2020 Other Codes Fee Schedule

This schedule is not a guaranty of payment. Variances in reimbursement may occur due to rounding calculations. Services represented are subject to

provisions of the health plan including, but not limited to, membership eligibility, premium payment, claim payment logic, provider contract terms and conditions, applicable medical policy and benefits, limitations and exclusions. Maximum allowables and components of rates such as modifiers or conversion factors, and applicable rules such as bundling, may change from time to time subject to notice requirements of applicable law and regulation and the prevailing provider agreement. Values reflect the component of a code related to the place of treatment. CPT codes are copyright American Medical Association. All Rights Reserved. BCBSTX - HCSC Confidential and Proprietary.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

Page 1 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 10012 $144.16 3/1/20 15824 $424.82 3/1/20 15825 $367.02 3/1/20 15826 $306.22 3/1/20 15828 $1,044.37 3/1/20 15829 $1,044.37 3/1/20 15847 $410.57 3/1/20 15876 $251.99 3/1/20 15877 $450.01 3/1/20 15878 $251.99 3/1/20 15879 $450.01 3/1/20 17380 $23.83 3/1/20 20930 $312.44 3/1/20 20936 $404.41 3/1/20 21088 $433.31 3/1/20 21742 $1,187.35 3/1/20 21743 $1,278.83 3/1/20

22841 $1,053.15 3/1/20 24940 $609.70 3/1/20 32850 $612.44 3/1/20 32855 $1,685.29 3/1/20 32856 $1,845.80 3/1/20 33928 $2,033.20 3/1/20 33929 $2,382.91 3/1/20 33930 $864.15 3/1/20 33933 $2,086.55 3/1/20 33940 $756.23 3/1/20 33944 $1,444.54 3/1/20 34839 $183.51 3/1/20 34841 $1,918.51 3/1/20 34844 $2,567.15 3/1/20 34845 $1,932.92 3/1/20 34846 $2,134.73 3/1/20 34847 $2,368.60 3/1/20 34848 $2,567.15 3/1/20 36415 26 $3.00 3/1/20 36415 TC $3.00 3/1/20 36415 $3.00 3/1/20 36416 26 $3.00 3/1/20 36416 TC $3.00 3/1/20 36416 $3.00 3/1/20 36468 $32.32 3/1/20 37195 $233.91 3/1/20 41820 $126.54 3/1/20 41821 $37.52 3/1/20 41850 $28.21 3/1/20 41870 $178.86 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 43496 $1,726.93 3/1/20 43647 $1,324.30 3/1/20 43648 $1,324.30 3/1/20 43881 $1,324.30 3/1/20 43882 $1,415.78 3/1/20 44132 $858.40 3/1/20 44133 $1,534.38 3/1/20 44135 $2,429.20 3/1/20 44136 $2,739.80 3/1/20 44137 $1,242.13 3/1/20 44715 $882.77 3/1/20 47133 $1,457.69 3/1/20 47143 $1,845.80 3/1/20 47144 $1,765.55 3/1/20 47145 $1,725.56 3/1/20 48160 $1,159.38 3/1/20 48550 $1,035.88 3/1/20

48551 $1,444.54 3/1/20 49906 $1,284.03 3/1/20 50300 $1,028.21 3/1/20 50323 $1,123.53 3/1/20 50325 $1,203.78 3/1/20 54440 $675.76 3/1/20 55970 $17,500.00 3/1/20 55980 $7,155.41 3/1/20 58974 $325.94 3/1/20 63043 $241.58 3/1/20 63044 $241.58 3/1/20 65757 $116.47 3/1/20 65760 $1,156.67 3/1/20 65765 $1,265.13 3/1/20 65767 $1,012.33 3/1/20 65771 $506.44 3/1/20 69090 $30.68 3/1/20 69710 $385.92 3/1/20 70555 TC $741.17 3/1/20 70555 $839.22 3/1/20 74235 TC $88.81 3/1/20 74235 $148.58 3/1/20 74300 TC $27.07 3/1/20 74300 $45.30 3/1/20 74301 TC $15.88 3/1/20 74301 $26.44 3/1/20 74328 TC $138.52 3/1/20 74328 $174.02 3/1/20 74329 TC $91.21 3/1/20 74329 $118.87 3/1/20

2020 Other Codes Fee Schedule

Page 2 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 74330 TC $138.52 3/1/20 74330 $183.88 3/1/20 74340 TC $115.21 3/1/20 74340 $142.29 3/1/20 74355 TC $115.21 3/1/20 74355 $153.21 3/1/20 74360 TC $138.52 3/1/20 74360 $166.51 3/1/20 74363 TC $86.20 3/1/20 74363 $129.15 3/1/20 74742 TC $45.38 3/1/20 74742 $76.29 3/1/20 75894 TC $95.96 3/1/20 75894 $167.30 3/1/20 75956 TC $270.34 3/1/20 75956 $270.34 3/1/20 75957 TC $231.72 3/1/20 75957 $231.72 3/1/20 75958 TC $154.20 3/1/20 75958 $154.20 3/1/20 75959 TC $135.31 3/1/20 75959 $135.31 3/1/20 75970 TC $506.00 3/1/20 75970 $545.80 3/1/20 76125 TC $34.61 3/1/20 76125 $48.63 3/1/20

76140 26 $12.60 3/1/20

76140 TC $12.60 3/1/20 76140 $12.60 3/1/20 76496 26 $62.35 3/1/20 76496 $62.35 3/1/20 76497 26 $62.35 3/1/20 76497 $62.35 3/1/20 76498 26 $62.35 3/1/20 76498 $62.35 3/1/20 76930 TC $39.72 3/1/20 76930 $65.46 3/1/20 76932 TC $67.60 3/1/20 76932 $100.72 3/1/20 76940 TC $77.54 3/1/20 76940 $179.88 3/1/20 76941 TC $66.95 3/1/20 76941 $135.93 3/1/20 76945 TC $66.95 3/1/20 76945 $101.61 3/1/20 76998 TC $115.21 3/1/20 76998 $177.95 3/1/20 77013 TC $416.19 3/1/20 77013 $608.50 3/1/20 77022 TC $542.93 3/1/20 77022 $759.13 3/1/20 77061 26 $64.15 3/1/20 77061 TC $149.67 3/1/20 77061 $213.82 3/1/20 77062 26 $65.45 3/1/20 77062 TC $152.72 3/1/20 77062 $218.17 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 77371 26 $828.27 3/1/20 77371 TC $828.27 3/1/20 77371 $828.27 3/1/20 77385 26 $391.67 3/1/20 77385 TC $391.67 3/1/20 77385 $391.67 3/1/20 77386 26 $783.35 3/1/20 77386 TC $783.35 3/1/20 77386 $783.35 3/1/20 77387 26 $33.69 3/1/20 77387 TC $55.88 3/1/20 77387 $89.56 3/1/20 77402 26 $107.09 3/1/20 77402 TC $107.09 3/1/20 77402 $107.09 3/1/20 77407 26 $194.47 3/1/20 77407 TC $194.47 3/1/20 77407 $194.47 3/1/20 77412 26 $184.61 3/1/20 77412 TC $184.61 3/1/20 77412 $184.61 3/1/20 77423 26 $50.12 3/1/20 77423 TC $50.12 3/1/20 77423 $50.12 3/1/20 77424 26 $183.51 3/1/20 77424 TC $183.51 3/1/20

77424 $183.51 3/1/20

77425 26 $198.85 3/1/20 77425 TC $198.85 3/1/20 77425 $198.85 3/1/20 77520 26 $780.55 3/1/20 77520 TC $780.55 3/1/20 77520 $786.41 3/1/20 77522 26 $780.55 3/1/20 77522 TC $780.55 3/1/20 77522 $780.55 3/1/20 77523 26 $270.90 3/1/20 77523 TC $632.11 3/1/20 77523 $903.01 3/1/20 77525 26 $305.88 3/1/20 77525 TC $713.71 3/1/20 77525 $1,019.59 3/1/20 78414 TC $235.00 3/1/20 78414 $252.26 3/1/20 79300 TC $170.09 3/1/20 79300 $222.41 3/1/20 79445 TC $76.14 3/1/20 79445 $165.43 3/1/20 80050 26 $26.84 3/1/20 80050 TC $26.84 3/1/20 80050 $26.84 3/1/20 80320 26 $0.00 3/1/20 80320 TC $0.00 3/1/20 80320 $0.00 3/1/20 80321 26 $0.00 3/1/20 80321 TC $0.00 3/1/20 80321 $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 3 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 80322 26 $0.00 3/1/20 80322 TC $0.00 3/1/20 80322 $0.00 3/1/20 80323 26 $0.00 3/1/20 80323 TC $0.00 3/1/20 80323 $0.00 3/1/20 80324 26 $0.00 3/1/20 80324 TC $0.00 3/1/20 80324 $0.00 3/1/20 80325 26 $0.00 3/1/20 80325 TC $0.00 3/1/20 80325 $0.00 3/1/20 80326 26 $0.00 3/1/20 80326 TC $0.00 3/1/20 80326 $0.00 3/1/20 80327 26 $0.00 3/1/20 80327 TC $0.00 3/1/20 80327 $0.00 3/1/20 80328 26 $0.00 3/1/20 80328 TC $0.00 3/1/20 80328 $0.00 3/1/20 80329 26 $0.00 3/1/20 80329 TC $0.00 3/1/20 80329 $0.00 3/1/20 80330 26 $0.00 3/1/20 80330 TC $0.00 3/1/20

80330 $0.00 3/1/20

80331 26 $0.00 3/1/20 80331 TC $0.00 3/1/20 80331 $0.00 3/1/20 80332 26 $0.00 3/1/20 80332 TC $0.00 3/1/20 80332 $0.00 3/1/20 80333 26 $0.00 3/1/20 80333 TC $0.00 3/1/20 80333 $0.00 3/1/20 80334 26 $0.00 3/1/20 80334 TC $0.00 3/1/20 80334 $0.00 3/1/20 80335 26 $0.00 3/1/20 80335 TC $0.00 3/1/20 80335 $0.00 3/1/20 80336 26 $0.00 3/1/20 80336 TC $0.00 3/1/20 80336 $0.00 3/1/20 80337 26 $0.00 3/1/20 80337 TC $0.00 3/1/20 80337 $0.00 3/1/20 80338 26 $0.00 3/1/20 80338 TC $0.00 3/1/20 80338 $0.00 3/1/20 80339 26 $0.00 3/1/20 80339 TC $0.00 3/1/20 80339 $0.00 3/1/20 80340 26 $0.00 3/1/20 80340 TC $0.00 3/1/20 80340 $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 80341 26 $0.00 3/1/20 80341 TC $0.00 3/1/20 80341 $0.00 3/1/20 80342 26 $0.00 3/1/20 80342 TC $0.00 3/1/20 80342 $0.00 3/1/20 80343 26 $0.00 3/1/20 80343 TC $0.00 3/1/20 80343 $0.00 3/1/20 80344 26 $0.00 3/1/20 80344 TC $0.00 3/1/20 80344 $0.00 3/1/20 80345 26 $0.00 3/1/20 80345 TC $0.00 3/1/20 80345 $0.00 3/1/20 80346 26 $0.00 3/1/20 80346 TC $0.00 3/1/20 80346 $0.00 3/1/20 80347 26 $0.00 3/1/20 80347 TC $0.00 3/1/20 80347 $0.00 3/1/20 80348 26 $0.00 3/1/20 80348 TC $0.00 3/1/20 80348 $0.00 3/1/20 80349 26 $0.00 3/1/20 80349 TC $0.00 3/1/20

80349 $0.00 3/1/20

80350 26 $0.00 3/1/20 80350 TC $0.00 3/1/20 80350 $0.00 3/1/20 80351 26 $0.00 3/1/20 80351 TC $0.00 3/1/20 80351 $0.00 3/1/20 80352 26 $0.00 3/1/20 80352 TC $0.00 3/1/20 80352 $0.00 3/1/20 80353 26 $0.00 3/1/20 80353 TC $0.00 3/1/20 80353 $0.00 3/1/20 80354 26 $0.00 3/1/20 80354 TC $0.00 3/1/20 80354 $0.00 3/1/20 80355 26 $0.00 3/1/20 80355 TC $0.00 3/1/20 80355 $0.00 3/1/20 80356 26 $0.00 3/1/20 80356 TC $0.00 3/1/20 80356 $0.00 3/1/20 80357 26 $0.00 3/1/20 80357 TC $0.00 3/1/20 80357 $0.00 3/1/20 80358 26 $0.00 3/1/20 80358 TC $0.00 3/1/20 80358 $0.00 3/1/20 80359 26 $0.00 3/1/20 80359 TC $0.00 3/1/20 80359 $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 4 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 80360 26 $0.00 3/1/20 80360 TC $0.00 3/1/20 80360 $0.00 3/1/20 80361 26 $0.00 3/1/20 80361 TC $0.00 3/1/20 80361 $0.00 3/1/20 80362 26 $0.00 3/1/20 80362 TC $0.00 3/1/20 80362 $0.00 3/1/20 80363 26 $0.00 3/1/20 80363 TC $0.00 3/1/20 80363 $0.00 3/1/20 80364 26 $0.00 3/1/20 80364 TC $0.00 3/1/20 80364 $0.00 3/1/20 80365 26 $0.00 3/1/20 80365 TC $0.00 3/1/20 80365 $0.00 3/1/20 80366 26 $0.00 3/1/20 80366 TC $0.00 3/1/20 80366 $0.00 3/1/20 80367 26 $0.00 3/1/20 80367 TC $0.00 3/1/20 80367 $0.00 3/1/20 80368 26 $0.00 3/1/20 80368 TC $0.00 3/1/20

80368 $0.00 3/1/20

80369 26 $0.00 3/1/20 80369 TC $0.00 3/1/20 80369 $0.00 3/1/20 80370 26 $0.00 3/1/20 80370 TC $0.00 3/1/20 80370 $0.00 3/1/20 80371 26 $0.00 3/1/20 80371 TC $0.00 3/1/20 80371 $0.00 3/1/20 80372 26 $0.00 3/1/20 80372 TC $0.00 3/1/20 80372 $0.00 3/1/20 80373 26 $0.00 3/1/20 80373 TC $0.00 3/1/20 80373 $0.00 3/1/20 80374 26 $0.00 3/1/20 80374 TC $0.00 3/1/20 80374 $0.00 3/1/20 80375 26 $0.00 3/1/20 80375 TC $0.00 3/1/20 80375 $0.00 3/1/20 80376 26 $0.00 3/1/20 80376 TC $0.00 3/1/20 80376 $0.00 3/1/20 80377 26 $0.00 3/1/20 80377 TC $0.00 3/1/20 80377 $0.00 3/1/20 81479 26 $38.47 3/1/20 81479 TC $25.65 3/1/20 81479 $67.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 83992 26 $19.45 3/1/20 83992 TC $19.45 3/1/20 83992 $19.45 3/1/20 86485 26 $5.75 3/1/20 86485 TC $5.75 3/1/20 86485 $5.75 3/1/20 86860 26 $21.36 3/1/20 86860 TC $21.36 3/1/20 86860 $21.36 3/1/20 86870 26 $7.94 3/1/20 86870 TC $7.94 3/1/20 86870 $7.94 3/1/20 86890 26 $29.58 3/1/20 86890 TC $29.58 3/1/20 86890 $29.58 3/1/20 86891 26 $40.81 3/1/20 86891 TC $40.81 3/1/20 86891 $40.81 3/1/20 86910 26 $39.72 3/1/20 86910 TC $39.72 3/1/20 86910 $39.72 3/1/20 86911 26 $9.04 3/1/20 86911 TC $9.04 3/1/20 86911 $9.04 3/1/20 86920 26 $9.86 3/1/20 86920 TC $9.86 3/1/20

86920 $9.86 3/1/20

86921 26 $11.50 3/1/20 86921 TC $11.50 3/1/20 86921 $11.50 3/1/20 86922 26 $11.50 3/1/20 86922 TC $11.50 3/1/20 86922 $11.50 3/1/20 86923 26 $11.23 3/1/20 86923 TC $11.23 3/1/20 86923 $11.23 3/1/20 86927 26 $9.86 3/1/20 86927 TC $9.86 3/1/20 86927 $9.86 3/1/20 86930 26 $69.30 3/1/20 86930 TC $69.30 3/1/20 86930 $69.30 3/1/20 86931 26 $69.30 3/1/20 86931 TC $69.30 3/1/20 86931 $69.30 3/1/20 86932 26 $71.49 3/1/20 86932 TC $71.49 3/1/20 86932 $71.49 3/1/20 86945 26 $16.71 3/1/20 86945 TC $16.71 3/1/20 86945 $16.71 3/1/20 86950 26 $44.37 3/1/20 86950 TC $44.37 3/1/20 86950 $44.37 3/1/20 86960 26 $18.35 3/1/20 86960 TC $18.35 3/1/20 86960 $18.35 3/1/20

2020 Other Codes Fee Schedule

Page 5 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 86965 26 $12.60 3/1/20 86965 TC $12.60 3/1/20 86965 $12.60 3/1/20 86970 26 $19.72 3/1/20 86970 TC $19.72 3/1/20 86970 $19.72 3/1/20 86971 26 $9.86 3/1/20 86971 TC $9.86 3/1/20 86971 $9.86 3/1/20 86972 26 $9.86 3/1/20 86972 TC $9.86 3/1/20 86972 $9.86 3/1/20 86975 26 $24.10 3/1/20 86975 TC $24.10 3/1/20 86975 $24.10 3/1/20 86976 26 $24.10 3/1/20 86976 TC $24.10 3/1/20 86976 $24.10 3/1/20 86977 26 $24.10 3/1/20 86977 TC $24.10 3/1/20 86977 $24.10 3/1/20 86978 26 $30.95 3/1/20 86978 TC $30.95 3/1/20 86978 $30.95 3/1/20 86985 26 $14.79 3/1/20 86985 TC $14.79 3/1/20

86985 $14.79 3/1/20

87804 26 $16.55 3/1/20 87804 TC $16.55 3/1/20 87804 $16.55 3/1/20 88000 26 $328.40 3/1/20 88000 TC $328.40 3/1/20 88000 $328.40 3/1/20 88005 26 $369.49 3/1/20 88005 TC $369.49 3/1/20 88005 $369.49 3/1/20 88007 26 $410.57 3/1/20 88007 TC $410.57 3/1/20 88007 $410.57 3/1/20 88012 26 $344.56 3/1/20 88012 TC $344.56 3/1/20 88012 $344.56 3/1/20 88014 26 $344.56 3/1/20 88014 TC $344.56 3/1/20 88014 $344.56 3/1/20 88016 26 $328.40 3/1/20 88016 TC $328.40 3/1/20 88016 $328.40 3/1/20 88020 26 $410.57 3/1/20 88020 TC $410.57 3/1/20 88020 $410.57 3/1/20 88025 26 $451.38 3/1/20 88025 TC $451.38 3/1/20 88025 $451.38 3/1/20 88027 26 $492.74 3/1/20 88027 TC $492.74 3/1/20 88027 $492.74 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 88028 26 $426.73 3/1/20 88028 TC $426.73 3/1/20 88028 $426.73 3/1/20 88029 26 $426.73 3/1/20 88029 TC $426.73 3/1/20 88029 $426.73 3/1/20 88036 26 $353.33 3/1/20 88036 TC $353.33 3/1/20 88036 $353.33 3/1/20 88037 26 $287.05 3/1/20 88037 TC $287.05 3/1/20 88037 $287.05 3/1/20 88040 26 $1,067.38 3/1/20 88040 TC $1,067.38 3/1/20 88040 $1,067.38 3/1/20 89250 26 $370.04 3/1/20 89250 TC $370.04 3/1/20 89250 $370.04 3/1/20 89251 26 $44.80 3/1/20 89251 TC $67.20 3/1/20 89251 $112.00 3/1/20 89253 26 $342.05 3/1/20 89253 TC $228.03 3/1/20 89253 $570.08 3/1/20 89254 26 $345.04 3/1/20 89254 TC $230.03 3/1/20

89254 $575.07 3/1/20

89255 26 $196.34 3/1/20 89255 TC $130.90 3/1/20 89255 $327.24 3/1/20 89257 26 $630.00 3/1/20 89257 TC $420.00 3/1/20 89257 $1,050.00 3/1/20 89258 26 $284.15 3/1/20 89258 TC $189.44 3/1/20 89258 $473.59 3/1/20 89259 26 $142.16 3/1/20 89259 TC $94.78 3/1/20 89259 $236.94 3/1/20 89260 26 $61.12 3/1/20 89260 TC $40.74 3/1/20 89260 $101.86 3/1/20 89261 26 $91.28 3/1/20 89261 TC $60.86 3/1/20 89261 $152.14 3/1/20 89264 26 $473.25 3/1/20 89264 TC $315.50 3/1/20 89264 $788.75 3/1/20 89268 26 $411.39 3/1/20 89268 TC $274.26 3/1/20 89268 $685.65 3/1/20 89272 26 $421.79 3/1/20 89272 TC $281.19 3/1/20 89272 $702.98 3/1/20 89280 26 $605.80 3/1/20 89280 TC $403.87 3/1/20 89280 $1,009.67 3/1/20

2020 Other Codes Fee Schedule

Page 6 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 89281 26 $836.16 3/1/20 89281 TC $557.44 3/1/20 89281 $1,393.60 3/1/20 89290 26 $519.11 3/1/20 89290 TC $346.07 3/1/20 89290 $865.18 3/1/20 89291 26 $684.38 3/1/20 89291 TC $456.25 3/1/20 89291 $1,140.63 3/1/20 89335 26 $352.00 3/1/20 89335 TC $528.00 3/1/20 89335 $880.00 3/1/20 89337 26 $517.50 3/1/20 89337 TC $345.00 3/1/20 89337 $862.50 3/1/20 89342 26 $161.98 3/1/20 89342 TC $107.98 3/1/20 89342 $269.96 3/1/20 89343 26 $115.20 3/1/20 89343 TC $76.80 3/1/20 89343 $192.00 3/1/20 89344 26 $70.40 3/1/20 89344 TC $105.60 3/1/20 89344 $176.00 3/1/20 89346 26 $70.40 3/1/20 89346 TC $105.60 3/1/20

89346 $176.00 3/1/20

89352 26 $224.86 3/1/20 89352 TC $149.90 3/1/20 89352 $374.76 3/1/20 89353 26 $25.13 3/1/20 89353 TC $16.75 3/1/20 89353 $41.88 3/1/20 89354 26 $16.80 3/1/20 89354 TC $25.20 3/1/20 89354 $42.00 3/1/20 89356 26 $25.20 3/1/20 89356 TC $16.80 3/1/20 89356 $42.00 3/1/20 90460 $19.65 3/1/20 90461 $9.83 3/1/20 90471 $15.72 3/1/20 90472 $7.86 3/1/20 90473 $15.72 3/1/20 90474 $7.86 3/1/20 90867 $450.65 3/1/20 90868 $269.29 3/1/20 90869 $533.23 3/1/20 90882 $0.82 3/1/20 90889 $0.82 3/1/20 90899 $46.86 3/1/20 90940 26 $21.00 3/1/20 90940 TC $21.00 3/1/20 90940 $21.00 3/1/20 90952 $458.78 3/1/20 90953 $345.11 3/1/20 90989 $141.88 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 90993 $34.24 3/1/20 92531 26 $8.22 3/1/20 92531 TC $8.22 3/1/20 92531 $8.22 3/1/20 92532 26 $10.96 3/1/20 92532 TC $10.96 3/1/20 92532 $10.96 3/1/20 92533 26 $6.57 3/1/20 92533 TC $6.57 3/1/20 92533 $6.57 3/1/20 92534 26 $3.29 3/1/20 92534 TC $3.29 3/1/20 92534 $3.29 3/1/20 92558 26 $7.67 3/1/20 92558 TC $7.67 3/1/20 92559 26 $11.50 3/1/20 92559 TC $11.50 3/1/20 92559 $11.50 3/1/20 92560 26 $6.57 3/1/20 92560 TC $6.57 3/1/20 92560 $6.57 3/1/20 92585 26 $27.39 3/1/20 92585 TC $109.92 3/1/20 92585 $137.31 3/1/20 92586 26 $94.06 3/1/20 92586 TC $94.06 3/1/20

92586 $94.06 3/1/20

92587 26 $18.74 3/1/20 92587 TC $3.60 3/1/20 92587 $22.34 3/1/20 92588 26 $29.55 3/1/20 92588 TC $4.32 3/1/20 92588 $33.88 3/1/20 92590 26 $35.61 3/1/20 92590 TC $35.61 3/1/20 92590 $35.61 3/1/20 92591 26 $53.41 3/1/20 92591 TC $53.41 3/1/20 92591 $53.41 3/1/20 92592 26 $13.15 3/1/20 92592 TC $13.15 3/1/20 92592 $13.15 3/1/20 92593 26 $19.17 3/1/20 92593 TC $19.17 3/1/20 92593 $19.17 3/1/20 92594 26 $13.15 3/1/20 92594 TC $13.15 3/1/20 92594 $13.15 3/1/20 92595 26 $19.17 3/1/20 92595 TC $19.17 3/1/20 92595 $19.17 3/1/20 92630 $108.92 3/1/20 92633 $128.05 3/1/20 92921 $201.04 3/1/20 92925 $241.30 3/1/20 92929 $221.31 3/1/20 92934 $249.52 3/1/20

2020 Other Codes Fee Schedule

Page 7 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 92938 $201.04 3/1/20 92944 $241.30 3/1/20 92978 TC $131.20 3/1/20 92978 $207.61 3/1/20 92979 TC $66.83 3/1/20 92979 $127.64 3/1/20 92992 $1,277.46 3/1/20 92993 $1,355.80 3/1/20 93299 26 $27.10 3/1/20 93299 TC $18.07 3/1/20 93299 $39.90 3/1/20 93317 TC $164.61 3/1/20 93317 $236.92 3/1/20 93530 TC $18.00 3/1/20 93530 $24.01 3/1/20 93531 TC $51.47 3/1/20 93531 $63.90 3/1/20 93532 TC $1,352.23 3/1/20 93532 $1,775.95 3/1/20 93533 TC $1,359.63 3/1/20 93533 $1,642.57 3/1/20 93561 TC $15.34 3/1/20 93561 $51.22 3/1/20 93562 TC $9.86 3/1/20 93562 $38.89 3/1/20 93571 TC $146.26 3/1/20

93571 $207.61 3/1/20

93572 TC $77.79 3/1/20 93572 $127.36 3/1/20 93600 TC $57.52 3/1/20 93600 $152.01 3/1/20 93602 TC $31.77 3/1/20 93602 $124.35 3/1/20 93603 TC $48.21 3/1/20 93603 $141.06 3/1/20 93609 TC $79.16 3/1/20 93609 $301.01 3/1/20 93610 TC $39.44 3/1/20 93610 $170.09 3/1/20 93612 TC $47.11 3/1/20 93612 $176.39 3/1/20 93615 TC $9.59 3/1/20 93615 $39.44 3/1/20 93616 TC $10.96 3/1/20 93616 $57.79 3/1/20 93618 TC $115.58 3/1/20 93618 $291.70 3/1/20 93619 TC $224.32 3/1/20 93619 $535.74 3/1/20 93620 TC $456.59 3/1/20 93620 $957.00 3/1/20 93621 TC $457.41 3/1/20 93621 $550.26 3/1/20 93622 TC $456.31 3/1/20 93622 $593.81 3/1/20 93623 TC $23.01 3/1/20 93623 $149.27 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 93624 TC $63.82 3/1/20 93624 $256.64 3/1/20 93631 TC $186.25 3/1/20 93631 $500.96 3/1/20 93640 TC $208.44 3/1/20 93640 $350.86 3/1/20 93641 TC $208.16 3/1/20 93641 $457.41 3/1/20 93655 26 $339.63 3/1/20 93655 TC $339.63 3/1/20 93662 TC $114.49 3/1/20 93662 $225.97 3/1/20 93745 26 $17.51 3/1/20 93745 TC $40.83 3/1/20 93745 $58.33 3/1/20 93895 26 $4.61 3/1/20 93895 TC $4.61 3/1/20 93895 $4.61 3/1/20 94642 $71.49 3/1/20 94772 26 $76.63 3/1/20 94772 TC $51.08 3/1/20 94772 $127.71 3/1/20 94774 26 $125.45 3/1/20 94774 TC $83.63 3/1/20 94774 $209.08 3/1/20 94776 26 $171.50 3/1/20

94776 TC $171.50 3/1/20

94776 $171.50 3/1/20 94777 26 $27.60 3/1/20 94777 TC $18.40 3/1/20 94777 $46.00 3/1/20 95120 $25.20 3/1/20 95125 $33.42 3/1/20 95130 $13.97 3/1/20 95131 $19.72 3/1/20 95132 $22.73 3/1/20 95133 $25.47 3/1/20 95134 $28.49 3/1/20 95249 26 $42.73 3/1/20 95249 TC $42.73 3/1/20 95824 TC $63.54 3/1/20 95824 $94.49 3/1/20 95941 26 $140.78 3/1/20 95941 TC $140.78 3/1/20 95941 $140.78 3/1/20 95943 26 $46.89 3/1/20 95943 TC $42.94 3/1/20 95943 $89.83 3/1/20 95951 TC $1,331.68 3/1/20 95951 $1,652.35 3/1/20 95965 TC $3,196.94 3/1/20 95965 $3,527.53 3/1/20 95966 TC $882.23 3/1/20 95966 $1,049.58 3/1/20 95967 TC $582.03 3/1/20 95967 $728.29 3/1/20 96020 TC $43.82 3/1/20

2020 Other Codes Fee Schedule

Page 8 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 96020 $171.73 3/1/20 96376 $17.53 3/1/20 97039 $8.49 3/1/20 97139 $11.50 3/1/20 97151 $7.81 3/1/20 97152 $20.00 3/1/20 97153 $15.00 3/1/20 97154 $12.10 3/1/20 97155 $24.21 3/1/20 97156 $23.08 3/1/20 97157 $5.13 3/1/20 97158 $5.13 3/1/20 97169 $39.17 3/1/20 97170 $61.08 3/1/20 97171 $119.42 3/1/20 97172 $39.17 3/1/20 97545 $71.21 3/1/20 97546 $35.88 3/1/20 97602 $45.74 3/1/20 97607 $42.14 3/1/20 97608 $49.86 3/1/20 98969 $24.10 3/1/20 99000 26 $9.31 3/1/20 99000 TC $9.31 3/1/20 99000 $9.31 3/1/20 99001 26 $4.66 3/1/20

99001 TC $4.66 3/1/20

99001 $4.66 3/1/20 99002 $4.66 3/1/20 99024 $9.62 3/1/20 99026 $35.33 3/1/20 99027 $17.53 3/1/20 99050 $16.83 3/1/20 99051 $16.83 3/1/20 99053 $0.00 3/1/20 99056 $0.00 3/1/20 99058 $16.83 3/1/20 99060 $0.00 3/1/20 99070 $14.01 3/1/20 99071 $3.71 3/1/20 99075 $104.08 3/1/20 99078 $42.47 3/1/20 99080 $18.52 3/1/20 99082 $45.69 3/1/20 99172 $36.43 3/1/20 99190 $273.35 3/1/20 99191 $203.23 3/1/20 99192 $135.31 3/1/20 99288 $119.15 3/1/20 99367 $100.00 3/1/20 99368 $150.00 3/1/20 99444 $24.10 3/1/20 99450 $136.13 3/1/20 99455 $186.25 3/1/20 99456 $214.74 3/1/20 99500 $63.82 3/1/20 99501 $36.43 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 99502 $36.43 3/1/20 99503 $36.43 3/1/20 99504 $36.43 3/1/20 99505 $36.43 3/1/20 99506 $36.43 3/1/20 99507 $36.43 3/1/20 99509 $36.43 3/1/20 99510 $36.43 3/1/20 99511 $36.43 3/1/20 99512 $36.43 3/1/20 99601 $91.21 3/1/20 99602 $45.74 3/1/20 99605 $16.16 3/1/20 99606 $12.05 3/1/20 99607 $7.94 3/1/20 0001F 26 $0.00 3/1/20 0001F TC $0.00 3/1/20 0001F $0.00 3/1/20 0005F 26 $0.00 3/1/20 0005F TC $0.00 3/1/20 0005F $0.00 3/1/20 0012F $0.00 3/1/20 0014F $0.00 3/1/20 0015F $0.00 3/1/20 0018U 26 $38.47 3/1/20 0018U TC $25.65 3/1/20

0018U $67.00 3/1/20

0019U 26 $38.47 3/1/20 0019U TC $25.65 3/1/20 0019U $67.00 3/1/20 0021U 26 $38.47 3/1/20 0021U TC $25.65 3/1/20 0021U $67.00 3/1/20 0022U 26 $38.47 3/1/20 0022U TC $25.65 3/1/20 0022U $67.00 3/1/20 0023U 26 $38.47 3/1/20 0023U TC $25.65 3/1/20 0023U $67.00 3/1/20 0035U 26 $14.32 3/1/20 0035U TC $14.32 3/1/20 0035U $14.32 3/1/20 0042T 26 $42.00 3/1/20 0042T TC $98.00 3/1/20 0042T $140.00 3/1/20 0048U 26 $5.73 3/1/20 0048U TC $3.82 3/1/20 0048U $9.55 3/1/20 0050U 26 $5.73 3/1/20 0050U TC $3.82 3/1/20 0050U $9.55 3/1/20 0054T $615.00 3/1/20 0055T $500.00 3/1/20 0071T 26 $2,785.71 3/1/20 0071T TC $6,500.00 3/1/20 0071T $9,285.71 3/1/20 0072T 26 $3,750.00 3/1/20

2020 Other Codes Fee Schedule

Page 9 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 0072T TC $8,750.00 3/1/20 0072T $12,500.00 3/1/20 0075T 26 $212.16 3/1/20 0075T TC $848.65 3/1/20 0075T $1,060.81 3/1/20 0076T 26 $193.88 3/1/20 0076T TC $775.53 3/1/20 0076T $969.42 3/1/20 0078U 26 $38.47 3/1/20 0078U TC $25.65 3/1/20 0078U $67.00 3/1/20 0079U 26 $38.47 3/1/20 0079U TC $25.65 3/1/20 0079U $67.00 3/1/20 0080U 26 $2,871.00 3/1/20 0080U TC $2,871.00 3/1/20 0080U $2,871.00 3/1/20 0081U 26 $520.00 3/1/20 0081U TC $520.00 3/1/20 0081U $520.00 3/1/20 0082U 26 $0.00 3/1/20 0082U TC $0.00 3/1/20 0082U $0.00 3/1/20 0084U 26 $720.00 3/1/20 0084U TC $720.00 3/1/20 0084U $720.00 3/1/20

0085T 26 $16.84 3/1/20

0085T TC $16.84 3/1/20 0085T $16.84 3/1/20 0085U 26 $119.40 3/1/20 0085U TC $79.60 3/1/20 0085U $199.00 3/1/20 0086U 26 $20.46 3/1/20 0086U TC $20.46 3/1/20 0086U $20.46 3/1/20 0087U 26 $3,300.00 3/1/20 0087U TC $2,200.00 3/1/20 0087U $5,500.00 3/1/20 0088U 26 $3,300.00 3/1/20 0088U TC $2,200.00 3/1/20 0088U $5,500.00 3/1/20 0089U 26 $780.00 3/1/20 0089U TC $520.00 3/1/20 0089U $1,300.00 3/1/20 0090U 26 $1,170.00 3/1/20 0090U TC $780.00 3/1/20 0090U $1,950.00 3/1/20 0091U 26 $273.00 3/1/20 0091U TC $273.00 3/1/20 0091U $273.00 3/1/20 0092U 26 $2,871.00 3/1/20 0092U TC $2,871.00 3/1/20 0092U $2,871.00 3/1/20 0093U 26 $205.63 3/1/20 0093U TC $205.63 3/1/20 0093U $205.63 3/1/20 0094U 26 $5.73 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 0094U TC $3.82 3/1/20 0094U $9.55 3/1/20 0095T $208.82 3/1/20 0095U 26 $64.19 3/1/20 0095U TC $64.19 3/1/20 0095U $64.19 3/1/20 0096U 26 $38.99 3/1/20 0096U TC $38.99 3/1/20 0096U $38.99 3/1/20 0097U 26 $217.82 3/1/20 0097U TC $145.22 3/1/20 0097U $363.04 3/1/20 0098T $208.82 3/1/20 0098U 26 $148.69 3/1/20 0098U TC $99.13 3/1/20 0098U $247.82 3/1/20 0099U 26 $165.21 3/1/20 0099U TC $110.14 3/1/20 0099U $275.35 3/1/20 0100T $684.05 3/1/20 0100U 26 $179.16 3/1/20 0100U TC $119.44 3/1/20 0100U $298.60 3/1/20 0101T $1,500.00 3/1/20 0101U 26 $649.89 3/1/20 0101U TC $649.89 3/1/20

0101U $649.89 3/1/20

0102T $1,500.00 3/1/20 0102U 26 $487.70 3/1/20 0102U TC $487.70 3/1/20 0102U $487.70 3/1/20 0103U 26 $487.70 3/1/20 0103U TC $487.70 3/1/20 0103U $487.70 3/1/20 0105U 26 $15.69 3/1/20 0105U TC $15.69 3/1/20 0105U $15.69 3/1/20 0106U 26 $24.11 3/1/20 0106U TC $24.11 3/1/20 0106U $24.11 3/1/20 0107U 26 $13.32 3/1/20 0107U TC $13.32 3/1/20 0107U $13.32 3/1/20 0108U 26 $40.97 3/1/20 0108U TC $262.99 3/1/20 0108U $303.96 3/1/20 0109U 26 $13.32 3/1/20 0109U TC $13.32 3/1/20 0109U $13.32 3/1/20 0110U 26 $64.65 3/1/20 0110U TC $64.65 3/1/20 0110U $64.65 3/1/20 0111T 26 $21.45 3/1/20 0111T TC $21.45 3/1/20 0111T $21.45 3/1/20 0111U 26 $193.25 3/1/20 0111U TC $193.25 3/1/20

2020 Other Codes Fee Schedule

Page 10 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 0111U $193.25 3/1/20 0112U 26 $38.99 3/1/20 0112U TC $38.99 3/1/20 0112U $38.99 3/1/20 0113U 26 $255.05 3/1/20 0113U TC $255.05 3/1/20 0113U $255.05 3/1/20 0114U 26 $40.97 3/1/20 0114U TC $262.99 3/1/20 0114U $303.96 3/1/20 0115U 26 $38.99 3/1/20 0115U TC $38.99 3/1/20 0115U $38.99 3/1/20 0116U 26 $114.43 3/1/20 0116U TC $114.43 3/1/20 0116U $114.43 3/1/20 0117U 26 $12.81 3/1/20 0117U TC $12.81 3/1/20 0117U $12.81 3/1/20 0118U 26 $3,300.00 3/1/20 0118U TC $2,200.00 3/1/20 0118U $5,500.00 3/1/20 0119U 26 $24.09 3/1/20 0119U TC $24.09 3/1/20 0119U $24.09 3/1/20 0120U 26 $3,873.00 3/1/20

0120U TC $3,873.00 3/1/20

0120U $3,873.00 3/1/20 0121U 26 $6.12 3/1/20 0121U TC $6.12 3/1/20 0121U $6.12 3/1/20 0122U 26 $6.12 3/1/20 0122U TC $6.12 3/1/20 0122U $6.12 3/1/20 0123U 26 $9.56 3/1/20 0123U TC $9.56 3/1/20 0123U $9.56 3/1/20 0124U 26 $47.70 3/1/20 0124U TC $31.80 3/1/20 0124U $79.50 3/1/20 0125U 26 $16.75 3/1/20 0125U TC $11.16 3/1/20 0125U $27.91 3/1/20 0126T $88.40 3/1/20 0126U 26 $16.75 3/1/20 0126U TC $11.16 3/1/20 0126U $27.91 3/1/20 0127U 26 $47.70 3/1/20 0127U TC $31.80 3/1/20 0127U $79.50 3/1/20 0128U 26 $47.70 3/1/20 0128U TC $31.80 3/1/20 0128U $79.50 3/1/20 0129U 26 $2,027.64 3/1/20 0129U TC $2,027.64 3/1/20 0129U $2,027.64 3/1/20 0130U 26 $649.89 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 0130U TC $649.89 3/1/20 0130U $649.89 3/1/20 0131U 26 $754.50 3/1/20 0131U TC $754.50 3/1/20 0131U $754.50 3/1/20 0132U 26 $754.50 3/1/20 0132U TC $754.50 3/1/20 0132U $754.50 3/1/20 0133U 26 $2,027.64 3/1/20 0133U TC $2,027.64 3/1/20 0133U $2,027.64 3/1/20 0134U 26 $2,027.64 3/1/20 0134U TC $2,027.64 3/1/20 0134U $2,027.64 3/1/20 0135U 26 $2,027.64 3/1/20 0135U TC $2,027.64 3/1/20 0135U $2,027.64 3/1/20 0136U 26 $1,051.49 3/1/20 0136U TC $700.99 3/1/20 0136U $1,752.48 3/1/20 0137U 26 $333.27 3/1/20 0137U TC $222.18 3/1/20 0137U $555.45 3/1/20 0138U 26 $2,027.64 3/1/20 0138U TC $2,027.64 3/1/20 0138U $2,027.64 3/1/20

0163T $2,100.00 3/1/20

0174T 26 $14.24 3/1/20 0174T TC $14.24 3/1/20 0174T $14.24 3/1/20 0175T 26 $14.24 3/1/20 0175T TC $14.24 3/1/20 0175T $14.24 3/1/20 0184T $772.44 3/1/20 0191T $324.47 3/1/20 0198T 26 $4.55 3/1/20 0198T TC $3.03 3/1/20 0198T $7.58 3/1/20 0200T $900.60 3/1/20 0201T $1,165.17 3/1/20 0207T $383.34 3/1/20 0212T 26 $33.00 3/1/20 0212T TC $22.00 3/1/20 0212T $55.00 3/1/20 0216T $84.80 3/1/20 0217T $23.38 3/1/20 0230T $74.42 3/1/20 0232T $46.61 3/1/20 0234T $557.90 3/1/20 0236T $75.00 3/1/20 0237T $776.00 3/1/20 0238T $1,409.00 3/1/20 0249T $317.29 3/1/20 0253T $849.50 3/1/20 0254T $244.95 3/1/20 0263T $310.00 3/1/20 0264T $59.14 3/1/20

2020 Other Codes Fee Schedule

Page 11 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 0265T $310.00 3/1/20 0275T $603.10 3/1/20 0278T $1,000.00 3/1/20 0295T 26 $162.09 3/1/20 0295T TC $108.06 3/1/20 0295T $301.94 3/1/20 0296T 26 $49.43 3/1/20 0296T TC $32.96 3/1/20 0296T $18.83 3/1/20 0297T 26 $134.10 3/1/20 0297T TC $89.40 3/1/20 0297T $282.34 3/1/20 0298T 26 $92.34 3/1/20 0298T TC $61.56 3/1/20 0298T $25.27 3/1/20 0330T 26 $1.76 3/1/20 0330T TC $2.63 3/1/20 0330T $4.39 3/1/20 0351T 26 $17.92 3/1/20 0351T TC $41.80 3/1/20 0351T $59.72 3/1/20 0352T 26 $17.92 3/1/20 0352T TC $41.80 3/1/20 0352T $59.72 3/1/20 0353T 26 $17.92 3/1/20 0353T TC $41.80 3/1/20

0353T $59.72 3/1/20

0354T 26 $17.92 3/1/20 0354T TC $41.80 3/1/20 0354T $59.72 3/1/20 0357T 26 $284.15 3/1/20 0357T TC $189.44 3/1/20 0357T $473.59 3/1/20 0358T $65.21 3/1/20 0362T $0.00 3/1/20 0373T $0.00 3/1/20 0376T $2,550.00 3/1/20 0377T $488.30 3/1/20 0394T 26 $258.11 3/1/20 0394T TC $479.35 3/1/20 0394T $737.47 3/1/20 0395T 26 $258.11 3/1/20 0395T TC $479.35 3/1/20 0395T $737.47 3/1/20 0396T $1,666.10 3/1/20 0397T $428.94 3/1/20 0398T 26 $400.26 3/1/20 0398T TC $933.94 3/1/20 0398T $1,334.20 3/1/20 0399T 26 $66.45 3/1/20 0399T TC $156.91 3/1/20 0399T $223.35 3/1/20 0400T 26 $17.47 3/1/20 0400T TC $40.75 3/1/20 0400T $58.22 3/1/20 0401T 26 $17.47 3/1/20 0401T TC $40.75 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 0401T $58.22 3/1/20 0402T $2,500.00 3/1/20 0403T $59.69 3/1/20 0404T $2,250.00 3/1/20 0405T $100.66 3/1/20 0408T $505.26 3/1/20 0409T $315.79 3/1/20 0410T $363.15 3/1/20 0411T $466.77 3/1/20 0412T $229.93 3/1/20 0413T $472.03 3/1/20 0414T $347.04 3/1/20 0415T $293.09 3/1/20 0416T $330.59 3/1/20 0417T 26 $29.93 3/1/20 0417T TC $16.12 3/1/20 0417T $46.05 3/1/20 0418T 26 $19.74 3/1/20 0418T TC $14.47 3/1/20 0418T $34.21 3/1/20 0419T $1,022.36 3/1/20 0420T $1,022.36 3/1/20 0421T $796.37 3/1/20 0422T 26 $33.55 3/1/20 0422T TC $65.79 3/1/20 0422T $99.34 3/1/20

0423T 26 $3.33 3/1/20

0423T TC $3.33 3/1/20 0423T $3.33 3/1/20 0424T $247.69 3/1/20 0425T $229.60 3/1/20 0426T $229.60 3/1/20 0427T $247.69 3/1/20 0428T $229.93 3/1/20 0429T $229.93 3/1/20 0430T $229.93 3/1/20 0431T $229.93 3/1/20 0432T $229.93 3/1/20 0433T $229.93 3/1/20 0434T 26 $62.17 3/1/20 0434T TC $62.17 3/1/20 0434T $62.17 3/1/20 0435T 26 $231.58 3/1/20 0435T TC $231.58 3/1/20 0435T $231.58 3/1/20 0436T 26 $231.58 3/1/20 0436T TC $231.58 3/1/20 0436T $231.58 3/1/20 0437T $220.25 3/1/20 0439T 26 $45.77 3/1/20 0439T TC $96.18 3/1/20 0439T $131.22 3/1/20 0440T $1,561.05 3/1/20 0441T $1,561.05 3/1/20 0442T $1,561.05 3/1/20 0443T $220.96 3/1/20 0444T $55.94 3/1/20

2020 Other Codes Fee Schedule

Page 12 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 0445T $55.94 3/1/20 0449T $696.72 3/1/20 0450T $2,550.00 3/1/20 0469T $6.67 3/1/20 0472T 26 $29.93 3/1/20 0472T TC $16.12 3/1/20 0472T $46.05 3/1/20 0473T 26 $29.93 3/1/20 0473T TC $16.12 3/1/20 0473T $46.05 3/1/20 0474T $1,007.56 3/1/20 0481T $46.61 3/1/20 0488T $56.69 3/1/20 0494T $1,954.29 3/1/20 0495T $1,954.29 3/1/20 0496T $977.15 3/1/20 0497T 26 $9.37 3/1/20 0497T TC $9.37 3/1/20 0497T $9.37 3/1/20 0498T 26 $25.95 3/1/20 0498T TC $25.95 3/1/20 0498T $25.95 3/1/20 0499T $307.41 3/1/20 0500F $0.00 3/1/20 0501F $0.00 3/1/20 0501T 26 $59.93 3/1/20

0501T TC $59.93 3/1/20

0501T $59.93 3/1/20 0502F $0.00 3/1/20 0502T 26 $19.98 3/1/20 0502T TC $19.98 3/1/20 0502T $19.98 3/1/20 0503F $0.00 3/1/20 0503T 26 $19.98 3/1/20 0503T TC $19.98 3/1/20 0503T $19.98 3/1/20 0504T 26 $19.98 3/1/20 0504T TC $19.98 3/1/20 0504T $19.98 3/1/20 0505F $0.00 3/1/20 0507F $0.00 3/1/20 0509F $0.00 3/1/20 0510T $595.01 3/1/20 0511T $1,404.44 3/1/20 0512T $0.00 3/1/20 0513F $0.00 3/1/20 0513T $0.00 3/1/20 0514F $0.00 3/1/20 0514T $813.04 3/1/20 0515T $541.31 3/1/20 0516F $0.00 3/1/20 0516T $387.78 3/1/20 0517F $0.00 3/1/20 0517T $335.52 3/1/20 0518F $0.00 3/1/20 0518T $240.74 3/1/20 0519F $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 0519T $353.90 3/1/20 0520F $0.00 3/1/20 0520T $503.47 3/1/20 0521F $0.00 3/1/20 0521T 26 $541.31 3/1/20 0521T TC $541.31 3/1/20 0521T $541.31 3/1/20 0522T 26 $51.18 3/1/20 0522T TC $51.18 3/1/20 0522T $51.18 3/1/20 0523T $895.57 3/1/20 0524T $1,463.19 3/1/20 0525F $0.00 3/1/20 0525T $541.31 3/1/20 0526F $0.00 3/1/20 0526T $541.31 3/1/20 0527T $541.31 3/1/20 0528F $0.00 3/1/20 0528T $541.31 3/1/20 0529F $0.00 3/1/20 0529T $541.31 3/1/20 0530T $541.31 3/1/20 0531T $541.31 3/1/20 0532T $541.31 3/1/20 0533T 26 $168.66 3/1/20 0533T TC $283.99 3/1/20

0533T $452.65 3/1/20

0534T 26 $168.66 3/1/20 0534T TC $283.99 3/1/20 0534T $452.65 3/1/20 0535F $0.00 3/1/20 0535T 26 $168.66 3/1/20 0535T TC $283.99 3/1/20 0535T $452.65 3/1/20 0536T 26 $168.66 3/1/20 0536T TC $283.99 3/1/20 0536T $452.65 3/1/20 0537T $86.13 3/1/20 0538T $48.65 3/1/20 0539T $86.49 3/1/20 0540F $0.00 3/1/20 0540T $175.87 3/1/20 0541T 26 $381.46 3/1/20 0541T TC $3,707.20 3/1/20 0541T $4,088.66 3/1/20 0542T 26 $381.46 3/1/20 0542T TC $3,707.20 3/1/20 0542T $4,088.66 3/1/20 0543T $1,881.29 3/1/20 0544T $1,881.29 3/1/20 0545F $0.00 3/1/20 0545T $1,881.29 3/1/20 0546T 26 $17.92 3/1/20 0546T TC $41.80 3/1/20 0546T $59.72 3/1/20 0547T 26 $15.79 3/1/20 0547T TC $40.91 3/1/20

2020 Other Codes Fee Schedule

Page 13 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 0547T $56.70 3/1/20 0548T $780.22 3/1/20 0549T $780.22 3/1/20 0550F $0.00 3/1/20 0550T $665.02 3/1/20 0551F $0.00 3/1/20 0551T $128.93 3/1/20 0552T $22.28 3/1/20 0553T $1,859.03 3/1/20 0554T 26 $12.56 3/1/20 0554T TC $59.93 3/1/20 0554T $72.50 3/1/20 0555F $0.00 3/1/20 0555T 26 $12.56 3/1/20 0555T TC $59.93 3/1/20 0555T $72.50 3/1/20 0556F $0.00 3/1/20 0556T 26 $12.56 3/1/20 0556T TC $59.93 3/1/20 0556T $72.50 3/1/20 0557F $0.00 3/1/20 0557T 26 $12.56 3/1/20 0557T TC $59.93 3/1/20 0557T $72.50 3/1/20 0558T 26 $12.56 3/1/20 0558T TC $59.93 3/1/20

0558T $72.50 3/1/20

0559T $23.69 3/1/20 0560T $23.69 3/1/20 0561T $23.69 3/1/20 0562T $23.69 3/1/20 0575F $0.00 3/1/20 0580F $0.00 3/1/20 0581F $0.00 3/1/20 0582F $0.00 3/1/20 0583F $0.00 3/1/20 0584F $0.00 3/1/20 1000F $0.00 3/1/20 1002F $0.00 3/1/20 1003F $0.00 3/1/20 1004F $0.00 3/1/20 1005F $0.00 3/1/20 1006F $0.00 3/1/20 1007F $0.00 3/1/20 1008F $0.00 3/1/20 1010F $0.00 3/1/20 1011F $0.00 3/1/20 1012F $0.00 3/1/20 1015F $0.00 3/1/20 1018F $0.00 3/1/20 1019F $0.00 3/1/20 1022F $0.00 3/1/20 1026F $0.00 3/1/20 1030F $0.00 3/1/20 1031F $0.00 3/1/20 1032F $0.00 3/1/20 1033F $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 1034F $0.00 3/1/20 1035F $0.00 3/1/20 1036F $0.00 3/1/20 1038F $0.00 3/1/20 1039F $0.00 3/1/20 1040F $0.00 3/1/20 1050F $0.00 3/1/20 1052F $0.00 3/1/20 1055F $0.00 3/1/20 1060F $0.00 3/1/20 1061F $0.00 3/1/20 1065F $0.00 3/1/20 1066F $0.00 3/1/20 1070F $0.00 3/1/20 1071F $0.00 3/1/20 1090F $0.00 3/1/20 1091F $0.00 3/1/20 1100F $0.00 3/1/20 1101F $0.00 3/1/20 1110F $0.00 3/1/20 1111F $0.00 3/1/20 1116F $0.00 3/1/20 1118F $0.00 3/1/20 1119F $0.00 3/1/20 1121F $0.00 3/1/20 1123F $0.00 3/1/20

1124F $0.00 3/1/20

1125F $0.00 3/1/20 1126F $0.00 3/1/20 1127F $0.00 3/1/20 1128F $0.00 3/1/20 1130F $0.00 3/1/20 1134F $0.00 3/1/20 1135F $0.00 3/1/20 1136F $0.00 3/1/20 1137F $0.00 3/1/20 1150F $0.00 3/1/20 1151F $0.00 3/1/20 1152F $0.00 3/1/20 1153F $0.00 3/1/20 1157F $0.00 3/1/20 1158F $0.00 3/1/20 1159F $0.00 3/1/20 1160F $0.00 3/1/20 1170F $0.00 3/1/20 1175F $0.00 3/1/20 1180F $0.00 3/1/20 1181F $0.00 3/1/20 1182F $0.00 3/1/20 1183F $0.00 3/1/20 1200F $0.00 3/1/20 1205F $0.00 3/1/20 1220F $0.00 3/1/20 1400F $0.00 3/1/20 1450F $0.00 3/1/20 1451F $0.00 3/1/20 1460F $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 14 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 1461F $0.00 3/1/20 1490F $0.00 3/1/20 1491F $0.00 3/1/20 1493F $0.00 3/1/20 1494F $0.00 3/1/20 1500F $0.00 3/1/20 1501F $0.00 3/1/20 1502F $0.00 3/1/20 1503F $0.00 3/1/20 1504F $0.00 3/1/20 1505F $0.00 3/1/20 2000F $0.00 3/1/20 2001F $0.00 3/1/20 2002F $0.00 3/1/20 2004F $0.00 3/1/20 2010F $0.00 3/1/20 2014F $0.00 3/1/20 2015F $0.00 3/1/20 2016F $0.00 3/1/20 2018F $0.00 3/1/20 2019F $0.00 3/1/20 2020F $0.00 3/1/20 2021F $0.00 3/1/20 2022F $0.00 3/1/20 2023F $0.00 3/1/20 2024F $0.00 3/1/20

2025F $0.00 3/1/20

2026F $0.00 3/1/20 2027F $0.00 3/1/20 2028F $0.00 3/1/20 2029F $0.00 3/1/20 2030F $0.00 3/1/20 2031F $0.00 3/1/20 2033F $0.00 3/1/20 2035F $0.00 3/1/20 2040F $0.00 3/1/20 2044F $0.00 3/1/20 2050F $0.00 3/1/20 2060F $0.00 3/1/20 3006F $0.00 3/1/20 3008F $0.00 3/1/20 3011F $0.00 3/1/20 3014F $0.00 3/1/20 3015F $0.00 3/1/20 3016F $0.00 3/1/20 3017F $0.00 3/1/20 3018F $0.00 3/1/20 3019F $0.00 3/1/20 3020F $0.00 3/1/20 3021F $0.00 3/1/20 3022F $0.00 3/1/20 3023F $0.00 3/1/20 3025F $0.00 3/1/20 3027F $0.00 3/1/20 3028F $0.00 3/1/20 3035F $0.00 3/1/20 3037F $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 3038F $0.00 3/1/20 3040F $0.00 3/1/20 3042F $0.00 3/1/20 3044F $0.00 3/1/20 3045F $0.00 3/1/20 3046F $0.00 3/1/20 3048F $0.00 3/1/20 3049F $0.00 3/1/20 3050F $0.00 3/1/20 3051F $0.00 3/1/20 3052F $0.00 3/1/20 3055F $0.00 3/1/20 3056F $0.00 3/1/20 3060F $0.00 3/1/20 3061F $0.00 3/1/20 3062F $0.00 3/1/20 3066F $0.00 3/1/20 3072F $0.00 3/1/20 3073F $0.00 3/1/20 3074F $0.00 3/1/20 3075F $0.00 3/1/20 3077F $0.00 3/1/20 3078F $0.00 3/1/20 3079F $0.00 3/1/20 3080F $0.00 3/1/20 3082F $0.00 3/1/20

3083F $0.00 3/1/20

3084F $0.00 3/1/20 3085F $0.00 3/1/20 3088F $0.00 3/1/20 3089F $0.00 3/1/20 3090F $0.00 3/1/20 3091F $0.00 3/1/20 3092F $0.00 3/1/20 3093F $0.00 3/1/20 3095F $0.00 3/1/20 3096F $0.00 3/1/20 3100F $0.00 3/1/20 3110F $0.00 3/1/20 3111F $0.00 3/1/20 3112F $0.00 3/1/20 3115F $0.00 3/1/20 3117F $0.00 3/1/20 3118F $0.00 3/1/20 3119F $0.00 3/1/20 3120F $0.00 3/1/20 3126F $0.00 3/1/20 3130F $0.00 3/1/20 3132F $0.00 3/1/20 3140F $0.00 3/1/20 3141F $0.00 3/1/20 3142F $0.00 3/1/20 3150F $0.00 3/1/20 3155F $0.00 3/1/20 3160F $0.00 3/1/20 3170F $0.00 3/1/20 3200F $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 15 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 3210F $0.00 3/1/20 3215F $0.00 3/1/20 3216F $0.00 3/1/20 3218F $0.00 3/1/20 3220F $0.00 3/1/20 3230F $0.00 3/1/20 3250F $0.00 3/1/20 3260F $0.00 3/1/20 3265F $0.00 3/1/20 3266F $0.00 3/1/20 3267F $0.00 3/1/20 3268F $0.00 3/1/20 3269F $0.00 3/1/20 3270F $0.00 3/1/20 3271F $0.00 3/1/20 3272F $0.00 3/1/20 3273F $0.00 3/1/20 3274F $0.00 3/1/20 3278F $0.00 3/1/20 3279F $0.00 3/1/20 3280F $0.00 3/1/20 3281F $0.00 3/1/20 3284F $0.00 3/1/20 3285F $0.00 3/1/20 3288F $0.00 3/1/20 3290F $0.00 3/1/20

3291F $0.00 3/1/20

3292F $0.00 3/1/20 3293F $0.00 3/1/20 3294F $0.00 3/1/20 3300F $0.00 3/1/20 3301F $0.00 3/1/20 3315F $0.00 3/1/20 3316F $0.00 3/1/20 3317F $0.00 3/1/20 3318F $0.00 3/1/20 3319F $0.00 3/1/20 3320F $0.00 3/1/20 3321F $0.00 3/1/20 3322F $0.00 3/1/20 3323F $0.00 3/1/20 3324F $0.00 3/1/20 3325F $0.00 3/1/20 3328F $0.00 3/1/20 3330F $0.00 3/1/20 3331F $0.00 3/1/20 3340F $0.00 3/1/20 3341F $0.00 3/1/20 3342F $0.00 3/1/20 3343F $0.00 3/1/20 3344F $0.00 3/1/20 3345F $0.00 3/1/20 3350F $0.00 3/1/20 3351F $0.00 3/1/20 3352F $0.00 3/1/20 3353F $0.00 3/1/20 3354F $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 3370F $0.00 3/1/20 3372F $0.00 3/1/20 3374F $0.00 3/1/20 3376F $0.00 3/1/20 3378F $0.00 3/1/20 3380F $0.00 3/1/20 3382F $0.00 3/1/20 3384F $0.00 3/1/20 3386F $0.00 3/1/20 3388F $0.00 3/1/20 3390F $0.00 3/1/20 3394F $0.00 3/1/20 3395F $0.00 3/1/20 3450F $0.00 3/1/20 3451F $0.00 3/1/20 3452F $0.00 3/1/20 3455F $0.00 3/1/20 3470F $0.00 3/1/20 3471F $0.00 3/1/20 3472F $0.00 3/1/20 3475F $0.00 3/1/20 3476F $0.00 3/1/20 3490F $0.00 3/1/20 3491F $0.00 3/1/20 3492F $0.00 3/1/20 3493F $0.00 3/1/20

3494F $0.00 3/1/20

3495F $0.00 3/1/20 3496F $0.00 3/1/20 3497F $0.00 3/1/20 3498F $0.00 3/1/20 3500F $0.00 3/1/20 3502F $0.00 3/1/20 3503F $0.00 3/1/20 3510F $0.00 3/1/20 3511F $0.00 3/1/20 3512F $0.00 3/1/20 3513F $0.00 3/1/20 3514F $0.00 3/1/20 3515F $0.00 3/1/20 3517F $0.00 3/1/20 3520F $0.00 3/1/20 3550F $0.00 3/1/20 3551F $0.00 3/1/20 3552F $0.00 3/1/20 3555F $0.00 3/1/20 3570F $0.00 3/1/20 3572F $0.00 3/1/20 3573F $0.00 3/1/20 3650F $0.00 3/1/20 3700F $0.00 3/1/20 3720F $0.00 3/1/20 3725F $0.00 3/1/20 3750F $0.00 3/1/20 3751F $0.00 3/1/20 3752F $0.00 3/1/20 3753F $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 16 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 3754F $0.00 3/1/20 3755F $0.00 3/1/20 3756F $0.00 3/1/20 3757F $0.00 3/1/20 3758F $0.00 3/1/20 3759F $0.00 3/1/20 3760F $0.00 3/1/20 3761F $0.00 3/1/20 3762F $0.00 3/1/20 3763F $0.00 3/1/20 3775F $0.00 3/1/20 3776F $0.00 3/1/20 4000F $0.00 3/1/20 4001F $0.00 3/1/20 4003F $0.00 3/1/20 4004F $0.00 3/1/20 4005F $0.00 3/1/20 4008F $0.00 3/1/20 4010F $0.00 3/1/20 4011F $0.00 3/1/20 4012F $0.00 3/1/20 4013F $0.00 3/1/20 4014F $0.00 3/1/20 4015F $0.00 3/1/20 4016F $0.00 3/1/20 4017F $0.00 3/1/20

4018F $0.00 3/1/20

4019F $0.00 3/1/20 4025F $0.00 3/1/20 4030F $0.00 3/1/20 4033F $0.00 3/1/20 4035F $0.00 3/1/20 4037F $0.00 3/1/20 4040F $0.00 3/1/20 4041F $0.00 3/1/20 4042F $0.00 3/1/20 4043F $0.00 3/1/20 4044F $0.00 3/1/20 4045F $0.00 3/1/20 4046F $0.00 3/1/20 4047F $0.00 3/1/20 4048F $0.00 3/1/20 4049F $0.00 3/1/20 4050F $0.00 3/1/20 4051F $0.00 3/1/20 4052F $0.00 3/1/20 4053F $0.00 3/1/20 4054F $0.00 3/1/20 4055F $0.00 3/1/20 4056F $0.00 3/1/20 4058F $0.00 3/1/20 4060F $0.00 3/1/20 4062F $0.00 3/1/20 4063F $0.00 3/1/20 4064F $0.00 3/1/20 4065F $0.00 3/1/20 4066F $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 4067F $0.00 3/1/20 4069F $0.00 3/1/20 4070F $0.00 3/1/20 4073F $0.00 3/1/20 4075F $0.00 3/1/20 4077F $0.00 3/1/20 4079F $0.00 3/1/20 4084F $0.00 3/1/20 4086F $0.00 3/1/20 4090F $0.00 3/1/20 4095F $0.00 3/1/20 4100F $0.00 3/1/20 4110F $0.00 3/1/20 4115F $0.00 3/1/20 4120F $0.00 3/1/20 4124F $0.00 3/1/20 4130F $0.00 3/1/20 4131F $0.00 3/1/20 4132F $0.00 3/1/20 4133F $0.00 3/1/20 4134F $0.00 3/1/20 4135F $0.00 3/1/20 4136F $0.00 3/1/20 4140F $0.00 3/1/20 4142F $0.00 3/1/20 4144F $0.00 3/1/20

4145F $0.00 3/1/20

4148F $0.00 3/1/20 4149F $0.00 3/1/20 4150F $0.00 3/1/20 4151F $0.00 3/1/20 4153F $0.00 3/1/20 4155F $0.00 3/1/20 4157F $0.00 3/1/20 4158F $0.00 3/1/20 4159F $0.00 3/1/20 4163F $0.00 3/1/20 4164F $0.00 3/1/20 4165F $0.00 3/1/20 4167F $0.00 3/1/20 4168F $0.00 3/1/20 4169F $0.00 3/1/20 4171F $0.00 3/1/20 4172F $0.00 3/1/20 4174F $0.00 3/1/20 4175F $0.00 3/1/20 4176F $0.00 3/1/20 4177F $0.00 3/1/20 4178F $0.00 3/1/20 4179F $0.00 3/1/20 4180F $0.00 3/1/20 4181F $0.00 3/1/20 4182F $0.00 3/1/20 4185F $0.00 3/1/20 4186F $0.00 3/1/20 4187F $0.00 3/1/20 4188F $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 17 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 4189F $0.00 3/1/20 4190F $0.00 3/1/20 4191F $0.00 3/1/20 4192F $0.00 3/1/20 4193F $0.00 3/1/20 4194F $0.00 3/1/20 4195F $0.00 3/1/20 4196F $0.00 3/1/20 4200F $0.00 3/1/20 4201F $0.00 3/1/20 4210F $0.00 3/1/20 4220F $0.00 3/1/20 4221F $0.00 3/1/20 4230F $0.00 3/1/20 4240F $0.00 3/1/20 4242F $0.00 3/1/20 4245F $0.00 3/1/20 4248F $0.00 3/1/20 4250F $0.00 3/1/20 4255F $0.00 3/1/20 4256F $0.00 3/1/20 4260F $0.00 3/1/20 4261F $0.00 3/1/20 4265F $0.00 3/1/20 4266F $0.00 3/1/20 4267F $0.00 3/1/20

4268F $0.00 3/1/20

4269F $0.00 3/1/20 4270F $0.00 3/1/20 4271F $0.00 3/1/20 4274F $0.00 3/1/20 4276F $0.00 3/1/20 4279F $0.00 3/1/20 4280F $0.00 3/1/20 4290F $0.00 3/1/20 4293F $0.00 3/1/20 4300F $0.00 3/1/20 4301F $0.00 3/1/20 4305F $0.00 3/1/20 4306F $0.00 3/1/20 4320F $0.00 3/1/20 4322F $0.00 3/1/20 4324F $0.00 3/1/20 4325F $0.00 3/1/20 4326F $0.00 3/1/20 4328F $0.00 3/1/20 4330F $0.00 3/1/20 4340F $0.00 3/1/20 4350F $0.00 3/1/20 4400F $0.00 3/1/20 4450F $0.00 3/1/20 4470F $0.00 3/1/20 4480F $0.00 3/1/20 4481F $0.00 3/1/20 4500F $0.00 3/1/20 4510F $0.00 3/1/20 4525F $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 4526F $0.00 3/1/20 4540F $0.00 3/1/20 4541F $0.00 3/1/20 4550F $0.00 3/1/20 4551F $0.00 3/1/20 4552F $0.00 3/1/20 4553F $0.00 3/1/20 4554F $0.00 3/1/20 4555F $0.00 3/1/20 4556F $0.00 3/1/20 4557F $0.00 3/1/20 4558F $0.00 3/1/20 4559F $0.00 3/1/20 4560F $0.00 3/1/20 4561F $0.00 3/1/20 4562F $0.00 3/1/20 4563F $0.00 3/1/20 5005F $0.00 3/1/20 5010F $0.00 3/1/20 5015F $0.00 3/1/20 5020F $0.00 3/1/20 5050F $0.00 3/1/20 5060F $0.00 3/1/20 5062F $0.00 3/1/20 5100F $0.00 3/1/20 5200F $0.00 3/1/20

5250F $0.00 3/1/20

6005F $0.00 3/1/20 6010F $0.00 3/1/20 6015F $0.00 3/1/20 6020F $0.00 3/1/20 6030F $0.00 3/1/20 6040F $0.00 3/1/20 6045F $0.00 3/1/20 6070F $0.00 3/1/20 6080F $0.00 3/1/20 6090F $0.00 3/1/20 6100F $0.00 3/1/20 6101F $0.00 3/1/20 6102F $0.00 3/1/20 6110F $0.00 3/1/20 6150F $0.00 3/1/20 7010F $0.00 3/1/20 7020F $0.00 3/1/20 7025F $0.00 3/1/20 9001F $0.00 3/1/20 9002F $0.00 3/1/20 9003F $0.00 3/1/20 9004F $0.00 3/1/20 9005F $0.00 3/1/20 9006F $0.00 3/1/20 9007F $0.00 3/1/20 A0021 $0.00 3/1/20 A0080 $0.65 3/1/20 A0090 $0.18 3/1/20 A0100 $0.00 3/1/20 A0110 $40.00 3/1/20

2020 Other Codes Fee Schedule

Page 18 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 A0120 $0.00 3/1/20 A0130 $21.38 3/1/20 A0140 $0.00 3/1/20 A0160 $0.00 3/1/20 A0170 $0.33 3/1/20 A0180 $48.14 3/1/20 A0190 $0.00 3/1/20 A0200 $0.00 3/1/20 A0210 $0.00 3/1/20 A0225 $201.04 3/1/20 A0380 $4.00 3/1/20 A0382 $35.00 3/1/20 A0384 $70.00 3/1/20 A0390 $30.13 3/1/20 A0392 $70.00 3/1/20 A0394 $35.00 3/1/20 A0396 $70.00 3/1/20 A0398 $35.00 3/1/20 A0420 $41.05 3/1/20 A0422 $24.00 3/1/20 A0424 $88.90 3/1/20 A0425 $16.09 3/1/20 A0426 $573.88 3/1/20 A0427 $908.64 3/1/20 A0428 $478.23 3/1/20 A0429 $765.17 3/1/20

A0430 $14,193.52 3/1/20

A0431 $16,502.11 3/1/20 A0432 $836.90 3/1/20 A0433 $1,315.13 3/1/20 A0434 $1,554.23 3/1/20 A0435 $41.57 3/1/20 A0436 $110.90 3/1/20 A0888 $50.00 3/1/20 A0998 $66.20 3/1/20 D0120 $25.23 3/1/20 D0140 $36.04 3/1/20 D0145 $36.04 3/1/20 D0150 $36.04 3/1/20 D0160 $64.87 3/1/20 D0170 $32.44 3/1/20 D0171 $25.23 3/1/20 D0180 $36.04 3/1/20 D0190 $25.23 3/1/20 D0191 $18.02 3/1/20 D0210 $72.08 3/1/20 D0220 $18.02 3/1/20 D0230 $9.01 3/1/20 D0240 $21.62 3/1/20 D0250 $36.04 3/1/20 D0251 $36.04 3/1/20 D0270 $18.02 3/1/20 D0272 $21.62 3/1/20 D0273 $28.83 3/1/20 D0274 $36.04 3/1/20 D0277 $43.25 3/1/20 D0310 $151.36 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 D0320 $360.39 3/1/20 D0321 $111.72 3/1/20 D0322 $201.82 3/1/20 D0330 $57.66 3/1/20 D0340 $72.08 3/1/20 D0350 $36.04 3/1/20 D0351 $46.85 3/1/20 D0364 $302.73 3/1/20 D0365 $302.73 3/1/20 D0366 $302.73 3/1/20 D0367 $302.73 3/1/20 D0368 $443.28 3/1/20 D0369 $792.86 3/1/20 D0370 $266.69 3/1/20 D0371 $302.73 3/1/20 D0380 $241.46 3/1/20 D0381 $241.46 3/1/20 D0382 $241.46 3/1/20 D0383 $241.46 3/1/20 D0384 $353.18 3/1/20 D0385 $576.63 3/1/20 D0386 $144.16 3/1/20 D0391 $281.10 3/1/20 D0393 $360.39 3/1/20 D0394 $43.25 3/1/20 D0395 $54.06 3/1/20

D0411 $18.02 3/1/20

D0412 $18.02 3/1/20 D0414 $81.00 3/1/20 D0415 $86.49 3/1/20 D0416 $79.29 3/1/20 D0417 $79.00 3/1/20 D0418 $86.49 3/1/20 D0422 $18.02 3/1/20 D0425 $46.85 3/1/20 D0431 $39.64 3/1/20 D0460 $28.83 3/1/20 D0470 $45.05 3/1/20 D0472 $54.06 3/1/20 D0473 $72.08 3/1/20 D0474 $86.49 3/1/20 D0475 $100.91 3/1/20 D0476 $169.38 3/1/20 D0477 $169.38 3/1/20 D0478 $79.29 3/1/20 D0479 $118.93 3/1/20 D0480 $82.89 3/1/20 D0481 $86.49 3/1/20 D0482 $43.25 3/1/20 D0483 $57.66 3/1/20 D0484 $79.29 3/1/20 D0485 $86.49 3/1/20 D0486 $75.68 3/1/20 D0502 $97.31 3/1/20 D0601 $10.81 3/1/20 D0602 $10.81 3/1/20 D0603 $10.81 3/1/20

2020 Other Codes Fee Schedule

Page 19 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 D1110 $54.06 3/1/20 D1120 $36.04 3/1/20 D1206 $21.62 3/1/20 D1208 $18.02 3/1/20 D1310 $43.25 3/1/20 D1320 $39.64 3/1/20 D1330 $25.23 3/1/20 D1351 $28.83 3/1/20 D1352 $32.44 3/1/20 D1353 $28.83 3/1/20 D1354 $15.00 3/1/20 D1510 $144.16 3/1/20 D1516 $216.23 3/1/20 D1517 $216.23 3/1/20 D1520 $180.20 3/1/20 D1526 $252.27 3/1/20 D1527 $252.27 3/1/20 D1575 $144.16 3/1/20 D2140 $72.08 3/1/20 D2150 $79.29 3/1/20 D2160 $97.31 3/1/20 D2161 $118.93 3/1/20 D2330 $72.08 3/1/20 D2331 $108.12 3/1/20 D2332 $126.14 3/1/20 D2335 $144.16 3/1/20

D2390 $245.07 3/1/20

D2391 $72.08 3/1/20 D2392 $144.16 3/1/20 D2393 $194.61 3/1/20 D2394 $205.42 3/1/20 D2410 $288.31 3/1/20 D2420 $342.37 3/1/20 D2430 $425.26 3/1/20 D2510 $410.85 3/1/20 D2520 $464.90 3/1/20 D2530 $468.51 3/1/20 D2542 $533.38 3/1/20 D2543 $558.61 3/1/20 D2544 $612.66 3/1/20 D2610 $450.49 3/1/20 D2620 $468.51 3/1/20 D2630 $612.66 3/1/20 D2642 $504.55 3/1/20 D2643 $576.63 3/1/20 D2644 $666.72 3/1/20 D2650 $414.45 3/1/20 D2651 $468.51 3/1/20 D2652 $612.66 3/1/20 D2662 $468.51 3/1/20 D2663 $576.63 3/1/20 D2664 $612.66 3/1/20 D2710 $360.39 3/1/20 D2712 $522.57 3/1/20 D2720 $720.78 3/1/20 D2721 $540.59 3/1/20 D2722 $612.66 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 D2740 $720.78 3/1/20 D2750 $792.86 3/1/20 D2751 $576.63 3/1/20 D2752 $648.70 3/1/20 D2780 $648.70 3/1/20 D2781 $468.51 3/1/20 D2782 $540.59 3/1/20 D2783 $684.74 3/1/20 D2790 $684.74 3/1/20 D2791 $504.55 3/1/20 D2792 $576.63 3/1/20 D2794 $562.21 3/1/20 D2799 $209.03 3/1/20 D2910 $54.06 3/1/20 D2915 $57.66 3/1/20 D2920 $54.06 3/1/20 D2921 $72.08 3/1/20 D2929 $216.23 3/1/20 D2930 $144.16 3/1/20 D2931 $216.23 3/1/20 D2932 $172.99 3/1/20 D2933 $162.18 3/1/20 D2934 $194.61 3/1/20 D2940 $54.06 3/1/20 D2941 $75.68 3/1/20 D2949 $126.14 3/1/20

D2950 $144.16 3/1/20

D2951 $36.04 3/1/20 D2952 $288.31 3/1/20 D2953 $234.25 3/1/20 D2954 $180.20 3/1/20 D2955 $144.16 3/1/20 D2957 $126.14 3/1/20 D2960 $216.23 3/1/20 D2961 $360.39 3/1/20 D2962 $518.96 3/1/20 D2971 $112.50 3/1/20 D2975 $302.73 3/1/20 D2980 $147.76 3/1/20 D2981 $133.00 3/1/20 D2982 $133.00 3/1/20 D2983 $133.00 3/1/20 D2990 $36.04 3/1/20 D3110 $121.00 3/1/20 D3120 $36.04 3/1/20 D3220 $247.00 3/1/20 D3221 $144.16 3/1/20 D3222 $251.00 3/1/20 D3230 $118.93 3/1/20 D3240 $133.34 3/1/20 D3310 $1,029.00 3/1/20 D3320 $1,261.00 3/1/20 D3330 $1,564.00 3/1/20 D3331 $363.99 3/1/20 D3332 $194.61 3/1/20 D3333 $144.16 3/1/20 D3346 $396.43 3/1/20

2020 Other Codes Fee Schedule

Page 20 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 D3347 $482.92 3/1/20 D3348 $594.65 3/1/20 D3351 $180.20 3/1/20 D3352 $136.95 3/1/20 D3353 $288.31 3/1/20 D3355 $216.23 3/1/20 D3356 $154.97 3/1/20 D3357 $154.97 3/1/20 D3410 $1,399.00 3/1/20 D3421 $378.41 3/1/20 D3425 $421.66 3/1/20 D3426 $180.20 3/1/20 D3427 $169.38 3/1/20 D3428 $194.61 3/1/20 D3429 $191.01 3/1/20 D3430 $438.00 3/1/20 D3431 $472.11 3/1/20 D3432 $576.63 3/1/20 D3450 $180.20 3/1/20 D3460 $558.61 3/1/20 D3470 $360.39 3/1/20 D3910 $93.70 3/1/20 D3920 $227.05 3/1/20 D3950 $108.12 3/1/20 D4210 $935.00 3/1/20 D4211 $126.14 3/1/20

D4212 $126.14 3/1/20

D4230 $331.56 3/1/20 D4231 $291.92 3/1/20 D4240 $392.83 3/1/20 D4241 $317.14 3/1/20 D4245 $464.90 3/1/20 D4249 $367.60 3/1/20 D4260 $576.63 3/1/20 D4261 $446.88 3/1/20 D4263 $342.37 3/1/20 D4264 $281.10 3/1/20 D4265 $237.86 3/1/20 D4266 $500.94 3/1/20 D4267 $576.63 3/1/20 D4268 $479.32 3/1/20 D4270 $439.68 3/1/20 D4273 $594.65 3/1/20 D4274 $367.60 3/1/20 D4275 $511.76 3/1/20 D4276 $576.63 3/1/20 D4277 $1,081.17 3/1/20 D4278 $360.39 3/1/20 D4283 $1,460.00 3/1/20 D4285 $1,099.00 3/1/20 D4320 $245.07 3/1/20 D4321 $216.23 3/1/20 D4341 $180.20 3/1/20 D4342 $97.31 3/1/20 D4346 $324.35 3/1/20 D4355 $90.10 3/1/20 D4381 $122.53 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 D4910 $72.08 3/1/20 D4920 $46.85 3/1/20 D4921 $36.04 3/1/20 D5110 $900.98 3/1/20 D5120 $900.98 3/1/20 D5130 $991.08 3/1/20 D5140 $991.08 3/1/20 D5211 $612.66 3/1/20 D5212 $637.89 3/1/20 D5213 $1,081.17 3/1/20 D5214 $1,081.17 3/1/20 D5221 $612.66 3/1/20 D5222 $637.89 3/1/20 D5223 $1,081.17 3/1/20 D5224 $1,081.17 3/1/20 D5225 $767.63 3/1/20 D5226 $767.63 3/1/20 D5282 $482.92 3/1/20 D5283 $482.92 3/1/20 D5410 $43.25 3/1/20 D5411 $43.25 3/1/20 D5421 $43.25 3/1/20 D5422 $43.25 3/1/20 D5511 $108.12 3/1/20 D5512 $108.12 3/1/20 D5520 $72.08 3/1/20

D5611 $108.12 3/1/20

D5612 $108.12 3/1/20 D5621 $147.76 3/1/20 D5622 $147.76 3/1/20 D5630 $133.34 3/1/20 D5640 $108.12 3/1/20 D5650 $108.12 3/1/20 D5660 $180.20 3/1/20 D5670 $536.98 3/1/20 D5671 $536.98 3/1/20 D5710 $360.39 3/1/20 D5711 $360.39 3/1/20 D5720 $288.31 3/1/20 D5721 $288.31 3/1/20 D5730 $216.23 3/1/20 D5731 $216.23 3/1/20 D5740 $180.20 3/1/20 D5741 $180.20 3/1/20 D5750 $288.31 3/1/20 D5751 $288.31 3/1/20 D5760 $288.31 3/1/20 D5761 $288.31 3/1/20 D5810 $432.47 3/1/20 D5811 $432.47 3/1/20 D5820 $360.39 3/1/20 D5821 $360.39 3/1/20 D5850 $93.70 3/1/20 D5851 $93.70 3/1/20 D5862 $320.75 3/1/20 D5863 $955.04 3/1/20 D5864 $973.06 3/1/20

2020 Other Codes Fee Schedule

Page 21 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 D5865 $955.04 3/1/20 D5866 $973.06 3/1/20 D5867 $136.95 3/1/20 D5875 $176.59 3/1/20 D5876 $122.53 3/1/20 D5911 $144.16 3/1/20 D5912 $216.23 3/1/20 D5913 $3,603.91 3/1/20 D5914 $3,603.91 3/1/20 D5915 $4,865.28 3/1/20 D5916 $5,045.47 3/1/20 D5919 $1,125.00 3/1/20 D5922 $2,342.54 3/1/20 D5923 $2,883.13 3/1/20 D5924 $437.50 3/1/20 D5925 $375.00 3/1/20 D5926 $1,801.96 3/1/20 D5927 $1,801.96 3/1/20 D5928 $2,432.64 3/1/20 D5929 $900.00 3/1/20 D5931 $1,153.25 3/1/20 D5932 $2,702.93 3/1/20 D5933 $753.11 3/1/20 D5934 $2,702.93 3/1/20 D5935 $2,702.93 3/1/20 D5936 $991.08 3/1/20

D5937 $327.96 3/1/20

D5951 $1,081.17 3/1/20 D5952 $1,081.17 3/1/20 D5953 $1,081.17 3/1/20 D5954 $443.75 3/1/20 D5955 $2,342.54 3/1/20 D5958 $1,369.49 3/1/20 D5959 $432.47 3/1/20 D5960 $288.31 3/1/20 D5982 $194.61 3/1/20 D5983 $162.50 3/1/20 D5984 $162.50 3/1/20 D5985 $1,009.09 3/1/20 D5986 $108.12 3/1/20 D5987 $360.39 3/1/20 D5988 $385.62 3/1/20 D5991 $215.00 3/1/20 D5992 $154.97 3/1/20 D5993 $273.90 3/1/20 D5994 $86.49 3/1/20 D6010 $1,189.29 3/1/20 D6011 $187.40 3/1/20 D6012 $3,227.00 3/1/20 D6013 $908.19 3/1/20 D6040 $4,288.65 3/1/20 D6050 $3,423.71 3/1/20 D6051 $205.42 3/1/20 D6052 $1,081.17 3/1/20 D6055 $1,351.47 3/1/20 D6056 $382.01 3/1/20 D6057 $533.38 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 D6058 $724.39 3/1/20 D6059 $706.37 3/1/20 D6060 $652.31 3/1/20 D6061 $666.72 3/1/20 D6062 $677.54 3/1/20 D6063 $630.68 3/1/20 D6064 $663.12 3/1/20 D6065 $900.98 3/1/20 D6066 $900.98 3/1/20 D6067 $900.98 3/1/20 D6068 $641.50 3/1/20 D6069 $702.76 3/1/20 D6070 $637.89 3/1/20 D6071 $666.72 3/1/20 D6072 $702.76 3/1/20 D6073 $609.06 3/1/20 D6074 $616.27 3/1/20 D6075 $727.99 3/1/20 D6076 $706.37 3/1/20 D6077 $785.65 3/1/20 D6080 $126.14 3/1/20 D6081 $180.20 3/1/20 D6085 $216.23 3/1/20 D6090 $403.64 3/1/20 D6091 $774.00 3/1/20 D6092 $151.00 3/1/20

D6093 $237.00 3/1/20

D6094 $609.06 3/1/20 D6095 $436.07 3/1/20 D6100 $464.90 3/1/20 D6101 $230.65 3/1/20 D6102 $403.64 3/1/20 D6103 $270.29 3/1/20 D6104 $363.99 3/1/20 D6110 $1,358.67 3/1/20 D6111 $1,358.67 3/1/20 D6112 $1,347.86 3/1/20 D6113 $1,347.86 3/1/20 D6114 $2,364.16 3/1/20 D6115 $2,364.16 3/1/20 D6116 $1,812.77 3/1/20 D6117 $1,812.77 3/1/20 D6118 $2,543.00 3/1/20 D6119 $2,543.00 3/1/20 D6190 $378.00 3/1/20 D6194 $727.99 3/1/20 D6205 $522.57 3/1/20 D6210 $720.78 3/1/20 D6211 $504.55 3/1/20 D6212 $576.63 3/1/20 D6214 $558.61 3/1/20 D6240 $792.86 3/1/20 D6241 $648.70 3/1/20 D6242 $720.78 3/1/20 D6245 $1,506.00 3/1/20 D6250 $720.78 3/1/20 D6251 $504.55 3/1/20

2020 Other Codes Fee Schedule

Page 22 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 D6252 $648.70 3/1/20 D6253 $382.01 3/1/20 D6545 $536.00 3/1/20 D6548 $589.00 3/1/20 D6549 $342.37 3/1/20 D6600 $515.36 3/1/20 D6601 $555.00 3/1/20 D6602 $529.77 3/1/20 D6603 $540.59 3/1/20 D6604 $504.55 3/1/20 D6605 $544.19 3/1/20 D6606 $511.76 3/1/20 D6607 $551.40 3/1/20 D6608 $558.61 3/1/20 D6609 $598.25 3/1/20 D6610 $573.02 3/1/20 D6611 $605.46 3/1/20 D6612 $544.19 3/1/20 D6613 $594.65 3/1/20 D6614 $569.42 3/1/20 D6615 $609.06 3/1/20 D6624 $573.02 3/1/20 D6634 $594.65 3/1/20 D6710 $544.19 3/1/20 D6720 $1,420.00 3/1/20 D6721 $1,347.00 3/1/20

D6722 $1,371.00 3/1/20

D6740 $1,493.00 3/1/20 D6750 $1,454.00 3/1/20 D6751 $1,357.00 3/1/20 D6752 $1,389.00 3/1/20 D6780 $1,371.00 3/1/20 D6781 $1,371.00 3/1/20 D6782 $1,274.00 3/1/20 D6783 $1,412.00 3/1/20 D6790 $684.74 3/1/20 D6791 $504.55 3/1/20 D6792 $612.66 3/1/20 D6793 $342.37 3/1/20 D6794 $497.34 3/1/20 D6920 $482.92 3/1/20 D6930 $72.08 3/1/20 D6940 $180.20 3/1/20 D6950 $288.31 3/1/20 D6980 $187.40 3/1/20 D6985 $486.53 3/1/20 D7111 $169.00 3/1/20 D7140 $79.29 3/1/20 D7210 $356.00 3/1/20 D7220 $422.00 3/1/20 D7230 $561.00 3/1/20 D7240 $659.00 3/1/20 D7241 $828.00 3/1/20 D7250 $144.16 3/1/20 D7251 $342.37 3/1/20 D7260 $432.47 3/1/20 D7261 $1,152.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 D7270 $259.48 3/1/20 D7272 $360.39 3/1/20 D7280 $216.23 3/1/20 D7282 $403.00 3/1/20 D7283 $273.90 3/1/20 D7285 $187.40 3/1/20 D7286 $144.16 3/1/20 D7287 $277.00 3/1/20 D7288 $90.10 3/1/20 D7290 $234.25 3/1/20 D7291 $136.95 3/1/20 D7292 $1,279.39 3/1/20 D7293 $937.02 3/1/20 D7294 $695.55 3/1/20 D7295 $425.00 3/1/20 D7296 $610.00 3/1/20 D7297 $1,053.00 3/1/20 D7310 $485.00 3/1/20 D7311 $191.01 3/1/20 D7320 $788.00 3/1/20 D7321 $277.50 3/1/20 D7340 $3,334.00 3/1/20 D7350 $1,009.09 3/1/20 D7410 $180.20 3/1/20 D7411 $2,303.00 3/1/20 D7412 $2,546.00 3/1/20

D7413 $1,697.00 3/1/20

D7414 $2,546.00 3/1/20 D7415 $2,849.00 3/1/20 D7440 $284.71 3/1/20 D7441 $576.63 3/1/20 D7450 $1,455.00 3/1/20 D7451 $1,988.00 3/1/20 D7460 $1,455.00 3/1/20 D7461 $1,988.00 3/1/20 D7465 $189.21 3/1/20 D7471 $1,801.00 3/1/20 D7472 $2,141.00 3/1/20 D7473 $2,020.00 3/1/20 D7485 $284.71 3/1/20 D7490 $4,468.85 3/1/20 D7510 $521.00 3/1/20 D7511 $158.57 3/1/20 D7520 $216.23 3/1/20 D7521 $270.29 3/1/20 D7530 $151.36 3/1/20 D7540 $306.33 3/1/20 D7550 $252.27 3/1/20 D7560 $468.51 3/1/20 D7610 $2,090.27 3/1/20 D7620 $1,729.88 3/1/20 D7630 $2,378.58 3/1/20 D7640 $1,441.56 3/1/20 D7650 $2,270.46 3/1/20 D7660 $1,369.49 3/1/20 D7670 $720.78 3/1/20 D7671 $4,303.00 3/1/20

2020 Other Codes Fee Schedule

Page 23 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 D7680 $3,423.71 3/1/20 D7710 $2,486.70 3/1/20 D7720 $1,585.72 3/1/20 D7730 $2,775.01 3/1/20 D7740 $1,621.76 3/1/20 D7750 $2,342.54 3/1/20 D7760 $2,162.35 3/1/20 D7770 $1,369.49 3/1/20 D7771 $3,564.00 3/1/20 D7780 $4,396.77 3/1/20 D7810 $2,270.46 3/1/20 D7820 $324.35 3/1/20 D7830 $327.96 3/1/20 D7840 $3,099.36 3/1/20 D7850 $2,955.21 3/1/20 D7852 $3,531.83 3/1/20 D7854 $3,603.91 3/1/20 D7856 $1,765.92 3/1/20 D7858 $4,036.38 3/1/20 D7860 $1,081.17 3/1/20 D7865 $3,027.28 3/1/20 D7870 $144.16 3/1/20 D7871 $1,416.34 3/1/20 D7872 $937.02 3/1/20 D7873 $1,027.11 3/1/20 D7874 $1,297.41 3/1/20

D7875 $1,387.51 3/1/20

D7876 $1,441.56 3/1/20 D7877 $1,333.45 3/1/20 D7880 $511.76 3/1/20 D7881 $162.18 3/1/20 D7910 $151.36 3/1/20 D7911 $194.61 3/1/20 D7912 $288.31 3/1/20 D7920 $1,189.29 3/1/20 D7921 $126.14 3/1/20 D7940 $1,910.07 3/1/20 D7941 $5,045.47 3/1/20 D7943 $5,117.55 3/1/20 D7944 $4,036.38 3/1/20 D7945 $4,072.42 3/1/20 D7946 $4,504.89 3/1/20 D7947 $4,504.89 3/1/20 D7948 $5,045.47 3/1/20 D7949 $7,351.98 3/1/20 D7950 $1,549.68 3/1/20 D7951 $1,412.73 3/1/20 D7952 $1,153.25 3/1/20 D7953 $684.74 3/1/20 D7955 $1,621.76 3/1/20 D7960 $667.00 3/1/20 D7963 $255.88 3/1/20 D7970 $288.31 3/1/20 D7971 $122.53 3/1/20 D7972 $1,358.00 3/1/20 D7979 $147.76 3/1/20 D7980 $299.12 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 D7981 $1,441.56 3/1/20 D7982 $882.96 3/1/20 D7983 $612.66 3/1/20 D7990 $598.25 3/1/20 D7991 $2,234.42 3/1/20 D7997 $144.16 3/1/20 D7998 $1,048.74 3/1/20 D8010 $792.86 3/1/20 D8020 $937.02 3/1/20 D8030 $1,261.37 3/1/20 D8040 $1,225.33 3/1/20 D8050 $1,189.29 3/1/20 D8060 $1,333.45 3/1/20 D8070 $3,928.26 3/1/20 D8080 $3,279.56 3/1/20 D8090 $3,423.71 3/1/20 D8210 $1,500.00 3/1/20 D8220 $1,500.00 3/1/20 D8660 $129.74 3/1/20 D8670 $97.31 3/1/20 D8680 $302.73 3/1/20 D8681 $117.13 3/1/20 D8690 $118.93 3/1/20 D8695 $144.16 3/1/20 D9110 $72.08 3/1/20 D9120 $126.14 3/1/20

D9130 $21.62 3/1/20

D9210 $32.44 3/1/20 D9211 $43.25 3/1/20 D9212 $136.95 3/1/20 D9215 $28.83 3/1/20 D9219 $144.16 3/1/20 D9222 $211.00 3/1/20 D9223 $269.00 3/1/20 D9230 $32.44 3/1/20 D9239 $179.00 3/1/20 D9243 $227.00 3/1/20 D9248 $160.37 3/1/20 D9310 $57.66 3/1/20 D9311 $64.87 3/1/20 D9410 $234.00 3/1/20 D9420 $378.00 3/1/20 D9430 $75.00 3/1/20 D9440 $72.08 3/1/20 D9450 $68.47 3/1/20 D9610 $36.04 3/1/20 D9612 $90.10 3/1/20 D9613 $28.83 3/1/20 D9630 $18.02 3/1/20 D9910 $32.44 3/1/20 D9911 $39.64 3/1/20 D9920 $57.66 3/1/20 D9930 $61.27 3/1/20 D9932 $28.83 3/1/20 D9933 $28.83 3/1/20 D9934 $28.83 3/1/20 D9935 $28.83 3/1/20

2020 Other Codes Fee Schedule

Page 24 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 D9941 $104.51 3/1/20 D9942 $122.53 3/1/20 D9943 $115.33 3/1/20 D9944 $309.94 3/1/20 D9945 $255.88 3/1/20 D9946 $234.25 3/1/20 D9950 $162.18 3/1/20 D9951 $119.02 3/1/20 D9952 $288.31 3/1/20 D9961 $72.08 3/1/20 D9970 $97.31 3/1/20 D9971 $97.31 3/1/20 D9972 $201.82 3/1/20 D9973 $129.74 3/1/20 D9974 $147.76 3/1/20 D9975 $172.99 3/1/20 D9986 $0.00 3/1/20 D9987 $0.00 3/1/20 D9990 $36.04 3/1/20 D9991 $18.02 3/1/20 D9992 $36.04 3/1/20 D9993 $18.02 3/1/20 D9994 $18.02 3/1/20 D9995 $24.00 3/1/20 D9996 $24.00 3/1/20 G0008 $18.08 3/1/20

G0009 $36.43 3/1/20

G0010 $39.44 3/1/20 G0129 $153.11 3/1/20 G0151 $38.35 3/1/20 G0152 $38.35 3/1/20 G0153 $38.35 3/1/20 G0155 $30.68 3/1/20 G0156 $19.17 3/1/20 G0157 $19.99 3/1/20 G0158 $19.99 3/1/20 G0159 $19.99 3/1/20 G0160 $19.99 3/1/20 G0161 $19.99 3/1/20 G0162 $16.16 3/1/20 G0175 $48.21 3/1/20 G0176 $100.52 3/1/20 G0177 $72.31 3/1/20 G0186 $603.40 3/1/20 G0219 26 $72.31 3/1/20 G0219 TC $1,609.42 3/1/20 G0219 $1,681.73 3/1/20 G0252 TC $2,060.81 3/1/20 G0252 $2,118.87 3/1/20 G0255 26 $61.44 3/1/20 G0255 TC $40.96 3/1/20 G0255 $102.40 3/1/20 G0257 $12.20 3/1/20 G0259 $120.79 3/1/20 G0260 $140.78 3/1/20 G0269 $80.53 3/1/20 G0282 $6.03 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G0293 $11.00 3/1/20 G0295 $17.64 3/1/20 G0299 $27.63 3/1/20 G0300 $27.63 3/1/20 G0302 $1,853.44 3/1/20 G0303 $1,737.60 3/1/20 G0304 $1,042.56 3/1/20 G0305 $551.70 3/1/20 G0333 $36.48 3/1/20 G0339 26 $920.00 3/1/20 G0339 TC $2,146.66 3/1/20 G0339 $2,472.34 3/1/20 G0340 26 $691.90 3/1/20 G0340 TC $1,614.42 3/1/20 G0340 $1,859.38 3/1/20 G0378 $96.69 3/1/20 G0379 $96.69 3/1/20 G0380 $47.38 3/1/20 G0381 $76.42 3/1/20 G0382 $126.27 3/1/20 G0383 $191.18 3/1/20 G0384 $282.94 3/1/20 G0390 $256.95 3/1/20 G0398 26 $106.19 3/1/20 G0398 TC $53.09 3/1/20 G0398 $159.30 3/1/20

G0399 26 $90.28 3/1/20

G0399 TC $37.16 3/1/20 G0399 $132.76 3/1/20 G0400 26 $56.87 3/1/20 G0400 TC $47.93 3/1/20 G0400 $104.79 3/1/20 G0410 $24.92 3/1/20 G0411 $24.92 3/1/20 G0428 $100.52 3/1/20 G0448 $30.13 3/1/20 G0463 $69.55 3/1/20 G0466 $115.00 3/1/20 G0467 $73.42 3/1/20 G0468 $1.79 3/1/20 G0470 $100.00 3/1/20 G0490 $27.63 3/1/20 G0493 $19.41 3/1/20 G0494 $14.47 3/1/20 G0495 $14.47 3/1/20 G0496 $14.47 3/1/20 G0498 $135.87 3/1/20 G0501 $17.16 3/1/20 G0913 $0.00 3/1/20 G0914 $0.00 3/1/20 G0915 $0.00 3/1/20 G0916 $0.00 3/1/20 G0917 $0.00 3/1/20 G0918 $0.00 3/1/20 G2000 $178.73 3/1/20 G6017 26 $34.02 3/1/20 G6017 TC $79.37 3/1/20

2020 Other Codes Fee Schedule

Page 25 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G6017 $56.15 3/1/20 G8395 $0.00 3/1/20 G8396 $0.00 3/1/20 G8397 $0.00 3/1/20 G8398 $0.00 3/1/20 G8399 $0.00 3/1/20 G8400 $0.00 3/1/20 G8404 $0.00 3/1/20 G8405 $0.00 3/1/20 G8410 $0.00 3/1/20 G8415 $0.00 3/1/20 G8416 $0.00 3/1/20 G8417 $0.00 3/1/20 G8418 $0.00 3/1/20 G8419 $0.00 3/1/20 G8420 $0.00 3/1/20 G8421 $0.00 3/1/20 G8422 $0.00 3/1/20 G8427 $0.00 3/1/20 G8428 $0.00 3/1/20 G8430 $0.00 3/1/20 G8431 $0.00 3/1/20 G8432 $0.00 3/1/20 G8433 $0.00 3/1/20 G8442 $0.00 3/1/20 G8450 $0.00 3/1/20

G8451 $0.00 3/1/20

G8452 $0.00 3/1/20 G8465 $0.00 3/1/20 G8473 $0.00 3/1/20 G8474 $0.00 3/1/20 G8475 $0.00 3/1/20 G8476 $0.00 3/1/20 G8477 $0.00 3/1/20 G8478 $0.00 3/1/20 G8482 $0.00 3/1/20 G8483 $0.00 3/1/20 G8484 $0.00 3/1/20 G8506 $0.00 3/1/20 G8509 $0.00 3/1/20 G8510 $0.00 3/1/20 G8511 $0.00 3/1/20 G8535 $0.00 3/1/20 G8536 $0.00 3/1/20 G8539 $0.00 3/1/20 G8540 $0.00 3/1/20 G8541 $0.00 3/1/20 G8542 $0.00 3/1/20 G8543 $0.00 3/1/20 G8559 $0.00 3/1/20 G8560 $0.00 3/1/20 G8561 $0.00 3/1/20 G8562 $0.00 3/1/20 G8563 $0.00 3/1/20 G8564 $0.00 3/1/20 G8565 $0.00 3/1/20 G8566 $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G8567 $0.00 3/1/20 G8568 $0.00 3/1/20 G8569 $0.00 3/1/20 G8570 $0.00 3/1/20 G8571 $0.00 3/1/20 G8572 $0.00 3/1/20 G8573 $0.00 3/1/20 G8574 $0.00 3/1/20 G8575 $0.00 3/1/20 G8576 $0.00 3/1/20 G8577 $0.00 3/1/20 G8578 $0.00 3/1/20 G8598 $0.00 3/1/20 G8600 $0.00 3/1/20 G8601 $0.00 3/1/20 G8602 $0.00 3/1/20 G8627 $0.00 3/1/20 G8628 $0.00 3/1/20 G8633 $0.00 3/1/20 G8635 $0.00 3/1/20 G8647 $0.00 3/1/20 G8648 $0.00 3/1/20 G8650 $0.00 3/1/20 G8651 $0.00 3/1/20 G8652 $0.00 3/1/20 G8654 $0.00 3/1/20

G8655 $0.00 3/1/20

G8656 $0.00 3/1/20 G8658 $0.00 3/1/20 G8659 $0.00 3/1/20 G8660 $0.00 3/1/20 G8661 $0.00 3/1/20 G8662 $0.00 3/1/20 G8663 $0.00 3/1/20 G8664 $0.00 3/1/20 G8666 $0.00 3/1/20 G8667 $0.00 3/1/20 G8668 $0.00 3/1/20 G8670 $0.00 3/1/20 G8671 $0.00 3/1/20 G8672 $0.00 3/1/20 G8674 $0.00 3/1/20 G8694 $0.00 3/1/20 G8708 $0.00 3/1/20 G8709 $0.00 3/1/20 G8710 $0.00 3/1/20 G8711 $0.00 3/1/20 G8712 $0.00 3/1/20 G8721 $0.00 3/1/20 G8722 $0.00 3/1/20 G8723 $0.00 3/1/20 G8724 $0.00 3/1/20 G8730 $0.00 3/1/20 G8731 $0.00 3/1/20 G8732 $0.00 3/1/20 G8733 $0.00 3/1/20 G8734 $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 26 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G8735 $0.00 3/1/20 G8749 $0.00 3/1/20 G8752 $0.00 3/1/20 G8753 $0.00 3/1/20 G8754 $0.00 3/1/20 G8755 $0.00 3/1/20 G8756 $0.00 3/1/20 G8783 $0.00 3/1/20 G8785 $0.00 3/1/20 G8797 $0.00 3/1/20 G8798 $0.00 3/1/20 G8806 $0.00 3/1/20 G8807 $0.00 3/1/20 G8808 $0.00 3/1/20 G8809 $0.00 3/1/20 G8810 $0.00 3/1/20 G8811 $0.00 3/1/20 G8815 $0.00 3/1/20 G8816 $0.00 3/1/20 G8817 $0.00 3/1/20 G8818 $0.00 3/1/20 G8825 $0.00 3/1/20 G8826 $0.00 3/1/20 G8833 $0.00 3/1/20 G8834 $0.00 3/1/20 G8838 $0.00 3/1/20

G8839 $0.00 3/1/20

G8840 $0.00 3/1/20 G8841 $0.00 3/1/20 G8842 $0.00 3/1/20 G8843 $0.00 3/1/20 G8844 $0.00 3/1/20 G8845 $0.00 3/1/20 G8846 $0.00 3/1/20 G8849 $0.00 3/1/20 G8850 $0.00 3/1/20 G8851 $0.00 3/1/20 G8852 $0.00 3/1/20 G8854 $0.00 3/1/20 G8855 $0.00 3/1/20 G8856 $0.00 3/1/20 G8857 $0.00 3/1/20 G8858 $0.00 3/1/20 G8863 $0.00 3/1/20 G8864 $0.00 3/1/20 G8865 $0.00 3/1/20 G8866 $0.00 3/1/20 G8867 $0.00 3/1/20 G8869 $0.00 3/1/20 G8872 $0.00 3/1/20 G8873 $0.00 3/1/20 G8874 $0.00 3/1/20 G8875 $0.00 3/1/20 G8876 $0.00 3/1/20 G8877 $0.00 3/1/20 G8878 $0.00 3/1/20 G8880 $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G8881 $0.00 3/1/20 G8882 $0.00 3/1/20 G8883 $0.00 3/1/20 G8884 $0.00 3/1/20 G8885 $0.00 3/1/20 G8907 $0.00 3/1/20 G8908 $0.00 3/1/20 G8909 $0.00 3/1/20 G8910 $0.00 3/1/20 G8911 $0.00 3/1/20 G8912 $0.00 3/1/20 G8913 $0.00 3/1/20 G8914 $0.00 3/1/20 G8915 $0.00 3/1/20 G8916 $0.00 3/1/20 G8917 $0.00 3/1/20 G8918 $0.00 3/1/20 G8923 $0.00 3/1/20 G8924 $0.00 3/1/20 G8925 $0.00 3/1/20 G8926 $0.00 3/1/20 G8934 $0.00 3/1/20 G8935 $0.00 3/1/20 G8936 $0.00 3/1/20 G8937 $0.00 3/1/20 G8938 $0.00 3/1/20

G8939 $0.00 3/1/20

G8941 $0.00 3/1/20 G8942 $0.00 3/1/20 G8944 $0.00 3/1/20 G8946 $0.00 3/1/20 G8950 $0.00 3/1/20 G8952 $0.00 3/1/20 G8955 $0.00 3/1/20 G8956 $0.00 3/1/20 G8958 $0.00 3/1/20 G8959 $0.00 3/1/20 G8960 $0.00 3/1/20 G8961 $0.00 3/1/20 G8962 $0.00 3/1/20 G8963 $0.00 3/1/20 G8964 $0.00 3/1/20 G8965 $0.00 3/1/20 G8966 $0.00 3/1/20 G8967 $0.00 3/1/20 G8968 $0.00 3/1/20 G8969 $0.00 3/1/20 G8970 $0.00 3/1/20 G8973 $0.00 3/1/20 G8974 $0.00 3/1/20 G8975 $0.00 3/1/20 G8976 $0.00 3/1/20 G9001 $0.00 3/1/20 G9002 $0.00 3/1/20 G9003 $0.00 3/1/20 G9004 $0.00 3/1/20 G9005 $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 27 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G9006 $0.00 3/1/20 G9007 $0.00 3/1/20 G9008 $0.00 3/1/20 G9009 $0.00 3/1/20 G9010 $0.00 3/1/20 G9011 $0.00 3/1/20 G9012 $0.00 3/1/20 G9013 $1.29 3/1/20 G9014 $18.23 3/1/20 G9016 $6.93 3/1/20 G9148 $0.00 3/1/20 G9149 $0.00 3/1/20 G9150 $0.00 3/1/20 G9151 $0.00 3/1/20 G9152 $0.00 3/1/20 G9153 $0.00 3/1/20 G9188 $0.00 3/1/20 G9189 $0.00 3/1/20 G9190 $0.00 3/1/20 G9191 $0.00 3/1/20 G9192 $0.00 3/1/20 G9196 $0.00 3/1/20 G9197 $0.00 3/1/20 G9198 $0.00 3/1/20 G9212 $0.00 3/1/20 G9213 $0.00 3/1/20

G9223 $0.00 3/1/20

G9225 $0.00 3/1/20 G9226 $0.00 3/1/20 G9227 $0.00 3/1/20 G9228 $0.00 3/1/20 G9229 $0.00 3/1/20 G9230 $0.00 3/1/20 G9231 $0.00 3/1/20 G9232 $0.00 3/1/20 G9239 $0.00 3/1/20 G9240 $0.00 3/1/20 G9241 $0.00 3/1/20 G9242 $0.00 3/1/20 G9243 $0.00 3/1/20 G9246 $0.00 3/1/20 G9247 $0.00 3/1/20 G9250 $0.00 3/1/20 G9251 $0.00 3/1/20 G9254 $0.00 3/1/20 G9255 $0.00 3/1/20 G9256 $0.00 3/1/20 G9257 $0.00 3/1/20 G9258 $0.00 3/1/20 G9259 $0.00 3/1/20 G9260 $0.00 3/1/20 G9261 $0.00 3/1/20 G9262 $0.00 3/1/20 G9263 $0.00 3/1/20 G9264 $0.00 3/1/20 G9265 $0.00 3/1/20 G9266 $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G9267 $0.00 3/1/20 G9268 $0.00 3/1/20 G9269 $0.00 3/1/20 G9270 $0.00 3/1/20 G9273 $0.00 3/1/20 G9274 $0.00 3/1/20 G9275 $0.00 3/1/20 G9276 $0.00 3/1/20 G9277 $0.00 3/1/20 G9278 $0.00 3/1/20 G9279 $0.00 3/1/20 G9280 $0.00 3/1/20 G9281 $0.00 3/1/20 G9282 $0.00 3/1/20 G9283 $0.00 3/1/20 G9284 $0.00 3/1/20 G9285 $0.00 3/1/20 G9286 $0.00 3/1/20 G9287 $0.00 3/1/20 G9288 $0.00 3/1/20 G9289 $0.00 3/1/20 G9290 $0.00 3/1/20 G9291 $0.00 3/1/20 G9292 $0.00 3/1/20 G9293 $0.00 3/1/20 G9294 $0.00 3/1/20

G9295 $0.00 3/1/20

G9296 $0.00 3/1/20 G9297 $0.00 3/1/20 G9298 $0.00 3/1/20 G9299 $0.00 3/1/20 G9300 $0.00 3/1/20 G9301 $0.00 3/1/20 G9302 $0.00 3/1/20 G9303 $0.00 3/1/20 G9304 $0.00 3/1/20 G9305 $0.00 3/1/20 G9306 $0.00 3/1/20 G9307 $0.00 3/1/20 G9308 $0.00 3/1/20 G9309 $0.00 3/1/20 G9310 $0.00 3/1/20 G9311 $0.00 3/1/20 G9312 $0.00 3/1/20 G9313 $0.00 3/1/20 G9314 $0.00 3/1/20 G9315 $0.00 3/1/20 G9316 $0.00 3/1/20 G9317 $0.00 3/1/20 G9318 $0.00 3/1/20 G9319 $0.00 3/1/20 G9321 $0.00 3/1/20 G9322 $0.00 3/1/20 G9326 $0.00 3/1/20 G9327 $0.00 3/1/20 G9329 $0.00 3/1/20 G9340 $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 28 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G9341 $0.00 3/1/20 G9342 $0.00 3/1/20 G9344 $0.00 3/1/20 G9345 $0.00 3/1/20 G9347 $0.00 3/1/20 G9348 $0.00 3/1/20 G9349 $0.00 3/1/20 G9350 $0.00 3/1/20 G9351 $0.00 3/1/20 G9352 $0.00 3/1/20 G9353 $0.00 3/1/20 G9354 $0.00 3/1/20 G9355 $0.00 3/1/20 G9356 $0.00 3/1/20 G9357 $0.00 3/1/20 G9358 $0.00 3/1/20 G9359 $0.00 3/1/20 G9360 $0.00 3/1/20 G9361 $11.93 3/1/20 G9364 $0.00 3/1/20 G9365 $0.00 3/1/20 G9366 $0.00 3/1/20 G9367 $0.00 3/1/20 G9368 $0.00 3/1/20 G9380 $0.00 3/1/20 G9382 $0.00 3/1/20

G9383 $0.00 3/1/20

G9384 $0.00 3/1/20 G9385 $0.00 3/1/20 G9386 $0.00 3/1/20 G9389 $0.00 3/1/20 G9390 $0.00 3/1/20 G9393 $0.00 3/1/20 G9394 $0.00 3/1/20 G9395 $0.00 3/1/20 G9396 $0.00 3/1/20 G9399 $0.00 3/1/20 G9400 $0.00 3/1/20 G9401 $0.00 3/1/20 G9402 $0.00 3/1/20 G9403 $0.00 3/1/20 G9404 $0.00 3/1/20 G9405 $0.00 3/1/20 G9406 $0.00 3/1/20 G9407 $0.00 3/1/20 G9408 $0.00 3/1/20 G9409 $0.00 3/1/20 G9410 $0.00 3/1/20 G9411 $0.00 3/1/20 G9412 $0.00 3/1/20 G9413 $0.00 3/1/20 G9414 $0.00 3/1/20 G9415 $0.00 3/1/20 G9416 $0.00 3/1/20 G9417 $0.00 3/1/20 G9418 $0.00 3/1/20 G9419 $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G9420 $0.00 3/1/20 G9421 $0.00 3/1/20 G9422 $0.00 3/1/20 G9423 $0.00 3/1/20 G9424 $0.00 3/1/20 G9425 $0.00 3/1/20 G9426 $0.00 3/1/20 G9427 $0.00 3/1/20 G9428 $0.00 3/1/20 G9429 $0.00 3/1/20 G9430 $0.00 3/1/20 G9431 $0.00 3/1/20 G9432 $0.00 3/1/20 G9434 $0.00 3/1/20 G9448 $0.00 3/1/20 G9449 $0.00 3/1/20 G9450 $0.00 3/1/20 G9451 $0.00 3/1/20 G9452 $0.00 3/1/20 G9453 $0.00 3/1/20 G9454 $0.00 3/1/20 G9455 $0.00 3/1/20 G9456 $0.00 3/1/20 G9457 $0.00 3/1/20 G9458 $0.00 3/1/20 G9459 $0.00 3/1/20

G9468 $0.00 3/1/20

G9469 $0.00 3/1/20 G9470 $0.00 3/1/20 G9471 $0.00 3/1/20 G9473 $0.00 3/1/20 G9474 $0.00 3/1/20 G9475 $0.00 3/1/20 G9476 $0.00 3/1/20 G9477 $0.00 3/1/20 G9478 $0.00 3/1/20 G9479 $0.00 3/1/20 G9480 $0.00 3/1/20 G9497 $0.00 3/1/20 G9498 $0.00 3/1/20 G9500 $0.00 3/1/20 G9501 $0.00 3/1/20 G9502 $0.00 3/1/20 G9503 $0.00 3/1/20 G9504 $0.00 3/1/20 G9505 $0.00 3/1/20 G9506 $0.00 3/1/20 G9507 $0.00 3/1/20 G9508 $0.00 3/1/20 G9509 $0.00 3/1/20 G9510 $0.00 3/1/20 G9511 $0.00 3/1/20 G9512 $0.00 3/1/20 G9513 $0.00 3/1/20 G9514 $0.00 3/1/20 G9515 $0.00 3/1/20 G9516 $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 29 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G9517 $0.00 3/1/20 G9518 $0.00 3/1/20 G9519 $0.00 3/1/20 G9520 $0.00 3/1/20 G9521 $0.00 3/1/20 G9522 $0.00 3/1/20 G9523 $0.00 3/1/20 G9524 $0.00 3/1/20 G9525 $0.00 3/1/20 G9526 $0.00 3/1/20 G9529 $0.00 3/1/20 G9530 $0.00 3/1/20 G9531 $0.00 3/1/20 G9532 $0.00 3/1/20 G9533 $0.00 3/1/20 G9537 $0.00 3/1/20 G9539 $0.00 3/1/20 G9540 $0.00 3/1/20 G9541 $0.00 3/1/20 G9542 $0.00 3/1/20 G9543 $0.00 3/1/20 G9544 $0.00 3/1/20 G9547 $0.00 3/1/20 G9548 $0.00 3/1/20 G9549 $0.00 3/1/20 G9550 $0.00 3/1/20

G9551 $0.00 3/1/20

G9552 $0.00 3/1/20 G9553 $0.00 3/1/20 G9554 $0.00 3/1/20 G9555 $0.00 3/1/20 G9556 $0.00 3/1/20 G9557 $0.00 3/1/20 G9558 $0.00 3/1/20 G9559 $0.00 3/1/20 G9560 $0.00 3/1/20 G9561 $0.00 3/1/20 G9562 $0.00 3/1/20 G9563 $0.00 3/1/20 G9573 $0.00 3/1/20 G9574 $0.00 3/1/20 G9577 $0.00 3/1/20 G9578 $0.00 3/1/20 G9579 $0.00 3/1/20 G9580 $0.00 3/1/20 G9582 $0.00 3/1/20 G9583 $0.00 3/1/20 G9584 $0.00 3/1/20 G9585 $0.00 3/1/20 G9593 $0.00 3/1/20 G9594 $0.00 3/1/20 G9595 $0.00 3/1/20 G9596 $0.00 3/1/20 G9597 $0.00 3/1/20 G9598 $0.00 3/1/20 G9599 $0.00 3/1/20 G9600 $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G9601 $0.00 3/1/20 G9602 $0.00 3/1/20 G9603 $0.00 3/1/20 G9604 $0.00 3/1/20 G9605 $0.00 3/1/20 G9606 $0.00 3/1/20 G9607 $0.00 3/1/20 G9608 $0.00 3/1/20 G9609 $0.00 3/1/20 G9610 $0.00 3/1/20 G9611 $0.00 3/1/20 G9612 $0.00 3/1/20 G9613 $0.00 3/1/20 G9614 $0.00 3/1/20 G9615 $0.00 3/1/20 G9616 $0.00 3/1/20 G9617 $0.00 3/1/20 G9618 $0.00 3/1/20 G9620 $0.00 3/1/20 G9621 $0.00 3/1/20 G9622 $0.00 3/1/20 G9623 $0.00 3/1/20 G9624 $0.00 3/1/20 G9625 $0.00 3/1/20 G9626 $0.00 3/1/20 G9627 $0.00 3/1/20

G9628 $0.00 3/1/20

G9629 $0.00 3/1/20 G9630 $0.00 3/1/20 G9631 $0.00 3/1/20 G9632 $0.00 3/1/20 G9633 $0.00 3/1/20 G9634 $0.00 3/1/20 G9635 $0.00 3/1/20 G9636 $0.00 3/1/20 G9637 $0.00 3/1/20 G9638 $0.00 3/1/20 G9639 $0.00 3/1/20 G9640 $0.00 3/1/20 G9641 $0.00 3/1/20 G9642 $0.00 3/1/20 G9643 $0.00 3/1/20 G9644 $0.00 3/1/20 G9645 $0.00 3/1/20 G9646 $0.00 3/1/20 G9647 $0.00 3/1/20 G9648 $0.00 3/1/20 G9649 $0.00 3/1/20 G9651 $0.00 3/1/20 G9654 $0.00 3/1/20 G9655 $0.00 3/1/20 G9656 $0.00 3/1/20 G9658 $0.00 3/1/20 G9659 $0.00 3/1/20 G9660 $0.00 3/1/20 G9661 $0.00 3/1/20 G9662 $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 30 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G9663 $0.00 3/1/20 G9664 $0.00 3/1/20 G9665 $0.00 3/1/20 G9666 $0.00 3/1/20 G9674 $0.00 3/1/20 G9675 $0.00 3/1/20 G9676 $0.00 3/1/20 G9678 $160.00 3/1/20 G9679 $69.01 3/1/20 G9680 $69.01 3/1/20 G9681 $69.01 3/1/20 G9682 $69.01 3/1/20 G9683 $69.01 3/1/20 G9684 $69.01 3/1/20 G9687 $0.00 3/1/20 G9688 $0.00 3/1/20 G9689 $0.00 3/1/20 G9690 $0.00 3/1/20 G9691 $0.00 3/1/20 G9692 $0.00 3/1/20 G9693 $0.00 3/1/20 G9694 $0.00 3/1/20 G9695 $0.00 3/1/20 G9696 $0.00 3/1/20 G9697 $0.00 3/1/20 G9698 $0.00 3/1/20

G9699 $0.00 3/1/20

G9700 $0.00 3/1/20 G9701 $0.00 3/1/20 G9702 $0.00 3/1/20 G9703 $0.00 3/1/20 G9704 $0.00 3/1/20 G9705 $0.00 3/1/20 G9706 $0.00 3/1/20 G9707 $0.00 3/1/20 G9708 $0.00 3/1/20 G9709 $0.00 3/1/20 G9710 $0.00 3/1/20 G9711 $0.00 3/1/20 G9712 $0.00 3/1/20 G9713 $0.00 3/1/20 G9714 $0.00 3/1/20 G9715 $0.00 3/1/20 G9716 $0.00 3/1/20 G9717 $0.00 3/1/20 G9718 $0.00 3/1/20 G9719 $0.00 3/1/20 G9720 $0.00 3/1/20 G9721 $0.00 3/1/20 G9722 $0.00 3/1/20 G9723 $0.00 3/1/20 G9724 $0.00 3/1/20 G9725 $0.00 3/1/20 G9726 $0.00 3/1/20 G9727 $0.00 3/1/20 G9728 $0.00 3/1/20 G9729 $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G9730 $0.00 3/1/20 G9731 $0.00 3/1/20 G9732 $0.00 3/1/20 G9733 $0.00 3/1/20 G9734 $0.00 3/1/20 G9735 $0.00 3/1/20 G9736 $0.00 3/1/20 G9737 $0.00 3/1/20 G9738 $0.00 3/1/20 G9739 $0.00 3/1/20 G9740 $0.00 3/1/20 G9741 $0.00 3/1/20 G9744 $0.00 3/1/20 G9745 $0.00 3/1/20 G9746 $0.00 3/1/20 G9747 $0.00 3/1/20 G9748 $0.00 3/1/20 G9749 $0.00 3/1/20 G9750 $0.00 3/1/20 G9751 $0.00 3/1/20 G9752 $0.00 3/1/20 G9753 $0.00 3/1/20 G9754 $0.00 3/1/20 G9755 $0.00 3/1/20 G9756 $0.00 3/1/20 G9757 $0.00 3/1/20

G9758 $0.00 3/1/20

G9759 $0.00 3/1/20 G9760 $0.00 3/1/20 G9761 $0.00 3/1/20 G9762 $0.00 3/1/20 G9763 $0.00 3/1/20 G9764 $0.00 3/1/20 G9765 $0.00 3/1/20 G9766 $0.00 3/1/20 G9767 $0.00 3/1/20 G9768 $0.00 3/1/20 G9769 $0.00 3/1/20 G9770 $0.00 3/1/20 G9771 $0.00 3/1/20 G9772 $0.00 3/1/20 G9773 $0.00 3/1/20 G9774 $0.00 3/1/20 G9775 $0.00 3/1/20 G9776 $0.00 3/1/20 G9777 $0.00 3/1/20 G9778 $0.00 3/1/20 G9779 $0.00 3/1/20 G9780 $0.00 3/1/20 G9781 $0.00 3/1/20 G9782 $0.00 3/1/20 G9783 $0.00 3/1/20 G9784 $0.00 3/1/20 G9785 $0.00 3/1/20 G9786 $0.00 3/1/20 G9787 $0.00 3/1/20 G9788 $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 31 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G9789 $0.00 3/1/20 G9790 $0.00 3/1/20 G9791 $0.00 3/1/20 G9792 $0.00 3/1/20 G9793 $0.00 3/1/20 G9794 $0.00 3/1/20 G9795 $0.00 3/1/20 G9796 $0.00 3/1/20 G9797 $0.00 3/1/20 G9798 $0.00 3/1/20 G9799 $0.00 3/1/20 G9800 $0.00 3/1/20 G9801 $0.00 3/1/20 G9802 $0.00 3/1/20 G9803 $0.00 3/1/20 G9804 $0.00 3/1/20 G9805 $0.00 3/1/20 G9806 $0.00 3/1/20 G9807 $0.00 3/1/20 G9808 $0.00 3/1/20 G9809 $0.00 3/1/20 G9810 $0.00 3/1/20 G9811 $0.00 3/1/20 G9812 $0.00 3/1/20 G9813 $0.00 3/1/20 G9814 $0.00 3/1/20

G9815 $0.00 3/1/20

G9816 $0.00 3/1/20 G9817 $0.00 3/1/20 G9818 $0.00 3/1/20 G9819 $0.00 3/1/20 G9820 $0.00 3/1/20 G9821 $0.00 3/1/20 G9822 $0.00 3/1/20 G9823 $0.00 3/1/20 G9824 $0.00 3/1/20 G9825 $0.00 3/1/20 G9826 $0.00 3/1/20 G9827 $0.00 3/1/20 G9828 $0.00 3/1/20 G9829 $0.00 3/1/20 G9830 $0.00 3/1/20 G9831 $0.00 3/1/20 G9832 $0.00 3/1/20 G9833 $0.00 3/1/20 G9834 $0.00 3/1/20 G9835 $0.00 3/1/20 G9836 $0.00 3/1/20 G9837 $0.00 3/1/20 G9838 $0.00 3/1/20 G9839 $0.00 3/1/20 G9840 $0.00 3/1/20 G9841 $0.00 3/1/20 G9842 $0.00 3/1/20 G9843 $0.00 3/1/20 G9844 $0.00 3/1/20 G9845 $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G9846 $0.00 3/1/20 G9847 $0.00 3/1/20 G9848 $0.00 3/1/20 G9849 $0.00 3/1/20 G9850 $0.00 3/1/20 G9851 $0.00 3/1/20 G9852 $0.00 3/1/20 G9853 $0.00 3/1/20 G9854 $0.00 3/1/20 G9855 $0.00 3/1/20 G9856 $0.00 3/1/20 G9857 $0.00 3/1/20 G9858 $0.00 3/1/20 G9859 $0.00 3/1/20 G9860 $0.00 3/1/20 G9861 $0.00 3/1/20 G9862 $0.00 3/1/20 G9873 $25.00 3/1/20 G9874 $50.00 3/1/20 G9875 $90.00 3/1/20 G9876 $15.00 3/1/20 G9877 $15.00 3/1/20 G9878 $60.00 3/1/20 G9879 $60.00 3/1/20 G9880 $160.00 3/1/20 G9881 $25.00 3/1/20

G9882 $50.00 3/1/20

G9883 $50.00 3/1/20 G9884 $50.00 3/1/20 G9885 $50.00 3/1/20 G9890 $25.00 3/1/20 G9891 $0.00 3/1/20 G9892 $0.00 3/1/20 G9893 $0.00 3/1/20 G9894 $0.00 3/1/20 G9895 $0.00 3/1/20 G9896 $0.00 3/1/20 G9897 $0.00 3/1/20 G9898 $0.00 3/1/20 G9899 $0.00 3/1/20 G9900 $0.00 3/1/20 G9901 $0.00 3/1/20 G9902 $0.00 3/1/20 G9903 $0.00 3/1/20 G9904 $0.00 3/1/20 G9905 $0.00 3/1/20 G9906 $0.00 3/1/20 G9907 $0.00 3/1/20 G9908 $0.00 3/1/20 G9909 $0.00 3/1/20 G9910 $0.00 3/1/20 G9911 $0.00 3/1/20 G9912 $0.00 3/1/20 G9913 $0.00 3/1/20 G9914 $0.00 3/1/20 G9915 $0.00 3/1/20 G9916 $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 32 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 G9917 $0.00 3/1/20 G9918 $0.00 3/1/20 G9919 $0.00 3/1/20 G9920 $0.00 3/1/20 G9921 $0.00 3/1/20 G9922 $0.00 3/1/20 G9923 $0.00 3/1/20 G9924 $0.00 3/1/20 G9925 $0.00 3/1/20 G9926 $0.00 3/1/20 G9927 $0.00 3/1/20 G9928 $0.00 3/1/20 G9929 $0.00 3/1/20 G9930 $0.00 3/1/20 G9931 $0.00 3/1/20 G9932 $0.00 3/1/20 G9933 $0.00 3/1/20 G9934 $0.00 3/1/20 G9935 $0.00 3/1/20 G9936 $0.00 3/1/20 G9937 $0.00 3/1/20 G9938 $0.00 3/1/20 G9939 $0.00 3/1/20 G9940 $0.00 3/1/20 G9942 $0.00 3/1/20 G9943 $0.00 3/1/20

G9945 $0.00 3/1/20

G9946 $0.00 3/1/20 G9948 $0.00 3/1/20 G9949 $0.00 3/1/20 G9954 $0.00 3/1/20 G9955 $0.00 3/1/20 G9956 $0.00 3/1/20 G9957 $0.00 3/1/20 G9958 $0.00 3/1/20 G9959 $0.00 3/1/20 G9960 $0.00 3/1/20 G9961 $0.00 3/1/20 G9962 $0.00 3/1/20 G9963 $0.00 3/1/20 G9964 $0.00 3/1/20 G9965 $0.00 3/1/20 G9966 $0.00 3/1/20 G9967 $0.00 3/1/20 G9968 $0.00 3/1/20 G9969 $0.00 3/1/20 G9970 $0.00 3/1/20 G9974 $0.00 3/1/20 G9975 $0.00 3/1/20 G9976 $0.00 3/1/20 G9977 $0.00 3/1/20 M0075 $37.50 3/1/20 M0076 $145.46 3/1/20 M1003 $0.00 3/1/20 M1004 $0.00 3/1/20 M1005 $0.00 3/1/20 M1006 $0.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 M1007 $0.00 3/1/20 M1008 $0.00 3/1/20 M1009 $0.00 3/1/20 M1010 $0.00 3/1/20 M1011 $0.00 3/1/20 M1012 $0.00 3/1/20 M1013 $0.00 3/1/20 M1014 $0.00 3/1/20 M1015 $0.00 3/1/20 M1016 $0.00 3/1/20 M1017 $0.00 3/1/20 M1018 $0.00 3/1/20 M1019 $0.00 3/1/20 M1020 $0.00 3/1/20 M1021 $0.00 3/1/20 M1022 $0.00 3/1/20 M1023 $0.00 3/1/20 M1024 $0.00 3/1/20 M1025 $0.00 3/1/20 M1026 $0.00 3/1/20 M1027 $0.00 3/1/20 M1028 $0.00 3/1/20 M1029 $0.00 3/1/20 M1031 $0.00 3/1/20 M1032 $0.00 3/1/20 M1033 $0.00 3/1/20

M1034 $0.00 3/1/20

M1035 $0.00 3/1/20 M1036 $0.00 3/1/20 M1037 $0.00 3/1/20 M1038 $0.00 3/1/20 M1039 $0.00 3/1/20 M1040 $0.00 3/1/20 M1041 $0.00 3/1/20 M1043 $0.00 3/1/20 M1045 $0.00 3/1/20 M1046 $0.00 3/1/20 M1049 $0.00 3/1/20 M1051 $0.00 3/1/20 M1052 $0.00 3/1/20 M1054 $0.00 3/1/20 M1055 $0.00 3/1/20 M1056 $0.00 3/1/20 M1057 $0.00 3/1/20 M1058 $0.00 3/1/20 M1059 $0.00 3/1/20 M1060 $0.00 3/1/20 M1061 $0.00 3/1/20 M1062 $0.00 3/1/20 M1063 $0.00 3/1/20 M1064 $0.00 3/1/20 M1065 $0.00 3/1/20 M1066 $0.00 3/1/20 M1067 $0.00 3/1/20 M1068 $0.00 3/1/20 M1069 $0.00 3/1/20 M1070 $0.00 3/1/20

2020 Other Codes Fee Schedule

Page 33 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 M1071 $0.00 3/1/20 P7001 26 $12.05 3/1/20 P7001 TC $12.05 3/1/20 P7001 $12.05 3/1/20 P9010 $124.83 3/1/20 P9011 $61.20 3/1/20 P9012 $68.00 3/1/20 P9016 $275.82 3/1/20 P9017 $8.50 3/1/20 P9019 $70.00 3/1/20 P9020 $202.36 3/1/20 P9021 $86.93 3/1/20 P9022 $68.00 3/1/20 P9023 26 $0.09 3/1/20 P9023 TC $0.85 3/1/20 P9023 $0.85 3/1/20 P9031 $67.85 3/1/20 P9032 $69.63 3/1/20 P9033 $556.00 3/1/20 P9034 $343.82 3/1/20 P9035 $762.27 3/1/20 P9036 $262.17 3/1/20 P9037 $6.00 3/1/20 P9038 $93.30 3/1/20 P9039 $9.00 3/1/20 P9040 $350.82 3/1/20

P9051 $75.00 3/1/20

P9052 $446.25 3/1/20 P9053 $437.98 3/1/20 P9054 $68.00 3/1/20 P9055 $374.09 3/1/20 P9056 $143.49 3/1/20 P9057 $51.00 3/1/20 P9058 $214.72 3/1/20 P9059 $51.00 3/1/20 P9060 $51.00 3/1/20 P9070 26 $0.85 3/1/20 P9070 TC $0.85 3/1/20 P9070 $0.85 3/1/20 P9071 26 $5.10 3/1/20 P9071 TC $3.40 3/1/20 P9071 $8.50 3/1/20 P9073 26 $624.71 3/1/20 P9073 TC $624.71 3/1/20 P9073 $624.71 3/1/20 P9100 26 $25.50 3/1/20 P9100 TC $25.50 3/1/20 P9100 $25.50 3/1/20 P9603 26 $0.03 3/1/20 P9603 TC $0.02 3/1/20 P9603 $0.05 3/1/20 P9604 26 $2.65 3/1/20 P9604 TC $1.76 3/1/20 P9604 $4.41 3/1/20 Q0081 $59.91 3/1/20 Q0083 $64.14 3/1/20 Q0084 $128.28 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 Q0085 $128.28 3/1/20 Q3014 $121.61 3/1/20 Q3031 26 $8.25 3/1/20 Q3031 TC $19.25 3/1/20 Q3031 $27.50 3/1/20 Q5001 $0.00 3/1/20 Q5002 $0.00 3/1/20 Q5003 $0.00 3/1/20 Q5004 $0.00 3/1/20 Q5005 $0.00 3/1/20 Q5006 $0.00 3/1/20 Q5007 $0.00 3/1/20 Q5008 $0.00 3/1/20 Q5010 $0.00 3/1/20 R0070 26 $59.98 3/1/20 R0070 TC $59.98 3/1/20 R0070 $59.98 3/1/20 R0075 $25.47 3/1/20 R0076 26 $2.25 3/1/20 R0076 TC $5.25 3/1/20 R0076 $7.50 3/1/20 S0199 $324.09 3/1/20 S0201 $38.88 3/1/20 S0209 $1.57 3/1/20 S0220 $20.00 3/1/20 S0221 $56.25 3/1/20

S0250 $10.00 3/1/20

S0257 $9.00 3/1/20 S0260 $45.65 3/1/20 S0265 $50.40 3/1/20 S0280 $0.00 3/1/20 S0281 $0.00 3/1/20 S0285 $48.98 3/1/20 S0302 $23.20 3/1/20 S0311 $0.00 3/1/20 S0315 $71.25 3/1/20 S0316 $46.07 3/1/20 S0317 $12.50 3/1/20 S0340 $12.50 3/1/20 S0353 $0.00 3/1/20 S0354 $0.00 3/1/20 S0390 $22.50 3/1/20 S0395 $40.18 3/1/20 S0400 $257.50 3/1/20 S0592 $22.96 3/1/20 S0601 26 $47.38 3/1/20 S0601 TC $47.38 3/1/20 S0601 $47.38 3/1/20 S0610 $47.38 3/1/20 S0612 $35.33 3/1/20 S0613 $45.00 3/1/20 S0618 26 $25.14 3/1/20 S0618 TC $16.76 3/1/20 S0618 $41.90 3/1/20 S0620 $47.11 3/1/20 S0621 $39.99 3/1/20 S0622 $14.38 3/1/20

2020 Other Codes Fee Schedule

Page 34 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 S0630 $20.44 3/1/20 S0800 $72.86 3/1/20 S0810 $72.86 3/1/20 S0812 $849.50 3/1/20 S2053 $5,690.00 3/1/20 S2054 $2,008.00 3/1/20 S2055 $2,008.00 3/1/20 S2060 $8,943.20 3/1/20 S2066 $21,693.17 3/1/20 S2067 $26,699.28 3/1/20 S2068 $16,687.05 3/1/20 S2070 $350.00 3/1/20 S2079 $1,600.00 3/1/20 S2083 $128.93 3/1/20 S2095 $902.43 3/1/20 S2107 $342.89 3/1/20 S2112 $1,500.00 3/1/20 S2117 $785.00 3/1/20 S2118 $2,583.66 3/1/20 S2120 $14.70 3/1/20 S2140 $105.29 3/1/20 S2142 $187.64 3/1/20 S2202 $293.54 3/1/20 S2205 $1,503.15 3/1/20 S2206 $1,652.15 3/1/20 S2207 $1,465.08 3/1/20

S2208 $1,639.55 3/1/20

S2209 $1,788.55 3/1/20 S2225 $167.41 3/1/20 S2230 $510.05 3/1/20 S2260 $750.00 3/1/20 S2300 $91.21 3/1/20 S2325 $1,052.88 3/1/20 S2340 $170.36 3/1/20 S2342 $771.39 3/1/20 S2348 $538.41 3/1/20 S2350 $1,070.39 3/1/20 S2351 $225.69 3/1/20 S2404 $5,000.00 3/1/20 S2405 $750.00 3/1/20 S2409 $5,000.00 3/1/20 S2411 $2,450.00 3/1/20 S2900 $853.74 3/1/20 S3000 $24.38 3/1/20 S3005 $0.00 3/1/20 S3600 26 $3.00 3/1/20 S3600 TC $2.00 3/1/20 S3600 $5.00 3/1/20 S3620 26 $0.00 3/1/20 S3620 TC $60.58 3/1/20 S3620 $60.58 3/1/20 S3630 26 $31.50 3/1/20 S3630 TC $31.50 3/1/20 S3630 $31.50 3/1/20 S3645 26 $5.40 3/1/20 S3645 TC $12.60 3/1/20 S3645 $18.00 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 S3650 26 $22.50 3/1/20 S3650 TC $52.50 3/1/20 S3650 $75.00 3/1/20 S3652 26 $67.38 3/1/20 S3652 TC $67.38 3/1/20 S3652 $67.38 3/1/20 S3800 26 $41.45 3/1/20 S3800 TC $48.92 3/1/20 S3800 $90.37 3/1/20 S3840 26 $687.27 3/1/20 S3840 TC $458.18 3/1/20 S3840 $1,145.45 3/1/20 S3841 26 $660.00 3/1/20 S3841 TC $440.00 3/1/20 S3841 $1,100.00 3/1/20 S3842 26 $792.83 3/1/20 S3842 TC $528.56 3/1/20 S3842 $1,321.39 3/1/20 S3845 26 $209.31 3/1/20 S3845 TC $209.31 3/1/20 S3845 $209.31 3/1/20 S3852 26 $231.60 3/1/20 S3852 TC $154.40 3/1/20 S3852 $386.00 3/1/20 S3853 26 $41.45 3/1/20 S3853 TC $48.92 3/1/20

S3853 $90.37 3/1/20

S3854 26 $1,197.92 3/1/20 S3854 TC $1,197.92 3/1/20 S3854 $1,197.92 3/1/20 S3865 26 $185.14 3/1/20 S3865 TC $123.42 3/1/20 S3865 $308.56 3/1/20 S3866 26 $432.00 3/1/20 S3866 TC $288.00 3/1/20 S3866 $720.00 3/1/20 S3900 26 $45.00 3/1/20 S3900 TC $30.00 3/1/20 S3900 $75.00 3/1/20 S3902 26 $21.98 3/1/20 S3902 TC $14.65 3/1/20 S3902 $36.63 3/1/20 S3904 26 $21.98 3/1/20 S3904 TC $14.65 3/1/20 S3904 $36.63 3/1/20 S4005 $603.50 3/1/20 S4011 $102.42 3/1/20 S4015 $4,000.00 3/1/20 S4020 $119.26 3/1/20 S4022 $375.00 3/1/20 S4025 $2,200.00 3/1/20 S4026 $295.00 3/1/20 S4027 $7.45 3/1/20 S4028 $910.00 3/1/20 S4037 $377.96 3/1/20 S4042 $10.45 3/1/20 S4981 $129.60 3/1/20

2020 Other Codes Fee Schedule

Page 35 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 S5035 $2.04 3/1/20 S5036 $0.42 3/1/20 S5108 $9.54 3/1/20 S5109 $9.54 3/1/20 S5110 $4.12 3/1/20 S5181 $153.77 3/1/20 S5190 $2.25 3/1/20 S5497 $8.15 3/1/20 S5498 $4.50 3/1/20 S5501 $31.47 3/1/20 S5502 $170.48 3/1/20 S5517 $100.44 3/1/20 S5518 $100.00 3/1/20 S5520 $117.00 3/1/20 S5521 $83.22 3/1/20 S5522 $98.00 3/1/20 S5523 $11.50 3/1/20 S8037 26 $145.44 3/1/20 S8037 TC $145.44 3/1/20 S8037 $145.44 3/1/20 S8040 26 $137.10 3/1/20 S8040 TC $319.90 3/1/20 S8040 $457.00 3/1/20 S8042 26 $99.75 3/1/20 S8042 TC $232.76 3/1/20 S8042 $332.51 3/1/20

S8110 $9.98 3/1/20

S8131 $390.00 3/1/20 S8930 $26.67 3/1/20 S8940 $9.50 3/1/20 S8948 $22.28 3/1/20 S8950 $45.01 3/1/20 S8990 $45.14 3/1/20 S9025 26 $31.12 3/1/20 S9025 TC $31.12 3/1/20 S9025 $31.12 3/1/20 S9083 $97.06 3/1/20 S9088 $24.89 3/1/20 S9090 $125.99 3/1/20 S9097 $35.00 3/1/20 S9098 $36.73 3/1/20 S9110 $37.73 3/1/20 S9117 $95.00 3/1/20 S9122 $50.00 3/1/20 S9123 $74.09 3/1/20 S9124 $15.85 3/1/20 S9126 $81.13 3/1/20 S9127 $50.00 3/1/20 S9128 $35.76 3/1/20 S9129 $45.00 3/1/20 S9131 $36.46 3/1/20 S9140 $77.92 3/1/20 S9141 $71.36 3/1/20 S9145 $265.59 3/1/20 S9150 $10.43 3/1/20 S9152 $253.88 3/1/20 S9208 $57.93 3/1/20

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 S9209 $57.93 3/1/20 S9211 $21.00 3/1/20 S9212 $35.00 3/1/20 S9213 $42.59 3/1/20 S9214 $20.48 3/1/20 S9325 $57.09 3/1/20 S9326 $47.00 3/1/20 S9327 $47.00 3/1/20 S9328 $47.00 3/1/20 S9329 $61.23 3/1/20 S9330 $148.37 3/1/20 S9331 $175.00 3/1/20 S9335 $360.00 3/1/20 S9336 $77.50 3/1/20 S9338 $24.25 3/1/20 S9339 $6.44 3/1/20 S9340 $14.99 3/1/20 S9341 $7.50 3/1/20 S9342 $12.50 3/1/20 S9343 $2.59 3/1/20 S9345 $89.41 3/1/20 S9346 $50.00 3/1/20 S9347 $77.50 3/1/20 S9348 $118.21 3/1/20 S9349 $35.00 3/1/20 S9351 $47.00 3/1/20

S9353 $16.00 3/1/20

S9355 $65.00 3/1/20 S9357 $179.05 3/1/20 S9359 $829.50 3/1/20 S9361 $10.00 3/1/20 S9363 $50.00 3/1/20 S9364 $117.00 3/1/20 S9365 $184.84 3/1/20 S9366 $162.50 3/1/20 S9367 $215.00 3/1/20 S9368 $309.00 3/1/20 S9370 $123.20 3/1/20 S9372 $125.11 3/1/20 S9373 $72.92 3/1/20 S9374 $114.50 3/1/20 S9375 $135.98 3/1/20 S9376 $65.00 3/1/20 S9377 $62.36 3/1/20 S9379 $61.62 3/1/20 S9381 $18.96 3/1/20 S9401 $16.50 3/1/20 S9430 $109.99 3/1/20 S9441 $34.46 3/1/20 S9442 $86.50 3/1/20 S9443 $51.95 3/1/20 S9444 $16.10 3/1/20 S9445 $24.91 3/1/20 S9446 $7.50 3/1/20 S9449 $40.00 3/1/20 S9451 $75.00 3/1/20 S9452 $12.72 3/1/20

2020 Other Codes Fee Schedule

Page 36 of 36

Procedure Modifier Maximum Allowable

Effective Date End Date

10011 $144.16 3/1/20 S9453 $2.65 3/1/20 S9455 $49.12 3/1/20 S9460 $69.84 3/1/20 S9465 $72.60 3/1/20 S9470 $29.76 3/1/20 S9472 $40.00 3/1/20 S9473 $74.00 3/1/20 S9474 $62.42 3/1/20 S9475 $410.80 3/1/20 S9476 $74.00 3/1/20 S9480 $100.22 3/1/20 S9482 $115.00 3/1/20 S9484 $135.00 3/1/20 S9485 $165.90 3/1/20 S9490 $97.52 3/1/20 S9494 $94.99 3/1/20 S9497 $74.00 3/1/20 S9500 $95.84 3/1/20 S9501 $90.44 3/1/20 S9502 $80.13 3/1/20 S9503 $53.86 3/1/20 S9504 $62.50 3/1/20 S9529 26 $5.00 3/1/20 S9529 TC $5.00 3/1/20 S9529 $5.00 3/1/20 S9537 $29.62 3/1/20

S9538 $10.60 3/1/20

S9542 $22.17 3/1/20 S9558 $3.58 3/1/20 S9559 $15.00 3/1/20 S9560 $147.92 3/1/20 S9562 $5.93 3/1/20 S9590 $75.00 3/1/20 S9810 $85.40 3/1/20 S9901 $90.00 3/1/20 S9975 $3.36 3/1/20 S9976 $8.05 3/1/20 S9977 $30.00 3/1/20 S9981 $7.94 3/1/20 S9982 $0.25 3/1/20 S9986 $14.50 3/1/20 S9988 $19.50 3/1/20 S9990 $0.36 3/1/20 S9991 $1.67 3/1/20 S9992 $40.00 3/1/20 S9994 $100.00 3/1/20 S9996 $30.00 3/1/20 V5362 $16.00 3/1/20 V5363 $16.00 3/1/20