCREEN DOC REV	0.00	0.00
M1278	Other professional services	PRE-HTN OR HTN DOC, F/U INDC	0.00	0.00
M1279	Other professional services	PRE-HTN/HTN, NO F/U, NOT GVN	0.00	0.00
M1280	Other professional services	BILAT MAST/HX BI /UNILAT MAS	0.00	0.00
M1281	Other professional services	BP SCRN NO PERF AT INTERVAL	0.00	0.00
M1282	Other professional services	PT SCRN TBCO ID AS NON USER	0.00	0.00
M1283	Other professional services	PT SCRN TBCO AND ID AS USER	0.00	0.00
M1284	Other professional services	PT 66+ SNP OR LTC POS > 90D	0.00	0.00
M1285	Other professional services	SCRN MAM PERF RSLTS NOT DOC	0.00	0.00
M1286	Other professional services	BMI DOC ONL FUP NOT CMPLTD	0.00	0.00
M1287	Other professional services	CALC BMI BLW LOW PARAM F/U	0.00	0.00
M1288	Other professional services	DOC RSN NO HBP SCRN OR F/U	0.00	0.00
M1289	Other professional services	NO PT TBCO CESS INTERV RNG	0.00	0.00
M1290	Other professional services	PT NOT ELI D/T ACT DIG HTN	0.00	0.00
M1291	Other professional services	PT 66+ FRAILTY AND MED DEM	0.00	0.00
M1292	Other professional services	PT 66+ FRAIL INPT ADV ILL	0.00	0.00
M1293	Other professional services	CALC BMI ABV UP PARAM F/U	0.00	0.00
M1294	Other professional services	BP SCRN PERF REC INTERVAL	0.00	0.00
M1295	Other professional services	PT HX TOT COL OR COLON CA	0.00	0.00
M1296	Other professional services	CALC BMI NORM PARAMETERS	0.00	0.00
M1297	Other professional services	BMI NOT DOC MEDRSN PTREF	0.00	0.00
M1298	Other professional services	DOC PT PREG DUR MSRMT PD	0.00	0.00
M1299	Other professional services	FLU IMMUNIZE ORDER/ADMIN	0.00	0.00
M1300	Other professional services	FLU IMM NO ADMIN DOC REA	0.00	0.00
M1301	Other professional services	PT RECV TBCO CESS INTERV	0.00	0.00
M1302	Other professional services	SCRN MAM PERF RSLTS DOC	0.00	0.00
M1303	Other professional services	HOSPC SERV DUR MEAS PD	0.00	0.00
M1304	Other professional services	NO PNEUM VAX ADMIN 19+	0.00	0.00
M1305	Other professional services	PNEUM VAX ADMIN 19+	0.00	0.00
M1306	Other professional services	PT ANPHX DUE TO PNEUM	0.00	0.00
M1307	Other professional services	DOC PT PAL OR HOSPICE	0.00	0.00
M1308	Other professional services	FLU IMMUNIZE NO ADMIN	0.00	0.00
M1309	Other professional services	PALL SERV DURING MEAS	0.00	0.00
M1310	Other professional services	PT SCR TOB & CESS INT	0.00	0.00
M1311	Other professional services	APHLX TO VAX BEF ENC	0.00	0.00
M1312	Other professional services	NO PT TBCO SCRN RNG	0.00	0.00
M1313	Other professional services	NO TOB SCR/CESS INT	0.00	0.00
M1314	Other professional services	BMI NOT CALCULATED	0.00	0.00
M1315	Other professional services	CRC NO DOC NO RSN	0.00	0.00
M1316	Other professional services	TOBACCO NON-USER	0.00	0.00
M1317	Other professional services	PTS COUNSL CPT OPT OUT	0.00	0.00
M1318	Other professional services	PTS NO CSP DOC CONTACT	0.00	0.00
M1319	Other professional services	PTS CSP DOC CONTACT	0.00	0.00
M1320	Other professional services	PTS SCRN + HRSN	0.00	0.00
M1321	Other professional services	PTS NO 7WK INJ,NO IOP,IOP>25	0.00	0.00
M1322	Other professional services	PTS 7WK INJ, SCRN IOP =<25	0.00	0.00
M1323	Other professional services	PTS 7WK INJ, SCRN IOP >25	0.00	0.00
M1324	Other professional services	PTS INTRAVITREAL/PCI	0.00	0.00
M1325	Other professional services	DOC MED RSN NOT SEEN	0.00	0.00
M1326	Other professional services	PTS DX HYPOTONY	0.00	0.00
M1327	Other professional services	PTS NO EVAL INI XM NO 8 WKS	0.00	0.00
M1328	Other professional services	PTS DX ACUTE VITREOUS HEM	0.00	0.00
M1329	Other professional services	PTS ACT PVD 2 WKS 8 WKS	0.00	0.00
M1330	Other professional services	DOC PTS RSN NO F/U XM	0.00	0.00
M1331	Other professional services	PTS EVAL INI XM 8 WKS	0.00	0.00
M1332	Other professional services	PTS NO EVAL INI XM NO 2 WKS	0.00	0.00
M1333	Other professional services	ACUTE VITREOUS HEMORRHAGE	0.00	0.00
M1334	Other professional services	PTS ACT PVD 2 WKS 2 WKS	0.00	0.00
M1335	Other professional services	DOC PTS RSN NO F/U XM	0.00	0.00
M1336	Other professional services	PTS EVAL INI XM 2 WKS	0.00	0.00
M1337	Other professional services	ACUTE PVD	0.00	0.00
M1338	Other professional services	PT F/U 30-180 DYS NO + IMPRV	0.00	0.00
M1339	Other professional services	PTS F/U 30-180 DYS + IMPROV	0.00	0.00
M1340	Other professional services	INDX WHODAS 2.0 OR SDS	0.00	0.00
M1341	Other professional services	PT NO F/U 30-180 DYS	0.00	0.00
M1342	Other professional services	PTS DIED PERF PER	0.00	0.00
M1343	Other professional services	PT PAM LVL 4 BASE OR SRT LIN	0.00	0.00
M1344	Other professional services	PTS NO BSLN OR 2ND PAM SCORE	0.00	0.00
M1345	Other professional services	PT BSLN PAM, 2ND SCR 6-12 MO	0.00	0.00
M1346	Other professional services	PTS NO PAM 6 PTS 6-12 MO	0.00	0.00
M1347	Other professional services	PT PAM INCR 3 PT 6-12 MO	0.00	0.00
M1348	Other professional services	PT PAM INCR 6 PT 6-12 MO	0.00	0.00
M1349	Other professional services	PT NO PAM 3 PTS 6-12 MO	0.00	0.00
M1350	Other professional services	PT W/ SUIC SAF PLN INIT REV	0.00	0.00
M1351	Other professional services	PT CMPLT SUICD SAF PLN 120DY	0.00	0.00
M1352	Other professional services	SUICD C-SSRS ASSESSMENT, EQU	0.00	0.00
M1353	Other professional services	PTS NO CMPLT SUICD SAF PLN	0.00	0.00
M1354	Other professional services	PT NO SUICD SAF PLN 120DY	0.00	0.00
M1355	Other professional services	SUICD BASED CLN EVAL	0.00	0.00
M1356	Other professional services	PT DIED DUR MEAS PD	0.00	0.00
M1357	Other professional services	PT W/RED SUIC IDEA 120 DAYS	0.00	0.00
M1358	Other professional services	PTS NO	0.00	0.00
M1359	Other professional services	INDX SUICD IDEA, NO 0 SCR	0.00	0.00
M1360	Other professional services	SUICD C-SSRS ASSESSMENT	0.00	0.00
M1361	Other professional services	SUICD BASED CLN EVAL	0.00	0.00
M1362	Other professional services	PT DIED DUR MEAS PD	0.00	0.00
M1363	Other professional services	PTS NO F/U 120 DYS	0.00	0.00
M1364	Other professional services	ASCVD RISK >=20PCT	0.00	0.00
M1365	Other professional services	HOSP+PALL CARE SPEC CODE 17	0.00	0.00
M1366	Other professional services	FOCUS ON WOMEN'S HEALTH MVP	0.00	0.00
M1367	Other professional services	QUAL CARE ENT DISORDER MVP	0.00	0.00
M1368	Other professional services	PREV TRT INF D/O HIV/HEP MVP	0.00	0.00
M1369	Other professional services	QUALCARE MENTAL HLTH/SUD MVP	0.00	0.00
M1370	Other professional services	REHAB SUPPORT MSK CARE MVP	0.00	0.00
P2028	Clinical Laboratory	CEPHALIN FLOCULATION TEST	7.43	7.43
P2029	Clinical Laboratory	CONGO RED BLOOD TEST	7.43	7.43
P2031	Clinical Laboratory	HAIR ANALYSIS	7.43	7.43
P2033	Clinical Laboratory	BLOOD THYMOL TURBIDITY	7.43	7.43
P2038	Clinical Laboratory	BLOOD MUCOPROTEIN	7.43	7.43
P3000	Clinical Laboratory	SCREEN PAP BY TECH W MD SUPV	26.64	26.64
P3001	Clinical Laboratory	SCREENING PAP SMEAR BY PHYS	33.57	33.57
P7001	Clinical Laboratory	CULTURE BACTERIAL URINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9010	Clinical Laboratory	WHOLE BLOOD FOR TRANSFUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9011	Clinical Laboratory	BLOOD SPLIT UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9012	Clinical Laboratory	CRYOPRECIPITATE EACH UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9016	Clinical Laboratory	RBC LEUKOCYTES REDUCED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9017	Clinical Laboratory	PLASMA 1 DONOR FRZ W/IN 8 HR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9019	Clinical Laboratory	PLATELETS, EACH UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9020	Clinical Laboratory	PLAELET RICH PLASMA UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9021	Clinical Laboratory	RED BLOOD CELLS UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9022	Clinical Laboratory	WASHED RED BLOOD CELLS UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9023	Clinical Laboratory	FROZEN PLASMA, POOLED, SD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9025	Clinical Laboratory	PLASMA CRYO REDU PATH EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9026	Clinical Laboratory	CRYO FIB COMP PATH REDU EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9031	Clinical Laboratory	PLATELETS LEUKOCYTES REDUCED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9032	Clinical Laboratory	PLATELETS, IRRADIATED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9033	Clinical Laboratory	PLATELETS LEUKOREDUCED IRRAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9034	Clinical Laboratory	PLATELETS, PHERESIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9035	Clinical Laboratory	PLATELET PHERES LEUKOREDUCED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9036	Clinical Laboratory	PLATELET PHERESIS IRRADIATED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9037	Clinical Laboratory	PLATE PHERES LEUKOREDU IRRAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9038	Clinical Laboratory	RBC IRRADIATED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9039	Clinical Laboratory	RBC DEGLYCEROLIZED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9040	Clinical Laboratory	RBC LEUKOREDUCED IRRADIATED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9041	Other professional services	ALBUMIN (HUMAN),5%, 50ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9043	Clinical Laboratory	PLASMA PROTEIN FRACT,5%,50ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9044	Clinical Laboratory	CRYOPRECIPITATEREDUCEDPLASMA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9045	Other professional services	ALBUMIN (HUMAN), 5%, 250 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9046	Other professional services	ALBUMIN (HUMAN), 25%, 20 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9047	Other professional services	ALBUMIN (HUMAN), 25%, 50ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9048	Clinical Laboratory	PLASMAPROTEIN FRACT,5%,250ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9050	Clinical Laboratory	GRANULOCYTES, PHERESIS UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9051	Clinical Laboratory	BLOOD, L/R, CMV-NEG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9052	Clinical Laboratory	PLATELETS, HLA-M, L/R, UNIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9053	Clinical Laboratory	PLT, PHER, L/R CMV-NEG, IRR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9054	Clinical Laboratory	BLOOD, L/R, FROZ/DEGLY/WASH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9055	Clinical Laboratory	PLT, APH/PHER, L/R, CMV-NEG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9056	Clinical Laboratory	BLOOD, L/R, IRRADIATED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9057	Clinical Laboratory	RBC, FRZ/DEG/WSH, L/R, IRRAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9058	Clinical Laboratory	RBC, L/R, CMV-NEG, IRRAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9059	Clinical Laboratory	PLASMA, FRZ BETWEEN 8-24HOUR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9060	Clinical Laboratory	FR FRZ PLASMA DONOR RETESTED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9070	Other professional services	PATHOGEN REDUCED PLASMA POOL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9071	Other professional services	PATHOGEN REDUCED PLASMA SING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9073	Other professional services	PLATELETS PHERESIS PATH REDU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9099	Other professional services	BLOOD COMPONENT/PRODUCT NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9100	Other professional services	PATHOGEN TEST FOR PLATELETS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9603	Clinical Laboratory	ONE-WAY ALLOW PRORATED MILES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9604	Clinical Laboratory	ONE-WAY ALLOW PRORATED TRIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
P9612	Clinical Laboratory	CATHETERIZE FOR URINE SPEC	13.25	13.25
P9615	Clinical Laboratory	URINE SPECIMEN COLLECT MULT	13.25	13.25
Q0035	Other professional services	CARDIOKYMOGRAPHY	24.47	24.47
Q0035-26	Other professional services	CARDIOKYMOGRAPHY	11.40	11.40
Q0035-TC	Other professional services	CARDIOKYMOGRAPHY	13.07	13.07
Q0081	Other professional services	INFUSION THER OTHER THAN CHE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0083	Other professional services	CHEMO BY OTHER THAN INFUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0084	Other professional services	CHEMOTHERAPY BY INFUSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0085	Other professional services	CHEMO BY BOTH INFUSION AND O	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0091	Other professional services	OBTAINING SCREEN PAP SMEAR	61.58	25.65
Q0092	Other professional services	SET UP PORT XRAY EQUIPMENT	35.36	35.36
Q0111	Clinical Laboratory	WET MOUNTS/ W PREPARATIONS	26.64	26.64
Q0112	Clinical Laboratory	POTASSIUM HYDROXIDE PREPS	8.75	8.75
Q0113	Clinical Laboratory	PINWORM EXAMINATIONS	6.41	6.41
Q0114	Clinical Laboratory	FERN TEST	14.61	14.61
Q0115	Clinical Laboratory	POST-COITAL MUCOUS EXAM	37.50	37.50
Q0138	Other professional services	FERUMOXYTOL, NON-ESRD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0139	Other professional services	FERUMOXYTOL, ESRD USE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0144	Other professional services	AZITHROMYCIN DIHYDRATE, ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0161	Other professional services	CHLORPROMAZINE HCL 5MG ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0162	Other professional services	ONDANSETRON ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0163	Other professional services	DIPHENHYDRAMINE HCL 50MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0164	Other professional services	PROCHLORPERAZINE MALEATE 5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0166	Other professional services	GRANISETRON HCL 1 MG ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0167	Other professional services	DRONABINOL 2.5MG ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0169	Other professional services	PROMETHAZINE HCL 12.5MG ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0173	Other professional services	TRIMETHOBENZAMIDE HCL 250MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0174	Other professional services	THIETHYLPERAZINE MALEATE10MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0175	Other professional services	PERPHENAZINE 4MG ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0177	Other professional services	HYDROXYZINE PAMOATE 25MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0180	Other professional services	DOLASETRON MESYLATE ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0181	Other professional services	UNSPECIFIED ORAL ANTI-EMETIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0220	DMEPOS	TIXAGEV AND CILGAV, 300MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0221	Other professional services	TIXAGEV AND CILGAV, 600MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0222	Other professional services	BEBTELOVIMAB 175 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0240	Other professional services	CASIRIVI AND IMDEVI 600 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0243	DMEPOS	CASIRIVIMAB AND IMDEVIMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0244	Other professional services	CASIRIVI AND IMDEVI 1200 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0245	Other professional services	BAMLANIVIMAB AND ETESEVIMA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0247	Other professional services	SOTROVIMAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0249	Other professional services	TOCILIZUMAB FOR COVID-19	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0477	DMEPOS	PWR MODULE PT CABLE LVAD RPL	919.64	919.64
Q0478	DMEPOS	POWER ADAPTER, COMBO VAD	217.81	217.81
Q0479	DMEPOS	POWER MODULE COMBO VAD, REP	14203.28	14203.28
Q0480	DMEPOS	DRIVER PNEUMATIC VAD, REP	99999.92	99999.92
Q0481	DMEPOS	MICROPRCSR CU ELEC VAD, REP	17223.57	17223.57
Q0482	DMEPOS	MICROPRCSR CU COMBO VAD, REP	5394.76	5394.76
Q0483	DMEPOS	MONITOR ELEC VAD, REP	22223.88	22223.88
Q0484	DMEPOS	MONITOR ELEC OR COMB VAD REP	4315.82	4315.82
Q0485	DMEPOS	MONITOR CABLE ELEC VAD, REP	416.68	416.68
Q0486	DMEPOS	MON CABLE ELEC/PNEUM VAD REP	346.79	346.79
Q0487	DMEPOS	LEADS ANY TYPE VAD, REP ONLY	404.60	404.60
Q0488	Other professional services	PWR PACK BASE ELEC VAD, REP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0489	DMEPOS	PWR PCK BASE COMBO VAD, REP	19266.89	19266.89
Q0490	DMEPOS	EMR PWR SOURCE ELEC VAD, REP	833.40	833.40
Q0491	DMEPOS	EMR PWR SOURCE COMBO VAD REP	1310.16	1310.16
Q0492	DMEPOS	EMR PWR CBL ELEC VAD, REP	105.59	105.59
Q0493	DMEPOS	EMR PWR CBL COMBO VAD, REP	300.49	300.49
Q0494	DMEPOS	EMR HD PMP ELEC/COMBO, REP	254.29	254.29
Q0495	DMEPOS	CHARGER ELEC/COMBO VAD, REP	4951.15	4951.15
Q0496	DMEPOS	BATTERY ELEC/COMBO VAD, REP	1777.06	1777.06
Q0497	DMEPOS	BAT CLPS ELEC/COMB VAD, REP	554.86	554.86
Q0498	DMEPOS	HOLSTER ELEC/COMBO VAD, REP	608.82	608.82
Q0499	DMEPOS	BELT/VEST ELEC/COMBO VAD REP	197.82	197.82
Q0500	DMEPOS	FILTERS ELEC/COMBO VAD, REP	36.19	36.19
Q0501	DMEPOS	SHWR COV ELEC/COMBO VAD, REP	605.32	605.32
Q0502	DMEPOS	MOBILITY CART PNEUM VAD, REP	770.65	770.65
Q0503	DMEPOS	BATTERY PNEUM VAD REPLACEMNT	1541.33	1541.33
Q0504	DMEPOS	PWR ADPT PNEUM VAD, REP VEH	813.30	813.30
Q0506	DMEPOS	LITH-ION BATT ELEC/PNEUM VAD	1012.41	1012.41
Q0507	Other professional services	MISC SUP/ACC EXT VAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0508	Other professional services	MIS SUP/ACC IMP VAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0509	Other professional services	MIS SUP/AC IMP VAD NOPAY MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0510	Other professional services	DISPENS FEE IMMUNOSUPRESSIVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0511	Other professional services	SUP FEE ANTIEM,ANTICA,IMMUNO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0512	Other professional services	PX SUP FEE ANTI-CAN SUB PRES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0513	Other professional services	DISP FEE INHAL DRUGS/30 DAYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0514	Other professional services	DISP FEE INHAL DRUGS/90 DAYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0515	Other professional services	SERMORELIN ACETATE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0516	Other professional services	SUPPLY FEE HIV PREP 30-DAYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0517	Other professional services	SUPPLY FEE HIV PREP 60-DAYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q0518	Other professional services	SUPPLY FEE HIV PREP 90-DAYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q1004	Other professional services	NTIOL CATEGORY 4	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q1005	Other professional services	NTIOL CATEGORY 5	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2004	Other professional services	BLADDER CALCULI IRRIG SOL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2009	Other professional services	FOSPHENYTOIN INJ PE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2017	Other professional services	TENIPOSIDE, 50 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2026	Other professional services	RADIESSE INJECTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2028	Other professional services	INJ, SCULPTRA, 0.5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2034	Other professional services	AGRIFLU VACCINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2035	Other professional services	AFLURIA VACC, 3 YRS & >, IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2036	Other professional services	FLULAVAL VACC, 3 YRS & >, IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2037	Other professional services	FLUVIRIN VACC, 3 YRS & >, IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2038	Other professional services	FLUZONE VACC, 3 YRS & >, IM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2039	Other professional services	INFLUENZA VIRUS VACCINE, NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2041	Other professional services	AXICABTAGENE CILOLEUCEL CAR+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2042	Other professional services	TISAGENLECLEUCEL CAR-POS T	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2043	Other professional services	SIPULEUCEL-T AUTO CD54+	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2049	Other professional services	IMPORTED LIPODOX INJ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2050	Other professional services	DOXORUBICIN INJ 10MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2052	Other professional services	HOME IVIG, SERVICES/SUPPLIES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2053	Other professional services	BREXUCABTAGENE CAR POS T	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2054	Other professional services	LISOCABTAGENE MARA CAR POS T	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2055	Other professional services	IDECABTAGENE VICLEUCEL CAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q2056	Other professional services	CILTACABTAGENE CAR-POS T	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q3001	Other professional services	BRACHYTHERAPY RADIOELEMENTS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q3014	Other professional services	TELEHEALTH FACILITY FEE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q3027	Other professional services	INJ BETA INTERFERON IM 1 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q3028	Other professional services	INJ BETA INTERFERON SQ 1 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q3031	Other professional services	COLLAGEN SKIN TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4001	DMEPOS	CAST SUP BODY CAST PLASTER	59.71	59.71
Q4002	DMEPOS	CAST SUP BODY CAST FIBERGLAS	225.61	225.61
Q4003	DMEPOS	CAST SUP SHOULDER CAST PLSTR	42.87	42.87
Q4004	DMEPOS	CAST SUP SHOULDER CAST FBRGL	148.43	148.43
Q4005	DMEPOS	CAST SUP LONG ARM ADULT PLST	15.81	15.81
Q4006	DMEPOS	CAST SUP LONG ARM ADULT FBRG	35.62	35.62
Q4007	DMEPOS	CAST SUP LONG ARM PED PLSTER	7.90	7.90
Q4008	DMEPOS	CAST SUP LONG ARM PED FBRGLS	17.80	17.80
Q4009	DMEPOS	CAST SUP SHT ARM ADULT PLSTR	10.56	10.56
Q4010	DMEPOS	CAST SUP SHT ARM ADULT FBRGL	23.74	23.74
Q4011	DMEPOS	CAST SUP SHT ARM PED PLASTER	5.26	5.26
Q4012	DMEPOS	CAST SUP SHT ARM PED FBRGLAS	11.90	11.90
Q4013	DMEPOS	CAST SUP GAUNTLET PLASTER	19.22	19.22
Q4014	DMEPOS	CAST SUP GAUNTLET FIBERGLASS	32.40	32.40
Q4015	DMEPOS	CAST SUP GAUNTLET PED PLSTER	9.62	9.62
Q4016	DMEPOS	CAST SUP GAUNTLET PED FBRGLS	16.19	16.19
Q4017	DMEPOS	CAST SUP LNG ARM SPLINT PLST	11.10	11.10
Q4018	DMEPOS	CAST SUP LNG ARM SPLINT FBRG	17.70	17.70
Q4019	DMEPOS	CAST SUP LNG ARM SPLNT PED P	5.56	5.56
Q4020	DMEPOS	CAST SUP LNG ARM SPLNT PED F	8.89	8.89
Q4021	DMEPOS	CAST SUP SHT ARM SPLINT PLST	8.22	8.22
Q4022	DMEPOS	CAST SUP SHT ARM SPLINT FBRG	14.84	14.84
Q4023	DMEPOS	CAST SUP SHT ARM SPLNT PED P	4.13	4.13
Q4024	DMEPOS	CAST SUP SHT ARM SPLNT PED F	7.43	7.43
Q4025	DMEPOS	CAST SUP HIP SPICA PLASTER	46.07	46.07
Q4026	DMEPOS	CAST SUP HIP SPICA FIBERGLAS	143.92	143.92
Q4027	DMEPOS	CAST SUP HIP SPICA PED PLSTR	23.06	23.06
Q4028	DMEPOS	CAST SUP HIP SPICA PED FBRGL	72.00	72.00
Q4029	DMEPOS	CAST SUP LONG LEG PLASTER	35.25	35.25
Q4030	DMEPOS	CAST SUP LONG LEG FIBERGLASS	92.79	92.79
Q4031	DMEPOS	CAST SUP LNG LEG PED PLASTER	17.61	17.61
Q4032	DMEPOS	CAST SUP LNG LEG PED FBRGLS	46.40	46.40
Q4033	DMEPOS	CAST SUP LNG LEG CYLINDER PL	32.89	32.89
Q4034	DMEPOS	CAST SUP LNG LEG CYLINDER FB	81.76	81.76
Q4035	DMEPOS	CAST SUP LNGLEG CYLNDR PED P	16.44	16.44
Q4036	DMEPOS	CAST SUP LNGLEG CYLNDR PED F	40.91	40.91
Q4037	DMEPOS	CAST SUP SHRT LEG PLASTER	20.03	20.03
Q4038	DMEPOS	CAST SUP SHRT LEG FIBERGLASS	50.24	50.24
Q4039	DMEPOS	CAST SUP SHRT LEG PED PLSTER	10.05	10.05
Q4040	DMEPOS	CAST SUP SHRT LEG PED FBRGLS	25.12	25.12
Q4041	DMEPOS	CAST SUP LNG LEG SPLNT PLSTR	24.39	24.39
Q4042	DMEPOS	CAST SUP LNG LEG SPLNT FBRGL	41.64	41.64
Q4043	DMEPOS	CAST SUP LNG LEG SPLNT PED P	12.20	12.20
Q4044	DMEPOS	CAST SUP LNG LEG SPLNT PED F	20.85	20.85
Q4045	DMEPOS	CAST SUP SHT LEG SPLNT PLSTR	14.16	14.16
Q4046	DMEPOS	CAST SUP SHT LEG SPLNT FBRGL	22.77	22.77
Q4047	DMEPOS	CAST SUP SHT LEG SPLNT PED P	7.05	7.05
Q4048	DMEPOS	CAST SUP SHT LEG SPLNT PED F	11.40	11.40
Q4049	DMEPOS	FINGER SPLINT, STATIC	2.57	2.57
Q4050	Other professional services	CAST SUPPLIES UNLISTED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4051	Other professional services	SPLINT SUPPLIES MISC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4074	Other professional services	ILOPROST NON-COMP UNIT DOSE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4081	Other professional services	EPOETIN ALFA, 100 UNITS ESRD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4082	Other professional services	DRUG/BIO NOC PART B DRUG CAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4100	Other professional services	SKIN SUBSTITUTE, NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4101	Other professional services	APLIGRAF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4102	Other professional services	OASIS WOUND MATRIX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4103	Other professional services	OASIS BURN MATRIX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4104	Other professional services	INTEGRA BMWD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4105	Other professional services	INTEGRA DRT OR OMNIGRAFT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4106	Other professional services	DERMAGRAFT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4107	Other professional services	GRAFTJACKET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4108	Other professional services	INTEGRA MATRIX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4110	Other professional services	PRIMATRIX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4111	Other professional services	GAMMAGRAFT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4112	Other professional services	CYMETRA INJECTABLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4113	Other professional services	GRAFTJACKET XPRESS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4114	Other professional services	INTEGRA FLOWABLE WOUND MATRI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4115	Other professional services	ALLOSKIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4116	Other professional services	ALLODERM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4117	Other professional services	HYALOMATRIX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4118	Other professional services	MATRISTEM MICROMATRIX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4121	Other professional services	THERASKIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4122	Other professional services	DERMACELL, AWM, POROUS SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4123	Other professional services	ALLOSKIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4124	Other professional services	OASIS TRI-LAYER WOUND MATRIX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4125	Other professional services	ARTHROFLEX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4126	Other professional services	MEMODERM/DERMA/TRANZ/INTEGUP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4127	Other professional services	TALYMED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4128	Other professional services	FLEXHD/ALLOPATCHHD/SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4130	Other professional services	STRATTICE TM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4132	Other professional services	GRAFIX CORE, GRAFIXPL CORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4133	Other professional services	GRAFIX STRAVIX PRIME PL SQCM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4134	Other professional services	HMATRIX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4135	Other professional services	MEDISKIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4136	Other professional services	EZDERM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4137	Other professional services	AMNIOEXCEL BIODEXCEL 1SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4138	Other professional services	BIODFENCE DRYFLEX, 1CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4139	Other professional services	AMNIO OR BIODMATRIX, INJ 1CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4140	Other professional services	BIODFENCE 1CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4141	Other professional services	ALLOSKIN AC, 1 CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4142	Other professional services	XCM BIOLOGIC TISS MATRIX 1CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4143	Other professional services	REPRIZA, 1CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4145	Other professional services	EPIFIX, INJ, 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4146	Other professional services	TENSIX, 1CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4147	Other professional services	ARCHITECT ECM PX FX 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4148	Other professional services	NEOX NEOX RT OR CLARIX CORD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4149	Other professional services	EXCELLAGEN, 0.1 CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4150	Other professional services	ALLOWRAP DS OR DRY 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4151	Other professional services	AMNIOBAND, GUARDIAN 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4152	Other professional services	DERMAPURE 1 SQUARE CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4153	Other professional services	DERMAVEST, PLURIVEST SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4154	Other professional services	BIOVANCE 1 SQUARE CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4155	Other professional services	NEOXFLO OR CLARIXFLO 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4156	Other professional services	NEOX 100 OR CLARIX 100	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4157	Other professional services	REVITALON 1 SQUARE CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4158	Other professional services	KERECIS OMEGA3, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4159	Other professional services	AFFINITY1 SQUARE CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4160	Other professional services	NUSHIELD 1 SQUARE CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4161	Other professional services	BIO-CONNEKT PER SQUARE CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4162	Other professional services	WNDEX FLW, BIOSKN FLW, 0.5CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4163	Other professional services	WOUNDEX, BIOSKIN, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4164	Other professional services	HELICOLL, PER SQUARE CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4165	Other professional services	KERAMATRIX, KERASORB SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4166	Other professional services	CYTAL, PER SQUARE CENTIMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4167	Other professional services	TRUSKIN, PER SQ CENTIMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4168	Other professional services	AMNIOBAND, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4169	Other professional services	ARTACENT WOUND, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4170	Other professional services	CYGNUS, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4171	Other professional services	INTERFYL, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4173	Other professional services	PALINGEN OR PALINGEN XPLUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4174	Other professional services	PALINGEN OR PROMATRX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4175	Other professional services	MIRODERM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4176	Other professional services	NEOPATCH, PER SQ CENTIMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4177	Other professional services	FLOWERAMNIOFLO, 0.1 CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4178	Other professional services	FLOWERAMNIOPATCH, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4179	Other professional services	FLOWERDERM, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4180	Other professional services	REVITA, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4181	Other professional services	AMNIO WOUND, PER SQUARE CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4182	Other professional services	TRANSCYTE, PER SQ CENTIMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4183	Other professional services	SURGIGRAFT, 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4184	Other professional services	CELLESTA OR DUO PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4185	Other professional services	CELLESTA FLOWAB AMNION 0.5CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4186	Other professional services	EPIFIX 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4187	Other professional services	EPICORD 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4188	Other professional services	AMNIOARMOR 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4189	Other professional services	ARTACENT AC, 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4190	Other professional services	ARTACENT AC 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4191	Other professional services	RESTORIGIN 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4192	Other professional services	RESTORIGIN, 1 CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4193	Other professional services	COLL-E-DERM 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4194	Other professional services	NOVACHOR 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4195	Other professional services	PURAPLY 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4196	Other professional services	PURAPLY AM 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4197	Other professional services	PURAPLY XT 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4198	Other professional services	GENESIS AMNIO MEMBRANE 1SQCM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4199	Other professional services	CYGNUS MATRIX, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4200	Other professional services	SKIN TE 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4201	Other professional services	MATRION 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4202	Other professional services	KEROXX (2.5G/CC), 1CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4203	Other professional services	DERMA-GIDE, 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4204	Other professional services	XWRAP 1 SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4205	Other professional services	MEMBRANE GRAFT OR WRAP SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4206	Other professional services	FLUID FLOW OR FLUID GF 1 CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4208	Other professional services	NOVAFIX PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4209	Other professional services	SURGRAFT PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4210	Other professional services	AXOLOTL GRAF DUALGRAF SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4211	Other professional services	AMNION BIO OR AXOBIO SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4212	Other professional services	ALLOGEN, PER CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4213	Other professional services	ASCENT, 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4214	Other professional services	CELLESTA CORD PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4215	Other professional services	AXOLOTL AMBIENT, CRYO 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4216	Other professional services	ARTACENT CORD PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4217	Other professional services	WOUNDFIX BIOWOUND PLUS XPLUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4218	Other professional services	SURGICORD PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4219	Other professional services	SURGIGRAFT DUAL PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4220	Other professional services	BELLACELL HD, SUREDERM SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4221	Other professional services	AMNIOWRAP2 PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4222	Other professional services	PROGENAMATRIX, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4224	Other professional services	HHF10-P PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4225	Other professional services	AMNIO OR DERMA TL, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4226	Other professional services	MYOWN HARV PREP PROC SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4227	DMEPOS	AMNIOCORE PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4229	DMEPOS	COGENEX AMNIO MEMB PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4230	DMEPOS	COGENEX FLOW AMNION 0.5 CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4231	DMEPOS	CORPLEX P, PER CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4232	DMEPOS	CORPLEX, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4233	DMEPOS	SURFACTOR /NUDYN PER 0.5 CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4234	DMEPOS	XCELLERATE, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4235	DMEPOS	AMNIOREPAIR OR ALTIPLY SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4236	DMEPOS	CAREPATCH PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4237	DMEPOS	CRYO-CORD, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4238	DMEPOS	DERM-MAXX, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4239	DMEPOS	AMNIO-MAXX OR LITE PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4240	DMEPOS	CORECYTE TOPICAL ONLY 0.5 CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4241	DMEPOS	POLYCYTE, TOPICAL ONLY 0.5CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4242	DMEPOS	AMNIOCYTE PLUS, PER 0.5 CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4244	DMEPOS	PROCENTA, PER 200 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4245	DMEPOS	AMNIOTEXT, PER CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4246	DMEPOS	CORETEXT OR PROTEXT, PER CC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4247	DMEPOS	AMNIOTEXT PATCH, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4248	DMEPOS	DERMACYTE AMN MEM ALLO SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4249	DMEPOS	AMNIPLY, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4250	DMEPOS	AMNIOAMP-MP PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4251	Other professional services	VIM, PER SQUARE CENTIMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4252	Other professional services	VENDAJE, PER SQUARE CENTIMET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4253	Other professional services	ZENITH AMNIOTIC MEMBRANE PSC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4254	DMEPOS	NOVAFIX DL PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4255	DMEPOS	REGUARD, TOPICAL USE PER SQ	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4256	Other professional services	MLG COMPLET, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4257	Other professional services	RELESE, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4258	Other professional services	ENVERSE, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4259	Other professional services	CELERA PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4260	Other professional services	SIGNATURE APATCH, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4261	Other professional services	TAG, PER SQUARE CENTIMETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4262	Other professional services	DUAL LAYER IMPAX, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4263	Other professional services	SURGRAFT TL, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4264	Other professional services	COCOON MEMBRANE, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4265	DMEPOS	NEOSTIM TL PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4266	DMEPOS	NEOSTIM PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4267	DMEPOS	NEOSTIM DL PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4268	DMEPOS	SURGRAFT FT PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4269	DMEPOS	SURGRAFT XT PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4270	DMEPOS	COMPLETE SL PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4271	DMEPOS	COMPLETE FT PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4272	DMEPOS	ESANO A, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4273	DMEPOS	ESANO AAA, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4274	DMEPOS	ESANO AC, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4275	DMEPOS	ESANO ACA, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4276	DMEPOS	ORION, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4277	DMEPOS	WOUNDPLUS E-GRAT, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4278	DMEPOS	EPIEFFECT, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4279	DMEPOS	VENDAJE AC, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4280	DMEPOS	XCELL AMNIO MATRIX PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4281	DMEPOS	BARRERA SLOR DL PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4282	DMEPOS	CYGNUS DUAL PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4283	DMEPOS	BIOVANCE TRI OR 3L, SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4284	DMEPOS	DERMABIND SL, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4285	DMEPOS	NUDYN DL OR DL MESH PR SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4286	DMEPOS	NUDYN SL OR SLW, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4287	DMEPOS	DERMABIND DL, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4288	DMEPOS	DERMABIND CH, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4289	DMEPOS	REVOSHIELD+ AMNIO, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4290	DMEPOS	MEMBRANE WRAP HYDR PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4291	DMEPOS	LAMELLAS XT, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4292	DMEPOS	LAMELLAS, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4293	DMEPOS	ACESSO DL, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4294	DMEPOS	AMNIO QUAD-CORE, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4295	DMEPOS	AMNIO TRI-CORE, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4296	DMEPOS	REBOUND MATRIX, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4297	DMEPOS	EMERGE MATRIX, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4298	DMEPOS	AMNICORE PRO, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4299	DMEPOS	AMNICORE PRO+, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4300	DMEPOS	ACESSO TL, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4301	DMEPOS	ACTIVATE MATRIX, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4302	DMEPOS	COMPLETE ACA, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4303	DMEPOS	COMPLETE AA, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q4304	DMEPOS	GRAFIX PLUS, PER SQ CM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5001	Other professional services	HOSPICE OR HOME HLTH IN HOME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5002	Other professional services	HOSPICE/HOME HLTH IN ASST LV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5003	Other professional services	HOSPICE IN LT/NON-SKILLED NF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5004	Other professional services	HOSPICE IN SNF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5005	Other professional services	HOSPICE, INPATIENT HOSPITAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5006	Other professional services	HOSPICE IN HOSPICE FACILITY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5007	Other professional services	HOSPICE IN LTCH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5008	Other professional services	HOSPICE IN INPATIENT PSYCH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5009	Other professional services	HOSPICE/HOME HLTH, PLACE NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5010	Other professional services	HOSPICE HOME CARE IN HOSPICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5101	Other professional services	INJECTION, ZARXIO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5103	Other professional services	INJECTION, INFLECTRA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5104	Other professional services	INJECTION, RENFLEXIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5105	Other professional services	INJ RETACRIT ESRD ON DIALYSI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5106	Other professional services	INJ RETACRIT NON-ESRD USE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5107	Other professional services	INJ MVASI 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5108	Other professional services	INJECTION, FULPHILA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5109	Other professional services	INJECTION, IXIFI, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5110	Other professional services	NIVESTYM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5111	Other professional services	INJECTION, UDENYCA 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5112	Other professional services	INJ ONTRUZANT 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5113	Other professional services	INJ HERZUMA 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5114	Other professional services	INJ OGIVRI 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5115	Other professional services	INJ TRUXIMA 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5116	Other professional services	INJ., TRAZIMERA, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5117	Other professional services	INJ., KANJINTI, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5118	Other professional services	INJ., ZIRABEV, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5119	Other professional services	INJ RUXIENCE, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5120	Other professional services	INJ PEGFILGRASTIM-BMEZ 0.5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5121	Other professional services	INJ. AVSOLA, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5122	Other professional services	INJ, NYVEPRIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5123	Other professional services	INJ. RIABNI, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5124	Other professional services	INJ. BYOOVIZ, 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5125	Other professional services	INJ, RELEUKO 1 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5126	Other professional services	INJ ALYMSYS 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5127	DMEPOS	INJ, STIMUFEND, 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5128	DMEPOS	INJ, CIMERLI, 0.1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5129	DMEPOS	INJ, VEGZELMA, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5130	DMEPOS	INJ, FYLNETRA, 0.5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5131	DMEPOS	INJ, IDACIO, 20 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q5132	DMEPOS	INJ, ABRILADA, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9001	Other professional services	CHAPLAIN ASSESSMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9002	Other professional services	CHAPLAIN COUNSEL INDIVIDU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9003	Other professional services	CHAPLAIN COUNSEL GROUP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9004	Other professional services	VA WHOLE HEALTH PARTNER SERV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9950	Other professional services	INJ SULF HEXA LIPID MICROSPH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9951	Other professional services	LOCM >= 400 MG/ML IODINE,1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9953	Other professional services	INJ FE-BASED MR CONTRAST,1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9954	Other professional services	ORAL MR CONTRAST, 100 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9955	Other professional services	INJ PERFLEXANE LIP MICROS,ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9956	Other professional services	INJ OCTAFLUOROPROPANE MIC,ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9957	Other professional services	INJ PERFLUTREN LIP MICROS,ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9958	Other professional services	HOCM <=149 MG/ML IODINE, 1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9959	Other professional services	HOCM 150-199MG/ML IODINE,1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9960	Other professional services	HOCM 200-249MG/ML IODINE,1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9961	Other professional services	HOCM 250-299MG/ML IODINE,1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9962	Other professional services	HOCM 300-349MG/ML IODINE,1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9963	Other professional services	HOCM 350-399MG/ML IODINE,1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9964	Other professional services	HOCM>= 400MG/ML IODINE, 1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9965	Other professional services	LOCM 100-199MG/ML IODINE,1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9966	Other professional services	LOCM 200-299MG/ML IODINE,1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9967	Other professional services	LOCM 300-399MG/ML IODINE,1ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9968	Other professional services	VISUALIZATION ADJUNCT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9969	Other professional services	NON-HEU TC-99M ADD-ON/DOSE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9982	Other professional services	FLUTEMETAMOL F18 DIAGNOSTIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9983	Other professional services	FLORBETABEN F18 DIAGNOSTIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9991	Other professional services	BUPRENORPH XR 100 MG OR LESS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
Q9992	Other professional services	BUPRENORPHINE XR OVER 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
R0070	Other professional services	TRANSPORT PORTABLE X-RAY	305.85	305.85
R0075	Other professional services	TRANSPORT PORT X-RAY MULTIPL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
R0076	Other professional services	TRANSPORT PORTABLE EKG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0012	Other professional services	BUTORPHANOL TARTRATE, NASAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0013	DMEPOS	ESKETAMINE, NASAL SPRAY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0014	Other professional services	TACRINE HYDROCHLORIDE, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0017	Other professional services	INJECTION, AMINOCAPROIC ACID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0021	Other professional services	INJECTION, CEFOPERAZONE SOD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0023	Other professional services	INJECTION, CIMETIDINE HYDROC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0028	Other professional services	INJECTION, FAMOTIDINE, 20 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0032	Other professional services	INJECTION, NAFCILLIN SODIUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0034	Other professional services	INJECTION, OFLOXACIN, 400 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0039	Other professional services	INJECTION, SULFAMETHOXAZOLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0040	Other professional services	INJECTION, TICARCILLIN DISOD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0074	Other professional services	INJECTION, CEFOTETAN DISODIU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0078	Other professional services	INJECTION, FOSPHENYTOIN SODI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0080	Other professional services	INJECTION, PENTAMIDINE ISETH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0081	Other professional services	INJECTION, PIPERACILLIN SODI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0088	Other professional services	IMATINIB 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0090	Other professional services	SILDENAFIL CITRATE, 25 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0091	Other professional services	GRANISETRON 1MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0092	Other professional services	HYDROMORPHONE 250 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0093	Other professional services	MORPHINE 500 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0104	Other professional services	ZIDOVUDINE, ORAL, 100 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0106	Other professional services	BUPROPION HCL SR 60 TABLETS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0108	Other professional services	MERCAPTOPURINE 50 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0109	Other professional services	METHADONE ORAL 5MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0117	Other professional services	TRETINOIN TOPICAL 5 G	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0119	Other professional services	ONDANSETRON 4 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0122	Other professional services	INJ MENOTROPINS 75 IU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0126	Other professional services	INJ FOLLITROPIN ALFA 75 IU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0128	Other professional services	INJ FOLLITROPIN BETA 75 IU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0132	Other professional services	INJ GANIRELIX ACETAT 250 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0136	Other professional services	CLOZAPINE, 25 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0137	Other professional services	DIDANOSINE, 25 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0138	Other professional services	FINASTERIDE, 5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0139	Other professional services	MINOXIDIL, 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0140	Other professional services	SAQUINAVIR, 200 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0142	Other professional services	COLISTIMETHATE INH SOL MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0145	Other professional services	PEG INTERFERON ALFA-2A/180	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0148	Other professional services	PEG INTERFERON ALFA-2B/10	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0155	Other professional services	EPOPROSTENOL DILUTANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0156	Other professional services	EXEMESTANE, 25 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0157	Other professional services	BECAPLERMIN GEL 1%, 0.5 GM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0160	Other professional services	DEXTROAMPHETAMINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0164	Other professional services	INJECTION PANTROPRAZOLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0169	Other professional services	CALCITROL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0170	Other professional services	ANASTROZOLE 1 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0172	Other professional services	CHLORAMBUCIL 2 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0174	Other professional services	DOLASETRON 50 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0175	Other professional services	FLUTAMIDE 125 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0176	Other professional services	HYDROXYUREA 500 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0177	Other professional services	LEVAMISOLE 50 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0178	Other professional services	LOMUSTINE 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0179	Other professional services	MEGESTROL 20 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0182	Other professional services	PROCARBAZINE, ORAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0183	Other professional services	PROCHLORPERAZINE 5 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0187	Other professional services	TAMOXIFEN 10 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0189	Other professional services	TESTOSTERONE PELLET 75 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0190	Other professional services	MIFEPRISTONE, ORAL, 200 MG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0191	Other professional services	MISOPROSTOL, ORAL, 200 MCG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0194	Other professional services	VITAMIN SUPPL 100 CAPS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0197	Other professional services	PRENATAL VITAMINS 30 DAY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0199	Other professional services	MED ABORTION INC ALL EX DRUG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0201	Other professional services	PARTIAL HOSPITALIZATION SERV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0207	Other professional services	PARAMEDICINTERCEP NONHOSPALS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0208	Other professional services	PARAMED INTRCEPT NONVOL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0209	Other professional services	WC VAN MILEAGE PER MI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0215	Other professional services	NONEMERG TRANSP MILEAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0220	Other professional services	MEDICAL CONFERENCE BY PHYSIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0221	Other professional services	MEDICAL CONFERENCE, 60 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0250	Other professional services	COMP GERIATR ASSMT TEAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0255	Other professional services	HOSPICE REFER VISIT NONMD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0257	Other professional services	END OF LIFE COUNSELING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0260	Other professional services	H&P FOR SURGERY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0265	Other professional services	GENETIC COUNSEL 15 MINS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0270	Other professional services	HOME STD CASE RATE 30 DAYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0271	Other professional services	HOME HOSPICE CASE 30 DAYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0272	Other professional services	HOME EPISODIC CASE 30 DAYS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0273	Other professional services	MD HOME VISIT OUTSIDE CAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0274	Other professional services	NURSE PRACTR VISIT OUTS CAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0280	Other professional services	MEDICAL HOME, INITIAL PLAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0281	Other professional services	MEDICAL HOME, MAINTENANCE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0285	Other professional services	CNSLT BEFORE SCREEN COLONOSC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0302	Other professional services	COMPLETED EPSDT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0310	Other professional services	HOSPITALIST VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0311	Other professional services	COMP MGMT CARE COORD ADV ILL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0315	Other professional services	DISEASE MANAGEMENT PROGRAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0316	Other professional services	FOLLOW-UP/REASSESSMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0317	Other professional services	DISEASE MGMT PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0320	Other professional services	RN TELEPHONE CALLS TO DMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0340	Other professional services	LIFESTYLE MOD 1ST STAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0341	Other professional services	LIFESTYLE MOD 2 OR 3 STAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0342	Other professional services	LIFESTYLE MOD 4TH STAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0353	Other professional services	CANCER TREATMENTPLAN INITIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0354	Other professional services	CANCER TREATMENT PLAN CHANGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0390	Other professional services	ROUT FOOT CARE PER VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0395	Other professional services	IMPRESSION CASTING FT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0400	Other professional services	GLOBAL ESWL KIDNEY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0500	Other professional services	DISPOS CONT LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0504	Other professional services	SINGL PRSCRP LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0506	Other professional services	BIFOC PRSCP LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0508	Other professional services	TRIFOC PRSCRP LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0510	Other professional services	NON-PRSCRP LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0512	Other professional services	DAILY CONT LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0514	Other professional services	COLOR CONT LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0515	Other professional services	SCLERAL LENS LIQUID BANDAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0516	Other professional services	SAFETY FRAMES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0518	Other professional services	SUNGLASS FRAMES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0580	Other professional services	POLYCARB LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0581	Other professional services	NONSTND LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0590	Other professional services	MISC INTEGRAL LENS SERV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0592	Other professional services	COMP CONT LENS EVAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0595	Other professional services	NEW LENSES IN PTS OLD FRAME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0596	Other professional services	PHAKIC IOL REFRACTIVE ERROR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0601	Other professional services	SCREENING PROCTOSCOPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0610	Other professional services	ANNUAL GYNECOLOGICAL EXAMINA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0612	Other professional services	ANNUAL GYNECOLOGICAL EXAMINA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0613	Other professional services	ANN BREAST EXAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0618	Other professional services	AUDIOMETRY FOR HEARING AID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0620	Other professional services	ROUTINE OPHTHALMOLOGICAL EXA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0621	Other professional services	ROUTINE OPHTHALMOLOGICAL EXA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0622	Other professional services	PHYS EXAM FOR COLLEGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0630	Other professional services	REMOVAL OF SUTURES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0800	Other professional services	LASER IN SITU KERATOMILEUSIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0810	Other professional services	PHOTOREFRACTIVE KERATECTOMY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S0812	Other professional services	PHOTOTHERAP KERATECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S1001	Other professional services	DELUXE ITEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S1002	Other professional services	CUSTOM ITEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S1015	Other professional services	IV TUBING EXTENSION SET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S1016	Other professional services	NON-PVC INTRAVENOUS ADMINIST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S1030	Other professional services	GLUC MONITOR PURCHASE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S1031	Other professional services	GLUC MONITOR RENTAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S1034	Other professional services	ART PANCREAS SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S1035	Other professional services	ART PANCREAS INV DISP SENSOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S1036	Other professional services	ART PANCREAS EXT TRANSMITTER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S1037	Other professional services	ART PANCREAS EXT RECEIVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S1040	Other professional services	CRANIAL REMOLDING ORTHOSIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S1091	Other professional services	STENT NON-CORONARY PROPEL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2053	Other professional services	TRANSPLANTATION OF SMALL INT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2054	Other professional services	TRANSPLANTATION OF MULTIVISC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2055	Other professional services	HARVESTING OF DONOR MULTIVIS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2060	Other professional services	LOBAR LUNG TRANSPLANTATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2061	Other professional services	DONOR LOBECTOMY (LUNG)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2065	Other professional services	SIMULT PANC KIDN TRANS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2066	Other professional services	BREAST GAP FLAP RECONST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2067	Other professional services	BREAST "STACKED" DIEP/GAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2068	Other professional services	BREAST DIEP OR SIEA FLAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2070	Other professional services	CYSTO LASER TX URETERAL CALC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2079	Other professional services	LAP ESOPHAGOMYOTOMY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2080	Other professional services	LAUP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2083	Other professional services	ADJUSTMENT GASTRIC BAND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2095	Other professional services	TRANSCATH EMBOLIZ MICROSPHER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2102	Other professional services	ISLET CELL TISSUE TRANSPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2103	Other professional services	ADRENAL TISSUE TRANSPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2107	Other professional services	ADOPTIVE IMMUNOTHERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2112	Other professional services	KNEE ARTHROSCP HARV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2115	Other professional services	PERIACETABULAR OSTEOTOMY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2117	Other professional services	ARTHROEREISIS, SUBTALAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2118	Other professional services	TOTAL HIP RESURFACING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2120	Other professional services	LOW DENSITY LIPOPROTEIN(LDL)	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2140	Other professional services	CORD BLOOD HARVESTING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2142	Other professional services	CORD BLOOD-DERIVED STEM-CELL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2150	Other professional services	BMT HARV/TRANSPL 28D PKG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2152	Other professional services	SOLID ORGAN TRANSPL PKG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2202	Other professional services	ECHOSCLEROTHERAPY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2205	Other professional services	MINIMALLY INVASIVE DIRECT CO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2206	Other professional services	MINIMALLY INVASIVE DIRECT CO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2207	Other professional services	MINIMALLY INVASIVE DIRECT CO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2208	Other professional services	MINIMALLY INVASIVE DIRECT CO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2209	Other professional services	MINIMALLY INVASIVE DIRECT CO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2225	Other professional services	MYRINGOTOMY LASER-ASSIST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2230	Other professional services	IMPLANT SEMI-IMP HEAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2235	Other professional services	IMPLANT AUDITORY BRAIN IMP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2260	Other professional services	INDUCED ABORTION 17-24 WEEKS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2265	Other professional services	INDUCED ABORTION 25-28 WKS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2266	Other professional services	INDUCED ABORTION 29-31 WKS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2267	Other professional services	INDUCED ABORTION 32 OR MORE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2300	Other professional services	ARTHROSCOPY, SHOULDER, SURGI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2325	Other professional services	HIP CORE DECOMPRESSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2340	Other professional services	CHEMODENERVATION OF ABDUCTOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2341	Other professional services	CHEMODENERV ADDUCT VOCAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2342	Other professional services	NASAL ENDOSCOP PO DEBRID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2348	Other professional services	DECOMPRESS DISC RF LUMBAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2350	Other professional services	DISKECTOMY, ANTERIOR, WITH D	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2351	Other professional services	DISKECTOMY, ANTERIOR, WITH D	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2400	Other professional services	FETAL SURG CONGEN HERNIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2401	Other professional services	FETAL SURG URIN TRAC OBSTR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2402	Other professional services	FETAL SURG CONG CYST MALF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2403	Other professional services	FETAL SURG PULMON SEQUEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2404	Other professional services	FETAL SURG MYELOMENINGO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2405	Other professional services	FETAL SURG SACROCOC TERATOMA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2409	Other professional services	FETAL SURG NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2411	Other professional services	FETOSCOP LASER THER TTTS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S2900	Other professional services	ROBOTIC SURGICAL SYSTEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3000	Other professional services	BILAT DIL RETINAL EXAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3005	Other professional services	EVAL SELF-ASSESS DEPRESSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3600	Other professional services	STAT LAB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3601	Other professional services	STAT LAB HOME/NF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3620	Other professional services	NEWBORN METABOLIC SCREENING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3630	Other professional services	EOSINOPHIL BLOOD COUNT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3645	Other professional services	HIV-1 ANTIBODY TESTING OF OR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3650	Other professional services	SALIVA TEST, HORMONE LEVEL;	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3652	Other professional services	SALIVA TEST, HORMONE LEVEL;	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3655	Other professional services	ANTISPERM ANTIBODIES TEST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3708	Other professional services	GASTROINTESTINAL FAT ABSORPT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3722	Other professional services	DOSE OPTIMIZATION AUC - 5FU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3800	Other professional services	GENETIC TESTING ALS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3840	Other professional services	DNA ANALYSIS RET-ONCOGENE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3841	Other professional services	GENE TEST RETINOBLASTOMA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3842	Other professional services	GENE TEST HIPPEL-LINDAU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3844	Other professional services	DNA ANALYSIS DEAFNESS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3845	Other professional services	GENE TEST ALPHA-THALASSEMIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3846	Other professional services	GENE TEST BETA-THALASSEMIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3849	Other professional services	GENE TEST NIEMANN-PICK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3850	Other professional services	GENE TEST SICKLE CELL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3852	Other professional services	DNA ANALYSIS APOE ALZHEIMER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3853	Other professional services	GENE TEST MYO MUSCLR DYST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3854	Other professional services	GENE PROFILE PANEL BREAST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3861	Other professional services	GENETIC TEST BRUGADA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3865	Other professional services	COMP GENET TEST HYP CARDIOMY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3866	Other professional services	SPEC GENE TEST HYP CARDIOMY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3870	Other professional services	CGH TEST DEVELOPMENTAL DELAY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3900	Other professional services	SURFACE EMG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3902	Other professional services	BALLISTOCARDIOGRAM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S3904	Other professional services	MASTERS TWO STEP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4005	Other professional services	INTERIM LABOR FACILITY GLOBA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4011	Other professional services	IVF PACKAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4013	Other professional services	COMPL GIFT CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4014	Other professional services	COMPL ZIFT CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4015	Other professional services	COMPLETE IVF NOS CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4016	Other professional services	FROZEN IVF CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4017	Other professional services	IVF CANC A STIM CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4018	Other professional services	F EMB TRNS CANC CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4020	Other professional services	IVF CANC A ASPIR CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4021	Other professional services	IVF CANC P ASPIR CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4022	Other professional services	ASST OOCYTE FERT CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4023	Other professional services	INCOMPL DONOR EGG CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4025	Other professional services	DONOR SERV IVF CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4026	Other professional services	PROCURE DONOR SPERM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4027	Other professional services	STORE PREV FROZ EMBRYOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4028	Other professional services	MICROSURG EPI SPERM ASP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4030	Other professional services	SPERM PROCURE INIT VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4031	Other professional services	SPERM PROCURE SUBS VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4035	Other professional services	STIMULATED IUI CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4037	Other professional services	CRYO EMBRYO TRANSF CASE RATE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4040	Other professional services	MONIT STORE CRYO EMBRYO 30 D	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4042	Other professional services	OVULATION MGMT PER CYCLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4981	Other professional services	INSERT LEVONORGESTREL IUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4989	Other professional services	CONTRACEPT IUD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4990	Other professional services	NICOTINE PATCH LEGEND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4991	Other professional services	NICOTINE PATCH NONLEGEND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4993	Other professional services	CONTRACEPTIVE PILLS FOR BC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S4995	Other professional services	SMOKING CESSATION GUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5000	Other professional services	PRESCRIPTION DRUG, GENERIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5001	Other professional services	PRESCRIPTION DRUG,BRAND NAME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5010	Other professional services	5% DEXTROSE AND 0.45% SALINE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5012	Other professional services	5% DEXTROSE WITH POTASSIUM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5013	Other professional services	5%DEXTROSE/0.45%SALINE1000ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5014	Other professional services	D5W/0.45NS W KCL AND MGS04	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5035	Other professional services	HIT ROUTINE DEVICE MAINT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5036	Other professional services	HIT DEVICE REPAIR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5100	Other professional services	ADULT DAYCARE SERVICES 15MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5101	Other professional services	ADULT DAY CARE PER HALF DAY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5102	Other professional services	ADULT DAY CARE PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5105	Other professional services	CENTERBASED DAY CARE PERDIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5108	Other professional services	HOMECARE TRAIN PT 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5109	Other professional services	HOMECARE TRAIN PT SESSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5110	Other professional services	FAMILY HOMECARE TRAINING 15M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5111	Other professional services	FAMILY HOMECARE TRAIN/SESSIO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5115	Other professional services	NONFAMILY HOMECARE TRAIN/15M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5116	Other professional services	NONFAMILY HC TRAIN/SESSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5120	Other professional services	CHORE SERVICES PER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5121	Other professional services	CHORE SERVICES PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5125	Other professional services	ATTENDANT CARE SERVICE /15M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5126	Other professional services	ATTENDANT CARE SERVICE /DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5130	Other professional services	HOMAKER SERVICE NOS PER 15M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5131	Other professional services	HOMEMAKER SERVICE NOS /DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5135	Other professional services	ADULT COMPANIONCARE PER 15M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5136	Other professional services	ADULT COMPANIONCARE PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5140	Other professional services	ADULT FOSTER CARE PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5141	Other professional services	ADULT FOSTER CARE PER MONTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5145	Other professional services	CHILD FOSTERCARE TH PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5146	Other professional services	THER FOSTERCARE CHILD /MONTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5150	Other professional services	UNSKILLED RESPITE CARE /15M	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5151	Other professional services	UNSKILLED RESPITECARE /DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5160	Other professional services	EMER RESPONSE SYS INSTAL&TST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5161	Other professional services	EMER RSPNS SYS SERV PERMONTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5162	Other professional services	EMER RSPNS SYSTEM PURCHASE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5165	Other professional services	HOME MODIFICATIONS PER SERV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5170	Other professional services	HOMEDELIVERED PREPARED MEAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5175	Other professional services	LAUNDRY SERV,EXT,PROF,/ORDER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5180	Other professional services	HH RESPIRATORY THRPY IN EVAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5181	Other professional services	HH RESPIRATORY THRPY NOS/DAY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5185	Other professional services	MED REMINDER SERV PER MONTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5190	Other professional services	WELLNESS ASSESSMENT BY NONPH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5199	Other professional services	PERSONAL CARE ITEM NOS EACH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5497	Other professional services	HIT CATH CARE NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5498	Other professional services	HIT SIMPLE CATH CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5501	Other professional services	HIT COMPLEX CATH CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5502	Other professional services	HIT INTERIM CATH CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5517	Other professional services	HIT DECLOTTING KIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5518	Other professional services	HIT CATH REPAIR KIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5520	Other professional services	HIT PICC INSERT KIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5521	Other professional services	HIT MIDLINE CATH INSERT KIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5522	Other professional services	HIT PICC INSERT NO SUPP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5523	Other professional services	HIP MIDLINE CATH INSERT KIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5550	Other professional services	INSULIN RAPID 5 U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5551	Other professional services	INSULIN MOST RAPID 5 U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5552	Other professional services	INSULIN INTERMED 5 U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5553	Other professional services	INSULIN LONG ACTING 5 U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5560	Other professional services	INSULIN REUSE PEN 1.5 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5561	Other professional services	INSULIN REUSE PEN 3 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5565	Other professional services	INSULIN CARTRIDGE 150 U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5566	Other professional services	INSULIN CARTRIDGE 300 U	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5570	Other professional services	INSULIN DISPOS PEN 1.5 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S5571	Other professional services	INSULIN DISPOS PEN 3 ML	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8030	Other professional services	TANTALUM RING APPLICATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8035	Other professional services	MAGNETIC SOURCE IMAGING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8037	Other professional services	MRCP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8040	Other professional services	TOPOGRAPHIC BRAIN MAPPING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8042	Other professional services	MRI LOW FIELD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8055	Other professional services	US GUIDANCE FETAL REDUCT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8080	Other professional services	SCINTIMAMMOGRAPHY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8085	Other professional services	FLUORINE-18 FLUORODEOXYGLUCO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8092	Other professional services	ELECTRON BEAM COMPUTED TOMOG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8096	Other professional services	PORTABLE PEAK FLOW METER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8097	Other professional services	ASTHMA KIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8100	Other professional services	SPACER WITHOUT MASK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8101	Other professional services	SPACER WITH MASK	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8110	Other professional services	PEAK EXPIRATORY FLOW RATE (P	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8120	Other professional services	O2 CONTENTS GAS CUBIC FT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8121	Other professional services	O2 CONTENTS LIQUID LB	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8130	Other professional services	INTERFERENTIAL STIM 2 CHAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8131	Other professional services	INTERFERENTIAL STIM 4 CHAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8185	Other professional services	FLUTTER DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8186	Other professional services	SWIVEL ADAPTOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8189	Other professional services	TRACH SUPPLY NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8210	Other professional services	MUCUS TRAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8265	Other professional services	HABERMAN FEEDER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8270	Other professional services	ENURESIS ALARM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8301	Other professional services	INFECT CONTROL SUPPLIES NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8415	Other professional services	SUPPLIES FOR HOME DELIVERY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8420	Other professional services	CUSTOM GRADIENT SLEEV/GLOV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8421	Other professional services	READY GRADIENT SLEEV/GLOV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8422	Other professional services	CUSTOM GRAD SLEEVE MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8423	Other professional services	CUSTOM GRAD SLEEVE HEAVY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8424	Other professional services	READY GRADIENT SLEEVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8425	Other professional services	CUSTOM GRAD GLOVE MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8426	Other professional services	CUSTOM GRAD GLOVE HEAVY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8427	Other professional services	READY GRADIENT GLOVE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8428	Other professional services	READY GRADIENT GAUNTLET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8429	Other professional services	GRADIENT PRESSURE WRAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8430	Other professional services	PADDING FOR COMPRSSN BDG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8431	Other professional services	COMPRESSION BANDAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8450	Other professional services	SPLINT DIGIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8451	Other professional services	SPLINT WRIST OR ANKLE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8452	Other professional services	SPLINT ELBOW	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8460	Other professional services	CAMISOLE POST-MAST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8490	Other professional services	100 INSULIN SYRINGES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8930	Other professional services	AURICULAR ELECTROSTIMULATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8940	Other professional services	HIPPOTHERAPY PER SESSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8948	Other professional services	LOW-LEVEL LASER TRMT 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8950	Other professional services	COMPLEX LYMPHEDEMA THERAPY,	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8990	Other professional services	PT OR MANIP FOR MAINT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S8999	Other professional services	RESUSCITATION BAG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9001	Other professional services	HOME UTERINE MONITOR WITH OR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9007	Other professional services	ULTRAFILTRATION MONITOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9024	Other professional services	PARANASAL SINUS ULTRASOUND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9025	Other professional services	OMNICARDIOGRAM/CARDIOINTEGRA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9034	Other professional services	ESWL FOR GALLSTONES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9055	Other professional services	PROCUREN OR OTHER GROWTH FAC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9056	Other professional services	COMA STIMULATION PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9061	Other professional services	MEDICAL SUPPLIES AND EQUIPME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9083	Other professional services	URGENT CARE CENTER GLOBAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9088	Other professional services	SERVICES PROVIDED IN URGENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9090	Other professional services	VERTEBRAL AXIAL DECOMPRESSIO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9097	Other professional services	HOME VISIT WOUND CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9098	Other professional services	HOME PHOTOTHERAPY VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9110	Other professional services	TELEMONITORING/HOME PER MNTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9117	Other professional services	BACK SCHOOL VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9122	Other professional services	HOME HEALTH AIDE OR CERTIFIE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9123	Other professional services	NURSING CARE IN HOME RN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9124	Other professional services	NURSING CARE, IN THE HOME; B	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9125	Other professional services	RESPITE CARE, IN THE HOME, P	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9126	Other professional services	HOSPICE CARE, IN THE HOME, P	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9127	Other professional services	SOCIAL WORK VISIT, IN THE HO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9128	Other professional services	SPEECH THERAPY, IN THE HOME,	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9129	Other professional services	OCCUPATIONAL THERAPY, IN THE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9131	Other professional services	PT IN THE HOME PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9140	Other professional services	DIABETIC MANAGEMENT PROGRAM,	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9141	Other professional services	DIABETIC MANAGEMENT PROGRAM,	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9145	Other professional services	INSULIN PUMP INITIATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9150	Other professional services	EVALUATION BY OCULARIST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9152	Other professional services	SPEECH THERAPY, RE-EVAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9208	Other professional services	HOME MGMT PRETERM LABOR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9209	Other professional services	HOME MGMT PPROM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9211	Other professional services	HOME MGMT GEST HYPERTENSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9212	Other professional services	HM POSTPAR HYPER PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9213	Other professional services	HM PREECLAMP PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9214	Other professional services	HM GEST DM PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9325	Other professional services	HIT PAIN MGMT PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9326	Other professional services	HIT CONT PAIN PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9327	Other professional services	HIT INT PAIN PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9328	Other professional services	HIT PAIN IMP PUMP DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9329	Other professional services	HIT CHEMO PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9330	Other professional services	HIT CONT CHEM DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9331	Other professional services	HIT INTERMIT CHEMO DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9335	Other professional services	HT HEMODIALYSIS DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9336	Other professional services	HIT CONT ANTICOAG DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9338	Other professional services	HIT IMMUNOTHERAPY DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9339	Other professional services	HIT PERITON DIALYSIS DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9340	Other professional services	HIT ENTERAL PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9341	Other professional services	HIT ENTERAL GRAV DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9342	Other professional services	HIT ENTERAL PUMP DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9343	Other professional services	HIT ENTERAL BOLUS NURS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9345	Other professional services	HIT ANTI-HEMOPHIL DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9346	Other professional services	HIT ALPHA-1-PROTEINAS DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9347	Other professional services	HIT LONGTERM INFUSION DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9348	Other professional services	HIT SYMPATHOMIM DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9349	Other professional services	HIT TOCOLYSIS DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9351	Other professional services	HIT CONT ANTIEMETIC DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9353	Other professional services	HIT CONT INSULIN DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9355	Other professional services	HIT CHELATION DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9357	Other professional services	HIT ENZYME REPLACE DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9359	Other professional services	HIT ANTI-TNF PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9361	Other professional services	HIT DIURETIC INFUS DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9363	Other professional services	HIT ANTI-SPASMOTIC DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9364	Other professional services	HIT TPN TOTAL DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9365	Other professional services	HIT TPN 1 LITER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9366	Other professional services	HIT TPN 2 LITER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9367	Other professional services	HIT TPN 3 LITER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9368	Other professional services	HIT TPN OVER 3L DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9370	Other professional services	HT INJ ANTIEMETIC DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9372	Other professional services	HT INJ ANTICOAG DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9373	Other professional services	HIT HYDRA TOTAL DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9374	Other professional services	HIT HYDRA 1 LITER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9375	Other professional services	HIT HYDRA 2 LITER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9376	Other professional services	HIT HYDRA 3 LITER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9377	Other professional services	HIT HYDRA OVER 3L DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9379	Other professional services	HIT NOC PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9381	Other professional services	HIT HIGH RISK/ESCORT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9401	Other professional services	ANTICOAG CLINIC PER SESSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9430	Other professional services	PHARMACY COMP/DISP SERV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9432	Other professional services	MED FOOD NON INBORN ERR META	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9433	Other professional services	MEDICAL FOOD ORAL 100% NUTR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9434	Other professional services	MOD SOLID FOOD SUPPL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9435	Other professional services	MEDICAL FOODS FOR INBORN ERR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9436	Other professional services	LAMAZE CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9437	Other professional services	CHILDBIRTH REFRESHER CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9438	Other professional services	CESAREAN BIRTH CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9439	Other professional services	VBAC CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9441	Other professional services	ASTHMA EDUCATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9442	Other professional services	BIRTHING CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9443	Other professional services	LACTATION CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9444	Other professional services	PARENTING CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9445	Other professional services	PT EDUCATION NOC INDIVID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9446	Other professional services	PT EDUCATION NOC GROUP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9447	Other professional services	INFANT SAFETY CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9449	Other professional services	WEIGHT MGMT CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9451	Other professional services	EXERCISE CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9452	Other professional services	NUTRITION CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9453	Other professional services	SMOKING CESSATION CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9454	Other professional services	STRESS MGMT CLASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9455	Other professional services	DIABETIC MANAGEMENT PROGRAM,	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9460	Other professional services	DIABETIC MANAGEMENT PROGRAM,	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9465	Other professional services	DIABETIC MANAGEMENT PROGRAM,	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9470	Other professional services	NUTRITIONAL COUNSELING, DIET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9472	Other professional services	CARDIAC REHABILITATION PROGR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9473	Other professional services	PULMONARY REHABILITATION PRO	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9474	Other professional services	ENTEROSTOMAL THERAPY BY A RE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9475	Other professional services	AMBULATORY SETTING SUBSTANCE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9476	Other professional services	VESTIBULAR REHAB PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9480	Other professional services	INTENSIVE OUTPATIENT PSYCHIA	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9482	Other professional services	FAMILY STABILIZATION 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9484	Other professional services	CRISIS INTERVENTION PER HOUR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9485	Other professional services	CRISIS INTERVENTION MENTAL H	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9490	Other professional services	HIT CORTICOSTEROID/DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9494	Other professional services	HIT ANTIBIOTIC TOTAL DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9497	Other professional services	HIT ANTIBIOTIC Q3H DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9500	Other professional services	HIT ANTIBIOTIC Q24H DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9501	Other professional services	HIT ANTIBIOTIC Q12H DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9502	Other professional services	HIT ANTIBIOTIC Q8H DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9503	Other professional services	HIT ANTIBIOTIC Q6H DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9504	Other professional services	HIT ANTIBIOTIC Q4H DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9529	Other professional services	VENIPUNCTURE HOME/SNF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9537	Other professional services	HT HEM HORM INJ DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9538	Other professional services	HIT BLOOD PRODUCTS DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9542	Other professional services	HT INJ NOC PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9558	Other professional services	HT INJ GROWTH HORM DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9559	Other professional services	HIT INJ INTERFERON DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9560	Other professional services	HT INJ HORMONE DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9562	Other professional services	HT INJ PALIVIZUMAB/AB DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9563	Other professional services	HT INJ IMMUNO DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9590	Other professional services	HT IRRIGATION DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9810	Other professional services	HT PHARM PER HOUR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9900	Other professional services	CHRISTIAN SCI PRACT VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9901	Other professional services	CHRISTIAN SCI NURSE VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9960	Other professional services	AIR AMBULANC NONEMERG FIXED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9961	Other professional services	AIR AMBULAN NONEMERG ROTARY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9970	Other professional services	HEALTH CLUB MEMBERSHIP YR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9975	Other professional services	TRANSPLANT RELATED PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9976	Other professional services	LODGING PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9977	Other professional services	MEALS PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9981	Other professional services	MED RECORD COPY ADMIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9982	Other professional services	MED RECORD COPY PER PAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9986	Other professional services	NOT MEDICALLY NECESSARY SVC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9988	Other professional services	SERV PART OF PHASE I TRIAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9989	Other professional services	SERVICES OUTSIDE US	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9990	Other professional services	SERVICES PROVIDED AS PART OF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9991	Other professional services	SERVICES PROVIDED AS PART OF	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9992	Other professional services	TRANSPORTATION COSTS TO AND	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9994	Other professional services	LODGING COSTS (E.G. HOTEL CH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9996	Other professional services	MEALS FOR CLINICAL TRIAL PAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
S9999	Other professional services	SALES TAX	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1000	Other professional services	PRIVATE DUTY/INDEPENDENT NSG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1001	Other professional services	NURSING ASSESSMENT/EVALUATN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1002	Other professional services	RN SERVICES UP TO 15 MINUTES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1003	Other professional services	LPN/LVN SERVICES UP TO 15MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1004	Other professional services	NSG AIDE SERVICE UP TO 15MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1005	Other professional services	RESPITE CARE SERVICE 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1006	Other professional services	FAMILY/COUPLE COUNSELING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1007	Other professional services	TREATMENT PLAN DEVELOPMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1009	Other professional services	CHILD SITTING SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1010	Other professional services	MEALS WHEN RECEIVE SERVICES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1012	Other professional services	ALCOHOL/SUBSTANCE ABUSE SKIL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1013	Other professional services	SIGN LANG/ORAL INTERPRETER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1014	Other professional services	TELEHEALTH TRANSMIT, PER MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1015	Other professional services	CLINIC SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1016	Other professional services	CASE MANAGEMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1017	Other professional services	TARGETED CASE MANAGEMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1018	Other professional services	SCHOOL-BASED IEP SER BUNDLED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1019	Other professional services	PERSONAL CARE SER PER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1020	Other professional services	PERSONAL CARE SER PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1021	Other professional services	HH AIDE OR CN AIDE PER VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1022	Other professional services	CONTRACTED SERVICES PER DAY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1023	Other professional services	PROGRAM INTAKE ASSESSMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1024	Other professional services	TEAM EVALUATION & MANAGEMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1025	Other professional services	PED COMPR CARE PKG, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1026	Other professional services	PED COMPR CARE PKG, PER HOUR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1027	Other professional services	FAMILY TRAINING & COUNSELING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1028	Other professional services	HOME ENVIRONMENT ASSESSMENT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1029	Other professional services	DWELLING LEAD INVESTIGATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1030	Other professional services	RN HOME CARE PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1031	Other professional services	LPN HOME CARE PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1032	Other professional services	SV DOULA BRTH WRK PER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1033	Other professional services	SV DOULA BRTH WRK PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1040	Other professional services	COMM BH CLINIC SVC PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1041	Other professional services	COMM BH CLINIC SVC PER MONTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1502	Other professional services	MEDICATION ADMIN VISIT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1503	Other professional services	MED ADMIN, NOT ORAL/INJECT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1505	Other professional services	ELEC MED COMP DEV, NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T1999	Other professional services	NOC RETAIL ITEMS ANDSUPPLIES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2001	Other professional services	N-ET; PATIENT ATTEND/ESCORT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2002	Other professional services	N-ET; PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2003	Other professional services	N-ET; ENCOUNTER/TRIP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2004	Other professional services	N-ET; COMMERC CARRIER PASS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2005	Other professional services	N-ET; STRETCHER VAN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2007	Other professional services	NON-EMER TRANSPORT WAIT TIME	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2010	Other professional services	PASRR LEVEL I	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2011	Other professional services	PASRR LEVEL II	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2012	Other professional services	HABIL ED WAIVER, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2013	Other professional services	HABIL ED WAIVER PER HOUR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2014	Other professional services	HABIL PREVOC WAIVER, PER D	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2015	Other professional services	HABIL PREVOC WAIVER PER HR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2016	Other professional services	HABIL RES WAIVER PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2017	Other professional services	HABIL RES WAIVER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2018	Other professional services	HABIL SUP EMPL WAIVER/DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2019	Other professional services	HABIL SUP EMPL WAIVER 15MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2020	Other professional services	DAY HABIL WAIVER PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2021	Other professional services	DAY HABIL WAIVER PER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2022	Other professional services	CASE MANAGEMENT, PER MONTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2023	Other professional services	TARGETED CASE MGMT PER MONTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2024	Other professional services	SERV ASMNT/CARE PLAN WAIVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2025	Other professional services	WAIVER SERVICE, NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2026	Other professional services	SPECIAL CHILDCARE WAIVER/D	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2027	Other professional services	SPEC CHILDCARE WAIVER 15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2028	Other professional services	SPECIAL SUPPLY, NOS WAIVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2029	Other professional services	SPECIAL MED EQUIP, NOSWAIVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2030	Other professional services	ASSIST LIVING WAIVER/MONTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2031	Other professional services	ASSIST LIVING WAIVER/DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2032	Other professional services	RES CARE, NOS WAIVER/MONTH	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2033	Other professional services	RES, NOS WAIVER PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2034	Other professional services	CRISIS INTERVEN WAIVER/DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2035	Other professional services	UTILITY SERVICES WAIVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2036	Other professional services	CAMP OVERNITE WAIVER/SESSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2037	Other professional services	CAMP DAY WAIVER/SESSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2038	Other professional services	COMM TRANS WAIVER/SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2039	Other professional services	VEHICLE MOD WAIVER/SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2040	Other professional services	FINANCIAL MGT WAIVER/15MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2041	Other professional services	SUPPORT BROKER WAIVER/15 MIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2042	Other professional services	HOSPICE ROUTINE HOME CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2043	Other professional services	HOSPICE CONTINUOUS HOME CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2044	Other professional services	HOSPICE RESPITE CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2045	Other professional services	HOSPICE GENERAL CARE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2046	Other professional services	HOSPICE LONG TERM CARE, R&B	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2047	Other professional services	HAB PREVO WAIVER PER 15	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2048	Other professional services	BH LTC RES R&B, PER DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2049	Other professional services	N-ET; STRETCHER VAN, MILEAGE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2050	Other professional services	FINANCIAL MGT WAIVER/DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2051	Other professional services	SUPPORT BROKER WAIVER/DIEM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T2101	Other professional services	BREAST MILK PROC/STORE/DIST	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4521	Other professional services	ADULT SIZE BRIEF/DIAPER SM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4522	Other professional services	ADULT SIZE BRIEF/DIAPER MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4523	Other professional services	ADULT SIZE BRIEF/DIAPER LG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4524	Other professional services	ADULT SIZE BRIEF/DIAPER XL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4525	Other professional services	ADULT SIZE PULL-ON SM	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4526	Other professional services	ADULT SIZE PULL-ON MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4527	Other professional services	ADULT SIZE PULL-ON LG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4528	Other professional services	ADULT SIZE PULL-ON XL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4529	Other professional services	PED SIZE BRIEF/DIAPER SM/MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4530	Other professional services	PED SIZE BRIEF/DIAPER LG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4531	Other professional services	PED SIZE PULL-ON SM/MED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4532	Other professional services	PED SIZE PULL-ON LG	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4533	Other professional services	YOUTH SIZE BRIEF/DIAPER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4534	Other professional services	YOUTH SIZE PULL-ON	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4535	Other professional services	DISPOSABLE LINER/SHIELD/PAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4536	Other professional services	REUSABLE PULL-ON ANY SIZE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4537	Other professional services	REUSABLE UNDERPAD BED SIZE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4538	Other professional services	DIAPER SERV REUSABLE DIAPER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4539	Other professional services	REUSE DIAPER/BRIEF ANY SIZE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4540	Other professional services	REUSABLE UNDERPAD CHAIR SIZE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4541	Other professional services	LARGE DISPOSABLE UNDERPAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4542	Other professional services	SMALL DISPOSABLE UNDERPAD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4543	Other professional services	ADULT DISP BRIEF/DIAP ABV XL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4544	Other professional services	ADLT DISP UND/PULL ON ABV XL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T4545	Other professional services	INCON DISPOSABLE PENILE WRAP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T5001	Other professional services	POSITION SEAT SPEC ORTH NEED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
T5999	Other professional services	SUPPLY, NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
U0001	Clinical Laboratory	2019-NCOV DIAGNOSTIC P	53.88	53.88
U0002	Clinical Laboratory	COVID-19 LAB TEST NON-CDC	76.97	76.97
V2020	DMEPOS	VISION SVCS FRAMES PURCHASES	94.47	94.47
V2025	Other professional services	EYEGLASSES DELUX FRAMES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2100	DMEPOS	LENS SPHER SINGLE PLANO 4.00	45.92	45.92
V2101	DMEPOS	SINGLE VISN SPHERE 4.12-7.00	48.38	48.38
V2102	DMEPOS	SINGL VISN SPHERE 7.12-20.00	68.62	68.62
V2103	DMEPOS	SPHEROCYLINDR 4.00D/12-2.00D	39.86	39.86
V2104	DMEPOS	SPHEROCYLINDR 4.00D/2.12-4D	44.15	44.15
V2105	DMEPOS	SPHEROCYLINDER 4.00D/4.25-6D	54.06	54.06
V2106	DMEPOS	SPHEROCYLINDER 4.00D/>6.00D	54.86	54.86
V2107	DMEPOS	SPHEROCYLINDER 4.25D/12-2D	57.66	57.66
V2108	DMEPOS	SPHEROCYLINDER 4.25D/2.12-4D	55.92	55.92
V2109	DMEPOS	SPHEROCYLINDER 4.25D/4.25-6D	64.28	64.28
V2110	DMEPOS	SPHEROCYLINDER 4.25D/OVER 6D	75.02	75.02
V2111	DMEPOS	SPHEROCYLINDR 7.25D/.25-2.25	66.13	66.13
V2112	DMEPOS	SPHEROCYLINDR 7.25D/2.25-4D	65.26	65.26
V2113	DMEPOS	SPHEROCYLINDR 7.25D/4.25-6D	90.14	90.14
V2114	DMEPOS	SPHEROCYLINDER OVER 12.00D	79.75	79.75
V2115	DMEPOS	LENS LENTICULAR BIFOCAL	86.70	86.70
V2118	DMEPOS	LENS ANISEIKONIC SINGLE	85.95	85.95
V2121	DMEPOS	LENTICULAR LENS, SINGLE	88.74	88.74
V2199	Other professional services	LENS SINGLE VISION NOT OTH C	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2200	DMEPOS	LENS SPHER BIFOC PLANO 4.00D	60.09	60.09
V2201	DMEPOS	LENS SPHERE BIFOCAL 4.12-7.0	65.49	65.49
V2202	DMEPOS	LENS SPHERE BIFOCAL 7.12-20.	77.07	77.07
V2203	DMEPOS	LENS SPHCYL BIFOCAL 4.00D/.1	60.63	60.63
V2204	DMEPOS	LENS SPHCY BIFOCAL 4.00D/2.1	65.74	65.74
V2205	DMEPOS	LENS SPHCY BIFOCAL 4.00D/4.2	72.13	72.13
V2206	DMEPOS	LENS SPHCY BIFOCAL 4.00D/OVE	87.82	87.82
V2207	DMEPOS	LENS SPHCY BIFOCAL 4.25-7D/.	73.30	73.30
V2208	DMEPOS	LENS SPHCY BIFOCAL 4.25-7/2.	74.20	74.20
V2209	DMEPOS	LENS SPHCY BIFOCAL 4.25-7/4.	81.61	81.61
V2210	DMEPOS	LENS SPHCY BIFOCAL 4.25-7/OV	105.00	105.00
V2211	DMEPOS	LENS SPHCY BIFO 7.25-12/.25-	89.53	89.53
V2212	DMEPOS	LENS SPHCYL BIFO 7.25-12/2.2	97.43	97.43
V2213	DMEPOS	LENS SPHCYL BIFO 7.25-12/4.2	99.91	99.91
V2214	DMEPOS	LENS SPHCYL BIFOCAL OVER 12.	107.08	107.08
V2215	DMEPOS	LENS LENTICULAR BIFOCAL	115.89	115.89
V2218	DMEPOS	LENS ANISEIKONIC BIFOCAL	118.56	118.56
V2219	DMEPOS	LENS BIFOCAL SEG WIDTH OVER	52.19	52.19
V2220	DMEPOS	LENS BIFOCAL ADD OVER 3.25D	42.32	42.32
V2221	DMEPOS	LENTICULAR LENS, BIFOCAL	113.08	113.08
V2299	Other professional services	LENS BIFOCAL SPECIALITY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2300	DMEPOS	LENS SPHERE TRIFOCAL 4.00D	78.04	78.04
V2301	DMEPOS	LENS SPHERE TRIFOCAL 4.12-7.	90.50	90.50
V2302	DMEPOS	LENS SPHERE TRIFOCAL 7.12-20	99.13	99.13
V2303	DMEPOS	LENS SPHCY TRIFOCAL 4.0/.12-	82.14	82.14
V2304	DMEPOS	LENS SPHCY TRIFOCAL 4.0/2.25	85.96	85.96
V2305	DMEPOS	LENS SPHCY TRIFOCAL 4.0/4.25	105.41	105.41
V2306	DMEPOS	LENS SPHCYL TRIFOCAL 4.00/>6	98.29	98.29
V2307	DMEPOS	LENS SPHCY TRIFOCAL 4.25-7/.	97.45	97.45
V2308	DMEPOS	LENS SPHC TRIFOCAL 4.25-7/2.	103.99	103.99
V2309	DMEPOS	LENS SPHC TRIFOCAL 4.25-7/4.	121.65	121.65
V2310	DMEPOS	LENS SPHC TRIFOCAL 4.25-7/>6	133.82	133.82
V2311	DMEPOS	LENS SPHC TRIFO 7.25-12/.25-	127.45	127.45
V2312	DMEPOS	LENS SPHC TRIFO 7.25-12/2.25	112.34	112.34
V2313	DMEPOS	LENS SPHC TRIFO 7.25-12/4.25	153.34	153.34
V2314	DMEPOS	LENS SPHCYL TRIFOCAL OVER 12	167.97	167.97
V2315	DMEPOS	LENS LENTICULAR TRIFOCAL	186.47	186.47
V2318	DMEPOS	LENS ANISEIKONIC TRIFOCAL	171.93	171.93
V2319	DMEPOS	LENS TRIFOCAL SEG WIDTH > 28	58.21	58.21
V2320	DMEPOS	LENS TRIFOCAL ADD OVER 3.25D	61.41	61.41
V2321	DMEPOS	LENTICULAR LENS, TRIFOCAL	183.80	183.80
V2399	Other professional services	LENS TRIFOCAL SPECIALITY	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2410	DMEPOS	LENS VARIAB ASPHERICITY SING	105.10	105.10
V2430	DMEPOS	LENS VARIABLE ASPHERICITY BI	136.82	136.82
V2499	Other professional services	VARIABLE ASPHERICITY LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2500	DMEPOS	CONTACT LENS PMMA SPHERICAL	95.26	95.26
V2501	DMEPOS	CNTCT LENS PMMA-TORIC/PRISM	145.11	145.11
V2502	DMEPOS	CONTACT LENS PMMA BIFOCAL	178.77	178.77
V2503	DMEPOS	CNTCT LENS PMMA COLOR VISION	171.05	171.05
V2510	DMEPOS	CNTCT GAS PERMEABLE SPHERICL	130.05	130.05
V2511	DMEPOS	CNTCT TORIC PRISM BALLAST	186.86	186.86
V2512	DMEPOS	CNTCT LENS GAS PERMBL BIFOCL	220.80	220.80
V2513	DMEPOS	CONTACT LENS EXTENDED WEAR	185.37	185.37
V2520	DMEPOS	CONTACT LENS HYDROPHILIC	122.23	122.23
V2521	DMEPOS	CNTCT LENS HYDROPHILIC TORIC	212.82	212.82
V2522	DMEPOS	CNTCT LENS HYDROPHIL BIFOCL	207.11	207.11
V2523	DMEPOS	CNTCT LENS HYDROPHIL EXTEND	176.50	176.50
V2524	DMEPOS	CNTCT LENS HYDROPHIL PHOTOCH	147.87	147.87
V2525	DMEPOS	CL, HYDROPHILIC, DUAL FOCUS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2526	DMEPOS	CNTCT LENS BLUE VIOLET	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2530	DMEPOS	CONTACT LENS GAS IMPERMEABLE	261.42	261.42
V2531	DMEPOS	CONTACT LENS GAS PERMEABLE	641.77	641.77
V2599	Other professional services	CONTACT LENS/ES OTHER TYPE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2600	Other professional services	HAND HELD LOW VISION AIDS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2610	Other professional services	SINGLE LENS SPECTACLE MOUNT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2615	Other professional services	TELESCOP/OTHR COMPOUND LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2623	DMEPOS	PLASTIC EYE PROSTH CUSTOM	1052.13	1052.13
V2624	DMEPOS	POLISHING ARTIFICAL EYE	71.36	71.36
V2625	DMEPOS	ENLARGEMNT OF EYE PROSTHESIS	462.20	462.20
V2626	DMEPOS	REDUCTION OF EYE PROSTHESIS	293.23	293.23
V2627	DMEPOS	SCLERAL COVER SHELL	1678.77	1678.77
V2628	DMEPOS	FABRICATION & FITTING	383.83	383.83
V2629	Other professional services	PROSTHETIC EYE OTHER TYPE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2630	DMEPOS	ANTER CHAMBER INTRAOCUL LENS	139.52	139.52
V2631	DMEPOS	IRIS SUPPORT INTRAOCLR LENS	139.52	139.52
V2632	DMEPOS	POST CHMBR INTRAOCULAR LENS	139.52	139.52
V2700	DMEPOS	BALANCE LENS	51.35	51.35
V2702	Other professional services	DELUXE LENS FEATURE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2710	DMEPOS	GLASS/PLASTIC SLAB OFF PRISM	75.15	75.15
V2715	DMEPOS	PRISM LENS/ES	13.63	13.63
V2718	DMEPOS	FRESNELL PRISM PRESS-ON LENS	33.47	33.47
V2730	DMEPOS	SPECIAL BASE CURVE	24.71	24.71
V2744	DMEPOS	TINT PHOTOCHROMATIC LENS/ES	25.64	25.64
V2745	DMEPOS	TINT, ANY COLOR/SOLID/GRAD	14.53	14.53
V2750	DMEPOS	ANTI-REFLECTIVE COATING	29.83	29.83
V2755	DMEPOS	UV LENS/ES	21.56	21.56
V2756	Other professional services	EYE GLASS CASE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2760	DMEPOS	SCRATCH RESISTANT COATING	18.77	18.77
V2761	Other professional services	MIRROR COATING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2762	DMEPOS	POLARIZATION, ANY LENS	70.66	70.66
V2770	DMEPOS	OCCLUDER LENS/ES	24.23	24.23
V2780	DMEPOS	OVERSIZE LENS/ES	19.58	19.58
V2781	Other professional services	PROGRESSIVE LENS PER LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2782	DMEPOS	LENS, 1.54-1.65 P/1.60-1.79G	76.29	76.29
V2783	DMEPOS	LENS, >= 1.66 P/>=1.80 G	86.03	86.03
V2784	DMEPOS	LENS POLYCARB OR EQUAL	55.94	55.94
V2785	Other professional services	CORNEAL TISSUE PROCESSING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2786	DMEPOS	OCCUPATIONAL MULTIFOCAL LENS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2787	Other professional services	ASTIGMATISM-CORRECT FUNCTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2788	Other professional services	PRESBYOPIA-CORRECT FUNCTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2790	Other professional services	AMNIOTIC MEMBRANE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2797	Other professional services	VIS ITEM/SVC IN OTHER CODE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V2799	Other professional services	MISC VISION ITEM OR SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5008	Other professional services	HEARING SCREENING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5010	Other professional services	ASSESSMENT FOR HEARING AID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5011	Other professional services	HEARING AID FITTING/CHECKING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5014	Other professional services	HEARING AID REPAIR/MODIFYING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5020	Other professional services	CONFORMITY EVALUATION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5030	Other professional services	BODY-WORN HEARING AID AIR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5040	Other professional services	BODY-WORN HEARING AID BONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5050	Other professional services	HEARING AID MONAURAL IN EAR	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5060	Other professional services	BEHIND EAR HEARING AID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5070	Other professional services	GLASSES AIR CONDUCTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5080	Other professional services	GLASSES BONE CONDUCTION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5090	Other professional services	HEARING AID DISPENSING FEE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5095	Other professional services	IMPLANT MID EAR HEARING PROS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5100	Other professional services	BODY-WORN BILAT HEARING AID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5110	Other professional services	HEARING AID DISPENSING FEE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5120	Other professional services	BODY-WORN BINAUR HEARING AID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5130	Other professional services	IN EAR BINAURAL HEARING AID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5140	Other professional services	BEHIND EAR BINAUR HEARING AI	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5150	Other professional services	GLASSES BINAURAL HEARING AID	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5160	Other professional services	DISPENSING FEE BINAURAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5171	Other professional services	HEARING AID MONAURAL ITE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5172	Other professional services	HEARING AID MONAURAL ITC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5181	Other professional services	HEARING AID MONAURAL BTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5190	Other professional services	HEARING AID MONAURAL GLASSES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5200	Other professional services	DISP FEE CONTRALATERAL MONAU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5211	Other professional services	HEARING AID BINAURAL ITE/ITE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5212	Other professional services	HEARING AID BINAURAL ITE/ITC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5213	Other professional services	HEARING AID BINAURAL ITE/BTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5214	Other professional services	HEARING AID BINAURAL ITC/ITC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5215	Other professional services	HEARING AID BINAURAL ITC/BTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5221	Other professional services	HEARING AID BINAURAL BTE/BTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5230	Other professional services	HEARING AID BINAURAL GLASSES	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5240	Other professional services	DISP FEE CONTRALATERAL BINAU	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5241	Other professional services	DISPENSING FEE, MONAURAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5242	Other professional services	HEARING AID, MONAURAL, CIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5243	Other professional services	HEARING AID, MONAURAL, ITC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5244	Other professional services	HEARING AID, PROG, MON, CIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5245	Other professional services	HEARING AID, PROG, MON, ITC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5246	Other professional services	HEARING AID, PROG, MON, ITE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5247	Other professional services	HEARING AID, PROG, MON, BTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5248	Other professional services	HEARING AID, BINAURAL, CIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5249	Other professional services	HEARING AID, BINAURAL, ITC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5250	Other professional services	HEARING AID, PROG, BIN, CIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5251	Other professional services	HEARING AID, PROG, BIN, ITC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5252	Other professional services	HEARING AID, PROG, BIN, ITE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5253	Other professional services	HEARING AID, PROG, BIN, BTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5254	Other professional services	HEARING ID, DIGIT, MON, CIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5255	Other professional services	HEARING AID, DIGIT, MON, ITC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5256	Other professional services	HEARING AID, DIGIT, MON, ITE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5257	Other professional services	HEARING AID, DIGIT, MON, BTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5258	Other professional services	HEARING AID, DIGIT, BIN, CIC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5259	Other professional services	HEARING AID, DIGIT, BIN, ITC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5260	Other professional services	HEARING AID, DIGIT, BIN, ITE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5261	Other professional services	HEARING AID, DIGIT, BIN, BTE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5262	Other professional services	HEARING AID, DISP, MONAURAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5263	Other professional services	HEARING AID, DISP, BINAURAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5264	Other professional services	EAR MOLD/INSERT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5265	Other professional services	EAR MOLD/INSERT, DISP	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5266	Other professional services	BATTERY FOR HEARING DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5267	Other professional services	HEARING AID SUP/ACCESS/DEV	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5268	Other professional services	ALD TELEPHONE AMPLIFIER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5269	Other professional services	ALERTING DEVICE, ANY TYPE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5270	Other professional services	ALD, TV AMPLIFIER, ANY TYPE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5271	Other professional services	ALD, TV CAPTION DECODER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5272	Other professional services	TDD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5273	Other professional services	ALD FOR COCHLEAR IMPLANT	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5274	Other professional services	ALD UNSPECIFIED	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5275	Other professional services	EAR IMPRESSION	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5281	Other professional services	ALD FM/DM SYSTEM, MONAURAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5282	Other professional services	ALD FM/DM SYSTEM BINAURAL	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5283	Other professional services	ALD NECK, LOOP IND RECEIVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5284	Other professional services	ALD FM/DM EAR LEVEL RECEIVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5285	Other professional services	ALD FM/DM AUD INPUT RECEIVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5286	Other professional services	ALD BLU TOOTH FM/DM RECEIVER	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5287	Other professional services	ALD FM/DM RECEIVER, NOS	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5288	Other professional services	ALD FM/DM TRANSMITTER ALD	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5289	Other professional services	ALD FM/DM ADAPT/BOOT COUPLIN	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5290	Other professional services	ALD TRANSMITTER MICROPHONE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5298	Other professional services	HEARING AID NOC	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5299	Other professional services	HEARING SERVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5336	Other professional services	REPAIR COMMUNICATION DEVICE	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5362	Other professional services	SPEECH SCREENING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5363	Other professional services	LANGUAGE SCREENING	UCR or Pay Per Agreement	UCR or Pay Per Agreement
V5364	Other professional services	DYSPHAGIA SCREENING	UCR or Pay Per Agreement	UCR or Pay Per Agreement

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Workers' Compensation Fee Schedule
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North Carolina Industrial CommissionWorkers' Compensation Fee ScheduleFees Effective January 1, 2024

North Carolina Industrial Commission
Workers' Compensation Fee Schedule
Fees Effective January 1, 2024