CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A0225 00 F 2018-01-01 9901-01-01 CA $491.96 001A0225 00 F 2018-01-01 9901-01-01 CA $491.96 004A0430 00 2021-01-01 9901-01-01 CA $3,154.21 001A0430 00 F 2021-01-01 9901-01-01 CA $3,154.21 001A0430 00 2021-01-01 9901-01-01 CA $3,154.21 004A0430 00 F 2021-01-01 9901-01-01 CA $3,154.21 004A0430 00 2020-01-01 2021-01-01 CA $3,436.33 001A0430 00 F 2020-01-01 2021-01-01 CA $3,436.33 001A0430 00 2020-01-01 2021-01-01 CA $3,436.33 004A0430 00 F 2020-01-01 2021-01-01 CA $3,436.33 004A0430 00 2019-01-01 2020-01-01 CA $4,042.74 001A0430 00 F 2019-01-01 2020-01-01 CA $4,042.74 001A0430 00 2019-01-01 2020-01-01 CA $4,042.74 004A0430 00 F 2019-01-01 2020-01-01 CA $4,042.74 004A0430 00 2018-01-01 2019-01-01 CA $4,756.16 001A0430 00 F 2018-01-01 2019-01-01 CA $4,756.16 001A0430 00 2018-01-01 2019-01-01 CA $4,756.16 004A0430 00 F 2018-01-01 2019-01-01 CA $4,756.16 004A0430 00 2017-01-01 2018-01-01 CA $5,595.48 001A0430 00 F 2017-01-01 2018-01-01 CA $5,595.48 001A0430 00 2017-01-01 2018-01-01 CA $5,595.48 004A0430 00 F 2017-01-01 2018-01-01 CA $5,595.48 004A0430 00 F 2016-01-01 2017-01-01 CA $6,582.92 001A0430 00 F 2016-01-01 2017-01-01 CA $6,582.92 004A0431 00 2021-01-01 9901-01-01 CA $4,870.75 001A0431 00 F 2021-01-01 9901-01-01 CA $4,870.75 001A0431 00 2021-01-01 9901-01-01 CA $4,870.75 004A0431 00 F 2021-01-01 9901-01-01 CA $4,870.75 004A0431 00 2020-01-01 2021-01-01 CA $5,730.29 001A0431 00 F 2020-01-01 2021-01-01 CA $5,730.29 001A0431 00 2020-01-01 2021-01-01 CA $5,730.29 004A0431 00 F 2020-01-01 2021-01-01 CA $5,730.29 004A0431 00 2019-01-01 2020-01-01 CA $6,741.52 001A0431 00 F 2019-01-01 2020-01-01 CA $6,741.52 001A0431 00 2019-01-01 2020-01-01 CA $6,741.52 004A0431 00 F 2019-01-01 2020-01-01 CA $6,741.52 004A0431 00 2018-01-01 2019-01-01 CA $7,931.20 001A0431 00 F 2018-01-01 2019-01-01 CA $7,931.20 001A0431 00 2018-01-01 2019-01-01 CA $7,931.20 004A0431 00 F 2018-01-01 2019-01-01 CA $7,931.20 004A0431 00 2017-01-01 2018-01-01 CA $9,330.82 001A0431 00 F 2017-01-01 2018-01-01 CA $9,330.82 001A0431 00 2017-01-01 2018-01-01 CA $9,330.82 004A0431 00 F 2017-01-01 2018-01-01 CA $9,330.82 004A0431 00 F 2016-01-01 2017-01-01 CA $10,977.74 001A0431 00 F 2016-01-01 2017-01-01 CA $10,977.74 004A0435 00 2021-01-01 9901-01-01 CA $22.44 001A0435 00 F 2021-01-01 9901-01-01 CA $22.44 001A0435 00 2021-01-01 9901-01-01 CA $22.44 004A0435 00 F 2021-01-01 9901-01-01 CA $22.44 004A0435 00 2020-01-01 2021-01-01 CA $26.40 001A0435 00 F 2020-01-01 2021-01-01 CA $26.40 001A0435 00 2020-01-01 2021-01-01 CA $26.40 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 1 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A0435 00 F 2020-01-01 2021-01-01 CA $26.40 004A0435 00 2019-01-01 2020-01-01 CA $31.06 001A0435 00 F 2019-01-01 2020-01-01 CA $31.06 001A0435 00 2019-01-01 2020-01-01 CA $31.06 004A0435 00 F 2019-01-01 2020-01-01 CA $31.06 004A0435 00 2018-01-01 2019-01-01 CA $36.54 001A0435 00 F 2018-01-01 2019-01-01 CA $36.54 001A0435 00 2018-01-01 2019-01-01 CA $36.54 004A0435 00 F 2018-01-01 2019-01-01 CA $36.54 004A0435 00 2017-01-01 2018-01-01 CA $42.99 001A0435 00 F 2017-01-01 2018-01-01 CA $42.99 001A0435 00 2017-01-01 2018-01-01 CA $42.99 004A0435 00 F 2017-01-01 2018-01-01 CA $42.99 004A0435 00 F 2016-01-01 2017-01-01 CA $50.58 001A0435 00 F 2016-01-01 2017-01-01 CA $50.58 004A0436 00 2021-01-01 9901-01-01 CA $42.42 001A0436 00 F 2021-01-01 9901-01-01 CA $42.42 001A0436 00 2021-01-01 9901-01-01 CA $42.42 004A0436 00 F 2021-01-01 9901-01-01 CA $42.42 004A0436 00 2020-01-01 2021-01-01 CA $49.91 001A0436 00 F 2020-01-01 2021-01-01 CA $49.91 001A0436 00 2020-01-01 2021-01-01 CA $49.91 004A0436 00 F 2020-01-01 2021-01-01 CA $49.91 004A0436 00 2019-01-01 2020-01-01 CA $58.72 001A0436 00 F 2019-01-01 2020-01-01 CA $58.72 001A0436 00 2019-01-01 2020-01-01 CA $58.72 004A0436 00 F 2019-01-01 2020-01-01 CA $58.72 004A0436 00 2018-01-01 2019-01-01 CA $69.08 001A0436 00 F 2018-01-01 2019-01-01 CA $69.08 001A0436 00 2018-01-01 2019-01-01 CA $69.08 004A0436 00 F 2018-01-01 2019-01-01 CA $69.08 004A0436 00 2017-01-01 2018-01-01 CA $81.27 001A0436 00 F 2017-01-01 2018-01-01 CA $81.27 001A0436 00 2017-01-01 2018-01-01 CA $81.27 004A0436 00 F 2017-01-01 2018-01-01 CA $81.27 004A0436 00 F 2016-01-01 2017-01-01 CA $95.61 001A0436 00 F 2016-01-01 2017-01-01 CA $95.61 004A4206 00 G 2020-03-01 9901-01-01 CA $2.00 001A4206 00 G 2020-03-01 9901-01-01 CA $2.00 004A4206 00 G 2019-03-01 2020-03-01 CA $20.00 001A4206 00 G 2019-03-01 2020-03-01 CA $20.00 004A4206 00 G 2018-03-01 2019-03-01 CA $20.00 001A4206 00 G 2018-03-01 2019-03-01 CA $20.00 004A4206 00 G 2018-01-01 2018-03-01 CA $20.00 001A4206 00 G 2018-01-01 2018-03-01 CA $20.00 004A4206 00 G 2017-03-01 2018-01-01 CA $20.00 001A4206 00 G 2017-03-01 2018-01-01 CA $20.00 004A4206 00 G 2016-04-01 2017-03-01 CA $20.00 001A4207 00 G 2018-01-01 9901-01-01 CA $35.00 001A4207 00 G 2018-01-01 9901-01-01 CA $35.00 004A4208 00 G 2020-03-01 9901-01-01 CA $15.00 001A4208 00 G 2020-03-01 9901-01-01 CA $15.00 004A4208 00 G 2019-03-01 2020-03-01 CA $20.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 2 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4208 00 G 2019-03-01 2020-03-01 CA $20.00 004A4208 00 G 2018-03-01 2019-03-01 CA $20.00 001A4208 00 G 2018-03-01 2019-03-01 CA $20.00 004A4208 00 G 2018-01-01 2018-03-01 CA $20.00 001A4208 00 G 2018-01-01 2018-03-01 CA $20.00 004A4208 00 G 2017-03-01 2018-01-01 CA $20.00 001A4208 00 G 2017-03-01 2018-01-01 CA $20.00 004A4208 00 G 2016-04-01 2017-03-01 CA $20.00 001A4208 00 G 2016-04-01 2017-03-01 CA $20.00 004A4209 00 G 2020-03-01 9901-01-01 CA $25.00 001A4209 00 G 2020-03-01 9901-01-01 CA $25.00 004A4209 00 G 2019-03-01 2020-03-01 CA $25.00 001A4209 00 G 2019-03-01 2020-03-01 CA $25.00 004A4209 00 G 2018-03-01 2019-03-01 CA $25.00 001A4209 00 G 2018-03-01 2019-03-01 CA $25.00 004A4209 00 G 2018-01-01 2018-03-01 CA $20.00 001A4209 00 G 2018-01-01 2018-03-01 CA $20.00 004A4209 00 G 2017-03-01 2018-01-01 CA $20.00 001A4209 00 G 2017-03-01 2018-01-01 CA $20.00 004A4209 00 G 2016-04-01 2017-03-01 CA $6.00 001A4209 00 G 2016-04-01 2017-03-01 CA $6.00 004A4210 00 G 2018-03-01 9901-01-01 CA $16.00 001A4210 00 G 2018-03-01 9901-01-01 CA $16.00 004A4210 00 G 2018-01-01 2018-03-01 CA $16.00 001A4210 00 G 2018-01-01 2018-03-01 CA $16.00 004A4210 00 G 2017-03-01 2018-01-01 CA $16.00 001A4210 00 G 2017-03-01 2018-01-01 CA $16.00 004A4210 00 G 2016-04-01 2017-03-01 CA $16.00 001A4210 00 G 2016-04-01 2017-03-01 CA $16.00 004A4211 00 G 2021-03-01 9901-01-01 CA $222.48 001A4211 00 G 2021-03-01 9901-01-01 CA $222.48 004A4211 00 G 2020-03-01 2021-03-01 CA $85.00 001A4211 00 G 2020-03-01 2021-03-01 CA $85.00 004A4211 00 G 2018-01-01 2020-03-01 CA $109.37 001A4211 00 G 2018-01-01 2020-03-01 CA $109.37 004A4211 00 G 2017-03-01 2018-01-01 CA $109.37 001A4211 00 G 2017-03-01 2018-01-01 CA $109.37 004A4211 00 G 2016-04-01 2017-03-01 CA $20.52 001A4211 00 G 2016-04-01 2017-03-01 CA $20.52 004A4212 00 G 2019-03-01 9901-01-01 CA $695.00 001A4212 00 G 2019-03-01 9901-01-01 CA $695.00 004A4212 00 G 2018-03-01 2019-03-01 CA $82.00 001A4212 00 G 2018-03-01 2019-03-01 CA $82.00 004A4212 00 G 2018-01-01 2018-03-01 CA $82.00 001A4212 00 G 2018-01-01 2018-03-01 CA $82.00 004A4212 00 G 2017-03-01 2018-01-01 CA $82.00 001A4212 00 G 2017-03-01 2018-01-01 CA $82.00 004A4212 00 G 2016-04-01 2017-03-01 CA $82.00 001A4212 00 G 2016-04-01 2017-03-01 CA $82.00 004A4213 00 G 2020-03-01 9901-01-01 CA $15.00 001A4213 00 G 2020-03-01 9901-01-01 CA $15.00 004A4213 00 G 2019-03-01 2020-03-01 CA $15.00 001A4213 00 G 2019-03-01 2020-03-01 CA $15.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 3 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4213 00 G 2018-01-01 2019-03-01 CA $1.50 001A4213 00 G 2018-01-01 2019-03-01 CA $1.50 004A4213 00 G 2017-03-01 2018-01-01 CA $1.50 001A4213 00 G 2017-03-01 2018-01-01 CA $1.50 004A4213 00 G 2016-04-01 2017-03-01 CA $1.50 001A4215 00 G 2020-03-01 9901-01-01 CA $15.00 001A4215 00 G 2020-03-01 9901-01-01 CA $15.00 004A4215 00 G 2019-03-01 2020-03-01 CA $45.00 001A4215 00 G 2019-03-01 2020-03-01 CA $45.00 004A4215 00 G 2018-03-01 2019-03-01 CA $45.00 001A4215 00 G 2018-03-01 2019-03-01 CA $45.00 004A4215 00 G 2018-01-01 2018-03-01 CA $45.00 001A4215 00 G 2018-01-01 2018-03-01 CA $45.00 004A4215 00 G 2017-03-01 2018-01-01 CA $45.00 001A4215 00 G 2017-03-01 2018-01-01 CA $45.00 004A4215 00 G 2016-04-01 2017-03-01 CA $44.00 001A4215 00 G 2016-04-01 2017-03-01 CA $44.00 004A4218 00 G 2021-03-01 9901-01-01 CA $18.00 001A4218 00 G 2021-03-01 9901-01-01 CA $18.00 004A4218 00 G 2020-03-01 2021-03-01 CA $6.00 001A4218 00 G 2020-03-01 2021-03-01 CA $6.00 004A4218 00 G 2019-03-01 2020-03-01 CA $9.00 001A4218 00 G 2019-03-01 2020-03-01 CA $9.00 004A4218 00 G 2018-03-01 2019-03-01 CA $9.00 001A4218 00 G 2018-03-01 2019-03-01 CA $9.00 004A4218 00 G 2018-01-01 2018-03-01 CA $9.00 001A4218 00 G 2018-01-01 2018-03-01 CA $9.00 004A4218 00 G 2017-03-01 2018-01-01 CA $9.00 001A4218 00 G 2017-03-01 2018-01-01 CA $9.00 004A4218 00 G 2016-04-01 2017-03-01 CA $2.22 001A4218 00 G 2016-04-01 2017-03-01 CA $2.22 004A4220 00 G 2021-03-01 9901-01-01 CA $90.00 001A4220 00 G 2021-03-01 9901-01-01 CA $90.00 004A4220 00 G 2020-03-01 2021-03-01 CA $100.00 001A4220 00 G 2020-03-01 2021-03-01 CA $100.00 004A4220 00 G 2019-03-01 2020-03-01 CA $300.00 001A4220 00 G 2019-03-01 2020-03-01 CA $300.00 004A4220 00 G 2018-03-01 2019-03-01 CA $300.00 001A4220 00 G 2018-03-01 2019-03-01 CA $300.00 004A4220 00 G 2018-01-01 2018-03-01 CA $300.00 001A4220 00 G 2018-01-01 2018-03-01 CA $300.00 004A4220 00 G 2017-03-01 2018-01-01 CA $300.00 001A4220 00 G 2017-03-01 2018-01-01 CA $300.00 004A4220 00 G 2016-04-01 2017-03-01 CA $150.00 001A4220 00 G 2016-04-01 2017-03-01 CA $150.00 004A4223 00 G 2021-03-01 9901-01-01 CA $340.00 001A4223 00 G 2021-03-01 9901-01-01 CA $340.00 004A4223 00 G 2020-03-01 2021-03-01 CA $320.00 001A4223 00 G 2020-03-01 2021-03-01 CA $320.00 004A4223 00 G 2019-03-01 2020-03-01 CA $350.00 001A4223 00 G 2019-03-01 2020-03-01 CA $350.00 004A4223 00 G 2018-03-01 2019-03-01 CA $350.00 001A4223 00 G 2018-03-01 2019-03-01 CA $350.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 4 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4223 00 G 2018-01-01 2018-03-01 CA $350.00 001A4223 00 G 2018-01-01 2018-03-01 CA $350.00 004A4223 00 G 2017-03-01 2018-01-01 CA $350.00 001A4223 00 G 2017-03-01 2018-01-01 CA $350.00 004A4223 00 G 2016-04-01 2017-03-01 CA $350.00 001A4223 00 G 2016-04-01 2017-03-01 CA $350.00 004A4230 NU G 2021-03-01 9901-01-01 CA $17.82 001A4230 NU G 2021-03-01 9901-01-01 CA $17.82 004A4230 NU G 2020-03-01 2021-03-01 CA $17.82 001A4230 NU G 2020-03-01 2021-03-01 CA $17.82 004A4230 NU G 2019-03-01 2020-03-01 CA $35.00 001A4230 NU G 2019-03-01 2020-03-01 CA $35.00 004A4230 NU G 2018-03-01 2019-03-01 CA $16.20 001A4230 NU G 2018-03-01 2019-03-01 CA $16.20 004A4230 NU G 2018-01-01 2018-03-01 CA $16.20 001A4230 NU G 2018-01-01 2018-03-01 CA $16.20 004A4230 00 G 2021-03-01 9901-01-01 CA $35.00 001A4230 00 G 2021-03-01 9901-01-01 CA $35.00 004A4230 00 G 2020-03-01 2021-03-01 CA $35.00 001A4230 00 G 2020-03-01 2021-03-01 CA $35.00 004A4230 00 G 2019-03-01 2020-03-01 CA $35.00 001A4230 00 G 2019-03-01 2020-03-01 CA $35.00 004A4230 00 G 2018-03-01 2019-03-01 CA $16.20 001A4230 00 G 2018-03-01 2019-03-01 CA $16.20 004A4230 00 G 2018-01-01 2018-03-01 CA $16.20 001A4230 00 G 2018-01-01 2018-03-01 CA $16.20 004A4230 00 G 2017-03-01 2018-01-01 CA $16.20 001A4230 00 G 2017-03-01 2018-01-01 CA $16.20 004A4230 00 G 2016-04-01 2017-03-01 CA $15.10 001A4230 00 G 2016-04-01 2017-03-01 CA $15.10 004A4231 00 G 2021-03-01 9901-01-01 CA $34.53 001A4231 00 G 2021-03-01 9901-01-01 CA $34.53 004A4231 00 G 2018-03-01 2021-03-01 CA $9.70 001A4231 00 G 2018-03-01 2021-03-01 CA $9.70 004A4231 00 G 2018-01-01 2018-03-01 CA $9.70 001A4231 00 G 2018-01-01 2018-03-01 CA $9.70 004A4231 00 G 2017-03-01 2018-01-01 CA $9.70 001A4231 00 G 2017-03-01 2018-01-01 CA $9.70 004A4231 00 G 2016-04-01 2017-03-01 CA $9.46 001A4231 00 G 2016-04-01 2017-03-01 CA $9.46 004A4232 NU G 2021-03-01 9901-01-01 CA $4.29 001A4232 NU G 2021-03-01 9901-01-01 CA $4.29 004A4232 NU G 2020-03-01 2021-03-01 CA $4.29 001A4232 NU G 2020-03-01 2021-03-01 CA $4.29 004A4232 NU G 2019-03-01 2020-03-01 CA $8.52 001A4232 NU G 2019-03-01 2020-03-01 CA $8.52 004A4232 NU G 2018-03-01 2019-03-01 CA $3.90 001A4232 NU G 2018-03-01 2019-03-01 CA $3.90 004A4232 NU G 2018-01-01 2018-03-01 CA $3.90 001A4232 NU G 2018-01-01 2018-03-01 CA $3.90 004A4232 00 G 2021-03-01 9901-01-01 CA $8.25 001A4232 00 G 2021-03-01 9901-01-01 CA $8.25 004A4232 00 G 2020-03-01 2021-03-01 CA $8.52 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 5 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4232 00 G 2020-03-01 2021-03-01 CA $8.52 004A4232 00 G 2019-03-01 2020-03-01 CA $8.52 001A4232 00 G 2019-03-01 2020-03-01 CA $8.52 004A4232 00 G 2018-03-01 2019-03-01 CA $3.90 001A4232 00 G 2018-03-01 2019-03-01 CA $3.90 004A4232 00 G 2018-01-01 2018-03-01 CA $3.90 001A4232 00 G 2018-01-01 2018-03-01 CA $3.90 004A4232 00 G 2017-03-01 2018-01-01 CA $3.90 001A4232 00 G 2017-03-01 2018-01-01 CA $3.90 004A4232 00 G 2016-04-01 2017-03-01 CA $3.80 001A4232 00 G 2016-04-01 2017-03-01 CA $3.80 004A4244 00 G 2018-01-01 9901-01-01 CA $3.73 001A4244 00 G 2018-01-01 9901-01-01 CA $3.73 004A4245 00 G 2021-03-01 9901-01-01 CA $19.95 001A4245 00 G 2021-03-01 9901-01-01 CA $19.95 004A4245 00 G 2020-03-01 2021-03-01 CA $19.95 001A4245 00 G 2020-03-01 2021-03-01 CA $19.95 004A4245 00 G 2019-03-01 2020-03-01 CA $19.95 001A4245 00 G 2019-03-01 2020-03-01 CA $19.95 004A4245 00 G 2018-03-01 2019-03-01 CA $12.49 001A4245 00 G 2018-03-01 2019-03-01 CA $12.49 004A4245 00 G 2018-01-01 2018-03-01 CA $12.49 001A4245 00 G 2018-01-01 2018-03-01 CA $12.49 004A4245 00 G 2017-03-01 2018-01-01 CA $12.49 001A4245 00 G 2017-03-01 2018-01-01 CA $12.49 004A4245 00 G 2016-04-01 2017-03-01 CA $12.49 001A4245 00 G 2016-04-01 2017-03-01 CA $12.49 004A4246 00 G 2020-03-01 9901-01-01 CA $30.00 001A4246 00 G 2020-03-01 9901-01-01 CA $30.00 004A4246 00 G 2019-03-01 2020-03-01 CA $18.00 001A4246 00 G 2019-03-01 2020-03-01 CA $18.00 004A4246 00 G 2018-03-01 2019-03-01 CA $18.00 001A4246 00 G 2018-03-01 2019-03-01 CA $18.00 004A4246 00 G 2018-01-01 2018-03-01 CA $18.00 001A4246 00 G 2018-01-01 2018-03-01 CA $18.00 004A4246 00 G 2017-03-01 2018-01-01 CA $18.00 001A4246 00 G 2017-03-01 2018-01-01 CA $18.00 004A4246 00 G 2016-04-01 2017-03-01 CA $18.00 001A4246 00 G 2016-04-01 2017-03-01 CA $18.00 004A4247 00 G 2020-03-01 9901-01-01 CA $3.00 001A4247 00 G 2020-03-01 9901-01-01 CA $3.00 004A4247 00 G 2018-03-01 2020-03-01 CA $5.00 001A4247 00 G 2018-03-01 2020-03-01 CA $5.00 004A4247 00 G 2018-01-01 2018-03-01 CA $5.00 001A4247 00 G 2018-01-01 2018-03-01 CA $5.00 004A4247 00 G 2017-03-01 2018-01-01 CA $5.00 001A4247 00 G 2017-03-01 2018-01-01 CA $5.00 004A4247 00 G 2016-04-01 2017-03-01 CA $2.00 001A4247 00 G 2016-04-01 2017-03-01 CA $2.00 004A4248 00 G 2018-03-01 9901-01-01 CA $5.00 001A4248 00 G 2018-03-01 9901-01-01 CA $5.00 004A4248 00 G 2018-01-01 2018-03-01 CA $2.43 001A4248 00 G 2018-01-01 2018-03-01 CA $2.43 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 6 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4248 00 G 2016-04-01 2018-01-01 CA $2.43 001A4248 00 G 2016-04-01 2018-01-01 CA $2.43 004A4250 00 G 2021-03-01 9901-01-01 CA $5.00 001A4250 00 G 2021-03-01 9901-01-01 CA $5.00 004A4250 00 G 2020-03-01 2021-03-01 CA $10.00 001A4250 00 G 2020-03-01 2021-03-01 CA $10.00 004A4250 00 G 2019-03-01 2020-03-01 CA $20.00 001A4250 00 G 2019-03-01 2020-03-01 CA $20.00 004A4250 00 G 2018-03-01 2019-03-01 CA $20.00 001A4250 00 G 2018-03-01 2019-03-01 CA $20.00 004A4250 00 G 2018-01-01 2018-03-01 CA $20.00 001A4250 00 G 2018-01-01 2018-03-01 CA $20.00 004A4250 00 G 2017-03-01 2018-01-01 CA $20.00 001A4250 00 G 2017-03-01 2018-01-01 CA $20.00 004A4250 00 G 2016-04-01 2017-03-01 CA $12.00 001A4252 00 G 2020-03-01 9901-01-01 CA $8.00 001A4252 00 G 2020-03-01 9901-01-01 CA $8.00 004A4252 00 G 2018-03-01 2020-03-01 CA $10.00 001A4252 00 G 2018-03-01 2020-03-01 CA $10.00 004A4252 00 G 2018-01-01 2018-03-01 CA $10.00 001A4252 00 G 2018-01-01 2018-03-01 CA $10.00 004A4252 00 G 2017-03-01 2018-01-01 CA $10.00 001A4252 00 G 2017-03-01 2018-01-01 CA $10.00 004A4252 00 G 2016-04-01 2017-03-01 CA $10.00 001A4261 NU G 2021-05-29 9901-01-01 CA $26.07 001A4261 NU G 2021-05-29 9901-01-01 CA $26.07 004A4262 00 G 2018-01-01 9901-01-01 CA $42.89 001A4262 00 G 2018-01-01 9901-01-01 CA $42.89 004A4262 00 G 2016-04-01 2018-01-01 CA $42.89 001A4262 00 G 2016-04-01 2018-01-01 CA $42.89 004A4263 00 G 2019-03-01 9901-01-01 CA $1,131.00 001A4263 00 G 2019-03-01 9901-01-01 CA $1,131.00 004A4263 00 G 2018-03-01 2019-03-01 CA $150.00 001A4263 00 G 2018-03-01 2019-03-01 CA $150.00 004A4263 00 G 2018-01-01 2018-03-01 CA $150.00 001A4263 00 G 2018-01-01 2018-03-01 CA $150.00 004A4263 00 G 2017-03-01 2018-01-01 CA $150.00 001A4263 00 G 2017-03-01 2018-01-01 CA $150.00 004A4263 00 G 2016-04-01 2017-03-01 CA $85.00 001A4263 00 G 2016-04-01 2017-03-01 CA $85.00 004A4264 00 G 2018-01-01 9901-01-01 CA $6,417.00 001A4264 00 G 2018-01-01 9901-01-01 CA $6,417.00 004A4264 00 G 2016-04-01 2018-01-01 CA $6,417.00 001A4264 00 G 2016-04-01 2018-01-01 CA $6,417.00 004A4266 00 G 2020-04-25 9901-01-01 CA $120.00 001A4266 00 G 2020-04-25 9901-01-01 CA $120.00 004A4267 00 G 2018-01-01 9901-01-01 CA $0.05 001A4267 00 G 2018-01-01 9901-01-01 CA $0.05 004A4267 00 G 2017-03-01 2018-01-01 CA $0.05 001A4267 00 G 2017-03-01 2018-01-01 CA $0.05 004A4267 00 G 2016-04-01 2017-03-01 CA $0.05 001A4267 00 G 2016-04-01 2017-03-01 CA $0.05 004A4268 00 G 2018-01-01 9901-01-01 CA $0.60 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 7 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4268 00 G 2018-01-01 9901-01-01 CA $0.60 004A4270 00 G 2020-03-01 9901-01-01 CA $25.00 001A4270 00 G 2020-03-01 9901-01-01 CA $25.00 004A4270 00 G 2019-03-01 2020-03-01 CA $25.00 001A4270 00 G 2019-03-01 2020-03-01 CA $25.00 004A4270 00 G 2018-03-01 2019-03-01 CA $25.00 001A4270 00 G 2018-03-01 2019-03-01 CA $25.00 004A4270 00 G 2018-01-01 2018-03-01 CA $25.00 001A4270 00 G 2018-01-01 2018-03-01 CA $25.00 004A4270 00 G 2017-03-01 2018-01-01 CA $25.00 001A4270 00 G 2017-03-01 2018-01-01 CA $25.00 004A4270 00 G 2016-04-01 2017-03-01 CA $25.00 001A4290 00 G 2018-01-01 9901-01-01 CA $293.00 001A4290 00 G 2018-01-01 9901-01-01 CA $293.00 004A4300 00 G 2020-03-01 9901-01-01 CA $20.00 001A4300 00 G 2020-03-01 9901-01-01 CA $20.00 004A4300 00 G 2018-03-01 2020-03-01 CA $50.59 001A4300 00 G 2018-03-01 2020-03-01 CA $50.59 004A4300 00 G 2018-01-01 2018-03-01 CA $50.59 001A4300 00 G 2018-01-01 2018-03-01 CA $50.59 004A4300 00 G 2017-03-01 2018-01-01 CA $50.59 001A4300 00 G 2017-03-01 2018-01-01 CA $50.59 004A4300 00 G 2016-04-01 2017-03-01 CA $50.59 001A4300 00 G 2016-04-01 2017-03-01 CA $50.59 004A4301 00 G 2021-03-01 9901-01-01 CA $40.00 001A4301 00 G 2021-03-01 9901-01-01 CA $40.00 004A4301 00 G 2019-03-01 2021-03-01 CA $168.00 001A4301 00 G 2019-03-01 2021-03-01 CA $168.00 004A4301 00 G 2018-03-01 2019-03-01 CA $168.00 001A4301 00 G 2018-03-01 2019-03-01 CA $168.00 004A4301 00 G 2018-01-01 2018-03-01 CA $129.00 001A4301 00 G 2018-01-01 2018-03-01 CA $129.00 004A4301 00 G 2017-03-01 2018-01-01 CA $129.00 001A4301 00 G 2017-03-01 2018-01-01 CA $129.00 004A4301 00 G 2016-04-01 2017-03-01 CA $129.00 001A4301 00 G 2016-04-01 2017-03-01 CA $129.00 004A4305 00 G 2021-03-01 9901-01-01 CA $100.00 001A4305 00 G 2021-03-01 9901-01-01 CA $100.00 004A4305 00 G 2020-03-01 2021-03-01 CA $100.00 001A4305 00 G 2020-03-01 2021-03-01 CA $100.00 004A4305 00 G 2019-03-01 2020-03-01 CA $100.00 001A4305 00 G 2019-03-01 2020-03-01 CA $100.00 004A4305 00 G 2018-03-01 2019-03-01 CA $100.00 001A4305 00 G 2018-03-01 2019-03-01 CA $100.00 004A4305 00 G 2018-01-01 2018-03-01 CA $100.00 001A4305 00 G 2018-01-01 2018-03-01 CA $100.00 004A4305 00 G 2017-03-01 2018-01-01 CA $100.00 001A4305 00 G 2017-03-01 2018-01-01 CA $100.00 004A4305 00 G 2016-04-01 2017-03-01 CA $100.00 001A4305 00 G 2016-04-01 2017-03-01 CA $100.00 004A4306 00 G 2021-03-01 9901-01-01 CA $135.69 001A4306 00 G 2021-03-01 9901-01-01 CA $135.69 004A4306 00 G 2019-03-01 2021-03-01 CA $67.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 8 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4306 00 G 2019-03-01 2021-03-01 CA $67.00 004A4306 00 G 2018-03-01 2019-03-01 CA $67.00 001A4306 00 G 2018-03-01 2019-03-01 CA $67.00 004A4306 00 G 2018-01-01 2018-03-01 CA $63.00 001A4306 00 G 2018-01-01 2018-03-01 CA $63.00 004A4306 00 G 2017-03-01 2018-01-01 CA $63.00 001A4306 00 G 2017-03-01 2018-01-01 CA $63.00 004A4306 00 G 2016-04-01 2017-03-01 CA $63.00 001A4306 00 G 2016-04-01 2017-03-01 CA $63.00 004A4459 00 G 2019-03-01 9901-01-01 CA $4,612.50 001A4459 00 G 2019-03-01 9901-01-01 CA $4,612.50 004A4459 00 G 2018-03-01 2019-03-01 CA $450.00 001A4459 00 G 2018-03-01 2019-03-01 CA $450.00 004A4459 00 G 2018-01-01 2018-03-01 CA $450.00 001A4459 00 G 2018-01-01 2018-03-01 CA $450.00 004A4459 00 G 2016-12-14 2018-01-01 CA $450.00 001A4459 00 G 2016-12-14 2018-01-01 CA $450.00 004A4465 00 G 2018-03-01 9901-01-01 CA $30.00 001A4465 00 G 2018-03-01 9901-01-01 CA $30.00 004A4465 00 G 2018-01-01 2018-03-01 CA $30.00 001A4465 00 G 2018-01-01 2018-03-01 CA $30.00 004A4465 00 G 2017-03-01 2018-01-01 CA $30.00 001A4465 00 G 2017-03-01 2018-01-01 CA $30.00 004A4465 00 G 2016-04-01 2017-03-01 CA $30.00 001A4466 00 G 2016-04-01 9901-01-01 CA $105.00 001A4466 00 G 2016-04-01 9901-01-01 CA $105.00 004A4467 00 G 2020-03-01 9901-01-01 CA $52.00 001A4467 00 G 2020-03-01 9901-01-01 CA $52.00 004A4467 00 G 2019-03-01 2020-03-01 CA $140.00 001A4467 00 G 2019-03-01 2020-03-01 CA $140.00 004A4467 00 G 2018-03-01 2019-03-01 CA $140.00 001A4467 00 G 2018-03-01 2019-03-01 CA $140.00 004A4467 00 G 2018-01-01 2018-03-01 CA $140.00 001A4467 00 G 2018-01-01 2018-03-01 CA $140.00 004A4467 00 G 2017-02-21 2018-01-01 CA $140.00 001A4467 00 G 2017-02-21 2018-01-01 CA $140.00 004A4480 00 G 2018-01-01 9901-01-01 CA $50.00 001A4480 00 G 2018-01-01 9901-01-01 CA $50.00 004A4483 00 G 2021-03-01 9901-01-01 CA $2.32 001A4483 00 G 2021-03-01 9901-01-01 CA $2.32 004A4483 00 G 2020-03-01 2021-03-01 CA $3.85 001A4483 00 G 2020-03-01 2021-03-01 CA $3.85 004A4483 00 G 2019-03-01 2020-03-01 CA $37.79 001A4483 00 G 2019-03-01 2020-03-01 CA $37.79 004A4483 00 G 2018-03-01 2019-03-01 CA $37.79 001A4483 00 G 2018-03-01 2019-03-01 CA $37.79 004A4483 00 G 2018-01-01 2018-03-01 CA $29.70 001A4483 00 G 2018-01-01 2018-03-01 CA $29.70 004A4483 00 G 2017-03-01 2018-01-01 CA $29.70 001A4483 00 G 2017-03-01 2018-01-01 CA $29.70 004A4483 00 G 2016-04-01 2017-03-01 CA $29.70 001A4483 00 G 2016-04-01 2017-03-01 CA $29.70 004A4495 00 G 2018-01-01 9901-01-01 CA $30.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 9 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4495 00 G 2018-01-01 9901-01-01 CA $30.00 004A4495 00 G 2017-03-01 2018-01-01 CA $30.00 001A4495 00 G 2017-03-01 2018-01-01 CA $30.00 004A4500 00 G 2020-03-01 9901-01-01 CA $45.00 001A4500 00 G 2020-03-01 9901-01-01 CA $45.00 004A4500 00 G 2018-01-01 2020-03-01 CA $50.00 001A4500 00 G 2018-01-01 2020-03-01 CA $50.00 004A4510 00 G 2018-01-01 9901-01-01 CA $75.00 001A4510 00 G 2018-01-01 9901-01-01 CA $75.00 004A4550 00 G 2019-03-01 9901-01-01 CA $65.00 001A4550 00 G 2019-03-01 9901-01-01 CA $65.00 004A4550 00 G 2018-03-01 2019-03-01 CA $65.00 001A4550 00 G 2018-03-01 2019-03-01 CA $65.00 004A4550 00 G 2018-01-01 2018-03-01 CA $65.00 001A4550 00 G 2018-01-01 2018-03-01 CA $65.00 004A4550 00 G 2017-03-01 2018-01-01 CA $65.00 001A4550 00 G 2017-03-01 2018-01-01 CA $65.00 004A4550 00 G 2016-04-01 2017-03-01 CA $65.00 001A4554 00 G 2020-03-01 9901-01-01 CA $5.00 001A4554 00 G 2020-03-01 9901-01-01 CA $5.00 004A4554 00 G 2019-03-01 2020-03-01 CA $9.00 001A4554 00 G 2019-03-01 2020-03-01 CA $9.00 004A4554 00 G 2018-01-01 2019-03-01 CA $9.00 001A4554 00 G 2018-01-01 2019-03-01 CA $9.00 004A4554 00 G 2017-03-01 2018-01-01 CA $9.00 001A4554 00 G 2017-03-01 2018-01-01 CA $9.00 004A4554 00 G 2016-04-01 2017-03-01 CA $9.00 001A4554 00 G 2016-04-01 2017-03-01 CA $9.00 004A4566 00 G 2019-03-01 9901-01-01 CA $75.00 001A4566 00 G 2019-03-01 9901-01-01 CA $75.00 004A4566 00 G 2018-03-01 2019-03-01 CA $75.00 001A4566 00 G 2018-03-01 2019-03-01 CA $75.00 004A4566 00 G 2018-01-01 2018-03-01 CA $75.00 001A4566 00 G 2018-01-01 2018-03-01 CA $75.00 004A4566 00 G 2016-04-01 2018-01-01 CA $75.00 001A4570 00 G 2021-03-01 9901-01-01 CA $46.00 001A4570 00 G 2021-03-01 9901-01-01 CA $46.00 004A4570 00 G 2020-03-01 2021-03-01 CA $46.00 001A4570 00 G 2020-03-01 2021-03-01 CA $46.00 004A4570 00 G 2019-03-01 2020-03-01 CA $85.00 001A4570 00 G 2019-03-01 2020-03-01 CA $85.00 004A4570 00 G 2018-03-01 2019-03-01 CA $85.00 001A4570 00 G 2018-03-01 2019-03-01 CA $85.00 004A4570 00 G 2018-01-01 2018-03-01 CA $85.00 001A4570 00 G 2018-01-01 2018-03-01 CA $85.00 004A4570 00 G 2017-03-01 2018-01-01 CA $85.00 001A4570 00 G 2017-03-01 2018-01-01 CA $85.00 004A4570 00 G 2016-04-01 2017-03-01 CA $85.00 001A4570 00 G 2016-04-01 2017-03-01 CA $85.00 004A4580 00 G 2021-03-01 9901-01-01 CA $85.00 001A4580 00 G 2021-03-01 9901-01-01 CA $85.00 004A4580 00 G 2020-03-01 2021-03-01 CA $90.00 001A4580 00 G 2020-03-01 2021-03-01 CA $90.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 10 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4580 00 G 2019-03-01 2020-03-01 CA $110.00 001A4580 00 G 2019-03-01 2020-03-01 CA $110.00 004A4580 00 G 2018-03-01 2019-03-01 CA $110.00 001A4580 00 G 2018-03-01 2019-03-01 CA $110.00 004A4580 00 G 2018-01-01 2018-03-01 CA $110.00 001A4580 00 G 2018-01-01 2018-03-01 CA $110.00 004A4580 00 G 2017-03-01 2018-01-01 CA $110.00 001A4580 00 G 2017-03-01 2018-01-01 CA $110.00 004A4580 00 G 2016-04-01 2017-03-01 CA $110.00 001A4580 00 G 2016-04-01 2017-03-01 CA $110.00 004A4590 00 G 2021-03-01 9901-01-01 CA $45.00 001A4590 00 G 2021-03-01 9901-01-01 CA $45.00 004A4590 00 G 2020-03-01 2021-03-01 CA $33.40 001A4590 00 G 2020-03-01 2021-03-01 CA $33.40 004A4590 00 G 2019-03-01 2020-03-01 CA $85.00 001A4590 00 G 2019-03-01 2020-03-01 CA $85.00 004A4590 00 G 2018-03-01 2019-03-01 CA $85.00 001A4590 00 G 2018-03-01 2019-03-01 CA $85.00 004A4590 00 G 2018-01-01 2018-03-01 CA $85.00 001A4590 00 G 2018-01-01 2018-03-01 CA $85.00 004A4590 00 G 2017-03-01 2018-01-01 CA $85.00 001A4590 00 G 2017-03-01 2018-01-01 CA $85.00 004A4590 00 G 2016-04-01 2017-03-01 CA $85.00 001A4590 00 G 2016-04-01 2017-03-01 CA $85.00 004A4600 00 G 2018-01-01 9901-01-01 CA $201.56 001A4600 00 G 2018-01-01 9901-01-01 CA $201.56 004A4601 00 G 2018-01-01 9901-01-01 CA $99.00 001A4601 00 G 2018-01-01 9901-01-01 CA $99.00 004A4601 00 G 2016-12-14 2018-01-01 CA $99.00 001A4601 00 G 2016-12-14 2018-01-01 CA $99.00 004A4606 00 G 2021-03-01 9901-01-01 CA $392.00 001A4606 00 G 2021-03-01 9901-01-01 CA $392.00 004A4606 00 G 2019-03-01 2021-03-01 CA $196.00 001A4606 00 G 2019-03-01 2021-03-01 CA $196.00 004A4606 00 G 2018-03-01 2019-03-01 CA $196.00 001A4606 00 G 2018-03-01 2019-03-01 CA $196.00 004A4606 00 G 2018-01-01 2018-03-01 CA $196.00 001A4606 00 G 2018-01-01 2018-03-01 CA $196.00 004A4606 00 G 2017-03-01 2018-01-01 CA $196.00 001A4606 00 G 2017-03-01 2018-01-01 CA $196.00 004A4606 00 G 2016-04-01 2017-03-01 CA $196.00 001A4606 00 G 2016-04-01 2017-03-01 CA $196.00 004A4611 00 G 2018-01-01 9901-01-01 CA $800.00 001A4611 00 G 2018-01-01 9901-01-01 CA $800.00 004A4612 00 G 2018-01-01 9901-01-01 CA $400.00 001A4612 00 G 2018-01-01 9901-01-01 CA $400.00 004A4613 00 G 2018-01-01 9901-01-01 CA $300.00 001A4613 00 G 2018-01-01 9901-01-01 CA $300.00 004A4627 00 G 2021-03-01 9901-01-01 CA $46.00 001A4627 00 G 2021-03-01 9901-01-01 CA $46.00 004A4627 00 G 2020-03-01 2021-03-01 CA $46.00 001A4627 00 G 2020-03-01 2021-03-01 CA $46.00 004A4627 00 G 2019-03-01 2020-03-01 CA $54.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 11 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4627 00 G 2019-03-01 2020-03-01 CA $54.00 004A4627 00 G 2018-03-01 2019-03-01 CA $54.00 001A4627 00 G 2018-03-01 2019-03-01 CA $54.00 004A4627 00 G 2018-01-01 2018-03-01 CA $47.00 001A4627 00 G 2018-01-01 2018-03-01 CA $47.00 004A4627 00 G 2017-03-01 2018-01-01 CA $47.00 001A4627 00 G 2017-03-01 2018-01-01 CA $47.00 004A4627 00 G 2016-04-01 2017-03-01 CA $47.00 001A4627 00 G 2016-04-01 2017-03-01 CA $47.00 004A4641 00 G 2018-01-01 9901-01-01 CA $200.00 001A4641 00 G 2018-01-01 9901-01-01 CA $200.00 004A4642 00 G 2018-01-01 9901-01-01 CA $30.48 001A4642 00 G 2018-01-01 9901-01-01 CA $30.48 004A4648 00 G 2021-03-01 9901-01-01 CA $500.00 001A4648 00 G 2021-03-01 9901-01-01 CA $500.00 004A4648 00 G 2019-03-01 2021-03-01 CA $728.00 001A4648 00 G 2019-03-01 2021-03-01 CA $728.00 004A4648 00 G 2018-03-01 2019-03-01 CA $700.00 001A4648 00 G 2018-03-01 2019-03-01 CA $700.00 004A4648 00 G 2018-01-01 2018-03-01 CA $656.00 001A4648 00 G 2018-01-01 2018-03-01 CA $656.00 004A4648 00 G 2017-03-01 2018-01-01 CA $656.00 001A4648 00 G 2017-03-01 2018-01-01 CA $656.00 004A4648 00 G 2016-04-01 2017-03-01 CA $599.00 001A4648 00 G 2016-04-01 2017-03-01 CA $599.00 004A4651 00 G 2018-01-01 9901-01-01 CA $3.00 001A4651 00 G 2018-01-01 9901-01-01 CA $3.00 004A4651 00 G 2017-03-01 2018-01-01 CA $3.00 001A4651 00 G 2017-03-01 2018-01-01 CA $3.00 004A4651 00 G 2016-04-01 2017-03-01 CA $3.00 001A4652 00 G 2018-01-01 9901-01-01 CA $17.12 001A4652 00 G 2018-01-01 9901-01-01 CA $17.12 004A4657 00 G 2021-03-01 9901-01-01 CA $111.52 001A4657 00 G 2021-03-01 9901-01-01 CA $111.52 004A4657 00 G 2020-03-01 2021-03-01 CA $106.21 001A4657 00 G 2020-03-01 2021-03-01 CA $106.21 004A4657 00 G 2019-03-01 2020-03-01 CA $100.50 001A4657 00 G 2019-03-01 2020-03-01 CA $100.50 004A4657 00 G 2018-03-01 2019-03-01 CA $94.80 001A4657 00 G 2018-03-01 2019-03-01 CA $94.80 004A4657 00 G 2018-01-01 2018-03-01 CA $90.25 001A4657 00 G 2018-01-01 2018-03-01 CA $90.25 004A4657 00 G 2017-03-01 2018-01-01 CA $90.25 001A4657 00 G 2017-03-01 2018-01-01 CA $90.25 004A4657 00 G 2016-04-01 2017-03-01 CA $67.33 001A4657 00 G 2016-04-01 2017-03-01 CA $67.33 004A4660 00 G 2018-03-01 9901-01-01 CA $109.06 001A4660 00 G 2018-03-01 9901-01-01 CA $109.06 004A4660 00 G 2018-01-01 2018-03-01 CA $109.06 001A4660 00 G 2018-01-01 2018-03-01 CA $109.06 004A4663 00 G 2019-03-01 9901-01-01 CA $75.00 001A4663 00 G 2019-03-01 9901-01-01 CA $75.00 004A4663 00 G 2018-03-01 2019-03-01 CA $75.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 12 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4663 00 G 2018-03-01 2019-03-01 CA $75.00 004A4663 00 G 2018-01-01 2018-03-01 CA $75.00 001A4663 00 G 2018-01-01 2018-03-01 CA $75.00 004A4663 00 G 2017-03-01 2018-01-01 CA $75.00 001A4663 00 G 2017-03-01 2018-01-01 CA $75.00 004A4663 00 G 2016-04-01 2017-03-01 CA $75.00 001A4663 00 G 2016-04-01 2017-03-01 CA $75.00 004A4670 00 G 2018-03-01 9901-01-01 CA $367.50 001A4670 00 G 2018-03-01 9901-01-01 CA $367.50 004A4670 00 G 2018-01-01 2018-03-01 CA $367.50 001A4670 00 G 2018-01-01 2018-03-01 CA $367.50 004A4670 00 G 2017-03-01 2018-01-01 CA $367.50 001A4670 00 G 2017-03-01 2018-01-01 CA $367.50 004A4670 00 G 2016-04-01 2017-03-01 CA $367.50 001A4670 00 G 2016-04-01 2017-03-01 CA $367.50 004A4671 00 G 2018-01-01 9901-01-01 CA $75.05 001A4671 00 G 2018-01-01 9901-01-01 CA $75.05 004A4680 00 G 2018-01-01 9901-01-01 CA $354.00 001A4680 00 G 2018-01-01 9901-01-01 CA $354.00 004A4714 00 G 2018-01-01 9901-01-01 CA $1.39 001A4714 00 G 2018-01-01 9901-01-01 CA $1.39 004A4721 00 G 2018-01-01 9901-01-01 CA $23.39 001A4721 00 G 2018-01-01 9901-01-01 CA $23.39 004A4722 00 G 2018-01-01 9901-01-01 CA $31.79 001A4722 00 G 2018-01-01 9901-01-01 CA $31.79 004A4723 00 G 2018-01-01 9901-01-01 CA $30.37 001A4723 00 G 2018-01-01 9901-01-01 CA $30.37 004A4726 00 G 2018-01-01 9901-01-01 CA $39.54 001A4726 00 G 2018-01-01 9901-01-01 CA $39.54 004A4728 00 G 2020-01-11 9901-01-01 CA $190.55 001A4728 00 G 2020-01-11 9901-01-01 CA $190.55 004A4730 00 G 2018-01-01 9901-01-01 CA $1.54 001A4730 00 G 2018-01-01 9901-01-01 CA $1.54 004A4750 00 G 2018-01-01 9901-01-01 CA $50.00 001A4750 00 G 2018-01-01 9901-01-01 CA $50.00 004A4750 00 G 2016-04-01 2018-01-01 CA $50.00 001A4755 00 G 2018-01-01 9901-01-01 CA $25.80 001A4755 00 G 2018-01-01 9901-01-01 CA $25.80 004A4760 00 G 2018-01-01 9901-01-01 CA $383.00 001A4760 00 G 2018-01-01 9901-01-01 CA $383.00 004A4770 00 G 2018-03-01 9901-01-01 CA $25.00 001A4770 00 G 2018-03-01 9901-01-01 CA $25.00 004A4770 00 G 2018-01-01 2018-03-01 CA $25.00 001A4770 00 G 2018-01-01 2018-03-01 CA $25.00 004A4770 00 G 2017-03-01 2018-01-01 CA $25.00 001A4770 00 G 2017-03-01 2018-01-01 CA $25.00 004A4770 00 G 2016-04-01 2017-03-01 CA $25.00 001A4771 00 G 2018-01-01 9901-01-01 CA $24.80 001A4771 00 G 2018-01-01 9901-01-01 CA $24.80 004A4772 00 G 2018-01-01 9901-01-01 CA $3.92 001A4772 00 G 2018-01-01 9901-01-01 CA $3.92 004A4860 00 G 2018-01-01 9901-01-01 CA $48.57 001A4860 00 G 2018-01-01 9901-01-01 CA $48.57 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 13 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A4911 00 G 2018-01-01 9901-01-01 CA $9.97 001A4911 00 G 2018-01-01 9901-01-01 CA $9.97 004A4927 NU G 2021-03-01 9901-01-01 CA $20.50 001A4927 NU G 2021-03-01 9901-01-01 CA $20.50 004A4927 NU G 2020-03-01 2021-03-01 CA $20.50 001A4927 NU G 2020-03-01 2021-03-01 CA $20.50 004A4927 NU G 2019-03-01 2020-03-01 CA $20.00 001A4927 NU G 2019-03-01 2020-03-01 CA $20.00 004A4927 NU G 2018-03-01 2019-03-01 CA $20.00 001A4927 NU G 2018-03-01 2019-03-01 CA $20.00 004A4927 NU G 2018-01-01 2018-03-01 CA $20.00 001A4927 NU G 2018-01-01 2018-03-01 CA $20.00 004A4927 00 G 2021-03-01 9901-01-01 CA $16.00 001A4927 00 G 2021-03-01 9901-01-01 CA $16.00 004A4927 00 G 2020-03-01 2021-03-01 CA $12.61 001A4927 00 G 2020-03-01 2021-03-01 CA $12.61 004A4927 00 G 2019-03-01 2020-03-01 CA $20.00 001A4927 00 G 2019-03-01 2020-03-01 CA $20.00 004A4927 00 G 2018-03-01 2019-03-01 CA $20.00 001A4927 00 G 2018-03-01 2019-03-01 CA $20.00 004A4927 00 G 2018-01-01 2018-03-01 CA $20.00 001A4927 00 G 2018-01-01 2018-03-01 CA $20.00 004A4927 00 G 2017-03-01 2018-01-01 CA $20.00 001A4927 00 G 2017-03-01 2018-01-01 CA $20.00 004A4927 00 G 2016-04-01 2017-03-01 CA $15.00 001A4927 00 G 2016-04-01 2017-03-01 CA $15.00 004A4928 00 G 2018-01-01 9901-01-01 CA $9.55 001A4928 00 G 2018-01-01 9901-01-01 CA $9.55 004A4929 00 G 2018-01-01 9901-01-01 CA $6.05 001A4929 00 G 2018-01-01 9901-01-01 CA $6.05 004A4930 00 G 2021-03-01 9901-01-01 CA $25.00 001A4930 00 G 2021-03-01 9901-01-01 CA $25.00 004A4930 00 G 2020-03-01 2021-03-01 CA $25.00 001A4930 00 G 2020-03-01 2021-03-01 CA $25.00 004A4930 00 G 2019-03-01 2020-03-01 CA $25.00 001A4930 00 G 2019-03-01 2020-03-01 CA $25.00 004A4930 00 G 2018-01-01 2019-03-01 CA $5.00 001A4930 00 G 2018-01-01 2019-03-01 CA $5.00 004A4930 00 G 2017-03-01 2018-01-01 CA $5.00 001A4930 00 G 2017-03-01 2018-01-01 CA $5.00 004A4930 00 G 2016-04-01 2017-03-01 CA $5.00 001A5510 00 G 2018-01-01 9901-01-01 CA $250.00 001A5510 00 G 2018-01-01 9901-01-01 CA $250.00 004A6025 00 G 2021-03-01 9901-01-01 CA $60.00 001A6025 00 G 2021-03-01 9901-01-01 CA $60.00 004A6025 00 G 2020-03-01 2021-03-01 CA $7.00 001A6025 00 G 2020-03-01 2021-03-01 CA $7.00 004A6025 00 G 2018-03-01 2020-03-01 CA $45.00 001A6025 00 G 2018-03-01 2020-03-01 CA $45.00 004A6025 00 G 2018-01-01 2018-03-01 CA $45.00 001A6025 00 G 2018-01-01 2018-03-01 CA $45.00 004A6198 00 G 2018-01-01 9901-01-01 CA $123.58 001A6198 00 G 2018-01-01 9901-01-01 CA $123.58 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 14 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A6205 00 G 2018-01-01 9901-01-01 CA $102.70 001A6205 00 G 2018-01-01 9901-01-01 CA $102.70 004A6206 00 G 2021-03-01 9901-01-01 CA $13.74 001A6206 00 G 2021-03-01 9901-01-01 CA $13.74 004A6206 00 G 2020-03-01 2021-03-01 CA $13.58 001A6206 00 G 2020-03-01 2021-03-01 CA $13.58 004A6206 00 G 2018-01-01 2020-03-01 CA $22.27 001A6206 00 G 2018-01-01 2020-03-01 CA $22.27 004A6206 00 G 2016-04-01 2018-01-01 CA $22.27 001A6206 00 G 2016-04-01 2018-01-01 CA $22.27 004A6208 00 G 2018-01-01 9901-01-01 CA $5.38 001A6208 00 G 2018-01-01 9901-01-01 CA $5.38 004A6213 00 G 2018-01-01 9901-01-01 CA $31.30 001A6213 00 G 2018-01-01 9901-01-01 CA $31.30 004A6215 00 G 2018-01-01 9901-01-01 CA $4.83 001A6215 00 G 2018-01-01 9901-01-01 CA $4.83 004A6217 00 G 2020-03-01 9901-01-01 CA $25.00 001A6217 00 G 2020-03-01 9901-01-01 CA $25.00 004A6217 00 G 2019-03-01 2020-03-01 CA $25.00 001A6217 00 G 2019-03-01 2020-03-01 CA $25.00 004A6217 00 G 2018-01-01 2019-03-01 CA $2.29 001A6217 00 G 2018-01-01 2019-03-01 CA $2.29 004A6217 00 G 2017-03-01 2018-01-01 CA $2.29 001A6217 00 G 2017-03-01 2018-01-01 CA $2.29 004A6217 00 G 2016-04-01 2017-03-01 CA $2.29 001A6217 00 G 2016-04-01 2017-03-01 CA $2.29 004A6218 00 G 2018-01-01 9901-01-01 CA $78.00 001A6218 00 G 2018-01-01 9901-01-01 CA $78.00 004A6221 00 G 2018-01-01 9901-01-01 CA $2.44 001A6221 00 G 2018-01-01 9901-01-01 CA $2.44 004A6239 00 G 2018-01-01 9901-01-01 CA $37.43 001A6239 00 G 2018-01-01 9901-01-01 CA $37.43 004A6250 00 G 2021-03-01 9901-01-01 CA $55.56 001A6250 00 G 2021-03-01 9901-01-01 CA $55.56 004A6250 00 G 2019-03-01 2021-03-01 CA $191.67 001A6250 00 G 2019-03-01 2021-03-01 CA $191.67 004A6250 00 G 2018-03-01 2019-03-01 CA $63.00 001A6250 00 G 2018-03-01 2019-03-01 CA $63.00 004A6250 00 G 2018-01-01 2018-03-01 CA $63.00 001A6250 00 G 2018-01-01 2018-03-01 CA $63.00 004A6250 00 G 2017-03-01 2018-01-01 CA $63.00 001A6250 00 G 2017-03-01 2018-01-01 CA $63.00 004A6250 00 G 2016-04-01 2017-03-01 CA $53.20 001A6250 00 G 2016-04-01 2017-03-01 CA $53.20 004A6256 00 G 2018-01-01 9901-01-01 CA $103.95 001A6256 00 G 2018-01-01 9901-01-01 CA $103.95 004A6260 00 G 2021-03-01 9901-01-01 CA $45.00 001A6260 00 G 2021-03-01 9901-01-01 CA $45.00 004A6260 00 G 2020-03-01 2021-03-01 CA $45.00 001A6260 00 G 2020-03-01 2021-03-01 CA $45.00 004A6260 00 G 2019-03-01 2020-03-01 CA $45.00 001A6260 00 G 2019-03-01 2020-03-01 CA $45.00 004A6260 00 G 2018-03-01 2019-03-01 CA $45.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 15 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A6260 00 G 2018-03-01 2019-03-01 CA $45.00 004A6260 00 G 2018-01-01 2018-03-01 CA $25.00 001A6260 00 G 2018-01-01 2018-03-01 CA $25.00 004A6260 00 G 2017-03-01 2018-01-01 CA $25.00 001A6260 00 G 2017-03-01 2018-01-01 CA $25.00 004A6260 00 G 2016-04-01 2017-03-01 CA $25.00 001A6261 00 G 2018-01-01 9901-01-01 CA $8.00 001A6261 00 G 2018-01-01 9901-01-01 CA $8.00 004A6261 00 G 2016-04-01 2018-01-01 CA $8.00 001A6261 00 G 2016-04-01 2018-01-01 CA $8.00 004A6262 00 G 2018-01-01 9901-01-01 CA $3.42 001A6262 00 G 2018-01-01 9901-01-01 CA $3.42 004A6404 00 G 2018-01-01 9901-01-01 CA $3.58 001A6404 00 G 2018-01-01 9901-01-01 CA $3.58 004A6404 00 G 2017-03-01 2018-01-01 CA $3.58 001A6404 00 G 2017-03-01 2018-01-01 CA $3.58 004A6404 00 G 2016-04-01 2017-03-01 CA $3.58 001A6404 00 G 2016-04-01 2017-03-01 CA $3.58 004A6411 00 G 2018-01-01 9901-01-01 CA $10.00 001A6411 00 G 2018-01-01 9901-01-01 CA $10.00 004A6412 00 G 2018-01-01 9901-01-01 CA $1.02 001A6412 00 G 2018-01-01 9901-01-01 CA $1.02 004A6413 00 G 2021-03-01 9901-01-01 CA $10.00 001A6413 00 G 2021-03-01 9901-01-01 CA $10.00 004A6413 00 G 2020-03-01 2021-03-01 CA $10.00 001A6413 00 G 2020-03-01 2021-03-01 CA $10.00 004A6413 00 G 2019-03-01 2020-03-01 CA $50.00 001A6413 00 G 2019-03-01 2020-03-01 CA $50.00 004A6413 00 G 2018-01-01 2019-03-01 CA $50.00 001A6413 00 G 2018-01-01 2019-03-01 CA $50.00 004A6450 00 G 2016-04-01 2018-01-01 CA $30.00 001A6450 00 G 2016-04-01 2018-01-01 CA $30.00 004A6451 00 G 2016-04-01 2018-01-01 CA $40.00 001A6451 00 G 2016-04-01 2018-01-01 CA $40.00 004A6504 00 G 2018-01-01 9901-01-01 CA $752.00 001A6504 00 G 2018-01-01 9901-01-01 CA $752.00 004A6504 00 G 2017-03-01 2018-01-01 CA $752.00 001A6504 00 G 2017-03-01 2018-01-01 CA $752.00 004A6506 00 G 2018-01-01 9901-01-01 CA $219.00 001A6506 00 G 2018-01-01 9901-01-01 CA $219.00 004A6506 00 G 2016-12-02 2018-01-01 CA $219.00 001A6506 00 G 2016-12-02 2018-01-01 CA $219.00 004A6511 00 G 2018-01-01 9901-01-01 CA $453.00 001A6511 00 G 2018-01-01 9901-01-01 CA $453.00 004A6511 00 G 2017-06-27 2018-01-01 CA $453.00 001A6511 00 G 2017-06-27 2018-01-01 CA $453.00 004A6530 00 G 2021-03-01 9901-01-01 CA $72.60 001A6530 00 G 2021-03-01 9901-01-01 CA $72.60 004A6530 00 G 2020-03-01 2021-03-01 CA $200.00 001A6530 00 G 2020-03-01 2021-03-01 CA $200.00 004A6530 00 G 2018-03-01 2020-03-01 CA $76.50 001A6530 00 G 2018-03-01 2020-03-01 CA $76.50 004A6530 00 G 2018-01-01 2018-03-01 CA $76.50 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 16 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A6530 00 G 2018-01-01 2018-03-01 CA $76.50 004A6530 00 G 2017-03-01 2018-01-01 CA $76.50 001A6530 00 G 2017-03-01 2018-01-01 CA $76.50 004A6530 00 G 2016-04-01 2017-03-01 CA $76.50 001A6530 00 G 2016-04-01 2017-03-01 CA $76.50 004A6533 00 G 2021-03-01 9901-01-01 CA $81.82 001A6533 00 G 2021-03-01 9901-01-01 CA $81.82 004A6533 00 G 2020-03-01 2021-03-01 CA $81.82 001A6533 00 G 2020-03-01 2021-03-01 CA $81.82 004A6533 00 G 2018-03-01 2020-03-01 CA $99.00 001A6533 00 G 2018-03-01 2020-03-01 CA $99.00 004A6533 00 G 2018-01-01 2018-03-01 CA $99.00 001A6533 00 G 2018-01-01 2018-03-01 CA $99.00 004A6533 00 G 2017-03-01 2018-01-01 CA $99.00 001A6533 00 G 2017-03-01 2018-01-01 CA $99.00 004A6533 00 G 2016-04-01 2017-03-01 CA $99.00 001A6533 00 G 2016-04-01 2017-03-01 CA $99.00 004A6534 00 G 2021-03-01 9901-01-01 CA $175.00 001A6534 00 G 2021-03-01 9901-01-01 CA $175.00 004A6534 00 G 2018-03-01 2021-03-01 CA $97.00 001A6534 00 G 2018-03-01 2021-03-01 CA $97.00 004A6534 00 G 2018-01-01 2018-03-01 CA $97.00 001A6534 00 G 2018-01-01 2018-03-01 CA $97.00 004A6534 00 G 2017-03-01 2018-01-01 CA $97.00 001A6534 00 G 2017-03-01 2018-01-01 CA $97.00 004A6534 00 G 2016-04-01 2017-03-01 CA $97.00 001A6534 00 G 2016-04-01 2017-03-01 CA $97.00 004A6535 00 G 2018-01-01 9901-01-01 CA $110.00 001A6535 00 G 2018-01-01 9901-01-01 CA $110.00 004A6536 00 G 2018-01-01 9901-01-01 CA $130.00 001A6536 00 G 2018-01-01 9901-01-01 CA $130.00 004A6537 00 G 2018-01-01 9901-01-01 CA $134.40 001A6537 00 G 2018-01-01 9901-01-01 CA $134.40 004A6539 00 G 2021-03-01 9901-01-01 CA $200.00 001A6539 00 G 2021-03-01 9901-01-01 CA $200.00 004A6539 00 G 2018-03-01 2021-03-01 CA $157.99 001A6539 00 G 2018-03-01 2021-03-01 CA $157.99 004A6539 00 G 2018-01-01 2018-03-01 CA $157.99 001A6539 00 G 2018-01-01 2018-03-01 CA $157.99 004A6539 00 G 2017-03-01 2018-01-01 CA $157.99 001A6539 00 G 2017-03-01 2018-01-01 CA $157.99 004A6539 00 G 2016-04-01 2017-03-01 CA $157.99 001A6539 00 G 2016-04-01 2017-03-01 CA $157.99 004A6540 00 G 2018-01-01 9901-01-01 CA $133.76 001A6540 00 G 2018-01-01 9901-01-01 CA $133.76 004A6541 00 G 2018-01-01 9901-01-01 CA $335.00 001A6541 00 G 2018-01-01 9901-01-01 CA $335.00 004A9150 00 G 2018-01-01 9901-01-01 CA $9.50 001A9150 00 G 2018-01-01 9901-01-01 CA $9.50 004A9150 00 G 2017-03-01 2018-01-01 CA $9.50 001A9150 00 G 2017-03-01 2018-01-01 CA $9.50 004A9150 00 G 2016-04-01 2017-03-01 CA $7.26 001A9150 00 G 2016-04-01 2017-03-01 CA $7.26 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 17 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A9273 00 G 2020-03-01 9901-01-01 CA $20.00 001A9273 00 G 2020-03-01 9901-01-01 CA $20.00 004A9273 00 G 2019-03-01 2020-03-01 CA $45.00 001A9273 00 G 2019-03-01 2020-03-01 CA $45.00 004A9273 00 G 2018-03-01 2019-03-01 CA $45.00 001A9273 00 G 2018-03-01 2019-03-01 CA $45.00 004A9273 00 G 2018-01-01 2018-03-01 CA $45.00 001A9273 00 G 2018-01-01 2018-03-01 CA $45.00 004A9273 00 G 2016-04-01 2018-01-01 CA $45.00 001A9273 00 G 2016-04-01 2018-01-01 CA $45.00 004A9274 00 G 2021-03-01 9901-01-01 CA $75.00 001A9274 00 G 2021-03-01 9901-01-01 CA $75.00 004A9274 00 G 2020-03-01 2021-03-01 CA $75.00 001A9274 00 G 2020-03-01 2021-03-01 CA $75.00 004A9274 00 G 2019-03-01 2020-03-01 CA $75.00 001A9274 00 G 2019-03-01 2020-03-01 CA $75.00 004A9274 00 G 2018-03-01 2019-03-01 CA $75.00 001A9274 00 G 2018-03-01 2019-03-01 CA $75.00 004A9274 00 G 2018-01-01 2018-03-01 CA $75.00 001A9274 00 G 2018-01-01 2018-03-01 CA $75.00 004A9274 00 G 2016-11-29 2018-01-01 CA $75.00 001A9274 00 G 2016-11-29 2018-01-01 CA $75.00 004A9276 00 G 2021-03-01 9901-01-01 CA $75.00 001A9276 00 G 2021-03-01 9901-01-01 CA $75.00 004A9276 00 G 2020-03-01 2021-03-01 CA $75.00 001A9276 00 G 2020-03-01 2021-03-01 CA $75.00 004A9276 00 G 2019-03-01 2020-03-01 CA $75.00 001A9276 00 G 2019-03-01 2020-03-01 CA $75.00 004A9276 00 G 2018-03-01 2019-03-01 CA $15.76 001A9276 00 G 2018-03-01 2019-03-01 CA $15.76 004A9276 00 G 2018-01-01 2018-03-01 CA $15.76 001A9276 00 G 2018-01-01 2018-03-01 CA $15.76 004A9276 00 G 2017-03-01 2018-01-01 CA $15.76 001A9276 00 G 2017-03-01 2018-01-01 CA $15.76 004A9276 00 G 2016-04-01 2017-03-01 CA $15.76 001A9276 00 G 2016-04-01 2017-03-01 CA $15.76 004A9277 00 G 2021-03-01 9901-01-01 CA $1,499.00 001A9277 00 G 2021-03-01 9901-01-01 CA $1,499.00 004A9277 00 G 2020-03-01 2021-03-01 CA $1,499.00 001A9277 00 G 2020-03-01 2021-03-01 CA $1,499.00 004A9277 00 G 2019-03-01 2020-03-01 CA $1,499.00 001A9277 00 G 2019-03-01 2020-03-01 CA $1,499.00 004A9277 00 G 2018-03-01 2019-03-01 CA $763.00 001A9277 00 G 2018-03-01 2019-03-01 CA $763.00 004A9277 00 G 2018-01-01 2018-03-01 CA $706.00 001A9277 00 G 2018-01-01 2018-03-01 CA $706.00 004A9277 00 G 2017-03-01 2018-01-01 CA $706.00 001A9277 00 G 2017-03-01 2018-01-01 CA $706.00 004A9277 00 G 2016-04-01 2017-03-01 CA $659.00 001A9277 00 G 2016-04-01 2017-03-01 CA $659.00 004A9278 00 G 2021-03-01 9901-01-01 CA $1,399.00 001A9278 00 G 2021-03-01 9901-01-01 CA $1,399.00 004A9278 00 G 2020-03-01 2021-03-01 CA $1,399.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 18 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A9278 00 G 2020-03-01 2021-03-01 CA $1,399.00 004A9278 00 G 2018-01-01 2020-03-01 CA $649.00 001A9278 00 G 2018-01-01 2020-03-01 CA $649.00 004A9278 00 G 2017-03-01 2018-01-01 CA $649.00 001A9278 00 G 2017-03-01 2018-01-01 CA $649.00 004A9281 00 G 2018-01-01 9901-01-01 CA $20.00 001A9281 00 G 2018-01-01 9901-01-01 CA $20.00 004A9281 00 G 2016-08-18 2018-01-01 CA $20.00 001A9281 00 G 2016-08-18 2018-01-01 CA $20.00 004A9282 00 G 2021-01-01 9901-01-01 CA $2,388.00 001A9282 00 G 2021-01-01 9901-01-01 CA $2,388.00 004A9282 00 G 2020-01-01 2021-01-01 CA $2,348.00 001A9282 00 G 2020-01-01 2021-01-01 CA $2,348.00 004A9282 00 G 2019-01-01 2020-01-01 CA $2,295.00 001A9282 00 G 2019-01-01 2020-01-01 CA $2,295.00 004A9282 00 G 2018-01-01 2019-01-01 CA $2,246.00 001A9282 00 G 2018-01-01 2019-01-01 CA $2,246.00 004A9282 00 G 2017-01-01 2018-01-01 CA $2,213.00 001A9282 00 G 2017-01-01 2018-01-01 CA $2,213.00 004A9282 00 G 2016-01-01 2017-01-01 CA $2,213.00 001A9282 00 G 2016-01-01 2017-01-01 CA $2,213.00 004A9282 00 G 2015-01-01 2016-01-01 CA $2,176.00 001A9282 00 G 2015-01-01 2016-01-01 CA $2,176.00 004A9282 00 G 2014-01-01 2015-01-01 CA $2,131.00 001A9282 00 G 2014-01-01 2015-01-01 CA $2,131.00 004A9282 00 G 2013-01-01 2014-01-01 CA $2,095.00 001A9282 00 G 2013-01-01 2014-01-01 CA $2,095.00 004A9282 00 G 2012-01-01 2013-01-01 CA $2,022.00 001A9282 00 G 2012-01-01 2013-01-01 CA $2,022.00 004A9283 00 G 2018-01-01 9901-01-01 CA $3.38 001A9283 00 G 2018-01-01 9901-01-01 CA $3.38 004A9284 00 G 2018-01-01 9901-01-01 CA $10.16 001A9284 00 G 2018-01-01 9901-01-01 CA $10.16 004A9286 00 G 2020-03-01 9901-01-01 CA $7.22 001A9286 00 G 2020-03-01 9901-01-01 CA $7.22 004A9286 00 G 2019-06-29 2020-03-01 CA $7.22 001A9286 00 G 2019-06-29 2020-03-01 CA $7.22 004A9500 00 6 2021-03-01 9901-01-01 CA $421.00 001A9500 00 6 2021-03-01 9901-01-01 CA $421.00 004A9500 00 6 2020-03-01 2021-03-01 CA $750.00 001A9500 00 6 2019-03-01 2020-03-01 CA $660.00 001A9500 00 6 2019-03-01 2021-03-01 CA $500.00 004A9500 00 6 2018-03-01 2019-03-01 CA $500.00 001A9500 00 6 2018-03-01 2019-03-01 CA $500.00 004A9500 00 G 2018-01-01 9901-01-01 CA $500.00 001A9500 00 6 2018-01-01 2018-03-01 CA $500.00 001A9500 00 G 2018-01-01 9901-01-01 CA $500.00 004A9500 00 6 2018-01-01 2018-03-01 CA $500.00 004A9502 00 6 2021-03-01 9901-01-01 CA $370.00 001A9502 00 6 2019-03-01 2021-03-01 CA $600.00 001A9502 00 6 2018-03-01 2019-03-01 CA $472.00 001A9502 00 G 2018-01-01 9901-01-01 CA $278.00 001A9502 00 6 2018-01-01 2018-03-01 CA $278.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 19 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A9502 00 G 2018-01-01 9901-01-01 CA $278.00 004A9502 00 6 2018-01-01 9901-01-01 CA $278.00 004A9503 00 6 2021-03-01 9901-01-01 CA $71.00 001A9503 00 6 2021-03-01 9901-01-01 CA $71.00 004A9503 00 6 2019-03-01 2021-03-01 CA $352.89 001A9503 00 G 2018-01-01 9901-01-01 CA $74.00 001A9503 00 6 2018-01-01 2019-03-01 CA $74.00 001A9503 00 G 2018-01-01 9901-01-01 CA $74.00 004A9503 00 6 2018-01-01 2021-03-01 CA $74.00 004A9505 00 6 2021-03-01 9901-01-01 CA $225.00 001A9505 00 6 2019-03-01 2021-03-01 CA $1,194.00 001A9505 00 6 2018-03-01 2019-03-01 CA $1,194.00 001A9505 00 6 2018-01-01 2018-03-01 CA $1,194.00 001A9505 00 6 2018-01-01 9901-01-01 CA $225.00 004A9505 00 6 2017-03-01 2018-01-01 CA $1,194.00 001A9505 00 6 2016-04-01 2017-03-01 CA $225.00 001A9505 00 6 2016-04-01 2018-01-01 CA $225.00 004A9507 00 G 2018-01-01 9901-01-01 CA $1,643.24 001A9507 00 G 2018-01-01 9901-01-01 CA $1,643.24 004A9508 00 G 2018-01-01 9901-01-01 CA $316.88 001A9508 00 G 2018-01-01 9901-01-01 CA $316.88 004A9509 00 6 2018-01-01 9901-01-01 CA $953.00 001A9509 00 6 2018-01-01 9901-01-01 CA $504.83 004A9509 00 6 2017-03-01 2018-01-01 CA $953.00 001A9510 00 6 2018-01-01 9901-01-01 CA $267.52 001A9510 00 6 2018-01-01 9901-01-01 CA $267.52 004A9512 00 6 2020-03-01 9901-01-01 CA $171.00 001A9512 00 6 2019-03-01 2020-03-01 CA $287.00 001A9512 00 6 2018-03-01 2019-03-01 CA $215.00 001A9512 00 6 2018-01-01 2018-03-01 CA $215.00 001A9512 00 6 2018-01-01 9901-01-01 CA $56.40 004A9512 00 6 2017-03-01 2018-01-01 CA $215.00 001A9512 00 6 2016-04-01 2017-03-01 CA $215.00 001A9516 00 6 2021-03-01 9901-01-01 CA $539.00 001A9516 00 6 2020-03-01 2021-03-01 CA $500.00 001A9516 00 6 2019-03-01 2020-03-01 CA $509.00 001A9516 00 6 2018-01-01 2019-03-01 CA $141.01 001A9516 00 6 2018-01-01 9901-01-01 CA $141.01 004A9517 00 6 2020-03-01 9901-01-01 CA $200.00 001A9517 00 6 2019-03-01 2020-03-01 CA $289.00 001A9517 00 6 2018-03-01 2019-03-01 CA $289.00 001A9517 00 6 2018-01-01 2018-03-01 CA $289.00 001A9517 00 6 2018-01-01 9901-01-01 CA $112.00 004A9517 00 6 2017-03-01 2018-01-01 CA $289.00 001A9517 00 6 2016-04-01 2017-03-01 CA $289.00 001A9520 00 6 2019-03-01 9901-01-01 CA $2,300.00 001A9520 00 6 2018-03-01 2019-03-01 CA $1,500.00 001A9520 00 6 2018-01-01 2018-03-01 CA $1,500.00 001A9520 00 6 2018-01-01 9901-01-01 CA $1,243.00 004A9520 00 6 2017-03-01 2018-01-01 CA $1,500.00 001A9521 00 6 2018-01-01 9901-01-01 CA $5,563.00 001A9521 00 6 2018-01-01 9901-01-01 CA $5,563.00 004A9521 00 6 2016-08-25 2018-01-01 CA $5,563.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 20 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A9521 00 6 2016-08-25 2018-01-01 CA $5,563.00 004A9526 00 6 2018-01-01 9901-01-01 CA $25.60 001A9526 00 6 2018-01-01 9901-01-01 CA $25.60 004A9528 00 6 2018-03-01 9901-01-01 CA $1,001.00 001A9528 00 6 2018-01-01 2018-03-01 CA $1,001.00 001A9528 00 6 2018-01-01 9901-01-01 CA $100.00 004A9528 00 6 2017-03-01 2018-01-01 CA $1,001.00 001A9528 00 6 2016-04-01 2017-03-01 CA $200.00 001A9529 00 6 2018-01-01 9901-01-01 CA $44.06 001A9529 00 6 2018-01-01 9901-01-01 CA $44.06 004A9530 00 6 2018-01-01 9901-01-01 CA $110.00 001A9530 00 6 2018-01-01 9901-01-01 CA $110.00 004A9531 00 6 2018-01-01 9901-01-01 CA $46.08 001A9531 00 6 2018-01-01 9901-01-01 CA $46.08 004A9536 00 6 2018-01-01 9901-01-01 CA $177.48 001A9536 00 6 2018-01-01 9901-01-01 CA $177.48 004A9536 00 6 2016-04-01 2018-01-01 CA $177.48 001A9537 00 6 2021-03-01 9901-01-01 CA $189.00 001A9537 00 6 2021-03-01 9901-01-01 CA $189.00 004A9537 00 6 2019-03-01 2021-03-01 CA $500.00 001A9537 00 6 2019-03-01 2021-03-01 CA $500.00 004A9537 00 6 2018-03-01 2019-03-01 CA $500.00 001A9537 00 6 2018-03-01 2019-03-01 CA $500.00 004A9537 00 6 2018-01-01 2018-03-01 CA $500.00 001A9537 00 6 2018-01-01 2018-03-01 CA $500.00 004A9537 00 6 2017-03-01 2018-01-01 CA $500.00 001A9537 00 6 2017-03-01 2018-01-01 CA $500.00 004A9537 00 6 2016-04-01 2017-03-01 CA $500.00 001A9537 00 6 2016-04-01 2017-03-01 CA $500.00 004A9538 00 6 2018-01-01 9901-01-01 CA $190.32 001A9538 00 6 2018-01-01 9901-01-01 CA $190.32 004A9539 00 6 2018-01-01 9901-01-01 CA $330.00 001A9539 00 6 2018-01-01 9901-01-01 CA $296.40 004A9539 00 6 2016-04-01 2018-01-01 CA $330.00 001A9540 00 6 2019-03-01 9901-01-01 CA $438.00 001A9540 00 6 2018-03-01 2019-03-01 CA $438.00 001A9540 00 6 2018-01-01 2018-03-01 CA $438.00 001A9540 00 6 2018-01-01 9901-01-01 CA $225.25 004A9540 00 6 2017-03-01 2018-01-01 CA $438.00 001A9540 00 6 2016-04-01 2017-03-01 CA $438.00 001A9541 00 6 2021-03-01 9901-01-01 CA $170.00 001A9541 00 6 2021-03-01 9901-01-01 CA $170.00 004A9541 00 6 2019-03-01 2021-03-01 CA $599.00 001A9541 00 6 2019-03-01 2021-03-01 CA $549.00 004A9541 00 6 2018-03-01 2019-03-01 CA $599.00 001A9541 00 6 2018-03-01 2019-03-01 CA $549.00 004A9541 00 6 2018-01-01 2018-03-01 CA $599.00 001A9541 00 6 2018-01-01 2018-03-01 CA $549.00 004A9541 00 6 2017-03-01 2018-01-01 CA $599.00 001A9541 00 6 2017-03-01 2018-01-01 CA $549.00 004A9541 00 6 2016-04-01 2017-03-01 CA $599.00 001A9541 00 6 2016-04-01 2017-03-01 CA $423.30 004A9547 00 6 2018-01-01 9901-01-01 CA $5,916.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 21 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A9547 00 6 2018-01-01 9901-01-01 CA $2,085.00 004A9547 00 6 2016-04-01 2018-01-01 CA $5,916.00 001A9548 00 6 2018-01-01 9901-01-01 CA $3,200.00 001A9548 00 6 2018-01-01 9901-01-01 CA $1,980.00 004A9548 00 6 2017-03-01 2018-01-01 CA $3,200.00 001A9551 00 6 2018-03-01 9901-01-01 CA $1,976.93 001A9551 00 6 2018-01-01 2018-03-01 CA $781.00 001A9551 00 6 2018-01-01 9901-01-01 CA $696.00 004A9551 00 6 2017-03-01 2018-01-01 CA $781.00 001A9551 00 6 2016-04-01 2017-03-01 CA $731.00 001A9552 00 6 2021-03-01 9901-01-01 CA $900.00 001A9552 00 6 2021-03-01 9901-01-01 CA $900.00 004A9552 00 6 2020-03-01 2021-03-01 CA $1,500.00 001A9552 00 6 2020-03-01 2021-03-01 CA $1,500.00 004A9552 00 6 2019-03-01 2020-03-01 CA $1,699.40 001A9552 00 6 2019-03-01 2020-03-01 CA $1,575.00 004A9552 00 6 2018-03-01 2019-03-01 CA $1,699.40 001A9552 00 6 2018-03-01 2019-03-01 CA $1,575.00 004A9552 00 6 2018-01-01 2018-03-01 CA $1,699.40 001A9552 00 6 2018-01-01 2018-03-01 CA $1,575.00 004A9552 00 6 2017-03-01 2018-01-01 CA $1,699.40 001A9552 00 6 2017-03-01 2018-01-01 CA $1,575.00 004A9552 00 6 2016-04-01 2017-03-01 CA $1,330.00 001A9552 00 6 2016-04-01 2017-03-01 CA $1,264.76 004A9554 00 6 2019-03-01 9901-01-01 CA $346.81 001A9554 00 6 2019-03-01 9901-01-01 CA $346.81 004A9554 00 6 2018-01-01 2019-03-01 CA $346.81 001A9554 00 6 2018-01-01 2019-03-01 CA $346.81 004A9555 00 6 2018-01-01 9901-01-01 CA $1,500.00 001A9555 00 6 2018-01-01 9901-01-01 CA $1,500.00 004A9555 00 6 2017-03-01 2018-01-01 CA $1,500.00 001A9555 00 6 2017-03-01 2018-01-01 CA $1,500.00 004A9555 00 6 2016-04-01 2017-03-01 CA $1,500.00 001A9555 00 6 2016-04-01 2017-03-01 CA $1,500.00 004A9556 00 6 2018-01-01 9901-01-01 CA $63.23 001A9556 00 6 2018-01-01 9901-01-01 CA $63.23 004A9557 00 6 2018-01-01 9901-01-01 CA $28.58 001A9557 00 6 2018-01-01 9901-01-01 CA $28.58 004A9558 00 6 2018-03-01 9901-01-01 CA $987.00 001A9558 00 6 2018-01-01 2018-03-01 CA $446.00 001A9558 00 6 2018-01-01 9901-01-01 CA $98.55 004A9558 00 6 2017-03-01 2018-01-01 CA $446.00 001A9558 00 6 2016-04-01 2017-03-01 CA $300.00 001A9560 00 6 2019-03-01 9901-01-01 CA $1,326.00 001A9560 00 6 2018-03-01 2019-03-01 CA $1,326.00 001A9560 00 6 2018-01-01 2018-03-01 CA $734.40 001A9560 00 6 2018-01-01 9901-01-01 CA $266.00 004A9560 00 6 2017-03-01 2018-01-01 CA $734.40 001A9560 00 6 2016-04-01 2017-03-01 CA $280.00 001A9561 00 6 2018-03-01 9901-01-01 CA $385.00 001A9561 00 6 2018-01-01 2018-03-01 CA $385.00 001A9561 00 6 2018-01-01 9901-01-01 CA $184.34 004A9561 00 6 2017-03-01 2018-01-01 CA $385.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 22 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A9561 00 6 2016-04-01 2017-03-01 CA $385.00 001A9562 00 6 2021-03-01 9901-01-01 CA $1,300.00 001A9562 00 6 2019-03-01 2021-03-01 CA $1,997.00 001A9562 00 6 2018-03-01 2019-03-01 CA $1,498.94 001A9562 00 6 2018-01-01 2018-03-01 CA $1,498.94 001A9562 00 6 2018-01-01 9901-01-01 CA $900.00 004A9562 00 6 2017-03-01 2018-01-01 CA $1,498.94 001A9562 00 6 2016-04-01 2017-03-01 CA $1,177.00 001A9563 00 6 2018-01-01 9901-01-01 CA $112.69 001A9563 00 6 2018-01-01 9901-01-01 CA $112.69 004A9567 00 6 2018-03-01 9901-01-01 CA $647.00 001A9567 00 6 2018-01-01 2018-03-01 CA $647.00 001A9567 00 6 2018-01-01 9901-01-01 CA $150.00 004A9567 00 6 2017-03-01 2018-01-01 CA $647.00 001A9570 00 6 2018-01-01 9901-01-01 CA $1,331.25 001A9570 00 6 2018-01-01 9901-01-01 CA $1,331.25 004A9572 00 6 2018-03-01 9901-01-01 CA $14,815.00 001A9572 00 6 2018-01-01 2018-03-01 CA $9,569.86 001A9572 00 6 2018-01-01 9901-01-01 CA $3,235.32 004A9572 00 6 2017-03-01 2018-01-01 CA $9,569.86 001A9580 00 6 2018-01-01 9901-01-01 CA $803.72 001A9580 00 6 2018-01-01 9901-01-01 CA $381.00 004A9580 00 6 2017-03-01 2018-01-01 CA $803.72 001A9582 00 6 2018-01-01 9901-01-01 CA $6,600.00 001A9582 00 6 2018-01-01 9901-01-01 CA $6,600.00 004A9582 00 6 2017-03-01 2018-01-01 CA $6,600.00 001A9583 00 6 2018-01-01 9901-01-01 CA $113.00 001A9583 00 6 2018-01-01 9901-01-01 CA $113.00 004A9583 00 6 2017-08-10 2018-01-01 CA $113.00 001A9583 00 6 2017-08-10 2018-01-01 CA $113.00 004A9584 00 6 2018-03-01 9901-01-01 CA $11,445.00 001A9584 00 6 2018-03-01 9901-01-01 CA $11,445.00 004A9584 00 6 2018-01-01 2018-03-01 CA $11,445.00 001A9584 00 6 2018-01-01 2018-03-01 CA $11,445.00 004A9584 00 6 2017-03-01 2018-01-01 CA $11,445.00 001A9584 00 6 2017-03-01 2018-01-01 CA $11,445.00 004A9584 00 6 2016-04-01 2017-03-01 CA $11,445.00 001A9587 00 6 2019-03-01 9901-01-01 CA $659.00 001A9587 00 6 2019-03-01 9901-01-01 CA $659.00 004A9587 00 6 2018-07-28 2019-03-01 CA $659.00 001A9588 00 6 2021-03-01 9901-01-01 CA $1,200.00 001A9588 00 6 2021-03-01 9901-01-01 CA $1,200.00 004A9588 00 6 2020-02-29 2021-03-01 CA $1,597.00 001A9600 00 6 2018-01-01 9901-01-01 CA $388.43 001A9600 00 6 2018-01-01 9901-01-01 CA $388.43 004A9604 00 6 2018-01-01 9901-01-01 CA $2,774.00 001A9604 00 6 2018-01-01 9901-01-01 CA $2,774.00 004A9700 00 6 2018-01-01 9901-01-01 CA $176.13 001A9700 00 6 2018-01-01 9901-01-01 CA $176.13 004A9901 00 G 2021-03-01 9901-01-01 CA $150.00 001A9901 00 G 2021-03-01 9901-01-01 CA $150.00 004A9901 00 G 2020-03-01 2021-03-01 CA $150.00 001A9901 00 G 2020-03-01 2021-03-01 CA $150.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 23 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

A9901 00 G 2019-03-01 2020-03-01 CA $97.29 001A9901 00 G 2019-03-01 2020-03-01 CA $97.29 004A9901 00 G 2018-07-28 2019-03-01 CA $97.29 001A9901 00 G 2018-07-28 2019-03-01 CA $97.29 004B4100 00 G 2018-01-01 9901-01-01 CA $0.42 001B4100 00 G 2018-01-01 9901-01-01 CA $0.42 004B4102 00 G 2021-03-01 9901-01-01 CA $8.62 001B4102 00 G 2021-03-01 9901-01-01 CA $8.62 004B4102 00 G 2020-03-01 2021-03-01 CA $16.45 001B4102 00 G 2020-03-01 2021-03-01 CA $16.45 004B4102 00 G 2018-03-01 2020-03-01 CA $20.14 001B4102 00 G 2018-03-01 2020-03-01 CA $20.14 004B4102 00 G 2018-01-01 2018-03-01 CA $18.63 001B4102 00 G 2018-01-01 2018-03-01 CA $18.63 004B4102 00 G 2017-03-01 2018-01-01 CA $18.63 001B4102 00 G 2017-03-01 2018-01-01 CA $18.63 004B4102 00 G 2016-04-01 2017-03-01 CA $8.32 001B4102 00 G 2016-04-01 2017-03-01 CA $8.32 004B4103 00 G 2021-03-01 9901-01-01 CA $14.61 001B4103 00 G 2021-03-01 9901-01-01 CA $14.61 004B4103 00 G 2020-03-01 2021-03-01 CA $18.68 001B4103 00 G 2020-03-01 2021-03-01 CA $18.68 004B4103 00 G 2018-03-01 2020-03-01 CA $11.10 001B4103 00 G 2018-03-01 2020-03-01 CA $11.10 004B4103 00 G 2018-01-01 2018-03-01 CA $11.10 001B4103 00 G 2018-01-01 2018-03-01 CA $11.10 004B4103 00 G 2017-03-01 2018-01-01 CA $11.10 001B4103 00 G 2017-03-01 2018-01-01 CA $11.10 004B4103 00 G 2016-04-01 2017-03-01 CA $11.10 001B4103 00 G 2016-04-01 2017-03-01 CA $11.10 004B4104 00 G 2018-03-01 9901-01-01 CA $149.82 001B4104 00 G 2018-03-01 9901-01-01 CA $149.82 004B4104 00 G 2018-01-01 2018-03-01 CA $50.96 001B4104 00 G 2018-01-01 2018-03-01 CA $50.96 004B4104 00 G 2017-03-01 2018-01-01 CA $50.96 001B4104 00 G 2017-03-01 2018-01-01 CA $50.96 004B4104 00 G 2016-04-01 2017-03-01 CA $50.96 001B4104 00 G 2016-04-01 2017-03-01 CA $50.96 004B4105 00 G 2021-03-01 9901-01-01 CA $300.00 001B4105 00 G 2021-03-01 9901-01-01 CA $300.00 004B4105 00 G 2020-04-25 2021-03-01 CA $158.40 001B4105 00 G 2020-04-25 2021-03-01 CA $158.40 004B4157 00 G 2021-03-01 9901-01-01 CA $46.96 001B4157 00 G 2021-03-01 9901-01-01 CA $46.96 004B4157 00 G 2020-03-01 2021-03-01 CA $115.70 001B4157 00 G 2020-03-01 2021-03-01 CA $115.70 004B4157 00 G 2019-03-01 2020-03-01 CA $30.43 001B4157 00 G 2019-03-01 2020-03-01 CA $30.43 004B4157 00 G 2018-03-01 2019-03-01 CA $30.43 001B4157 00 G 2018-03-01 2019-03-01 CA $30.43 004B4157 00 G 2018-01-01 2018-03-01 CA $25.95 001B4157 00 G 2018-01-01 2018-03-01 CA $25.95 004B4157 00 G 2017-03-01 2018-01-01 CA $25.95 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 24 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

B4157 00 G 2017-03-01 2018-01-01 CA $25.95 004B4157 00 G 2016-04-01 2017-03-01 CA $25.95 001B4157 00 G 2016-04-01 2017-03-01 CA $25.95 004B4158 00 G 2021-03-01 9901-01-01 CA $7.54 001B4158 00 G 2021-03-01 9901-01-01 CA $7.54 004B4158 00 G 2020-03-01 2021-03-01 CA $5.60 001B4158 00 G 2020-03-01 2021-03-01 CA $5.60 004B4158 00 G 2019-03-01 2020-03-01 CA $5.60 001B4158 00 G 2019-03-01 2020-03-01 CA $5.60 004B4158 00 G 2018-03-01 2019-03-01 CA $5.60 001B4158 00 G 2018-03-01 2019-03-01 CA $5.60 004B4158 00 G 2018-01-01 2018-03-01 CA $4.96 001B4158 00 G 2018-01-01 2018-03-01 CA $4.96 004B4158 00 G 2017-03-01 2018-01-01 CA $4.96 001B4158 00 G 2017-03-01 2018-01-01 CA $4.96 004B4158 00 G 2016-04-01 2017-03-01 CA $4.10 001B4158 00 G 2016-04-01 2017-03-01 CA $4.10 004B4159 00 G 2020-03-01 9901-01-01 CA $4.22 001B4159 00 G 2020-03-01 9901-01-01 CA $4.22 004B4159 00 G 2018-01-01 2020-03-01 CA $4.68 001B4159 00 G 2018-01-01 2020-03-01 CA $4.68 004B4159 00 G 2017-03-01 2018-01-01 CA $4.68 001B4159 00 G 2017-03-01 2018-01-01 CA $4.68 004B4159 00 G 2016-04-01 2017-03-01 CA $4.68 001B4159 00 G 2016-04-01 2017-03-01 CA $4.68 004B4160 NU G 2019-03-01 2020-03-01 CA $7.00 001B4160 NU G 2019-03-01 2020-03-01 CA $7.00 004B4160 NU G 2018-03-01 2019-03-01 CA $7.00 001B4160 NU G 2018-03-01 2019-03-01 CA $7.00 004B4160 NU G 2018-01-01 2018-03-01 CA $7.00 001B4160 NU G 2018-01-01 2018-03-01 CA $7.00 004B4160 00 G 2021-03-01 9901-01-01 CA $4.60 001B4160 00 G 2021-03-01 9901-01-01 CA $4.60 004B4160 00 G 2020-03-01 2021-03-01 CA $4.60 001B4160 00 G 2020-03-01 2021-03-01 CA $4.60 004B4160 00 G 2019-03-01 2020-03-01 CA $7.00 001B4160 00 G 2019-03-01 2020-03-01 CA $7.00 004B4160 00 G 2018-03-01 2019-03-01 CA $7.00 001B4160 00 G 2018-03-01 2019-03-01 CA $7.00 004B4160 00 G 2018-01-01 2018-03-01 CA $7.00 001B4160 00 G 2018-01-01 2018-03-01 CA $7.00 004B4160 00 G 2017-03-01 2018-01-01 CA $7.00 001B4160 00 G 2017-03-01 2018-01-01 CA $7.00 004B4160 00 G 2016-04-01 2017-03-01 CA $7.00 001B4160 00 G 2016-04-01 2017-03-01 CA $7.00 004B4161 NU G 2021-03-01 9901-01-01 CA $34.00 001B4161 NU G 2021-03-01 9901-01-01 CA $34.00 004B4161 NU G 2020-03-01 2021-03-01 CA $34.00 001B4161 NU G 2020-03-01 2021-03-01 CA $34.00 004B4161 NU G 2019-03-01 2020-03-01 CA $17.20 001B4161 NU G 2019-03-01 2020-03-01 CA $17.20 004B4161 00 G 2021-03-01 9901-01-01 CA $12.20 001B4161 00 G 2021-03-01 9901-01-01 CA $12.20 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 25 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

B4161 00 G 2020-03-01 2021-03-01 CA $9.87 001B4161 00 G 2020-03-01 2021-03-01 CA $9.87 004B4161 00 G 2019-03-01 2020-03-01 CA $17.20 001B4161 00 G 2019-03-01 2020-03-01 CA $17.20 004B4161 00 G 2018-03-01 2019-03-01 CA $17.20 001B4161 00 G 2018-03-01 2019-03-01 CA $17.20 004B4161 00 G 2018-01-01 2018-03-01 CA $17.20 001B4161 00 G 2018-01-01 2018-03-01 CA $17.20 004B4161 00 G 2017-03-01 2018-01-01 CA $17.20 001B4161 00 G 2017-03-01 2018-01-01 CA $17.20 004B4161 00 G 2016-04-01 2017-03-01 CA $17.20 001B4161 00 G 2016-04-01 2017-03-01 CA $17.20 004B4162 00 G 2021-03-01 9901-01-01 CA $13.94 001B4162 00 G 2021-03-01 9901-01-01 CA $13.94 004B4162 00 G 2020-03-01 2021-03-01 CA $16.93 001B4162 00 G 2020-03-01 2021-03-01 CA $16.93 004B4162 00 G 2019-03-01 2020-03-01 CA $30.31 001B4162 00 G 2019-03-01 2020-03-01 CA $30.31 004B4162 00 G 2018-03-01 2019-03-01 CA $30.31 001B4162 00 G 2018-03-01 2019-03-01 CA $30.31 004B4162 00 G 2018-01-01 2018-03-01 CA $25.81 001B4162 00 G 2018-01-01 2018-03-01 CA $25.81 004B4162 00 G 2017-03-01 2018-01-01 CA $25.81 001B4162 00 G 2017-03-01 2018-01-01 CA $25.81 004B4162 00 G 2016-04-01 2017-03-01 CA $25.81 001B4162 00 G 2016-04-01 2017-03-01 CA $25.81 004B4187 00 G 2020-04-18 2020-07-01 CA $679.19 001B4187 00 G 2020-04-18 2020-07-01 CA $679.19 004B5200 00 G 2021-03-01 9901-01-01 CA $5.14 001B5200 00 G 2021-03-01 9901-01-01 CA $5.14 004B5200 00 G 2020-03-01 2021-03-01 CA $4.76 001B5200 00 G 2020-03-01 2021-03-01 CA $4.76 004B5200 00 G 2019-03-01 2020-03-01 CA $5.31 001B5200 00 G 2019-03-01 2020-03-01 CA $5.31 004B5200 00 G 2018-01-01 2019-03-01 CA $5.31 001B5200 00 G 2018-01-01 2019-03-01 CA $5.31 004B5200 00 G 2017-03-01 2018-01-01 CA $5.31 001B5200 00 G 2017-03-01 2018-01-01 CA $5.31 004B5200 00 G 2016-04-01 2017-03-01 CA $5.31 001B5200 00 G 2016-04-01 2017-03-01 CA $5.31 004C1713 00 G 2018-01-01 9901-01-01 CA $1,185.00 001C1713 00 G 2018-01-01 9901-01-01 CA $1,185.00 004C1713 00 G 2017-03-01 2018-01-01 CA $1,185.00 001C1713 00 G 2017-03-01 2018-01-01 CA $1,185.00 004C1713 00 G 2016-04-01 2017-03-01 CA $1,165.00 001C1713 00 G 2016-04-01 2017-03-01 CA $1,165.00 004C1714 00 G 2018-01-01 9901-01-01 CA $14,475.00 001C1714 00 G 2018-01-01 9901-01-01 CA $14,475.00 004C1714 00 G 2016-08-25 2018-01-01 CA $14,475.00 001C1714 00 G 2016-08-25 2018-01-01 CA $14,475.00 004C1715 00 G 2018-01-01 9901-01-01 CA $302.10 001C1715 00 G 2018-01-01 9901-01-01 CA $302.10 004C1716 00 G 2018-01-01 9901-01-01 CA $193.16 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 26 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1716 00 G 2018-01-01 9901-01-01 CA $193.16 004C1717 00 G 2019-03-01 9901-01-01 CA $1,377.00 001C1717 00 G 2019-03-01 9901-01-01 CA $1,377.00 004C1717 00 G 2018-03-01 2019-03-01 CA $1,066.00 001C1717 00 G 2018-03-01 2019-03-01 CA $1,066.00 004C1717 00 G 2018-01-01 2018-03-01 CA $1,066.00 001C1717 00 G 2018-01-01 2018-03-01 CA $1,066.00 004C1717 00 G 2017-03-01 2018-01-01 CA $1,066.00 001C1717 00 G 2017-03-01 2018-01-01 CA $1,066.00 004C1717 00 G 2016-04-01 2017-03-01 CA $1,066.00 001C1717 00 G 2016-04-01 2017-03-01 CA $1,066.00 004C1719 00 G 2018-01-01 9901-01-01 CA $28.52 001C1719 00 G 2018-01-01 9901-01-01 CA $28.52 004C1721 00 G 2018-01-01 9901-01-01 CA $81,890.00 001C1721 00 G 2018-01-01 9901-01-01 CA $81,890.00 004C1721 00 G 2017-03-01 2018-01-01 CA $81,890.00 001C1721 00 G 2017-03-01 2018-01-01 CA $81,890.00 004C1721 00 G 2016-04-01 2017-03-01 CA $81,890.00 001C1721 00 G 2016-04-01 2017-03-01 CA $81,890.00 004C1722 00 G 2018-01-01 9901-01-01 CA $72,750.00 001C1722 00 G 2018-01-01 9901-01-01 CA $72,750.00 004C1724 00 G 2018-01-01 9901-01-01 CA $14,875.00 001C1724 00 G 2018-01-01 9901-01-01 CA $14,875.00 004C1725 00 G 2018-01-01 9901-01-01 CA $1,583.00 001C1725 00 G 2018-01-01 9901-01-01 CA $1,583.00 004C1725 00 G 2017-03-01 2018-01-01 CA $1,583.00 001C1725 00 G 2017-03-01 2018-01-01 CA $1,583.00 004C1725 00 G 2016-04-01 2017-03-01 CA $1,583.00 001C1725 00 G 2016-04-01 2017-03-01 CA $1,583.00 004C1726 00 G 2018-01-01 9901-01-01 CA $4,273.50 001C1726 00 G 2018-01-01 9901-01-01 CA $4,273.50 004C1726 00 G 2017-03-01 2018-01-01 CA $4,273.50 001C1726 00 G 2017-03-01 2018-01-01 CA $4,273.50 004C1726 00 G 2016-04-01 2017-03-01 CA $4,273.50 001C1726 00 G 2016-04-01 2017-03-01 CA $4,273.50 004C1727 00 G 2018-01-01 9901-01-01 CA $2,828.00 001C1727 00 G 2018-01-01 9901-01-01 CA $2,828.00 004C1727 00 G 2017-03-01 2018-01-01 CA $2,828.00 001C1727 00 G 2017-03-01 2018-01-01 CA $2,828.00 004C1727 00 G 2016-04-01 2017-03-01 CA $2,719.00 001C1727 00 G 2016-04-01 2017-03-01 CA $2,719.00 004C1728 00 G 2018-01-01 9901-01-01 CA $302.10 001C1728 00 G 2018-01-01 9901-01-01 CA $302.10 004C1729 00 G 2018-01-01 9901-01-01 CA $498.00 001C1729 00 G 2018-01-01 9901-01-01 CA $498.00 004C1729 00 G 2017-03-01 2018-01-01 CA $498.00 001C1729 00 G 2017-03-01 2018-01-01 CA $498.00 004C1729 00 G 2016-04-01 2017-03-01 CA $486.50 001C1729 00 G 2016-04-01 2017-03-01 CA $486.50 004C1730 00 G 2018-01-01 9901-01-01 CA $3,786.00 001C1730 00 G 2018-01-01 9901-01-01 CA $3,786.00 004C1730 00 G 2017-03-01 2018-01-01 CA $3,786.00 001C1730 00 G 2017-03-01 2018-01-01 CA $3,786.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 27 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1730 00 G 2016-04-01 2017-03-01 CA $3,786.00 001C1730 00 G 2016-04-01 2017-03-01 CA $3,786.00 004C1731 00 G 2018-01-01 9901-01-01 CA $7,363.00 001C1731 00 G 2018-01-01 9901-01-01 CA $7,363.00 004C1731 00 G 2017-03-01 2018-01-01 CA $7,363.00 001C1731 00 G 2017-03-01 2018-01-01 CA $7,363.00 004C1731 00 G 2016-04-01 2017-03-01 CA $7,080.00 001C1731 00 G 2016-04-01 2017-03-01 CA $7,080.00 004C1732 00 G 2018-01-01 9901-01-01 CA $14,000.00 001C1732 00 G 2018-01-01 9901-01-01 CA $14,000.00 004C1732 00 G 2017-03-01 2018-01-01 CA $14,000.00 001C1732 00 G 2017-03-01 2018-01-01 CA $14,000.00 004C1732 00 G 2016-04-01 2017-03-01 CA $14,000.00 001C1732 00 G 2016-04-01 2017-03-01 CA $14,000.00 004C1733 00 G 2018-01-01 9901-01-01 CA $13,500.00 001C1733 00 G 2018-01-01 9901-01-01 CA $13,500.00 004C1733 00 G 2017-03-01 2018-01-01 CA $13,500.00 001C1733 00 G 2017-03-01 2018-01-01 CA $13,500.00 004C1733 00 G 2016-04-01 2017-03-01 CA $13,500.00 001C1733 00 G 2016-04-01 2017-03-01 CA $13,500.00 004C1750 00 G 2018-01-01 9901-01-01 CA $2,587.50 001C1750 00 G 2018-01-01 9901-01-01 CA $2,587.50 004C1750 00 G 2017-03-01 2018-01-01 CA $2,587.50 001C1750 00 G 2017-03-01 2018-01-01 CA $2,587.50 004C1750 00 G 2016-04-01 2017-03-01 CA $2,587.50 001C1750 00 G 2016-04-01 2017-03-01 CA $2,587.50 004C1751 00 G 2018-01-01 9901-01-01 CA $342.00 001C1751 00 G 2018-01-01 9901-01-01 CA $342.00 004C1751 00 G 2017-03-01 2018-01-01 CA $342.00 001C1751 00 G 2017-03-01 2018-01-01 CA $342.00 004C1751 00 G 2016-04-01 2017-03-01 CA $307.50 001C1751 00 G 2016-04-01 2017-03-01 CA $307.50 004C1752 00 G 2018-01-01 9901-01-01 CA $1,685.00 001C1752 00 G 2018-01-01 9901-01-01 CA $1,685.00 004C1752 00 G 2016-01-07 2018-01-01 CA $1,685.00 001C1752 00 G 2016-01-07 2018-01-01 CA $1,685.00 004C1753 00 G 2018-01-01 9901-01-01 CA $6,035.00 001C1753 00 G 2018-01-01 9901-01-01 CA $6,035.00 004C1753 00 G 2017-03-01 2018-01-01 CA $6,035.00 001C1753 00 G 2017-03-01 2018-01-01 CA $6,035.00 004C1753 00 G 2016-04-01 2017-03-01 CA $3,829.00 001C1753 00 G 2016-04-01 2017-03-01 CA $3,829.00 004C1755 00 G 2018-01-01 9901-01-01 CA $2,750.00 001C1755 00 G 2018-01-01 9901-01-01 CA $2,750.00 004C1755 00 G 2017-03-01 2018-01-01 CA $2,750.00 001C1755 00 G 2017-03-01 2018-01-01 CA $2,750.00 004C1757 00 G 2018-01-01 9901-01-01 CA $2,600.01 001C1757 00 G 2018-01-01 9901-01-01 CA $2,600.01 004C1757 00 G 2017-03-01 2018-01-01 CA $2,600.01 001C1757 00 G 2017-03-01 2018-01-01 CA $2,600.01 004C1757 00 G 2016-04-01 2017-03-01 CA $2,379.34 001C1757 00 G 2016-04-01 2017-03-01 CA $2,379.34 004C1758 00 G 2018-01-01 9901-01-01 CA $275.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 28 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1758 00 G 2018-01-01 9901-01-01 CA $275.00 004C1758 00 G 2017-03-01 2018-01-01 CA $275.00 001C1758 00 G 2017-03-01 2018-01-01 CA $275.00 004C1758 00 G 2016-04-01 2017-03-01 CA $275.00 001C1758 00 G 2016-04-01 2017-03-01 CA $275.00 004C1759 00 G 2018-01-01 9901-01-01 CA $13,570.00 001C1759 00 G 2018-01-01 9901-01-01 CA $13,570.00 004C1759 00 G 2017-03-01 2018-01-01 CA $13,570.00 001C1759 00 G 2017-03-01 2018-01-01 CA $13,570.00 004C1759 00 G 2016-04-01 2017-03-01 CA $13,570.00 001C1759 00 G 2016-04-01 2017-03-01 CA $13,570.00 004C1760 00 G 2018-01-01 9901-01-01 CA $1,643.83 001C1760 00 G 2018-01-01 9901-01-01 CA $1,643.83 004C1760 00 G 2017-03-01 2018-01-01 CA $1,643.83 001C1760 00 G 2017-03-01 2018-01-01 CA $1,643.83 004C1760 00 G 2016-04-01 2017-03-01 CA $1,643.83 001C1760 00 G 2016-04-01 2017-03-01 CA $1,643.83 004C1762 00 G 2018-01-01 9901-01-01 CA $9,344.00 001C1762 00 G 2018-01-01 9901-01-01 CA $9,344.00 004C1762 00 G 2017-03-01 2018-01-01 CA $9,344.00 001C1762 00 G 2017-03-01 2018-01-01 CA $9,344.00 004C1762 00 G 2016-04-01 2017-03-01 CA $9,344.00 001C1762 00 G 2016-04-01 2017-03-01 CA $9,344.00 004C1763 00 G 2018-01-01 9901-01-01 CA $3,603.75 001C1763 00 G 2018-01-01 9901-01-01 CA $3,603.75 004C1763 00 G 2017-03-01 2018-01-01 CA $3,603.75 001C1763 00 G 2017-03-01 2018-01-01 CA $3,603.75 004C1763 00 G 2016-04-01 2017-03-01 CA $3,435.00 001C1763 00 G 2016-04-01 2017-03-01 CA $3,435.00 004C1764 00 G 2018-01-01 9901-01-01 CA $26,440.28 001C1764 00 G 2018-01-01 9901-01-01 CA $26,440.28 004C1764 00 G 2017-03-01 2018-01-01 CA $26,440.28 001C1764 00 G 2017-03-01 2018-01-01 CA $26,440.28 004C1764 00 G 2016-04-01 2017-03-01 CA $24,975.00 001C1764 00 G 2016-04-01 2017-03-01 CA $24,975.00 004C1765 00 G 2018-01-01 9901-01-01 CA $3,245.00 001C1765 00 G 2018-01-01 9901-01-01 CA $3,245.00 004C1765 00 G 2017-03-01 2018-01-01 CA $3,245.00 001C1765 00 G 2017-03-01 2018-01-01 CA $3,245.00 004C1765 00 G 2016-04-01 2017-03-01 CA $2,385.00 001C1765 00 G 2016-04-01 2017-03-01 CA $2,385.00 004C1766 00 G 2018-01-01 9901-01-01 CA $283.71 001C1766 00 G 2018-01-01 9901-01-01 CA $283.71 004C1766 00 G 2017-03-01 2018-01-01 CA $283.71 001C1766 00 G 2017-03-01 2018-01-01 CA $283.71 004C1766 00 G 2016-04-01 2017-03-01 CA $283.71 001C1766 00 G 2016-04-01 2017-03-01 CA $283.71 004C1767 00 G 2018-01-01 9901-01-01 CA $99,689.00 001C1767 00 G 2018-01-01 9901-01-01 CA $99,689.00 004C1767 00 G 2017-03-01 2018-01-01 CA $99,689.00 001C1767 00 G 2017-03-01 2018-01-01 CA $99,689.00 004C1767 00 G 2016-04-01 2017-03-01 CA $78,909.00 001C1767 00 G 2016-04-01 2017-03-01 CA $78,909.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 29 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1768 00 G 2018-01-01 9901-01-01 CA $4,752.00 001C1768 00 G 2018-01-01 9901-01-01 CA $4,752.00 004C1768 00 G 2016-04-01 2018-01-01 CA $4,752.00 001C1768 00 G 2016-04-01 2018-01-01 CA $4,752.00 004C1769 00 G 2018-01-01 9901-01-01 CA $598.86 001C1769 00 G 2018-01-01 9901-01-01 CA $598.86 004C1769 00 G 2017-03-01 2018-01-01 CA $598.86 001C1769 00 G 2017-03-01 2018-01-01 CA $598.86 004C1769 00 G 2016-04-01 2017-03-01 CA $598.86 001C1769 00 G 2016-04-01 2017-03-01 CA $598.86 004C1771 00 G 2018-01-01 9901-01-01 CA $5,569.22 001C1771 00 G 2018-01-01 9901-01-01 CA $5,569.22 004C1771 00 G 2017-03-01 2018-01-01 CA $5,569.22 001C1771 00 G 2017-03-01 2018-01-01 CA $5,569.22 004C1771 00 G 2016-04-01 2017-03-01 CA $5,569.22 001C1771 00 G 2016-04-01 2017-03-01 CA $5,569.22 004C1772 00 G 2018-01-01 9901-01-01 CA $10,976.79 001C1772 00 G 2018-01-01 9901-01-01 CA $10,976.79 004C1773 00 G 2018-01-01 9901-01-01 CA $1,829.00 001C1773 00 G 2018-01-01 9901-01-01 CA $1,829.00 004C1773 00 G 2017-03-01 2018-01-01 CA $1,829.00 001C1773 00 G 2017-03-01 2018-01-01 CA $1,829.00 004C1773 00 G 2016-04-01 2017-03-01 CA $1,631.48 001C1773 00 G 2016-04-01 2017-03-01 CA $1,631.48 004C1776 00 G 2018-01-01 9901-01-01 CA $9,135.00 001C1776 00 G 2018-01-01 9901-01-01 CA $9,135.00 004C1776 00 G 2017-03-01 2018-01-01 CA $9,135.00 001C1776 00 G 2017-03-01 2018-01-01 CA $9,135.00 004C1776 00 G 2016-04-01 2017-03-01 CA $7,051.59 001C1776 00 G 2016-04-01 2017-03-01 CA $7,051.59 004C1777 00 G 2018-01-01 9901-01-01 CA $33,600.00 001C1777 00 G 2018-01-01 9901-01-01 CA $33,600.00 004C1777 00 G 2017-03-01 2018-01-01 CA $33,600.00 001C1777 00 G 2017-03-01 2018-01-01 CA $33,600.00 004C1778 00 G 2018-01-01 9901-01-01 CA $18,000.00 001C1778 00 G 2018-01-01 9901-01-01 CA $18,000.00 004C1778 00 G 2017-03-01 2018-01-01 CA $18,000.00 001C1778 00 G 2017-03-01 2018-01-01 CA $18,000.00 004C1778 00 G 2016-04-01 2017-03-01 CA $14,097.12 001C1778 00 G 2016-04-01 2017-03-01 CA $14,097.12 004C1779 00 G 2018-01-01 9901-01-01 CA $3,467.00 001C1779 00 G 2018-01-01 9901-01-01 CA $3,467.00 004C1780 00 G 2018-01-01 9901-01-01 CA $992.00 001C1780 00 G 2018-01-01 9901-01-01 CA $992.00 004C1780 00 G 2017-03-01 2018-01-01 CA $992.00 001C1780 00 G 2017-03-01 2018-01-01 CA $992.00 004C1780 00 G 2016-04-01 2017-03-01 CA $992.00 001C1780 00 G 2016-04-01 2017-03-01 CA $992.00 004C1781 00 G 2018-01-01 9901-01-01 CA $2,625.00 001C1781 00 G 2018-01-01 9901-01-01 CA $2,625.00 004C1781 00 G 2017-03-01 2018-01-01 CA $2,625.00 001C1781 00 G 2017-03-01 2018-01-01 CA $2,625.00 004C1781 00 G 2016-04-01 2017-03-01 CA $2,221.80 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 30 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1781 00 G 2016-04-01 2017-03-01 CA $2,221.80 004C1782 00 G 2018-01-01 9901-01-01 CA $4,725.00 001C1782 00 G 2018-01-01 9901-01-01 CA $4,725.00 004C1782 00 G 2017-03-01 2018-01-01 CA $4,725.00 001C1782 00 G 2017-03-01 2018-01-01 CA $4,725.00 004C1782 00 G 2016-04-01 2017-03-01 CA $4,725.00 001C1782 00 G 2016-04-01 2017-03-01 CA $4,725.00 004C1783 00 G 2018-01-01 9901-01-01 CA $3,658.00 001C1783 00 G 2018-01-01 9901-01-01 CA $3,658.00 004C1784 00 G 2018-01-01 9901-01-01 CA $4,278.32 001C1784 00 G 2018-01-01 9901-01-01 CA $4,278.32 004C1784 00 G 2016-04-01 2018-01-01 CA $4,278.32 001C1784 00 G 2016-04-01 2018-01-01 CA $4,278.32 004C1785 00 G 2018-01-01 9901-01-01 CA $37,684.00 001C1785 00 G 2018-01-01 9901-01-01 CA $37,684.00 004C1785 00 G 2017-03-01 2018-01-01 CA $37,684.00 001C1785 00 G 2017-03-01 2018-01-01 CA $37,684.00 004C1785 00 G 2016-04-01 2017-03-01 CA $37,684.00 001C1785 00 G 2016-04-01 2017-03-01 CA $37,684.00 004C1787 00 G 2018-01-01 9901-01-01 CA $6,926.00 001C1787 00 G 2018-01-01 9901-01-01 CA $6,926.00 004C1787 00 G 2017-03-01 2018-01-01 CA $6,926.00 001C1787 00 G 2017-03-01 2018-01-01 CA $6,926.00 004C1787 00 G 2016-04-01 2017-03-01 CA $4,975.00 001C1788 00 G 2018-01-01 9901-01-01 CA $2,941.00 001C1788 00 G 2018-01-01 9901-01-01 CA $2,941.00 004C1788 00 G 2017-03-01 2018-01-01 CA $2,941.00 001C1788 00 G 2017-03-01 2018-01-01 CA $2,941.00 004C1788 00 G 2016-04-01 2017-03-01 CA $2,788.00 001C1788 00 G 2016-04-01 2017-03-01 CA $2,788.00 004C1789 00 G 2018-01-01 9901-01-01 CA $6,095.50 001C1789 00 G 2018-01-01 9901-01-01 CA $6,095.50 004C1789 00 G 2017-03-01 2018-01-01 CA $6,095.50 001C1789 00 G 2017-03-01 2018-01-01 CA $6,095.50 004C1789 00 G 2016-04-01 2017-03-01 CA $4,960.00 001C1789 00 G 2016-04-01 2017-03-01 CA $4,960.00 004C1813 00 G 2018-01-01 9901-01-01 CA $33,379.50 001C1813 00 G 2018-01-01 9901-01-01 CA $33,379.50 004C1813 00 G 2017-03-01 2018-01-01 CA $33,379.50 001C1813 00 G 2017-03-01 2018-01-01 CA $33,379.50 004C1814 00 G 2018-01-01 9901-01-01 CA $2,866.00 001C1814 00 G 2018-01-01 9901-01-01 CA $2,866.00 004C1814 00 G 2017-03-01 2018-01-01 CA $2,866.00 001C1814 00 G 2017-03-01 2018-01-01 CA $2,866.00 004C1814 00 G 2016-04-01 2017-03-01 CA $2,866.00 001C1814 00 G 2016-04-01 2017-03-01 CA $2,866.00 004C1817 00 G 2018-01-01 9901-01-01 CA $10,285.90 001C1817 00 G 2018-01-01 9901-01-01 CA $10,285.90 004C1819 00 G 2018-01-01 9901-01-01 CA $229.00 001C1819 00 G 2018-01-01 9901-01-01 CA $229.00 004C1820 00 G 2018-01-01 9901-01-01 CA $86,704.00 001C1820 00 G 2018-01-01 9901-01-01 CA $86,704.00 004C1820 00 G 2017-03-01 2018-01-01 CA $86,704.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 31 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1820 00 G 2017-03-01 2018-01-01 CA $86,704.00 004C1820 00 G 2016-04-01 2017-03-01 CA $77,125.00 001C1820 00 G 2016-04-01 2017-03-01 CA $77,125.00 004C1822 00 G 2018-01-01 9901-01-01 CA $93,610.00 001C1822 00 G 2018-01-01 9901-01-01 CA $93,610.00 004C1822 00 G 2017-08-15 2018-01-01 CA $93,610.00 001C1822 00 G 2017-08-15 2018-01-01 CA $93,610.00 004C1830 00 6 2018-01-01 9901-01-01 CA $567.00 001C1830 00 6 2018-01-01 9901-01-01 CA $567.00 004C1874 00 G 2018-01-01 9901-01-01 CA $9,095.65 001C1874 00 G 2018-01-01 9901-01-01 CA $9,095.65 004C1874 00 G 2017-03-01 2018-01-01 CA $9,095.65 001C1874 00 G 2017-03-01 2018-01-01 CA $9,095.65 004C1874 00 G 2016-04-01 2017-03-01 CA $9,095.65 001C1874 00 G 2016-04-01 2017-03-01 CA $9,095.65 004C1875 00 G 2018-01-01 9901-01-01 CA $522.50 001C1875 00 G 2018-01-01 9901-01-01 CA $522.50 004C1876 00 G 2018-01-01 9901-01-01 CA $5,439.25 001C1876 00 G 2018-01-01 9901-01-01 CA $5,439.25 004C1876 00 G 2017-03-01 2018-01-01 CA $5,439.25 001C1876 00 G 2017-03-01 2018-01-01 CA $5,439.25 004C1876 00 G 2016-04-01 2017-03-01 CA $5,263.00 001C1876 00 G 2016-04-01 2017-03-01 CA $5,263.00 004C1877 00 G 2018-01-01 9901-01-01 CA $2,839.74 001C1877 00 G 2018-01-01 9901-01-01 CA $2,839.74 004C1878 00 G 2018-01-01 9901-01-01 CA $3,680.00 001C1878 00 G 2018-01-01 9901-01-01 CA $3,680.00 004C1878 00 G 2016-04-01 2018-01-01 CA $3,680.00 001C1878 00 G 2016-04-01 2018-01-01 CA $3,680.00 004C1880 00 G 2018-01-01 9901-01-01 CA $5,779.20 001C1880 00 G 2018-01-01 9901-01-01 CA $5,779.20 004C1882 00 G 2018-01-01 9901-01-01 CA $99,091.00 001C1882 00 G 2018-01-01 9901-01-01 CA $99,091.00 004C1882 00 G 2016-04-01 2018-01-01 CA $99,091.00 001C1882 00 G 2016-04-01 2018-01-01 CA $99,091.00 004C1883 00 G 2018-01-01 9901-01-01 CA $9,475.00 001C1883 00 G 2018-01-01 9901-01-01 CA $9,475.00 004C1884 00 G 2018-01-01 9901-01-01 CA $3,568.81 001C1884 00 G 2018-01-01 9901-01-01 CA $3,568.81 004C1886 00 G 2018-01-01 9901-01-01 CA $6,875.00 001C1886 00 G 2018-01-01 9901-01-01 CA $6,875.00 004C1887 00 G 2018-01-01 9901-01-01 CA $1,600.00 001C1887 00 G 2018-01-01 9901-01-01 CA $1,600.00 004C1887 00 G 2017-03-01 2018-01-01 CA $1,600.00 001C1887 00 G 2017-03-01 2018-01-01 CA $1,600.00 004C1887 00 G 2016-04-01 2017-03-01 CA $1,600.00 001C1887 00 G 2016-04-01 2017-03-01 CA $1,600.00 004C1888 00 G 2018-01-01 9901-01-01 CA $8,867.00 001C1888 00 G 2018-01-01 9901-01-01 CA $8,867.00 004C1888 00 G 2017-03-01 2018-01-01 CA $8,867.00 001C1888 00 G 2017-03-01 2018-01-01 CA $8,867.00 004C1888 00 G 2016-04-01 2017-03-01 CA $7,586.00 001C1888 00 G 2016-04-01 2017-03-01 CA $7,586.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 32 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C1889 00 G 2018-10-13 9901-01-01 CA $27,966.00 001C1889 00 G 2018-10-13 9901-01-01 CA $27,966.00 004C1892 00 G 2018-01-01 9901-01-01 CA $604.00 001C1892 00 G 2018-01-01 9901-01-01 CA $604.00 004C1892 00 G 2017-03-01 2018-01-01 CA $604.00 001C1892 00 G 2017-03-01 2018-01-01 CA $604.00 004C1892 00 G 2016-04-01 2017-03-01 CA $604.00 001C1892 00 G 2016-04-01 2017-03-01 CA $604.00 004C1893 00 G 2018-01-01 9901-01-01 CA $1,209.00 001C1893 00 G 2018-01-01 9901-01-01 CA $1,209.00 004C1893 00 G 2017-03-01 2018-01-01 CA $1,209.00 001C1893 00 G 2017-03-01 2018-01-01 CA $1,209.00 004C1893 00 G 2016-04-01 2017-03-01 CA $1,170.00 001C1893 00 G 2016-04-01 2017-03-01 CA $1,170.00 004C1894 00 G 2018-01-01 9901-01-01 CA $405.00 001C1894 00 G 2018-01-01 9901-01-01 CA $405.00 004C1894 00 G 2017-03-01 2018-01-01 CA $405.00 001C1894 00 G 2017-03-01 2018-01-01 CA $405.00 004C1894 00 G 2016-04-01 2017-03-01 CA $386.24 001C1894 00 G 2016-04-01 2017-03-01 CA $386.24 004C1895 00 G 2018-01-01 9901-01-01 CA $22,015.00 001C1895 00 G 2018-01-01 9901-01-01 CA $22,015.00 004C1897 00 G 2018-01-01 9901-01-01 CA $7,620.00 001C1897 00 G 2018-01-01 9901-01-01 CA $7,620.00 004C1897 00 G 2017-03-01 2018-01-01 CA $7,620.00 001C1897 00 G 2017-03-01 2018-01-01 CA $7,620.00 004C1897 00 G 2016-04-01 2017-03-01 CA $5,000.00 001C1897 00 G 2016-04-01 2017-03-01 CA $5,000.00 004C1898 00 G 2018-01-01 9901-01-01 CA $4,146.00 001C1898 00 G 2018-01-01 9901-01-01 CA $4,146.00 004C1898 00 G 2017-03-01 2018-01-01 CA $4,146.00 001C1898 00 G 2017-03-01 2018-01-01 CA $4,146.00 004C1898 00 G 2016-04-01 2017-03-01 CA $4,146.00 001C1898 00 G 2016-04-01 2017-03-01 CA $4,146.00 004C1900 00 G 2018-01-01 9901-01-01 CA $15,152.00 001C1900 00 G 2018-01-01 9901-01-01 CA $15,152.00 004C1900 00 G 2016-04-01 2018-01-01 CA $15,152.00 001C1900 00 G 2016-04-01 2018-01-01 CA $15,152.00 004C2614 00 G 2018-01-01 9901-01-01 CA $527.76 001C2614 00 G 2018-01-01 9901-01-01 CA $527.76 004C2614 00 G 2016-04-01 2018-01-01 CA $527.76 004C2615 00 G 2018-01-01 9901-01-01 CA $2,215.00 001C2615 00 G 2018-01-01 9901-01-01 CA $2,215.00 004C2615 00 G 2017-03-01 2018-01-01 CA $2,215.00 001C2615 00 G 2017-03-01 2018-01-01 CA $2,215.00 004C2616 00 G 2018-01-01 9901-01-01 CA $74,074.00 001C2616 00 G 2018-01-01 9901-01-01 CA $74,074.00 004C2616 00 G 2017-03-01 2018-01-01 CA $74,074.00 001C2616 00 G 2017-03-01 2018-01-01 CA $74,074.00 004C2617 00 G 2018-01-01 9901-01-01 CA $873.60 001C2617 00 G 2018-01-01 9901-01-01 CA $873.60 004C2617 00 G 2017-03-01 2018-01-01 CA $873.60 001C2617 00 G 2017-03-01 2018-01-01 CA $873.60 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 33 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C2617 00 G 2016-04-01 2017-03-01 CA $764.50 001C2617 00 G 2016-04-01 2017-03-01 CA $764.50 004C2618 00 G 2018-01-01 9901-01-01 CA $4,342.15 001C2618 00 G 2018-01-01 9901-01-01 CA $4,342.15 004C2625 00 G 2018-01-01 9901-01-01 CA $3,475.00 001C2625 00 G 2018-01-01 9901-01-01 CA $3,475.00 004C2625 00 G 2017-03-01 2018-01-01 CA $3,475.00 001C2625 00 G 2017-03-01 2018-01-01 CA $3,475.00 004C2625 00 G 2016-04-01 2017-03-01 CA $1,685.00 001C2625 00 G 2016-04-01 2017-03-01 CA $1,685.00 004C2626 00 G 2018-01-01 9901-01-01 CA $2,050.22 001C2626 00 G 2018-01-01 9901-01-01 CA $2,050.22 004C2627 00 G 2018-01-01 9901-01-01 CA $596.30 001C2627 00 G 2018-01-01 9901-01-01 CA $596.30 004C2627 00 G 2017-03-01 2018-01-01 CA $596.30 001C2627 00 G 2017-03-01 2018-01-01 CA $596.30 004C2627 00 G 2016-04-01 2017-03-01 CA $267.00 001C2627 00 G 2016-04-01 2017-03-01 CA $267.00 004C2628 00 G 2018-01-01 9901-01-01 CA $800.00 001C2628 00 G 2018-01-01 9901-01-01 CA $800.00 004C2628 00 G 2017-03-01 2018-01-01 CA $800.00 001C2628 00 G 2017-03-01 2018-01-01 CA $800.00 004C2628 00 G 2016-04-01 2017-03-01 CA $800.00 001C2628 00 G 2016-04-01 2017-03-01 CA $800.00 004C2629 00 G 2018-01-01 9901-01-01 CA $383.67 001C2629 00 G 2018-01-01 9901-01-01 CA $383.67 004C2629 00 G 2017-03-01 2018-01-01 CA $383.67 001C2629 00 G 2017-03-01 2018-01-01 CA $383.67 004C2630 00 G 2018-01-01 9901-01-01 CA $16,544.00 001C2630 00 G 2018-01-01 9901-01-01 CA $16,544.00 004C2630 00 G 2016-04-01 2018-01-01 CA $16,544.00 001C2630 00 G 2016-04-01 2018-01-01 CA $16,544.00 004C2631 00 G 2018-01-01 9901-01-01 CA $5,952.86 001C2631 00 G 2018-01-01 9901-01-01 CA $5,952.86 004C2631 00 G 2017-03-01 2018-01-01 CA $5,952.86 001C2631 00 G 2017-03-01 2018-01-01 CA $5,952.86 004C2634 00 G 2018-01-01 9901-01-01 CA $57.14 001C2634 00 G 2018-01-01 9901-01-01 CA $57.14 004C2635 00 G 2018-01-01 9901-01-01 CA $29.11 001C2635 00 G 2018-01-01 9901-01-01 CA $29.11 004C2636 00 G 2018-01-01 9901-01-01 CA $37.74 001C2636 00 G 2018-01-01 9901-01-01 CA $37.74 004C2638 00 G 2018-01-01 9901-01-01 CA $42.29 001C2638 00 G 2018-01-01 9901-01-01 CA $42.29 004C2639 00 G 2018-01-01 9901-01-01 CA $37.13 001C2639 00 G 2018-01-01 9901-01-01 CA $37.13 004C2640 00 G 2018-01-01 9901-01-01 CA $73.89 001C2640 00 G 2018-01-01 9901-01-01 CA $73.89 004C2641 00 G 2018-01-01 9901-01-01 CA $66.61 001C2641 00 G 2018-01-01 9901-01-01 CA $66.61 004C2642 00 G 2018-01-01 9901-01-01 CA $126.27 001C2642 00 G 2018-01-01 9901-01-01 CA $126.27 004C2643 00 G 2018-01-01 9901-01-01 CA $67.64 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 34 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C2643 00 G 2018-01-01 9901-01-01 CA $67.64 004C2698 00 G 2018-01-01 9901-01-01 CA $42.29 001C2698 00 G 2018-01-01 9901-01-01 CA $42.29 004C5271 00 6 2018-01-01 9901-01-01 CA $1,410.78 001C5271 00 6 2018-01-01 9901-01-01 CA $1,410.78 004C5275 26 P 2018-01-01 9901-01-01 CA $10,030.00 001C5275 26 P 2018-01-01 9901-01-01 CA $10,030.00 004C8900 00 5 2018-01-01 9901-01-01 CA $443.97 001C8900 00 5 2018-01-01 9901-01-01 CA $443.97 004C8901 00 5 2018-01-01 9901-01-01 CA $348.42 001C8901 00 5 2018-01-01 9901-01-01 CA $348.42 004C8902 00 5 2018-01-01 9901-01-01 CA $542.14 001C8902 00 5 2018-01-01 9901-01-01 CA $542.14 004C8903 00 5 2018-01-01 9901-01-01 CA $443.97 001C8903 00 5 2018-01-01 9901-01-01 CA $443.97 004C8904 00 5 2018-01-01 9901-01-01 CA $348.42 001C8904 00 5 2018-01-01 9901-01-01 CA $348.42 004C8905 00 5 2018-01-01 9901-01-01 CA $542.14 001C8905 00 5 2018-01-01 9901-01-01 CA $542.14 004C8906 00 5 2018-01-01 9901-01-01 CA $443.97 001C8906 00 5 2018-01-01 9901-01-01 CA $443.97 004C8907 00 5 2018-01-01 9901-01-01 CA $348.42 001C8907 00 5 2018-01-01 9901-01-01 CA $348.42 004C8908 00 5 2018-01-01 9901-01-01 CA $542.14 001C8908 00 5 2018-01-01 9901-01-01 CA $542.14 004C8909 00 5 2018-01-01 9901-01-01 CA $443.97 001C8909 00 5 2018-01-01 9901-01-01 CA $443.97 004C8910 00 5 2018-01-01 9901-01-01 CA $348.42 001C8910 00 5 2018-01-01 9901-01-01 CA $348.42 004C8911 00 5 2018-01-01 9901-01-01 CA $542.14 001C8911 00 5 2018-01-01 9901-01-01 CA $542.14 004C8912 00 5 2018-01-01 9901-01-01 CA $443.97 001C8912 00 5 2018-01-01 9901-01-01 CA $443.97 004C8913 00 5 2018-01-01 9901-01-01 CA $348.42 001C8913 00 5 2018-01-01 9901-01-01 CA $348.42 004C8914 00 5 2018-01-01 9901-01-01 CA $542.14 001C8914 00 5 2018-01-01 9901-01-01 CA $542.14 004C8918 00 5 2018-01-01 9901-01-01 CA $443.97 001C8918 00 5 2018-01-01 9901-01-01 CA $443.97 004C8919 00 5 2018-01-01 9901-01-01 CA $348.42 001C8919 00 5 2018-01-01 9901-01-01 CA $348.42 004C8920 00 5 2018-01-01 9901-01-01 CA $542.14 001C8920 00 5 2018-01-01 9901-01-01 CA $542.14 004C8921 00 5 2018-01-01 9901-01-01 CA $507.01 001C8921 00 5 2018-01-01 9901-01-01 CA $507.01 004C8922 00 5 2018-01-01 9901-01-01 CA $507.01 001C8922 00 5 2018-01-01 9901-01-01 CA $507.01 004C8923 00 5 2018-01-01 9901-01-01 CA $507.01 001C8923 00 5 2018-01-01 9901-01-01 CA $507.01 004C8924 00 5 2018-01-01 9901-01-01 CA $507.01 001C8924 00 5 2018-01-01 9901-01-01 CA $507.01 004C8925 00 5 2018-01-01 9901-01-01 CA $507.01 001C8925 00 5 2018-01-01 9901-01-01 CA $507.01 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 35 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C8926 00 5 2018-01-01 9901-01-01 CA $507.01 001C8926 00 5 2018-01-01 9901-01-01 CA $507.01 004C8927 00 5 2018-01-01 9901-01-01 CA $507.01 001C8927 00 5 2018-01-01 9901-01-01 CA $507.01 004C8928 00 5 2018-01-01 9901-01-01 CA $507.01 001C8928 00 5 2018-01-01 9901-01-01 CA $507.01 004C8929 00 5 2018-01-01 9901-01-01 CA $507.01 001C8929 00 5 2018-01-01 9901-01-01 CA $507.01 004C8930 00 5 2018-01-01 9901-01-01 CA $507.01 001C8930 00 5 2018-01-01 9901-01-01 CA $507.01 004C8931 00 5 2018-01-01 9901-01-01 CA $588.89 001C8931 00 5 2018-01-01 9901-01-01 CA $588.89 004C8932 00 5 2018-01-01 9901-01-01 CA $588.89 001C8932 00 5 2018-01-01 9901-01-01 CA $588.89 004C8933 00 5 2018-01-01 9901-01-01 CA $588.89 001C8933 00 5 2018-01-01 9901-01-01 CA $588.89 004C8934 00 5 2018-01-01 9901-01-01 CA $579.91 001C8934 00 5 2018-01-01 9901-01-01 CA $579.91 004C8935 00 5 2018-01-01 9901-01-01 CA $579.91 001C8935 00 5 2018-01-01 9901-01-01 CA $579.91 004C8936 00 5 2018-01-01 9901-01-01 CA $579.91 001C8936 00 5 2018-01-01 9901-01-01 CA $579.91 004C8937 00 P 2019-11-23 9901-01-01 CA $923.00 001C8957 00 6 2018-01-01 9901-01-01 CA $209.15 001C8957 00 6 2018-01-01 9901-01-01 CA $209.15 004C9046 00 6 2020-02-29 9901-01-01 CA $4.18 001C9113 00 6 2018-01-01 9901-01-01 CA $216.00 001C9113 00 6 2018-01-01 9901-01-01 CA $216.00 004C9113 00 6 2017-03-01 2018-01-01 CA $216.00 001C9113 00 6 2017-03-01 2018-01-01 CA $216.00 004C9113 00 6 2016-04-01 2017-03-01 CA $216.00 001C9113 00 6 2016-04-01 2017-03-01 CA $216.00 004C9250 00 G 2018-01-01 9901-01-01 CA $3,461.00 001C9250 00 G 2018-01-01 9901-01-01 CA $3,461.00 004C9254 00 6 2018-01-01 9901-01-01 CA $121.53 001C9254 00 6 2018-01-01 9901-01-01 CA $121.53 004C9275 00 6 2018-01-01 9901-01-01 CA $636.00 001C9275 00 6 2018-01-01 9901-01-01 CA $636.00 004C9285 00 6 2018-01-01 9901-01-01 CA $152.91 001C9285 00 6 2018-01-01 9901-01-01 CA $67.20 004C9285 00 6 2017-03-01 2018-01-01 CA $152.91 001C9285 00 6 2017-03-01 2018-01-01 CA $67.20 004C9285 00 6 2016-04-01 2017-03-01 CA $152.91 001C9356 00 G 2018-01-01 9901-01-01 CA $26.94 001C9358 00 G 2018-01-01 9901-01-01 CA $11.64 001C9358 00 G 2018-01-01 9901-01-01 CA $11.64 004C9359 00 G 2018-01-01 9901-01-01 CA $1,306.00 001C9359 00 G 2018-01-01 9901-01-01 CA $1,306.00 004C9359 00 G 2017-03-01 2018-01-01 CA $1,306.00 001C9359 00 G 2017-03-01 2018-01-01 CA $1,306.00 004C9360 00 6 2018-01-01 9901-01-01 CA $12.02 001C9360 00 6 2018-01-01 9901-01-01 CA $12.02 004C9361 00 6 2018-01-01 9901-01-01 CA $273.48 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 36 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

C9361 00 6 2018-01-01 9901-01-01 CA $273.48 004C9362 00 6 2018-01-01 9901-01-01 CA $50.71 001C9362 00 6 2018-01-01 9901-01-01 CA $50.71 004C9363 00 6 2018-01-01 9901-01-01 CA $19.35 001C9363 00 6 2018-01-01 9901-01-01 CA $19.35 004C9364 00 6 2018-01-01 9901-01-01 CA $19.03 001C9364 00 6 2018-01-01 9901-01-01 CA $19.03 004C9447 00 6 2018-01-01 9901-01-01 CA $3,874.42 001C9447 00 6 2018-01-01 9901-01-01 CA $3,874.42 004C9447 00 6 2017-07-19 2018-01-01 CA $3,874.42 001C9447 00 6 2017-07-19 2018-01-01 CA $3,874.42 004C9472 00 6 2016-11-30 9901-01-01 CA $88.10 001C9472 00 6 2016-11-30 9901-01-01 CA $88.10 004C9484 26 P 2017-07-20 9901-01-01 CA $1,126.49 001C9484 26 P 2017-07-20 9901-01-01 CA $1,126.49 004C9485 26 P 2017-09-28 9901-01-01 CA $215.24 001C9485 26 P 2017-09-28 9901-01-01 CA $215.24 004C9600 00 6 2018-01-01 9901-01-01 CA $39,508.00 001C9600 00 6 2018-01-01 9901-01-01 CA $39,508.00 004C9600 00 6 2017-03-01 2018-01-01 CA $39,508.00 001C9600 00 6 2017-03-01 2018-01-01 CA $39,508.00 004C9600 00 6 2016-04-01 2017-03-01 CA $39,508.00 001C9600 00 6 2016-04-01 2017-03-01 CA $39,508.00 004C9601 00 6 2018-01-01 9901-01-01 CA $32,900.00 001C9601 00 6 2018-01-01 9901-01-01 CA $32,900.00 004C9601 00 6 2016-07-22 2018-01-01 CA $32,900.00 001C9601 00 6 2016-07-22 2018-01-01 CA $32,900.00 004C9606 00 6 2018-01-01 9901-01-01 CA $75,913.00 001C9606 00 6 2018-01-01 9901-01-01 CA $75,913.00 004C9606 00 6 2016-07-22 2018-01-01 CA $75,913.00 001C9606 00 6 2016-07-22 2018-01-01 CA $75,913.00 004C9725 00 2 2018-01-01 9901-01-01 CA $420.97 001C9725 00 2 2018-01-01 9901-01-01 CA $420.97 004C9726 00 2 2018-01-01 9901-01-01 CA $1,680.09 001C9727 00 2 2018-01-01 9901-01-01 CA $554.19 001C9727 00 2 2018-01-01 9901-01-01 CA $554.19 004C9728 00 2 2018-01-01 9901-01-01 CA $941.57 001C9728 00 2 2018-01-01 9901-01-01 CA $941.57 004C9734 26 P 2018-01-01 9901-01-01 CA $1,500.00 001C9734 26 P 2018-01-01 9901-01-01 CA $1,500.00 004C9734 26 P 2016-12-29 2018-01-01 CA $1,500.00 001C9734 26 P 2016-12-29 2018-01-01 CA $1,500.00 004C9740 00 6 2018-01-01 9901-01-01 CA $36,033.60 001C9740 00 6 2018-01-01 9901-01-01 CA $36,033.60 004C9740 00 6 2017-10-25 2018-01-01 CA $36,033.60 001C9740 00 6 2017-10-25 2018-01-01 CA $36,033.60 004C9745 00 0 2020-03-01 9901-01-01 CA $9,349.00 001C9745 00 0 2020-03-01 9901-01-01 CA $9,349.00 004C9745 00 0 2018-10-27 2020-03-01 CA $21,780.00 001C9749 00 6 2020-03-01 9901-01-01 CA $5,974.00 001C9749 00 6 2020-03-01 9901-01-01 CA $5,974.00 004C9749 00 6 2018-10-20 2020-03-01 CA $4,650.77 001C9803 00 P 2020-08-08 9901-01-01 CA $98.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 37 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D0120 00 7 2021-03-01 9901-01-01 CA $61.00 001D0120 00 7 2020-03-01 2021-03-01 CA $69.00 001D0120 00 7 2019-03-01 2020-03-01 CA $69.00 001D0120 00 7 2019-03-01 9901-01-01 CA $52.22 004D0120 00 7 2018-03-01 2019-03-01 CA $69.00 001D0120 00 7 2018-01-01 2018-03-01 CA $60.00 001D0120 00 7 2018-01-01 2019-03-01 CA $52.22 004D0120 00 7 2017-03-01 2018-01-01 CA $60.00 001D0120 00 7 2016-04-01 2017-03-01 CA $60.00 001D0140 00 7 2021-03-01 9901-01-01 CA $150.00 001D0140 00 7 2020-03-01 2021-03-01 CA $137.00 001D0140 00 7 2018-01-01 2020-03-01 CA $125.00 001D0140 00 7 2018-01-01 9901-01-01 CA $95.00 004D0140 00 7 2017-03-01 2018-01-01 CA $125.00 001D0140 00 7 2016-04-01 2017-03-01 CA $100.00 001D0145 00 7 2021-03-01 9901-01-01 CA $78.00 001D0145 00 7 2021-03-01 9901-01-01 CA $78.00 004D0145 00 7 2018-01-01 2021-03-01 CA $100.00 001D0145 00 7 2018-01-01 2021-03-01 CA $100.00 004D0150 00 7 2021-03-01 9901-01-01 CA $104.00 001D0150 00 7 2020-03-01 2021-03-01 CA $120.00 001D0150 00 7 2018-03-01 2020-03-01 CA $125.00 001D0150 00 7 2018-01-01 2018-03-01 CA $116.00 001D0150 00 7 2018-01-01 9901-01-01 CA $100.00 004D0150 00 7 2017-03-01 2018-01-01 CA $116.00 001D0150 00 7 2016-04-01 2017-03-01 CA $100.00 001D0150 00 7 2016-04-01 2018-01-01 CA $100.00 004D0160 00 7 2018-01-01 9901-01-01 CA $163.84 001D0171 00 7 2020-08-08 9901-01-01 CA $125.00 001D0210 00 7 2020-03-01 9901-01-01 CA $187.00 001D0210 00 7 2018-03-01 2020-03-01 CA $187.00 001D0210 00 7 2018-03-01 9901-01-01 CA $187.00 004D0210 00 7 2018-01-01 2018-03-01 CA $187.00 001D0210 00 7 2018-01-01 2018-03-01 CA $187.00 004D0220 00 7 2021-03-01 9901-01-01 CA $45.00 001D0220 00 7 2020-03-01 2021-03-01 CA $42.00 001D0220 00 7 2019-03-01 2020-03-01 CA $44.00 001D0220 00 7 2018-03-01 2019-03-01 CA $42.00 001D0220 00 7 2018-01-01 2018-03-01 CA $42.00 001D0220 00 7 2018-01-01 9901-01-01 CA $38.00 004D0220 00 7 2017-03-01 2018-01-01 CA $42.00 001D0220 00 7 2016-04-01 2017-03-01 CA $42.00 001D0230 00 7 2021-03-01 9901-01-01 CA $42.00 001D0230 00 7 2020-03-01 2021-03-01 CA $32.00 001D0230 00 7 2019-03-01 2020-03-01 CA $40.00 001D0230 00 7 2018-03-01 2019-03-01 CA $39.00 001D0230 00 7 2018-01-01 2018-03-01 CA $39.00 001D0230 00 7 2018-01-01 9901-01-01 CA $32.00 004D0230 00 7 2017-03-01 2018-01-01 CA $39.00 001D0230 00 7 2017-03-01 2018-01-01 CA $32.00 004D0230 00 7 2016-04-01 2017-03-01 CA $39.00 001D0230 00 7 2016-04-01 2017-03-01 CA $32.00 004D0251 00 7 2020-10-03 9901-01-01 CA $75.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 38 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D0270 00 7 2018-01-01 9901-01-01 CA $38.00 001D0270 00 7 2018-01-01 9901-01-01 CA $38.00 004D0270 00 7 2017-06-13 2018-01-01 CA $38.00 001D0270 00 7 2017-06-13 2018-01-01 CA $38.00 004D0272 00 7 2020-03-01 9901-01-01 CA $54.00 001D0272 00 7 2020-03-01 9901-01-01 CA $54.00 004D0272 00 7 2018-01-01 2020-03-01 CA $56.00 001D0272 00 7 2018-01-01 2020-03-01 CA $56.00 004D0274 00 7 2021-03-01 9901-01-01 CA $90.00 001D0274 00 7 2020-03-01 2021-03-01 CA $85.00 001D0274 00 7 2020-03-01 9901-01-01 CA $85.00 004D0274 00 7 2018-03-01 2020-03-01 CA $100.00 001D0274 00 7 2018-03-01 2020-03-01 CA $88.00 004D0274 00 7 2018-01-01 2018-03-01 CA $100.00 001D0274 00 7 2018-01-01 2018-03-01 CA $88.00 004D0274 00 7 2017-03-01 2018-01-01 CA $100.00 001D0274 00 7 2017-03-01 2018-01-01 CA $88.00 004D0274 00 7 2016-04-01 2017-03-01 CA $100.00 001D0321 00 7 2018-01-01 9901-01-01 CA $111.62 001D0321 00 7 2018-01-01 9901-01-01 CA $111.62 004D0330 00 7 2021-03-01 9901-01-01 CA $149.00 001D0330 00 7 2020-03-01 2021-03-01 CA $149.00 001D0330 00 7 2018-03-01 2020-03-01 CA $161.00 001D0330 00 7 2018-01-01 2018-03-01 CA $138.00 001D0330 00 7 2018-01-01 9901-01-01 CA $125.00 004D0330 00 7 2017-03-01 2018-01-01 CA $138.00 001D0330 00 7 2016-04-01 2017-03-01 CA $138.00 001D0340 00 7 2018-01-01 9901-01-01 CA $97.00 001D0340 00 7 2018-01-01 9901-01-01 CA $97.00 004D0350 00 7 2020-03-01 9901-01-01 CA $90.00 001D0350 00 7 2018-01-01 2020-03-01 CA $88.06 001D0350 00 7 2018-01-01 9901-01-01 CA $88.06 004D0367 00 7 2020-03-01 9901-01-01 CA $795.00 001D0367 00 7 2020-03-01 9901-01-01 CA $795.00 004D0367 00 7 2018-01-01 2020-03-01 CA $2,100.00 001D0367 00 7 2018-01-01 2020-03-01 CA $2,100.00 004D0382 00 7 2021-02-27 9901-01-01 CA $205.00 001D0470 00 7 2021-03-01 9901-01-01 CA $450.00 001D0470 00 7 2020-03-01 2021-03-01 CA $450.00 001D0470 00 7 2018-01-01 2020-03-01 CA $250.00 001D0470 00 7 2018-01-01 9901-01-01 CA $149.50 004D0470 00 7 2016-04-01 2018-01-01 CA $250.00 001D0474 00 7 2018-01-01 9901-01-01 CA $225.28 001D0474 00 7 2018-01-01 9901-01-01 CA $225.28 004D1110 00 7 2021-03-01 9901-01-01 CA $95.00 001D1110 00 7 2021-03-01 9901-01-01 CA $95.00 004D1110 00 7 2020-03-01 2021-03-01 CA $130.00 001D1110 00 7 2019-03-01 2020-03-01 CA $130.00 001D1110 00 7 2018-03-01 2019-03-01 CA $127.00 001D1110 00 7 2018-01-01 2018-03-01 CA $123.00 001D1110 00 7 2018-01-01 2021-03-01 CA $118.00 004D1110 00 7 2017-03-01 2018-01-01 CA $123.00 001D1110 00 7 2017-03-01 2018-01-01 CA $118.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 39 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D1110 00 7 2016-04-01 2017-03-01 CA $123.00 001D1120 00 7 2021-03-01 9901-01-01 CA $75.00 001D1120 00 7 2021-03-01 9901-01-01 CA $75.00 004D1120 00 7 2020-03-01 2021-03-01 CA $89.00 001D1120 00 7 2018-03-01 2020-03-01 CA $90.00 001D1120 00 7 2018-01-01 2018-03-01 CA $90.00 001D1120 00 7 2018-01-01 2021-03-01 CA $78.00 004D1120 00 7 2016-04-01 2018-01-01 CA $90.00 001D1206 00 7 2021-03-01 9901-01-01 CA $45.00 001D1206 00 7 2021-03-01 9901-01-01 CA $45.00 004D1206 00 7 2020-03-01 2021-03-01 CA $60.00 001D1206 00 7 2020-03-01 2021-03-01 CA $60.00 004D1206 00 7 2019-03-01 2020-03-01 CA $70.00 001D1206 00 7 2019-03-01 2020-03-01 CA $70.00 004D1206 00 7 2018-03-01 2019-03-01 CA $70.00 001D1206 00 7 2018-03-01 2019-03-01 CA $70.00 004D1206 00 7 2018-01-01 2018-03-01 CA $70.00 001D1206 00 7 2018-01-01 2018-03-01 CA $70.00 004D1206 00 7 2017-03-01 2018-01-01 CA $70.00 001D1206 00 7 2017-03-01 2018-01-01 CA $70.00 004D1206 00 7 2016-04-01 2017-03-01 CA $70.00 001D1206 00 7 2016-04-01 2017-03-01 CA $70.00 004D1208 00 7 2021-03-01 9901-01-01 CA $42.00 001D1208 00 7 2020-03-01 2021-03-01 CA $60.00 001D1208 00 7 2018-03-01 2020-03-01 CA $40.00 001D1208 00 7 2018-03-01 9901-01-01 CA $40.00 004D1208 00 7 2018-01-01 2018-03-01 CA $40.00 001D1208 00 7 2018-01-01 2018-03-01 CA $40.00 004D1208 00 7 2016-04-01 2018-01-01 CA $40.00 001D1330 00 7 2018-01-01 9901-01-01 CA $75.00 001D1330 00 7 2018-01-01 9901-01-01 CA $75.00 004D1351 00 7 2021-03-01 9901-01-01 CA $75.00 001D1351 00 7 2020-03-01 2021-03-01 CA $67.00 001D1351 00 7 2020-03-01 9901-01-01 CA $67.00 004D1351 00 7 2018-03-01 2020-03-01 CA $555.00 001D1351 00 7 2018-03-01 2020-03-01 CA $555.00 004D1351 00 7 2018-01-01 2018-03-01 CA $555.00 001D1351 00 7 2018-01-01 2018-03-01 CA $555.00 004D2150 00 7 2018-01-01 9901-01-01 CA $5,000.00 001D2150 00 7 2018-01-01 9901-01-01 CA $5,000.00 004D2330 00 7 2018-01-01 9901-01-01 CA $205.00 001D2330 00 7 2018-01-01 9901-01-01 CA $205.00 004D2331 00 7 2018-01-01 9901-01-01 CA $555.00 001D2331 00 7 2018-01-01 9901-01-01 CA $555.00 004D2332 00 7 2018-03-01 9901-01-01 CA $555.00 001D2332 00 7 2018-03-01 9901-01-01 CA $555.00 004D2332 00 7 2018-01-01 2018-03-01 CA $555.00 001D2332 00 7 2018-01-01 2018-03-01 CA $555.00 004D2332 00 7 2016-11-30 2018-01-01 CA $555.00 001D2332 00 7 2016-11-30 2018-01-01 CA $555.00 004D2391 00 7 2021-03-01 9901-01-01 CA $200.00 001D2391 00 7 2020-03-01 2021-03-01 CA $185.00 001D2391 00 7 2020-03-01 9901-01-01 CA $185.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 40 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D2391 00 7 2019-03-01 2020-03-01 CA $300.00 001D2391 00 7 2018-03-01 2019-03-01 CA $300.00 001D2391 00 7 2018-01-01 2018-03-01 CA $300.00 001D2391 00 7 2018-01-01 2020-03-01 CA $205.00 004D2391 00 7 2017-03-01 2018-01-01 CA $300.00 001D2391 00 7 2016-04-01 2017-03-01 CA $208.00 001D2392 00 7 2021-03-01 9901-01-01 CA $262.00 001D2392 00 7 2020-03-01 2021-03-01 CA $285.00 001D2392 00 7 2018-03-01 2020-03-01 CA $300.00 001D2392 00 7 2018-01-01 2018-03-01 CA $300.00 001D2392 00 7 2018-01-01 9901-01-01 CA $239.00 004D2392 00 7 2017-03-01 2018-01-01 CA $300.00 001D2392 00 7 2016-04-01 2017-03-01 CA $270.00 001D2393 00 7 2020-03-01 9901-01-01 CA $132.86 001D2393 00 7 2020-03-01 9901-01-01 CA $132.86 004D2393 00 7 2018-01-01 2020-03-01 CA $345.00 001D2393 00 7 2018-01-01 2020-03-01 CA $345.00 004D2740 00 7 2018-01-01 9901-01-01 CA $1,300.00 001D2740 00 7 2018-01-01 9901-01-01 CA $1,300.00 004D2740 00 7 2017-02-23 2018-01-01 CA $1,300.00 001D2740 00 7 2017-02-23 2018-01-01 CA $1,300.00 004D2750 00 7 2018-01-01 9901-01-01 CA $1,024.12 001D2751 00 7 2018-01-01 9901-01-01 CA $907.29 001D2751 00 7 2018-01-01 9901-01-01 CA $907.29 004D2930 00 7 2020-03-01 9901-01-01 CA $300.00 001D2930 00 7 2018-01-01 2020-03-01 CA $555.00 001D2930 00 7 2018-01-01 9901-01-01 CA $158.56 004D2930 00 7 2017-03-01 2018-01-01 CA $555.00 001D2930 00 7 2016-04-01 2017-03-01 CA $555.00 001D2932 00 7 2018-01-01 9901-01-01 CA $146.00 001D2932 00 7 2018-01-01 9901-01-01 CA $146.00 004D2932 00 7 2016-04-01 2018-01-01 CA $146.00 001D2932 00 7 2016-04-01 2018-01-01 CA $146.00 004D2954 00 7 2018-01-01 9901-01-01 CA $420.00 001D2954 00 7 2018-01-01 9901-01-01 CA $420.00 004D2954 00 7 2016-07-15 2018-01-01 CA $420.00 001D2954 00 7 2016-07-15 2018-01-01 CA $420.00 004D2971 00 7 2018-01-01 9901-01-01 CA $86.36 001D2971 00 7 2018-01-01 9901-01-01 CA $86.36 004D3120 00 7 2018-01-01 9901-01-01 CA $600.00 001D3120 00 7 2018-01-01 9901-01-01 CA $600.00 004D3220 00 7 2020-03-01 9901-01-01 CA $107.75 001D3220 00 7 2020-03-01 9901-01-01 CA $107.75 004D3220 00 7 2018-01-01 2020-03-01 CA $3,695.00 001D3220 00 7 2018-01-01 2020-03-01 CA $3,695.00 004D3220 00 7 2017-03-01 2018-01-01 CA $3,695.00 001D3220 00 7 2017-03-01 2018-01-01 CA $3,695.00 004D3310 00 7 2018-01-01 9901-01-01 CA $1,050.00 001D3310 00 7 2018-01-01 9901-01-01 CA $1,050.00 004D3310 00 7 2017-05-03 2018-01-01 CA $1,050.00 001D3310 00 7 2017-05-03 2018-01-01 CA $1,050.00 004D3330 00 7 2018-01-01 9901-01-01 CA $1,100.00 001D3330 00 7 2018-01-01 9901-01-01 CA $1,100.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 41 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D3330 00 7 2016-12-08 2018-01-01 CA $1,100.00 001D3330 00 7 2016-12-08 2018-01-01 CA $1,100.00 004D4263 00 7 2018-01-01 9901-01-01 CA $2,730.00 001D4263 00 7 2018-01-01 9901-01-01 CA $2,730.00 004D4263 00 7 2017-08-04 2018-01-01 CA $2,730.00 001D4263 00 7 2017-08-04 2018-01-01 CA $2,730.00 004D4266 00 7 2018-03-01 9901-01-01 CA $700.00 001D4266 00 7 2018-03-01 9901-01-01 CA $700.00 004D4266 00 7 2018-01-01 2018-03-01 CA $700.00 001D4266 00 7 2018-01-01 2018-03-01 CA $700.00 004D4266 00 7 2017-11-07 2018-01-01 CA $700.00 001D4266 00 7 2017-11-07 2018-01-01 CA $700.00 004D4273 00 7 2020-10-03 9901-01-01 CA $1,200.00 001D4341 00 7 2021-03-01 9901-01-01 CA $263.00 001D4341 00 7 2021-03-01 9901-01-01 CA $263.00 004D4341 00 7 2018-01-01 2021-03-01 CA $280.00 001D4341 00 7 2018-01-01 2021-03-01 CA $280.00 004D4910 00 7 2018-01-01 9901-01-01 CA $180.00 001D4910 00 7 2018-01-01 9901-01-01 CA $180.00 004D6010 00 7 2018-01-01 9901-01-01 CA $1,996.80 001D6056 00 7 2018-01-01 9901-01-01 CA $631.95 001D6056 00 7 2018-01-01 9901-01-01 CA $631.95 004D6076 00 7 2018-01-01 9901-01-01 CA $1,177.60 001D6076 00 7 2018-01-01 9901-01-01 CA $1,177.60 004D7140 00 7 2020-03-01 9901-01-01 CA $231.00 001D7140 00 7 2018-03-01 2020-03-01 CA $473.00 001D7140 00 7 2018-01-01 2018-03-01 CA $473.00 001D7140 00 7 2018-01-01 9901-01-01 CA $145.00 004D7140 00 7 2017-03-01 2018-01-01 CA $473.00 001D7140 00 7 2016-04-01 2017-03-01 CA $436.00 001D7210 00 7 2021-03-01 9901-01-01 CA $406.00 001D7210 00 7 2020-03-01 2021-03-01 CA $409.00 001D7210 00 7 2018-03-01 2020-03-01 CA $415.00 001D7210 00 7 2018-01-01 2018-03-01 CA $415.00 001D7210 00 7 2018-01-01 9901-01-01 CA $312.32 004D7210 00 7 2017-03-01 2018-01-01 CA $415.00 001D7210 00 7 2016-04-01 2017-03-01 CA $415.00 001D7220 00 7 2021-03-01 9901-01-01 CA $440.00 001D7220 00 7 2018-03-01 2021-03-01 CA $462.00 001D7220 00 7 2018-01-01 2018-03-01 CA $380.00 001D7220 00 7 2018-01-01 9901-01-01 CA $380.00 004D7230 00 7 2021-03-01 9901-01-01 CA $535.00 001D7230 00 7 2020-03-01 2021-03-01 CA $440.00 001D7230 00 7 2020-03-01 9901-01-01 CA $440.00 004D7230 00 7 2019-03-01 2020-03-01 CA $650.00 001D7230 00 7 2018-03-01 2019-03-01 CA $525.00 001D7230 00 7 2018-03-01 2020-03-01 CA $476.00 004D7230 00 7 2018-01-01 2018-03-01 CA $525.00 001D7230 00 7 2018-01-01 2018-03-01 CA $476.00 004D7230 00 7 2017-03-01 2018-01-01 CA $525.00 001D7230 00 7 2017-03-01 2018-01-01 CA $476.00 004D7230 00 7 2016-04-01 2017-03-01 CA $525.00 001D7240 00 7 2021-03-01 9901-01-01 CA $590.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 42 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D7240 00 7 2020-03-01 2021-03-01 CA $582.00 001D7240 00 7 2019-03-01 2020-03-01 CA $625.00 001D7240 00 7 2018-03-01 2019-03-01 CA $625.00 001D7240 00 7 2018-01-01 2018-03-01 CA $625.00 001D7240 00 7 2018-01-01 9901-01-01 CA $433.83 004D7240 00 7 2017-03-01 2018-01-01 CA $625.00 001D7240 00 7 2016-04-01 2017-03-01 CA $530.00 001D7286 00 7 2018-01-01 9901-01-01 CA $850.00 001D7286 00 7 2018-01-01 9901-01-01 CA $850.00 004D7871 00 7 2018-01-01 9901-01-01 CA $2,500.00 001D7871 00 7 2018-01-01 9901-01-01 CA $2,500.00 004D7871 00 7 2017-05-17 2018-01-01 CA $2,500.00 001D7871 00 7 2017-05-17 2018-01-01 CA $2,500.00 004D7880 00 7 2021-03-01 9901-01-01 CA $4,125.00 001D7880 00 7 2020-03-01 2021-03-01 CA $4,000.00 001D7880 00 7 2019-03-01 2020-03-01 CA $4,125.00 001D7880 00 7 2018-03-01 2019-03-01 CA $4,125.00 001D7880 00 7 2018-01-01 2018-03-01 CA $4,125.00 001D7880 00 7 2018-01-01 9901-01-01 CA $1,650.00 004D7880 00 7 2017-03-01 2018-01-01 CA $4,125.00 001D7880 00 7 2016-04-01 2017-03-01 CA $4,125.00 001D7953 00 7 2018-01-01 9901-01-01 CA $109.73 001D7960 00 7 2020-03-01 9901-01-01 CA $700.00 001D7960 00 7 2018-03-01 2020-03-01 CA $412.00 001D7960 00 7 2018-03-01 9901-01-01 CA $412.00 004D7960 00 7 2018-01-01 2018-03-01 CA $412.00 001D7960 00 7 2018-01-01 2018-03-01 CA $412.00 004D7960 00 7 2016-04-22 2018-01-01 CA $412.00 001D7960 00 7 2016-04-22 2018-01-01 CA $412.00 004D8060 00 7 2018-01-01 9901-01-01 CA $2,567.85 001D8070 00 7 2021-03-01 9901-01-01 CA $880.00 001D8070 00 7 2020-03-01 2021-03-01 CA $880.00 001D8070 00 7 2018-01-01 2020-03-01 CA $292.50 001D8070 00 7 2018-01-01 9901-01-01 CA $292.50 004D8070 00 7 2016-04-01 2018-01-01 CA $292.50 001D8080 00 7 2021-03-01 9901-01-01 CA $970.00 001D8080 00 7 2020-03-01 2021-03-01 CA $970.00 001D8080 00 7 2020-03-01 9901-01-01 CA $970.00 004D8080 00 7 2019-03-01 2020-03-01 CA $6,000.00 001D8080 00 7 2019-03-01 2020-03-01 CA $6,000.00 004D8080 00 7 2018-03-01 2019-03-01 CA $6,000.00 001D8080 00 7 2018-03-01 2019-03-01 CA $6,000.00 004D8080 00 7 2018-01-01 2018-03-01 CA $6,000.00 001D8080 00 7 2018-01-01 2018-03-01 CA $6,000.00 004D8080 00 7 2016-04-01 2018-01-01 CA $6,000.00 001D8080 00 7 2016-04-01 2018-01-01 CA $6,000.00 004D8090 00 7 2021-03-01 9901-01-01 CA $400.00 001D8090 00 7 2021-03-01 9901-01-01 CA $400.00 004D8090 00 7 2020-03-01 2021-03-01 CA $880.00 001D8090 00 7 2020-03-01 2021-03-01 CA $880.00 004D8090 00 7 2018-01-01 2020-03-01 CA $1,778.00 001D8670 00 7 2020-03-01 9901-01-01 CA $350.00 001D8670 00 7 2018-01-01 2020-03-01 CA $204.80 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 43 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D8670 00 7 2018-01-01 9901-01-01 CA $204.80 004D8690 00 7 2018-01-01 9901-01-01 CA $275.00 001D8690 00 7 2018-01-01 9901-01-01 CA $275.00 004D9110 00 7 2018-01-01 9901-01-01 CA $178.00 001D9110 00 7 2018-01-01 9901-01-01 CA $178.00 004D9110 00 7 2016-12-09 2018-01-01 CA $178.00 001D9110 00 7 2016-12-09 2018-01-01 CA $178.00 004D9222 00 7 2021-03-01 9901-01-01 CA $433.00 001D9222 00 7 2020-03-01 2021-03-01 CA $300.00 001D9222 00 7 2019-03-01 2020-03-01 CA $265.00 001D9222 00 7 2019-03-01 9901-01-01 CA $258.00 004D9222 00 7 2018-07-28 2019-03-01 CA $265.00 001D9223 00 7 2021-03-01 9901-01-01 CA $308.00 001D9223 00 7 2020-03-01 2021-03-01 CA $308.00 001D9223 00 7 2019-03-01 2020-03-01 CA $275.00 001D9223 00 7 2019-03-01 9901-01-01 CA $275.00 004D9223 00 7 2018-03-01 2019-03-01 CA $275.00 001D9223 00 7 2018-03-01 2019-03-01 CA $275.00 004D9223 00 7 2018-01-01 2018-03-01 CA $275.00 001D9223 00 7 2018-01-01 2018-03-01 CA $275.00 004D9223 00 7 2017-03-01 2018-01-01 CA $275.00 001D9223 00 7 2017-03-01 2018-01-01 CA $275.00 004D9223 00 7 2016-01-22 2017-03-01 CA $275.00 001D9223 00 7 2016-01-22 2017-03-01 CA $275.00 004D9230 00 7 2018-01-01 9901-01-01 CA $450.00 001D9230 00 7 2018-01-01 9901-01-01 CA $450.00 004D9248 00 7 2018-01-01 9901-01-01 CA $275.00 001D9248 00 7 2018-01-01 9901-01-01 CA $275.00 004D9310 00 7 2021-03-01 9901-01-01 CA $258.00 001D9310 00 7 2020-03-01 2021-03-01 CA $235.00 001D9310 00 7 2019-03-01 2020-03-01 CA $220.00 001D9310 00 7 2018-03-01 2019-03-01 CA $220.00 001D9310 00 7 2018-01-01 2018-03-01 CA $220.00 001D9310 00 7 2018-01-01 9901-01-01 CA $181.26 004D9310 00 7 2016-04-01 2018-01-01 CA $220.00 001D9430 00 7 2018-01-01 9901-01-01 CA $89.00 001D9430 00 7 2018-01-01 9901-01-01 CA $89.00 004D9610 00 7 2021-03-01 9901-01-01 CA $75.00 001D9610 00 7 2020-03-01 2021-03-01 CA $80.00 001D9610 00 7 2018-03-01 2020-03-01 CA $265.00 001D9610 00 7 2018-01-01 2018-03-01 CA $265.00 001D9610 00 7 2018-01-01 9901-01-01 CA $75.00 004D9610 00 7 2017-03-01 2018-01-01 CA $265.00 001D9610 00 7 2016-05-06 2017-03-01 CA $75.00 001D9610 00 7 2016-05-06 2018-01-01 CA $75.00 004D9612 00 7 2020-03-01 9901-01-01 CA $279.00 001D9612 00 7 2018-03-01 2020-03-01 CA $194.00 001D9612 00 7 2018-01-01 2018-03-01 CA $90.00 001D9612 00 7 2018-01-01 9901-01-01 CA $90.00 004D9612 00 7 2016-04-01 2018-01-01 CA $90.00 001D9910 00 7 2018-01-01 9901-01-01 CA $45.00 001D9910 00 7 2018-01-01 9901-01-01 CA $45.00 004D9910 00 7 2016-11-30 2018-01-01 CA $45.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 44 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

D9910 00 7 2016-11-30 2018-01-01 CA $45.00 004D9930 00 7 2018-01-01 9901-01-01 CA $100.70 001D9940 00 7 2018-01-01 2019-01-01 CA $735.00 001D9944 00 7 2021-03-01 9901-01-01 CA $650.00 001D9944 00 7 2020-03-01 2021-03-01 CA $570.00 001D9944 00 7 2020-03-01 9901-01-01 CA $570.00 004D9944 00 7 2019-09-14 2020-03-01 CA $570.00 001D9952 00 7 2018-01-01 9901-01-01 CA $38.91 001D9952 00 7 2018-01-01 9901-01-01 CA $38.91 004D9971 00 7 2018-01-01 9901-01-01 CA $81.92 001E0118 NU G 2021-03-01 9901-01-01 CA $1,100.00 001E0118 NU G 2021-03-01 9901-01-01 CA $1,100.00 004E0118 NU G 2020-03-01 2021-03-01 CA $1,500.00 001E0118 NU G 2020-03-01 2021-03-01 CA $1,500.00 004E0118 NU G 2019-03-01 2020-03-01 CA $1,995.00 001E0118 NU G 2019-03-01 2020-03-01 CA $1,995.00 004E0118 NU G 2018-01-01 2019-03-01 CA $1,260.00 001E0118 NU G 2018-01-01 2019-03-01 CA $1,260.00 004E0118 RR H 2021-03-01 9901-01-01 CA $350.00 001E0118 RR H 2021-03-01 9901-01-01 CA $350.00 004E0118 RR H 2020-03-01 2021-03-01 CA $350.00 001E0118 RR H 2020-03-01 2021-03-01 CA $350.00 004E0118 RR H 2019-03-01 2020-03-01 CA $350.00 001E0118 RR H 2019-03-01 2020-03-01 CA $350.00 004E0118 RR H 2018-03-01 2019-03-01 CA $350.00 001E0118 RR H 2018-03-01 2019-03-01 CA $350.00 004E0118 RR H 2018-01-01 2018-03-01 CA $300.00 001E0118 RR H 2018-01-01 2018-03-01 CA $300.00 004E0118 RR H 2017-03-01 2018-01-01 CA $300.00 001E0118 RR H 2017-03-01 2018-01-01 CA $300.00 004E0118 RR H 2016-04-01 2017-03-01 CA $300.00 001E0118 RR H 2016-04-01 2017-03-01 CA $300.00 004E0118 00 G 2021-03-01 9901-01-01 CA $2,200.00 001E0118 00 G 2021-03-01 9901-01-01 CA $2,200.00 004E0118 00 G 2020-03-01 2021-03-01 CA $300.00 001E0118 00 G 2020-03-01 2021-03-01 CA $300.00 004E0118 00 G 2018-03-01 2020-03-01 CA $1,260.00 001E0118 00 G 2018-03-01 2020-03-01 CA $1,260.00 004E0118 00 G 2018-01-01 2018-03-01 CA $1,260.00 001E0118 00 G 2018-01-01 2018-03-01 CA $1,260.00 004E0118 00 G 2017-03-01 2018-01-01 CA $1,260.00 001E0118 00 G 2017-03-01 2018-01-01 CA $1,260.00 004E0118 00 G 2016-04-01 2017-03-01 CA $1,260.00 001E0118 00 G 2016-04-01 2017-03-01 CA $1,260.00 004E0190 00 G 2020-03-01 9901-01-01 CA $26.00 001E0190 00 G 2020-03-01 9901-01-01 CA $26.00 004E0190 00 G 2018-03-01 2020-03-01 CA $300.00 001E0190 00 G 2018-03-01 2020-03-01 CA $300.00 004E0190 00 G 2018-01-01 2018-03-01 CA $300.00 001E0190 00 G 2018-01-01 2018-03-01 CA $300.00 004E0190 00 G 2017-03-01 2018-01-01 CA $300.00 001E0190 00 G 2017-03-01 2018-01-01 CA $300.00 004E0190 00 G 2016-04-01 2017-03-01 CA $300.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 45 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

E0190 00 G 2016-04-01 2017-03-01 CA $300.00 004E0218 RR G 2018-01-01 9901-01-01 CA $67.11 001E0218 RR G 2018-01-01 9901-01-01 CA $67.11 004E0218 00 G 2018-03-01 9901-01-01 CA $1,974.00 001E0218 00 G 2018-03-01 9901-01-01 CA $1,974.00 004E0218 00 G 2018-01-01 2018-03-01 CA $1,974.00 001E0218 00 G 2018-01-01 2018-03-01 CA $1,974.00 004E0240 RR H 2018-01-01 9901-01-01 CA $13.82 001E0240 RR H 2018-01-01 9901-01-01 CA $13.82 004E0240 00 G 2018-01-01 9901-01-01 CA $670.67 001E0240 00 G 2018-01-01 9901-01-01 CA $670.67 004E0241 00 G 2018-01-01 9901-01-01 CA $85.00 001E0241 00 G 2018-01-01 9901-01-01 CA $85.00 004E0241 00 G 2016-11-30 2018-01-01 CA $85.00 001E0241 00 G 2016-11-30 2018-01-01 CA $85.00 004E0244 00 G 2018-01-01 9901-01-01 CA $113.00 001E0244 00 G 2018-01-01 9901-01-01 CA $113.00 004E0245 RR H 2018-01-01 9901-01-01 CA $2.37 001E0245 RR H 2018-01-01 9901-01-01 CA $2.37 004E0245 00 G 2018-01-01 9901-01-01 CA $94.33 001E0245 00 G 2018-01-01 9901-01-01 CA $94.33 004E0247 RR H 2018-01-01 9901-01-01 CA $14.61 001E0247 RR H 2018-01-01 9901-01-01 CA $14.61 004E0247 00 G 2018-01-01 9901-01-01 CA $255.05 001E0247 00 G 2018-01-01 9901-01-01 CA $255.05 004E0248 NU G 2020-08-22 9901-01-01 CA $339.00 001E0248 NU G 2020-08-22 9901-01-01 CA $339.00 004E0274 RR H 2018-01-01 9901-01-01 CA $121.92 001E0274 RR H 2018-01-01 9901-01-01 CA $121.92 004E0274 00 G 2018-01-01 9901-01-01 CA $1,584.96 001E0274 00 G 2018-01-01 9901-01-01 CA $1,584.96 004E0315 00 G 2018-03-01 9901-01-01 CA $556.90 001E0315 00 G 2018-03-01 9901-01-01 CA $556.90 004E0315 00 G 2018-01-01 2018-03-01 CA $556.90 001E0315 00 G 2018-01-01 2018-03-01 CA $556.90 004E0315 00 G 2017-10-17 2018-01-01 CA $556.90 001E0315 00 G 2017-10-17 2018-01-01 CA $556.90 004E0328 RR H 2018-01-01 9901-01-01 CA $8,528.00 001E0328 RR H 2018-01-01 9901-01-01 CA $8,528.00 004E0329 RR H 2018-01-01 9901-01-01 CA $238.10 001E0329 RR H 2018-01-01 9901-01-01 CA $238.10 004E0352 00 G 2018-01-01 9901-01-01 CA $85.67 001E0352 00 G 2018-01-01 9901-01-01 CA $85.67 004E0445 RR H 2021-03-01 9901-01-01 CA $1,282.31 001E0445 RR H 2021-03-01 9901-01-01 CA $1,282.31 004E0445 RR H 2020-03-01 2021-03-01 CA $1,282.31 001E0445 RR H 2020-03-01 2021-03-01 CA $1,282.31 004E0445 RR H 2019-03-01 2020-03-01 CA $1,282.31 001E0445 RR H 2019-03-01 2020-03-01 CA $1,282.31 004E0445 RR H 2018-03-01 2019-03-01 CA $1,282.31 001E0445 RR H 2018-03-01 2019-03-01 CA $1,282.31 004E0445 RR H 2018-01-01 2018-03-01 CA $1,282.31 001E0445 RR H 2018-01-01 2018-03-01 CA $1,282.31 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 46 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

E0445 RR H 2017-03-01 2018-01-01 CA $1,282.31 001E0445 RR H 2017-03-01 2018-01-01 CA $1,282.31 004E0445 RR H 2016-04-01 2017-03-01 CA $1,282.31 001E0445 RR H 2016-04-01 2017-03-01 CA $1,282.31 004E0445 00 G 2018-03-01 9901-01-01 CA $384.00 001E0445 00 G 2018-03-01 9901-01-01 CA $384.00 004E0445 00 G 2018-01-01 2018-03-01 CA $384.00 001E0445 00 G 2018-01-01 2018-03-01 CA $384.00 004E0445 00 G 2017-03-01 2018-01-01 CA $384.00 001E0445 00 G 2017-03-01 2018-01-01 CA $384.00 004E0445 00 G 2016-04-01 2017-03-01 CA $384.00 001E0445 00 G 2016-04-01 2017-03-01 CA $384.00 004E0481 00 H 2018-01-01 9901-01-01 CA $750.00 001E0481 00 H 2018-01-01 9901-01-01 CA $750.00 004E0485 00 G 2018-01-01 9901-01-01 CA $3,888.00 001E0485 00 G 2018-01-01 9901-01-01 CA $3,888.00 004E0485 00 G 2016-04-01 2018-01-01 CA $3,888.00 001E0485 00 G 2016-04-01 2018-01-01 CA $3,888.00 004E0486 RR H 2018-01-01 9901-01-01 CA $222.74 001E0486 RR H 2018-01-01 9901-01-01 CA $222.74 004E0486 00 G 2020-03-01 9901-01-01 CA $9,785.00 001E0486 00 G 2020-03-01 9901-01-01 CA $9,785.00 004E0486 00 G 2018-03-01 2020-03-01 CA $6,500.00 001E0486 00 G 2018-03-01 2020-03-01 CA $6,500.00 004E0486 00 G 2018-01-01 2018-03-01 CA $6,500.00 001E0486 00 G 2018-01-01 2018-03-01 CA $6,500.00 004E0486 00 G 2017-03-01 2018-01-01 CA $6,500.00 001E0486 00 G 2017-03-01 2018-01-01 CA $6,500.00 004E0486 00 G 2016-04-01 2017-03-01 CA $6,500.00 001E0486 00 G 2016-04-01 2017-03-01 CA $6,500.00 004E0487 00 G 2018-01-01 9901-01-01 CA $60.00 001E0487 00 G 2018-01-01 9901-01-01 CA $60.00 004E0619 RR H 2021-03-01 9901-01-01 CA $853.78 001E0619 RR H 2021-03-01 9901-01-01 CA $853.78 004E0619 RR H 2019-03-01 2021-03-01 CA $776.16 001E0619 RR H 2019-03-01 2021-03-01 CA $776.16 004E0619 RR H 2018-03-01 2019-03-01 CA $776.16 001E0619 RR H 2018-03-01 2019-03-01 CA $776.16 004E0619 RR H 2018-01-01 2018-03-01 CA $776.16 001E0619 RR H 2018-01-01 2018-03-01 CA $776.16 004E0619 RR H 2017-03-01 2018-01-01 CA $776.16 001E0619 RR H 2017-03-01 2018-01-01 CA $776.16 004E0619 RR H 2016-04-01 2017-03-01 CA $776.16 001E0619 RR H 2016-04-01 2017-03-01 CA $776.16 004E0619 00 G 2018-01-01 9901-01-01 CA $9,009.00 001E0619 00 G 2018-01-01 9901-01-01 CA $9,009.00 004E0637 00 G 2018-01-01 9901-01-01 CA $10,590.69 001E0637 00 G 2018-01-01 9901-01-01 CA $10,590.69 004E0637 00 G 2017-10-17 2018-01-01 CA $10,590.69 001E0637 00 G 2017-10-17 2018-01-01 CA $10,590.69 004E0641 RR H 2018-01-01 9901-01-01 CA $355.95 001E0641 RR H 2018-01-01 9901-01-01 CA $355.95 004E0641 00 G 2018-01-01 9901-01-01 CA $5,110.70 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 47 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

E0641 00 G 2018-01-01 9901-01-01 CA $5,110.70 004E0700 00 G 2021-03-01 9901-01-01 CA $40.00 001E0700 00 G 2021-03-01 9901-01-01 CA $40.00 004E0700 00 G 2020-05-30 2021-03-01 CA $40.00 001E0700 00 G 2020-05-30 2021-03-01 CA $40.00 004E0746 00 G 2018-01-01 9901-01-01 CA $100.00 001E0746 00 G 2018-01-01 9901-01-01 CA $100.00 004E0746 00 G 2017-06-27 2018-01-01 CA $100.00 001E0746 00 G 2017-06-27 2018-01-01 CA $100.00 004E0770 RR H 2019-03-01 9901-01-01 CA $476.92 001E0770 RR H 2019-03-01 9901-01-01 CA $476.92 004E0770 RR H 2018-03-01 2019-03-01 CA $476.92 001E0770 RR H 2018-03-01 2019-03-01 CA $476.92 004E0770 RR H 2018-01-01 2018-03-01 CA $476.92 001E0770 RR H 2018-01-01 2018-03-01 CA $476.92 004E0770 00 G 2018-03-01 9901-01-01 CA $6,200.00 001E0770 00 G 2018-03-01 9901-01-01 CA $6,200.00 004E0770 00 G 2018-01-01 2018-03-01 CA $6,200.00 001E0770 00 G 2018-01-01 2018-03-01 CA $6,200.00 004E0830 00 G 2018-01-01 9901-01-01 CA $945.00 001E0830 00 G 2018-01-01 9901-01-01 CA $945.00 004E0936 RR H 2020-03-01 9901-01-01 CA $35.00 001E0936 RR H 2020-03-01 9901-01-01 CA $35.00 004E0936 RR H 2019-03-01 2020-03-01 CA $85.00 001E0936 RR H 2019-03-01 2020-03-01 CA $85.00 004E0936 RR H 2018-03-01 2019-03-01 CA $85.00 001E0936 RR H 2018-03-01 2019-03-01 CA $85.00 004E0936 RR H 2018-01-01 2018-03-01 CA $85.00 001E0936 RR H 2018-01-01 2018-03-01 CA $85.00 004E0936 RR H 2017-03-01 2018-01-01 CA $85.00 001E0936 RR H 2017-03-01 2018-01-01 CA $85.00 004E0936 RR H 2016-04-01 2017-03-01 CA $85.00 001E0936 RR H 2016-04-01 2017-03-01 CA $85.00 004E0936 00 G 2018-01-01 9901-01-01 CA $1,105.00 001E0936 00 G 2018-01-01 9901-01-01 CA $1,105.00 004E1130 RR H 2018-01-01 9901-01-01 CA $93.80 001E1130 RR H 2018-01-01 9901-01-01 CA $93.80 004E1130 00 G 2018-01-01 9901-01-01 CA $1,219.40 001E1130 00 G 2018-01-01 9901-01-01 CA $1,219.40 004E1140 RR H 2018-03-01 9901-01-01 CA $196.80 001E1140 RR H 2018-03-01 9901-01-01 CA $196.80 004E1140 RR H 2018-01-01 2018-03-01 CA $196.80 001E1140 RR H 2018-01-01 2018-03-01 CA $196.80 004E1140 RR H 2016-04-01 2018-01-01 CA $196.80 001E1140 RR H 2016-04-01 2018-01-01 CA $196.80 004E1140 00 G 2018-01-01 9901-01-01 CA $2,060.50 001E1140 00 G 2018-01-01 9901-01-01 CA $2,060.50 004E1229 RR H 2018-01-01 9901-01-01 CA $225.56 001E1229 RR H 2018-01-01 9901-01-01 CA $225.56 004E1250 RR H 2018-01-01 9901-01-01 CA $23.96 001E1250 RR H 2018-01-01 9901-01-01 CA $23.96 004E1260 RR H 2018-01-01 9901-01-01 CA $238.55 001E1260 RR H 2018-01-01 9901-01-01 CA $238.55 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 48 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

E1260 00 G 2018-01-01 9901-01-01 CA $2,747.29 001E1260 00 G 2018-01-01 9901-01-01 CA $2,747.29 004E1354 00 G 2018-01-01 9901-01-01 CA $28.79 001E1354 00 G 2018-01-01 9901-01-01 CA $28.79 004E1637 00 G 2021-07-03 9901-01-01 CA $100.00 001E1637 00 G 2021-07-03 9901-01-01 CA $100.00 004E2291 00 G 2018-01-01 9901-01-01 CA $670.00 001E2291 00 G 2018-01-01 9901-01-01 CA $670.00 004E2292 00 G 2018-01-01 9901-01-01 CA $1,142.70 001E2292 00 G 2018-01-01 9901-01-01 CA $1,142.70 004E2293 RR H 2018-01-01 9901-01-01 CA $65.10 001E2293 RR H 2018-01-01 9901-01-01 CA $65.10 004E2293 00 G 2018-01-01 9901-01-01 CA $846.33 001E2293 00 G 2018-01-01 9901-01-01 CA $846.33 004E2294 RR H 2018-01-01 9901-01-01 CA $44.54 001E2294 RR H 2018-01-01 9901-01-01 CA $44.54 004E2294 00 G 2018-01-01 9901-01-01 CA $579.03 001E2294 00 G 2018-01-01 9901-01-01 CA $579.03 004E2300 00 G 2018-01-01 9901-01-01 CA $3,770.20 001E2300 00 G 2018-01-01 9901-01-01 CA $3,770.20 004E2512 NU G 2020-04-25 9901-01-01 CA $1,480.00 001E2512 NU G 2020-04-25 9901-01-01 CA $1,480.00 004E2609 RR H 2018-01-01 9901-01-01 CA $53.81 001E2609 RR H 2018-01-01 9901-01-01 CA $53.81 004E2609 00 G 2018-01-01 9901-01-01 CA $897.00 001E2609 00 G 2018-01-01 9901-01-01 CA $897.00 004E2617 RR H 2018-01-01 9901-01-01 CA $57.08 001E2617 RR H 2018-01-01 9901-01-01 CA $57.08 004E2617 00 G 2018-01-01 9901-01-01 CA $1,353.00 001E2617 00 G 2018-01-01 9901-01-01 CA $1,353.00 004E8000 RR H 2018-01-01 9901-01-01 CA $361.54 001E8000 RR H 2018-01-01 9901-01-01 CA $361.54 004E8000 00 G 2018-01-01 9901-01-01 CA $4,700.00 001E8000 00 G 2018-01-01 9901-01-01 CA $4,700.00 004E8001 RR H 2018-01-01 9901-01-01 CA $268.46 001E8001 RR H 2018-01-01 9901-01-01 CA $268.46 004E8001 00 G 2018-01-01 9901-01-01 CA $3,671.04 001E8001 00 G 2018-01-01 9901-01-01 CA $3,671.04 004G0129 00 D 2018-03-01 9901-01-01 CA $230.00 001G0129 00 D 2018-01-01 2018-03-01 CA $230.00 001G0129 00 D 2018-01-01 9901-01-01 CA $230.00 004G0129 00 D 2017-03-01 2018-01-01 CA $230.00 001G0129 00 D 2016-04-01 2017-03-01 CA $230.00 001G0129 00 D 2016-04-01 2018-01-01 CA $230.00 004G0155 00 6 2016-04-01 2018-01-01 CA $118.33 001G0155 00 6 2016-04-01 2018-01-01 CA $71.00 004G0159 00 D 2018-01-01 9901-01-01 CA $62.50 001G0159 00 D 2018-01-01 9901-01-01 CA $62.50 004G0159 00 D 2016-04-01 2018-01-01 CA $62.50 001G0159 00 D 2016-04-01 2018-01-01 CA $62.50 004G0160 00 D 2018-01-01 9901-01-01 CA $250.00 001G0160 00 D 2018-01-01 9901-01-01 CA $250.00 004G0162 00 6 2018-01-01 9901-01-01 CA $78.10 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 49 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

G0162 00 6 2018-01-01 9901-01-01 CA $78.10 004G0162 00 6 2016-04-01 2018-01-01 CA $78.10 001G0162 00 6 2016-04-01 2018-01-01 CA $78.10 004G0163 00 6 2016-04-01 9901-01-01 CA $235.00 001G0164 00 6 2016-04-01 9901-01-01 CA $235.00 001G0176 00 C 2019-03-01 9901-01-01 CA $207.00 001G0176 00 C 2019-03-01 9901-01-01 CA $207.00 004G0176 00 C 2018-03-01 2019-03-01 CA $207.00 001G0176 00 C 2018-01-01 2018-03-01 CA $178.50 001G0176 00 C 2018-01-01 2019-03-01 CA $178.50 004G0176 00 C 2017-03-01 2018-01-01 CA $178.50 001G0176 00 C 2017-03-01 2018-01-01 CA $178.50 004G0176 00 C 2016-04-01 2017-03-01 CA $178.50 001G0176 00 C 2016-04-01 2017-03-01 CA $178.50 004G0177 00 6 2021-03-06 9901-01-01 CA $80.00 001G0177 00 6 2018-03-01 2019-03-01 CA $300.00 001G0177 00 6 2018-01-01 2018-03-01 CA $197.00 001G0177 00 6 2018-01-01 2019-03-01 CA $197.00 004G0177 00 6 2017-03-01 2018-01-01 CA $197.00 001G0177 00 6 2017-03-01 2018-01-01 CA $197.00 004G0177 00 6 2016-04-01 2017-03-01 CA $188.00 001G0177 00 6 2016-04-01 2017-03-01 CA $188.00 004G0259 00 2 2018-01-01 9901-01-01 CA $182.82 001G0259 00 2 2018-01-01 9901-01-01 CA $155.39 004G0299 00 L 2018-03-01 2019-03-01 CA $230.00 001G0299 00 L 2018-01-01 2018-03-01 CA $173.00 001G0299 00 L 2017-03-01 2018-01-01 CA $173.00 001G0299 00 L 2017-03-01 2018-01-01 CA $115.00 004G0299 00 L 2016-01-08 2017-03-01 CA $95.00 001G0299 00 L 2016-01-08 2017-03-01 CA $95.00 004G0339 00 2 2018-01-01 9901-01-01 CA $17,009.00 001G0339 00 2 2018-01-01 9901-01-01 CA $17,009.00 004G0340 00 E 2018-01-01 2018-03-01 CA $12,038.00 001G0340 00 E 2017-03-01 2018-01-01 CA $12,038.00 001G0340 00 E 2016-04-01 2017-03-01 CA $11,200.00 001G0378 00 6 2019-03-01 9901-01-01 CA $413.56 001G0378 00 6 2019-03-01 9901-01-01 CA $395.75 004G0378 00 6 2018-03-01 2019-03-01 CA $362.00 001G0378 00 6 2018-01-01 2018-03-01 CA $305.00 001G0378 00 6 2018-01-01 2019-03-01 CA $298.00 004G0378 00 6 2017-03-01 2018-01-01 CA $305.00 001G0378 00 6 2017-03-01 2018-01-01 CA $298.00 004G0378 00 6 2016-04-01 2017-03-01 CA $298.00 001G0378 00 6 2016-04-01 2017-03-01 CA $283.00 004G0379 00 6 2019-03-01 9901-01-01 CA $567.56 001G0379 00 6 2018-03-01 2019-03-01 CA $567.56 001G0379 00 6 2018-01-01 2018-03-01 CA $254.00 001G0379 00 6 2018-01-01 9901-01-01 CA $254.00 004G0379 00 6 2017-03-01 2018-01-01 CA $254.00 001G0379 00 6 2017-03-01 2018-01-01 CA $254.00 004G0379 00 6 2016-04-01 2017-03-01 CA $254.00 001G0379 00 6 2016-04-01 2017-03-01 CA $254.00 004G0380 00 6 2019-03-01 9901-01-01 CA $240.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 50 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

G0380 00 6 2018-03-01 2019-03-01 CA $231.00 001G0380 00 6 2018-01-01 2018-03-01 CA $222.00 001G0380 00 6 2018-01-01 9901-01-01 CA $222.00 004G0380 00 6 2017-03-01 2018-01-01 CA $222.00 001G0380 00 6 2017-03-01 2018-01-01 CA $222.00 004G0380 00 6 2016-04-01 2017-03-01 CA $211.00 001G0380 00 6 2016-04-01 2017-03-01 CA $211.00 004G0381 00 6 2019-03-01 9901-01-01 CA $325.00 001G0381 00 6 2019-03-01 9901-01-01 CA $325.00 004G0381 00 6 2018-03-01 2019-03-01 CA $304.00 001G0381 00 6 2018-01-01 2018-03-01 CA $291.00 001G0381 00 6 2018-01-01 2019-03-01 CA $291.00 004G0381 00 6 2017-03-01 2018-01-01 CA $291.00 001G0381 00 6 2017-03-01 2018-01-01 CA $291.00 004G0381 00 6 2016-04-01 2017-03-01 CA $277.00 001G0381 00 6 2016-04-01 2017-03-01 CA $277.00 004G0382 00 6 2019-03-01 9901-01-01 CA $1,231.25 001G0382 00 6 2019-03-01 9901-01-01 CA $1,231.25 004G0382 00 6 2018-03-01 2019-03-01 CA $1,141.50 001G0382 00 6 2018-01-01 2018-03-01 CA $987.50 001G0382 00 6 2018-01-01 2019-03-01 CA $978.00 004G0382 00 6 2017-03-01 2018-01-01 CA $987.50 001G0382 00 6 2017-03-01 2018-01-01 CA $978.00 004G0382 00 6 2016-04-01 2017-03-01 CA $978.00 001G0382 00 6 2016-04-01 2017-03-01 CA $978.00 004G0383 00 6 2019-03-01 9901-01-01 CA $1,968.00 001G0383 00 6 2018-03-01 2019-03-01 CA $1,968.00 001G0383 00 6 2018-01-01 2018-03-01 CA $1,812.50 001G0383 00 6 2018-01-01 9901-01-01 CA $1,812.50 004G0383 00 6 2017-03-01 2018-01-01 CA $1,812.50 001G0383 00 6 2016-04-01 2017-03-01 CA $1,812.50 001G0383 00 6 2016-04-01 2018-01-01 CA $1,812.50 004G0384 00 6 2019-03-01 9901-01-01 CA $4,124.00 001G0384 00 6 2019-03-01 9901-01-01 CA $2,392.88 004G0384 00 6 2018-03-01 2019-03-01 CA $4,124.00 001G0384 00 6 2018-01-01 2018-03-01 CA $3,408.00 001G0384 00 6 2018-01-01 2019-03-01 CA $2,392.88 004G0384 00 6 2016-04-01 2018-01-01 CA $3,408.00 001G0390 00 6 2018-01-01 9901-01-01 CA $18,662.40 001G0398 00 6 2016-04-01 2018-01-01 CA $850.00 001G0398 00 6 2016-04-01 2018-01-01 CA $850.00 004G0410 00 C 2021-03-01 9901-01-01 CA $812.00 001G0410 00 C 2019-03-01 2021-03-01 CA $482.00 001G0410 00 C 2019-03-01 9901-01-01 CA $482.00 004G0410 00 C 2018-03-01 2019-03-01 CA $482.00 001G0410 00 C 2018-01-01 2018-03-01 CA $434.00 001G0410 00 C 2018-01-01 2019-03-01 CA $434.00 004G0410 00 C 2017-03-01 2018-01-01 CA $434.00 001G0410 00 C 2017-03-01 2018-01-01 CA $434.00 004G0410 00 C 2016-04-01 2017-03-01 CA $430.00 001G0410 00 C 2016-04-01 2017-03-01 CA $430.00 004G0411 00 C 2019-03-01 9901-01-01 CA $207.00 001G0411 00 C 2019-03-01 9901-01-01 CA $207.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 51 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

G0411 00 C 2018-03-01 2019-03-01 CA $207.00 001G0411 00 C 2018-01-01 2018-03-01 CA $197.00 001G0411 00 C 2018-01-01 2019-03-01 CA $197.00 004G0411 00 C 2017-03-01 2018-01-01 CA $197.00 001G0411 00 C 2017-03-01 2018-01-01 CA $197.00 004G0411 00 C 2016-04-01 2017-03-01 CA $188.00 001G0411 00 C 2016-04-01 2017-03-01 CA $188.00 004G0463 00 6 2021-03-01 9901-01-01 CA $270.00 001G0463 00 6 2021-03-01 9901-01-01 CA $270.00 004G0463 00 6 2019-03-01 2021-03-01 CA $485.00 001G0463 00 6 2019-03-01 2021-03-01 CA $485.00 004G0463 00 6 2018-03-01 2019-03-01 CA $485.00 001G0463 00 6 2018-03-01 2019-03-01 CA $485.00 004G0463 00 6 2018-01-01 2018-03-01 CA $485.00 001G0463 00 6 2018-01-01 2018-03-01 CA $485.00 004G0463 00 6 2017-03-01 2018-01-01 CA $485.00 001G0463 00 6 2017-03-01 2018-01-01 CA $485.00 004G0463 00 6 2016-04-01 2017-03-01 CA $485.00 001G0463 00 6 2016-04-01 2017-03-01 CA $485.00 004G0467 00 C 2018-01-01 9901-01-01 CA $192.00 001G0467 00 C 2018-01-01 9901-01-01 CA $192.00 004G0467 00 C 2016-05-06 2018-01-01 CA $192.00 001G0467 00 C 2016-05-06 2018-01-01 CA $192.00 004G0468 00 C 2018-01-09 9901-01-01 CA $130.00 001G0468 00 C 2018-01-09 9901-01-01 CA $130.00 004G0470 00 C 2018-01-01 9901-01-01 CA $237.00 001G0470 00 C 2018-01-01 9901-01-01 CA $237.00 004G0470 00 C 2016-11-30 2018-01-01 CA $237.00 001G0470 00 C 2016-11-30 2018-01-01 CA $237.00 004G0475 00 P 2017-03-01 2018-01-01 CA $172.00 001G0475 26 P 2016-05-13 2018-01-01 CA $172.00 001G0475 26 P 2016-05-13 2018-01-01 CA $172.00 004G0476 26 P 2016-01-08 2018-01-01 CA $174.00 001G0476 26 P 2016-01-08 2018-01-01 CA $174.00 004G0477 00 8 2016-02-25 9901-01-01 CA $55.00 001G0477 00 8 2016-02-25 9901-01-01 CA $55.00 004G0479 00 8 2016-02-19 9901-01-01 CA $550.00 001G0479 00 8 2016-02-19 9901-01-01 CA $550.00 004G0480 00 8 2016-02-19 2018-01-01 CA $334.35 001G0480 00 8 2016-02-19 2018-01-01 CA $334.35 004G0481 00 8 2016-03-11 2018-01-01 CA $787.28 001G0481 00 8 2016-03-11 2018-01-01 CA $787.28 004G0482 00 8 2016-03-24 2018-01-01 CA $1,030.11 001G0482 00 8 2016-03-24 2018-01-01 CA $1,030.11 004G0483 00 8 2016-02-25 2018-01-01 CA $1,600.00 001G0483 00 8 2016-02-25 2018-01-01 CA $1,600.00 004G0490 00 6 2021-01-23 9901-01-01 CA $120.00 001G0493 00 L 2020-03-21 9901-01-01 CA $197.50 001G0495 00 L 2020-03-21 9901-01-01 CA $197.50 001G0496 00 L 2020-03-21 9901-01-01 CA $395.00 001G0498 00 6 2018-01-01 2018-03-01 CA $1,500.00 001G0498 00 6 2018-01-01 2018-03-01 CA $1,500.00 004G0498 00 6 2017-03-02 2018-01-01 CA $1,500.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 52 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

G0498 00 6 2017-03-02 2018-01-01 CA $1,500.00 004G2025 00 6 2020-12-05 2021-01-01 CA $233.00 001G2066 00 6 2020-02-15 2021-03-01 CA $250.00 001G8539 00 6 2018-01-01 9901-01-01 CA $31.25 001G8539 00 6 2018-01-01 9901-01-01 CA $31.25 004G8542 00 6 2018-01-01 9901-01-01 CA $31.25 001G8542 00 6 2018-01-01 9901-01-01 CA $31.25 004G9313 00 6 2018-03-01 9901-01-01 CA $10.00 001G9313 00 6 2018-01-01 2018-03-01 CA $10.00 001G9313 00 6 2018-01-01 9901-01-01 CA $10.00 004G9313 00 6 2016-05-06 2018-01-01 CA $10.00 001G9313 00 6 2016-05-06 2018-01-01 CA $10.00 004G9511 00 6 2020-11-28 9901-01-01 CA $65.00 001G9658 00 6 2018-01-05 9901-01-01 CA $200.00 001G9658 00 6 2018-01-05 9901-01-01 CA $200.00 004G9793 00 6 2019-05-04 9901-01-01 CA $127.21 001G9919 00 6 2020-04-04 9901-01-01 CA $45.00 001G9920 00 6 2020-02-15 9901-01-01 CA $89.00 001H0001 00 6 2018-01-01 9901-01-01 CA $293.00 001H0001 00 6 2018-01-01 9901-01-01 CA $293.00 004H0001 00 6 2017-03-01 2018-01-01 CA $293.00 001H0002 00 C 2018-01-01 9901-01-01 CA $201.40 001H0002 00 C 2018-01-01 9901-01-01 CA $201.40 004H0006 00 C 2018-01-01 9901-01-01 CA $332.00 001H0006 00 C 2018-01-01 9901-01-01 CA $332.00 004H0006 00 C 2017-03-01 2018-01-01 CA $332.00 001H0010 00 C 2020-10-03 9901-01-01 CA $4,500.00 001H0011 00 C 2020-10-03 9901-01-01 CA $1,600.00 001H0012 00 C 2020-03-01 9901-01-01 CA $3,195.00 001H0012 00 C 2020-03-01 9901-01-01 CA $3,195.00 004H0012 00 C 2019-06-22 2020-03-01 CA $3,195.00 001H0013 00 C 2020-03-01 9901-01-01 CA $1,000.00 001H0013 00 C 2020-03-01 9901-01-01 CA $1,000.00 004H0013 00 C 2019-04-27 2020-03-01 CA $1,000.00 001H0016 29 C 2018-01-01 9901-01-01 CA $20.00 001H0016 29 C 2018-01-01 9901-01-01 CA $20.00 004H0016 29 C 2017-03-01 2018-01-01 CA $20.00 001H0016 29 C 2016-11-30 2017-03-01 CA $20.00 001H0016 29 C 2016-11-30 2018-01-01 CA $20.00 004H0017 00 C 2021-03-13 9901-01-01 CA $1,500.00 001H0018 29 C 2018-03-01 9901-01-01 CA $666.67 001H0018 29 C 2018-01-01 2018-03-01 CA $457.00 001H0018 29 C 2018-01-01 9901-01-01 CA $373.74 004H0018 29 C 2017-03-01 2018-01-01 CA $457.00 001H0018 29 C 2016-11-30 2017-03-01 CA $373.74 001H0018 29 C 2016-11-30 2018-01-01 CA $373.74 004H0019 00 C 2018-01-01 9901-01-01 CA $309.25 001H0022 29 C 2019-03-01 9901-01-01 CA $248.00 001H0022 29 C 2019-03-01 9901-01-01 CA $40.00 004H0022 29 C 2018-07-28 2019-03-01 CA $248.00 001H0031 00 C 2018-01-01 9901-01-01 CA $12.59 004H0032 00 C 2018-01-01 9901-01-01 CA $150.00 001H0032 00 C 2018-01-01 9901-01-01 CA $150.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 53 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

H0034 00 6 2018-01-01 9901-01-01 CA $420.00 001H0034 00 6 2018-01-01 9901-01-01 CA $353.40 004H0034 00 6 2017-03-01 2018-01-01 CA $420.00 001H0034 00 6 2017-03-01 2018-01-01 CA $353.40 004H0034 00 6 2016-04-01 2017-03-01 CA $420.00 001H0034 00 6 2016-04-01 2017-03-01 CA $353.40 004H0035 00 C 2021-03-01 9901-01-01 CA $3,250.00 001H0035 00 C 2020-03-01 2021-03-01 CA $2,690.00 001H0035 00 C 2019-03-01 2020-03-01 CA $3,600.00 001H0035 00 C 2018-01-01 2019-03-01 CA $3,600.00 001H0035 00 C 2018-01-01 9901-01-01 CA $267.00 004H0035 00 C 2017-03-01 2018-01-01 CA $3,600.00 001H0035 00 C 2017-03-01 2018-01-01 CA $267.00 004H0035 00 C 2016-04-01 2017-03-01 CA $972.00 001H0037 00 C 2018-01-01 9901-01-01 CA $356.00 001H0037 00 C 2018-01-01 9901-01-01 CA $356.00 004H0038 00 C 2018-01-01 9901-01-01 CA $24.24 001H0038 00 C 2018-01-01 9901-01-01 CA $24.24 004H0038 00 C 2016-02-26 2018-01-01 CA $24.24 001H0038 00 C 2016-02-26 2018-01-01 CA $24.24 004H0048 00 6 2018-01-01 9901-01-01 CA $20.48 001H0048 00 6 2018-01-01 9901-01-01 CA $20.48 004H0049 00 8 2018-01-01 9901-01-01 CA $30.00 001H0049 00 8 2018-01-01 9901-01-01 CA $30.00 004H0049 00 8 2017-03-01 2018-01-01 CA $30.00 001H0049 00 8 2017-03-01 2018-01-01 CA $30.00 004H1002 00 3 2018-03-01 9901-01-01 CA $60.00 001H1002 00 3 2018-01-01 2018-03-01 CA $45.00 001H1002 00 3 2018-01-01 9901-01-01 CA $30.00 004H1002 00 3 2017-03-01 2018-01-01 CA $45.00 001H1002 00 3 2016-04-01 2017-03-01 CA $45.00 001H1003 00 3 2018-03-01 9901-01-01 CA $60.00 001H1003 00 3 2018-03-01 9901-01-01 CA $60.00 004H1003 00 3 2018-01-01 2018-03-01 CA $60.00 001H1003 00 3 2018-01-01 2018-03-01 CA $60.00 004H1003 00 3 2017-03-01 2018-01-01 CA $60.00 001H1003 00 3 2017-03-01 2018-01-01 CA $60.00 004H2010 00 C 2018-01-01 9901-01-01 CA $121.05 001H2010 00 C 2018-01-01 9901-01-01 CA $121.05 004H2013 00 C 2018-01-01 9901-01-01 CA $20.00 001H2013 00 C 2018-01-01 9901-01-01 CA $20.00 004H2013 00 C 2016-07-26 2018-01-01 CA $20.00 001H2013 00 C 2016-07-26 2018-01-01 CA $20.00 004H2014 00 C 2018-01-01 9901-01-01 CA $12.00 001H2014 00 C 2018-01-01 9901-01-01 CA $12.00 004H2015 00 C 2018-01-01 9901-01-01 CA $32.43 001H2015 00 C 2018-01-01 9901-01-01 CA $32.43 004H2016 00 C 2018-01-01 9901-01-01 CA $50.00 001H2016 00 C 2018-01-01 9901-01-01 CA $50.00 004H2017 00 C 2018-01-01 9901-01-01 CA $8.89 001H2017 00 C 2018-01-01 9901-01-01 CA $8.89 004H2019 00 6 2018-01-01 2020-03-01 CA $18.75 001H2019 00 6 2018-01-01 2020-03-01 CA $12.50 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 54 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

H2030 00 C 2018-01-01 9901-01-01 CA $120.06 001H2030 00 C 2018-01-01 9901-01-01 CA $120.06 004H2036 00 C 2020-03-01 9901-01-01 CA $2,000.00 001H2036 00 C 2020-03-01 9901-01-01 CA $2,000.00 004H2036 00 C 2019-08-31 2020-03-01 CA $2,660.00 001K0462 00 H 2018-01-01 9901-01-01 CA $580.00 001K0462 00 H 2018-01-01 9901-01-01 CA $580.00 004K0669 00 G 2018-01-01 9901-01-01 CA $1,550.00 001K0669 00 G 2018-01-01 9901-01-01 CA $1,550.00 004K0669 00 G 2016-09-13 2018-01-01 CA $1,550.00 001K0669 00 G 2016-09-13 2018-01-01 CA $1,550.00 004L2861 00 G 2018-01-01 9901-01-01 CA $1,245.00 001L2861 00 G 2018-01-01 9901-01-01 CA $1,245.00 004L3201 00 G 2018-01-22 9901-01-01 CA $67.00 001L3201 00 G 2018-01-22 9901-01-01 CA $67.00 004L3209 00 G 2018-01-01 9901-01-01 CA $25.00 001L3209 00 G 2018-01-01 9901-01-01 CA $25.00 004L3209 00 G 2017-07-25 2018-01-01 CA $25.00 001L3209 00 G 2017-07-25 2018-01-01 CA $25.00 004L3215 00 G 2020-03-01 9901-01-01 CA $25.00 001L3215 00 G 2020-03-01 9901-01-01 CA $25.00 004L3215 00 G 2019-03-01 2020-03-01 CA $25.00 001L3215 00 G 2019-03-01 2020-03-01 CA $25.00 004L3215 00 G 2018-03-01 2019-03-01 CA $25.00 001L3215 00 G 2018-03-01 2019-03-01 CA $25.00 004L3215 00 G 2018-01-01 2018-03-01 CA $25.00 001L3215 00 G 2018-01-01 2018-03-01 CA $25.00 004L3215 00 G 2017-03-01 2018-01-01 CA $25.00 001L3215 00 G 2017-03-01 2018-01-01 CA $25.00 004L3219 00 G 2020-03-01 9901-01-01 CA $25.00 001L3219 00 G 2020-03-01 9901-01-01 CA $25.00 004L3219 00 G 2018-03-01 2020-03-01 CA $25.00 001L3219 00 G 2018-03-01 2020-03-01 CA $25.00 004L3219 00 G 2018-01-01 2018-03-01 CA $25.00 001L3219 00 G 2018-01-01 2018-03-01 CA $25.00 004L3219 00 G 2016-11-30 2018-01-01 CA $25.00 001L3219 00 G 2016-11-30 2018-01-01 CA $25.00 004L3221 00 G 2018-01-01 9901-01-01 CA $181.90 001L3221 00 G 2018-01-01 9901-01-01 CA $181.90 004L3260 NU G 2021-03-01 9901-01-01 CA $52.00 001L3260 NU G 2021-03-01 9901-01-01 CA $52.00 004L3260 NU G 2020-03-01 2021-03-01 CA $51.00 001L3260 NU G 2020-03-01 2021-03-01 CA $51.00 004L3260 NU G 2019-03-01 2020-03-01 CA $160.00 001L3260 NU G 2019-03-01 2020-03-01 CA $160.00 004L3260 NU G 2018-03-01 2019-03-01 CA $160.00 001L3260 NU G 2018-03-01 2019-03-01 CA $160.00 004L3260 NU G 2018-01-01 2018-03-01 CA $160.00 001L3260 NU G 2018-01-01 2018-03-01 CA $160.00 004L3260 00 G 2021-03-01 9901-01-01 CA $50.00 001L3260 00 G 2021-03-01 9901-01-01 CA $50.00 004L3260 00 G 2020-03-01 2021-03-01 CA $45.00 001L3260 00 G 2020-03-01 2021-03-01 CA $45.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 55 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

L3260 00 G 2019-03-01 2020-03-01 CA $160.00 001L3260 00 G 2019-03-01 2020-03-01 CA $160.00 004L3260 00 G 2018-03-01 2019-03-01 CA $160.00 001L3260 00 G 2018-03-01 2019-03-01 CA $160.00 004L3260 00 G 2018-01-01 2018-03-01 CA $160.00 001L3260 00 G 2018-01-01 2018-03-01 CA $160.00 004L3260 00 G 2017-03-01 2018-01-01 CA $160.00 001L3260 00 G 2017-03-01 2018-01-01 CA $160.00 004L3260 00 G 2016-04-01 2017-03-01 CA $51.00 001L3260 00 G 2016-04-01 2017-03-01 CA $51.00 004L3265 00 G 2021-03-01 9901-01-01 CA $50.00 001L3265 00 G 2021-03-01 9901-01-01 CA $50.00 004L3265 00 G 2020-03-01 2021-03-01 CA $55.00 001L3265 00 G 2020-03-01 2021-03-01 CA $55.00 004L3265 00 G 2019-03-01 2020-03-01 CA $70.00 001L3265 00 G 2019-03-01 2020-03-01 CA $70.00 004L3265 00 G 2018-03-01 2019-03-01 CA $70.00 001L3265 00 G 2018-03-01 2019-03-01 CA $70.00 004L3265 00 G 2018-01-01 2018-03-01 CA $70.00 001L3265 00 G 2018-01-01 2018-03-01 CA $70.00 004L3265 00 G 2017-03-01 2018-01-01 CA $70.00 001L3265 00 G 2017-03-01 2018-01-01 CA $70.00 004L3265 00 G 2016-04-01 2017-03-01 CA $70.00 001L3265 00 G 2016-04-01 2017-03-01 CA $70.00 004L3320 00 G 2018-01-01 9901-01-01 CA $151.05 001L3485 00 G 2018-01-01 9901-01-01 CA $58.00 001L3485 00 G 2018-01-01 9901-01-01 CA $58.00 004L3677 00 G 2018-01-01 9901-01-01 CA $153.60 001L3677 00 G 2018-01-01 9901-01-01 CA $153.60 004L3891 00 G 2018-01-01 9901-01-01 CA $358.40 001L3891 00 G 2018-01-01 9901-01-01 CA $358.40 004L4002 00 G 2018-01-01 9901-01-01 CA $52.74 001L4002 00 G 2018-01-01 9901-01-01 CA $52.74 004L4210 00 G 2020-03-01 9901-01-01 CA $200.00 001L4210 00 G 2020-03-01 9901-01-01 CA $200.00 004L4210 00 G 2018-03-01 2020-03-01 CA $200.00 001L4210 00 G 2018-03-01 2020-03-01 CA $200.00 004L4210 00 G 2018-01-01 2018-03-01 CA $200.00 001L4210 00 G 2018-01-01 2018-03-01 CA $200.00 004L4210 00 G 2017-03-01 2018-01-01 CA $200.00 001L4210 00 G 2017-03-01 2018-01-01 CA $200.00 004L4210 00 G 2016-04-01 2017-03-01 CA $200.00 001L4210 00 G 2016-04-01 2017-03-01 CA $200.00 004L7900 00 G 2020-03-01 9901-01-01 CA $799.00 001L7900 00 G 2020-03-01 9901-01-01 CA $799.00 004L7900 00 G 2018-01-01 2020-03-01 CA $659.00 001L7900 00 G 2018-01-01 2020-03-01 CA $659.00 004L7900 00 G 2017-03-01 2018-01-01 CA $659.00 001L7900 00 G 2017-03-01 2018-01-01 CA $659.00 004L8010 00 G 2018-03-01 9901-01-01 CA $326.00 001L8010 00 G 2018-03-01 9901-01-01 CA $326.00 004L8010 00 G 2018-01-01 2018-03-01 CA $120.00 001L8010 00 G 2018-01-01 2018-03-01 CA $120.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 56 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

L8505 00 G 2018-01-01 9901-01-01 CA $38.10 001L8505 00 G 2018-01-01 9901-01-01 CA $38.10 004L8604 00 G 2018-01-01 9901-01-01 CA $3,963.00 001L8604 00 G 2018-01-01 9901-01-01 CA $3,963.00 004L8680 00 G 2019-03-01 9901-01-01 CA $1,320.00 001L8680 00 G 2019-03-01 9901-01-01 CA $1,320.00 004L8680 00 G 2018-03-01 2019-03-01 CA $1,320.00 001L8680 00 G 2018-03-01 2019-03-01 CA $1,320.00 004L8680 00 G 2018-01-01 2018-03-01 CA $1,320.00 001L8680 00 G 2018-01-01 2018-03-01 CA $1,320.00 004L8680 00 G 2017-03-01 2018-01-01 CA $1,320.00 001L8680 00 G 2017-03-01 2018-01-01 CA $1,320.00 004L8680 00 G 2016-04-01 2017-03-01 CA $1,320.00 001L8680 00 G 2016-04-01 2017-03-01 CA $1,320.00 004L8686 00 G 2018-01-01 9901-01-01 CA $43,540.00 001L8686 00 G 2018-01-01 9901-01-01 CA $43,540.00 004L8687 00 G 2018-01-01 9901-01-01 CA $40,000.00 001L8687 00 G 2018-01-01 9901-01-01 CA $40,000.00 004L8692 00 G 2020-03-01 9901-01-01 CA $10,940.00 001L8692 00 G 2020-03-01 9901-01-01 CA $10,940.00 004L8692 00 G 2018-03-01 2020-03-01 CA $17,104.00 001L8692 00 G 2018-03-01 2020-03-01 CA $17,104.00 004L8692 00 G 2018-01-01 2018-03-01 CA $7,891.00 001L8692 00 G 2018-01-01 2018-03-01 CA $7,891.00 004M0076 00 2 2018-01-01 9901-01-01 CA $284.98 001P9011 00 1 2020-03-01 9901-01-01 CA $520.00 001P9011 00 1 2019-03-01 2020-03-01 CA $751.00 001P9011 00 1 2018-03-01 2019-03-01 CA $751.00 001P9011 00 1 2018-01-01 2018-03-01 CA $751.00 001P9011 00 1 2018-01-01 9901-01-01 CA $273.02 004P9011 00 1 2017-03-01 2018-01-01 CA $751.00 001P9011 00 1 2016-04-01 2017-03-01 CA $751.00 001P9012 00 1 2018-01-01 9901-01-01 CA $242.06 001P9012 00 1 2018-01-01 9901-01-01 CA $242.06 004P9016 00 1 2021-03-01 9901-01-01 CA $520.00 001P9016 00 1 2020-03-01 2021-03-01 CA $675.00 001P9016 00 1 2019-03-01 2020-03-01 CA $675.00 001P9016 00 1 2018-03-01 2019-03-01 CA $605.00 001P9016 00 P 2018-01-01 9901-01-01 CA $529.81 001P9016 00 1 2018-01-01 2018-03-01 CA $516.00 001P9016 00 P 2018-01-01 9901-01-01 CA $469.00 004P9016 00 1 2018-01-01 9901-01-01 CA $516.00 004P9016 00 P 2017-03-01 2018-01-01 CA $529.81 001P9016 00 P 2017-03-01 2018-01-01 CA $469.00 004P9017 00 1 2018-03-01 9901-01-01 CA $363.49 001P9017 00 1 2018-03-01 9901-01-01 CA $363.49 004P9017 00 1 2018-01-01 2018-03-01 CA $363.49 001P9017 00 1 2018-01-01 2018-03-01 CA $363.49 004P9017 00 1 2017-03-01 2018-01-01 CA $363.49 001P9017 00 1 2017-03-01 2018-01-01 CA $363.49 004P9017 00 1 2016-04-01 2017-03-01 CA $363.49 001P9017 00 1 2016-04-01 2017-03-01 CA $363.49 004P9019 00 1 2018-01-01 9901-01-01 CA $225.89 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 57 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

P9019 00 1 2018-01-01 9901-01-01 CA $225.89 004P9020 00 1 2018-01-01 9901-01-01 CA $500.00 001P9020 00 1 2018-01-01 9901-01-01 CA $500.00 004P9020 00 1 2016-04-01 2018-01-01 CA $500.00 001P9021 00 1 2020-03-01 9901-01-01 CA $666.74 001P9021 00 1 2019-03-01 2020-03-01 CA $1,258.00 001P9021 00 1 2018-03-01 2019-03-01 CA $1,258.00 001P9021 00 1 2018-01-01 2018-03-01 CA $1,258.00 001P9021 00 1 2018-01-01 9901-01-01 CA $428.00 004P9021 00 1 2017-03-01 2018-01-01 CA $1,258.00 001P9021 00 1 2016-04-01 2017-03-01 CA $1,258.00 001P9022 00 1 2018-01-01 9901-01-01 CA $533.40 001P9022 00 1 2018-01-01 9901-01-01 CA $533.40 004P9032 00 1 2018-01-01 9901-01-01 CA $184.91 001P9032 00 1 2018-01-01 9901-01-01 CA $184.91 004P9033 00 1 2018-01-01 9901-01-01 CA $203.01 001P9033 00 1 2018-01-01 9901-01-01 CA $203.01 004P9034 00 1 2018-01-01 9901-01-01 CA $1,424.12 001P9034 00 1 2018-01-01 9901-01-01 CA $1,424.12 004P9034 00 1 2017-03-01 2018-01-01 CA $1,424.12 001P9034 00 1 2017-03-01 2018-01-01 CA $1,424.12 004P9035 00 1 2019-03-01 9901-01-01 CA $1,445.88 001P9035 00 1 2018-03-01 2019-03-01 CA $1,010.00 001P9035 00 1 2018-03-01 9901-01-01 CA $1,010.00 004P9035 00 1 2018-01-01 2018-03-01 CA $1,010.00 001P9035 00 1 2018-01-01 2018-03-01 CA $1,010.00 004P9035 00 1 2017-03-01 2018-01-01 CA $1,010.00 001P9035 00 1 2017-03-01 2018-01-01 CA $1,010.00 004P9035 00 1 2016-04-01 2017-03-01 CA $1,010.00 001P9035 00 1 2016-04-01 2017-03-01 CA $1,010.00 004P9037 00 1 2020-03-01 9901-01-01 CA $3,893.00 001P9037 00 1 2019-03-01 2020-03-01 CA $4,325.00 001P9037 00 1 2018-03-01 2019-03-01 CA $4,324.10 001P9037 00 1 2018-01-01 2018-03-01 CA $4,324.10 001P9037 00 1 2018-01-01 9901-01-01 CA $2,867.00 004P9037 00 1 2017-03-01 2018-01-01 CA $4,324.10 001P9037 00 1 2016-04-01 2017-03-01 CA $3,269.00 001P9038 00 1 2018-01-01 9901-01-01 CA $409.80 001P9038 00 1 2018-01-01 9901-01-01 CA $409.80 004P9040 00 1 2020-03-01 9901-01-01 CA $1,126.00 001P9040 00 1 2019-03-01 2020-03-01 CA $1,220.00 001P9040 00 1 2018-03-01 2019-03-01 CA $1,220.00 001P9040 00 1 2018-01-01 2018-03-01 CA $1,220.00 001P9040 00 1 2018-01-01 9901-01-01 CA $1,047.00 004P9040 00 1 2017-03-01 2018-01-01 CA $1,220.00 001P9040 00 1 2016-04-01 2017-03-01 CA $1,220.00 001P9044 00 8 2018-01-01 9901-01-01 CA $188.42 001P9044 00 8 2018-01-01 9901-01-01 CA $188.42 004P9051 00 1 2018-01-01 9901-01-01 CA $647.17 001P9051 00 1 2018-01-01 9901-01-01 CA $647.17 004P9052 00 1 2018-01-01 9901-01-01 CA $2,056.15 001P9052 00 1 2018-01-01 9901-01-01 CA $2,056.15 004P9053 00 1 2018-01-01 9901-01-01 CA $1,380.44 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 58 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

P9053 00 1 2018-01-01 9901-01-01 CA $1,380.44 004P9055 00 1 2018-01-01 9901-01-01 CA $1,953.79 001P9055 00 1 2018-01-01 9901-01-01 CA $1,953.79 004P9056 00 1 2018-01-01 9901-01-01 CA $911.36 001P9056 00 1 2018-01-01 9901-01-01 CA $911.36 004P9058 00 1 2018-01-01 9901-01-01 CA $797.26 001P9058 00 1 2018-01-01 9901-01-01 CA $797.26 004P9059 00 1 2018-01-01 9901-01-01 CA $397.00 001P9059 00 1 2018-01-01 9901-01-01 CA $397.00 004P9072 00 1 2017-11-22 9901-01-01 CA $668.00 001P9072 00 1 2017-11-22 9901-01-01 CA $668.00 004P9073 00 1 2019-03-01 9901-01-01 CA $989.00 001P9073 00 1 2019-03-01 9901-01-01 CA $668.00 004P9073 00 1 2018-07-28 2019-03-01 CA $989.00 001P9603 00 8 2018-03-01 9901-01-01 CA $2.54 001P9603 00 8 2018-03-01 9901-01-01 CA $2.54 004P9603 00 8 2018-01-01 2018-03-01 CA $2.54 001P9603 00 8 2018-01-01 2018-03-01 CA $2.54 004P9604 00 8 2020-03-01 9901-01-01 CA $50.00 001P9604 00 8 2020-03-01 9901-01-01 CA $50.00 004P9604 00 8 2019-03-01 2020-03-01 CA $51.50 001P9604 00 8 2019-03-01 2020-03-01 CA $51.50 004P9604 00 8 2018-03-01 2019-03-01 CA $51.50 001P9604 00 8 2018-03-01 2019-03-01 CA $51.50 004P9604 00 8 2018-01-01 2018-03-01 CA $51.50 001P9604 00 8 2018-01-01 2018-03-01 CA $51.50 004P9604 00 8 2017-03-01 2018-01-01 CA $51.50 001P9604 00 8 2017-03-01 2018-01-01 CA $51.50 004P9604 00 8 2016-04-01 2017-03-01 CA $50.75 001P9604 00 8 2016-04-01 2017-03-01 CA $50.75 004Q0081 00 6 2018-01-01 2020-03-01 CA $181.86 001Q0081 00 6 2018-01-01 2020-03-01 CA $181.86 004Q0083 00 6 2018-01-01 9901-01-01 CA $70.45 001Q0083 00 6 2018-01-01 9901-01-01 CA $59.88 004Q0084 00 6 2018-01-01 2020-03-01 CA $112.19 001Q0084 00 6 2018-01-01 2020-03-01 CA $95.36 004Q0508 00 G 2018-01-01 9901-01-01 CA $636.00 001Q0508 00 G 2018-01-01 9901-01-01 CA $636.00 004Q0508 00 G 2016-11-30 2018-01-01 CA $636.00 001Q0508 00 G 2016-11-30 2018-01-01 CA $636.00 004Q0513 00 G 2018-01-01 9901-01-01 CA $33.00 001Q4104 00 6 2018-01-01 9901-01-01 CA $156.00 001Q4104 00 6 2018-01-01 9901-01-01 CA $156.00 004Q4104 00 6 2017-02-07 2018-01-01 CA $156.00 001Q4104 00 6 2017-02-07 2018-01-01 CA $156.00 004Q4125 00 6 2018-03-01 9901-01-01 CA $6,583.00 001Q4125 00 6 2018-03-01 9901-01-01 CA $6,583.00 004Q4125 00 6 2018-01-01 2018-03-01 CA $6,583.00 001Q4125 00 6 2018-01-01 2018-03-01 CA $6,583.00 004Q4125 00 6 2017-03-23 2018-01-01 CA $6,583.00 001Q4125 00 6 2017-03-23 2018-01-01 CA $6,583.00 004Q4128 00 6 2018-01-01 9901-01-01 CA $7,880.00 001Q4128 00 6 2018-01-01 9901-01-01 CA $7,880.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 59 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

Q4128 00 6 2017-10-24 2018-01-01 CA $7,880.00 001Q4128 00 6 2017-10-24 2018-01-01 CA $7,880.00 004Q4139 00 6 2021-03-01 9901-01-01 CA $17,500.00 001Q4139 00 6 2018-01-01 2021-03-01 CA $1,500.00 001Q4139 00 6 2018-01-01 9901-01-01 CA $1,500.00 004Q4139 00 6 2016-04-01 2018-01-01 CA $1,500.00 001Q4139 00 6 2016-04-01 2018-01-01 CA $1,500.00 004Q4177 00 6 2021-03-01 9901-01-01 CA $450.00 001Q4177 00 6 2021-03-01 9901-01-01 CA $450.00 004Q4177 00 6 2020-05-09 2021-03-01 CA $450.00 001Q4178 00 6 2021-03-01 9901-01-01 CA $550.00 001Q4178 00 6 2021-03-01 9901-01-01 CA $550.00 004Q4178 00 6 2020-05-02 2021-03-01 CA $550.00 001Q5002 00 6 2020-03-01 9901-01-01 CA $222.27 001Q5002 00 6 2020-03-01 9901-01-01 CA $222.27 004Q5002 00 6 2019-03-01 2020-03-01 CA $237.28 001Q5002 00 6 2019-03-01 2020-03-01 CA $237.28 004Q5002 00 6 2018-03-01 2019-03-01 CA $237.28 001Q5002 00 6 2018-01-01 2018-03-01 CA $237.28 001Q5002 00 6 2018-01-01 2019-03-01 CA $237.28 004Q5002 00 6 2017-03-01 2018-01-01 CA $237.28 001Q5002 00 6 2017-03-01 2018-01-01 CA $237.28 004Q5003 00 6 2018-03-01 9901-01-01 CA $217.52 001Q5003 00 6 2018-01-01 2018-03-01 CA $217.52 001Q5003 00 6 2018-01-01 9901-01-01 CA $217.52 004Q5003 00 6 2016-12-14 2018-01-01 CA $217.52 001Q5003 00 6 2016-12-14 2018-01-01 CA $217.52 004Q5004 00 6 2020-03-01 9901-01-01 CA $230.23 001Q5004 00 6 2020-03-01 9901-01-01 CA $230.23 004Q5004 00 6 2018-03-01 2020-03-01 CA $862.42 001Q5004 00 6 2018-01-01 2018-03-01 CA $862.42 001Q5004 00 6 2018-01-01 2020-03-01 CA $862.42 004Q5004 00 6 2017-07-12 2018-01-01 CA $862.42 001Q5004 00 6 2017-07-12 2018-01-01 CA $862.42 004Q5005 00 6 2020-12-12 9901-01-01 CA $413.94 001Q5006 00 6 2018-01-01 9901-01-01 CA $71.92 001Q9951 00 6 2018-01-01 9901-01-01 CA $0.60 001Q9951 00 6 2018-01-01 9901-01-01 CA $0.60 004Q9959 00 6 2018-01-01 9901-01-01 CA $2.00 001Q9959 00 6 2018-01-01 9901-01-01 CA $2.00 004Q9959 00 6 2016-04-01 2018-01-01 CA $2.00 001Q9959 00 6 2016-04-01 2018-01-01 CA $2.00 004Q9962 00 6 2019-03-01 9901-01-01 CA $62.00 001Q9962 00 6 2018-01-01 2019-03-01 CA $62.00 001Q9962 00 6 2018-01-01 9901-01-01 CA $10.24 004Q9962 00 6 2016-04-01 2018-01-01 CA $62.00 001Q9964 00 6 2018-01-01 9901-01-01 CA $0.92 001Q9964 00 6 2018-01-01 9901-01-01 CA $0.92 004Q9964 00 6 2017-03-01 2018-01-01 CA $0.92 001Q9984 00 6 2017-09-28 9901-01-01 CA $1,802.00 001Q9984 00 6 2017-09-28 9901-01-01 CA $1,802.00 004R0070 00 5 2021-03-01 9901-01-01 CA $549.45 001R0070 00 5 2020-03-01 2021-03-01 CA $537.10 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 60 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

R0070 00 5 2019-03-01 2020-03-01 CA $528.65 001R0070 00 5 2018-03-01 2019-03-01 CA $523.43 001R0070 00 5 2018-01-01 2018-03-01 CA $509.60 001R0070 00 5 2018-01-01 9901-01-01 CA $494.65 004R0070 00 5 2017-03-01 2018-01-01 CA $509.60 001R0070 00 5 2017-03-01 2018-01-01 CA $494.65 004R0070 00 5 2016-04-01 2017-03-01 CA $509.60 001R0075 00 5 2021-03-01 9901-01-01 CA $250.00 001R0075 00 5 2020-03-01 2021-03-01 CA $250.00 001R0075 00 5 2018-01-01 2020-03-01 CA $184.32 001R0075 00 5 2018-01-01 9901-01-01 CA $184.32 004R0076 00 5 2018-01-01 9901-01-01 CA $317.97 001R0076 00 5 2018-01-01 9901-01-01 CA $317.97 004S0138 00 6 2018-01-22 9901-01-01 CA $22.40 001S0138 00 6 2018-01-22 9901-01-01 CA $22.40 004S0191 00 6 2018-01-01 9901-01-01 CA $2.50 001S0191 00 6 2018-01-01 9901-01-01 CA $2.50 004S0191 00 6 2017-03-01 2018-01-01 CA $2.50 001S0201 00 C 2020-03-01 9901-01-01 CA $2,500.00 001S0201 00 C 2020-03-01 9901-01-01 CA $2,500.00 004S0201 00 C 2019-08-24 2020-03-01 CA $2,800.00 001S0257 00 6 2018-01-01 9901-01-01 CA $339.99 001S0257 00 6 2018-01-01 9901-01-01 CA $339.99 004S0265 00 6 2018-03-01 9901-01-01 CA $150.00 001S0265 00 6 2018-01-01 2018-03-01 CA $150.00 001S0265 00 6 2018-01-01 9901-01-01 CA $150.00 004S0265 00 6 2016-04-01 2018-01-01 CA $150.00 001S0395 00 G 2018-03-01 9901-01-01 CA $150.00 001S0395 00 G 2018-03-01 9901-01-01 CA $150.00 004S0395 00 G 2018-01-01 2018-03-01 CA $80.00 001S0395 00 G 2018-01-01 2018-03-01 CA $80.00 004S0395 00 G 2017-03-01 2018-01-01 CA $80.00 001S0395 00 G 2017-03-01 2018-01-01 CA $80.00 004S0395 00 G 2016-04-01 2017-03-01 CA $80.00 001S0395 00 G 2016-04-01 2017-03-01 CA $80.00 004S0592 00 6 2018-01-01 9901-01-01 CA $400.00 001S0592 00 6 2018-01-01 9901-01-01 CA $400.00 004S0592 00 6 2017-03-01 2018-01-01 CA $400.00 001S0610 00 6 2020-03-01 9901-01-01 CA $507.00 001S0610 00 6 2018-03-01 2020-03-01 CA $260.00 001S0610 00 6 2018-01-01 2018-03-01 CA $250.00 001S0610 00 6 2018-01-01 9901-01-01 CA $250.00 004S0610 00 6 2016-04-01 2018-01-01 CA $250.00 001S0610 00 6 2016-04-01 2018-01-01 CA $250.00 004S0612 00 6 2020-03-01 9901-01-01 CA $150.00 001S0612 00 6 2020-03-01 9901-01-01 CA $150.00 004S0612 00 6 2019-03-01 2020-03-01 CA $398.21 001S0612 00 6 2018-03-01 2019-03-01 CA $398.21 001S0612 00 6 2018-01-01 2018-03-01 CA $398.21 001S0612 00 6 2018-01-01 2020-03-01 CA $213.00 004S0612 00 6 2017-03-01 2018-01-01 CA $398.21 001S0612 00 6 2016-04-01 2017-03-01 CA $225.00 001S0613 00 6 2018-03-01 9901-01-01 CA $179.91 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 61 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

S0613 00 6 2018-01-01 2018-03-01 CA $179.91 001S0613 00 6 2018-01-01 9901-01-01 CA $50.00 004S0613 00 6 2017-03-01 2018-01-01 CA $179.91 001S0613 00 6 2016-04-01 2017-03-01 CA $50.00 001S0621 00 6 2018-01-01 9901-01-01 CA $150.00 001S0621 00 6 2018-01-01 9901-01-01 CA $150.00 004S0630 00 6 2020-03-01 9901-01-01 CA $130.00 001S0630 00 6 2019-03-01 2020-03-01 CA $130.00 001S0630 00 6 2018-03-01 2019-03-01 CA $80.00 001S0630 00 6 2018-03-01 9901-01-01 CA $80.00 004S0630 00 6 2018-01-01 2018-03-01 CA $80.00 001S0630 00 6 2018-01-01 2018-03-01 CA $80.00 004S0630 00 6 2017-03-01 2018-01-01 CA $80.00 001S0630 00 6 2016-04-01 2017-03-01 CA $80.00 001S0630 00 6 2016-04-01 2018-01-01 CA $80.00 004S1015 00 G 2020-03-01 9901-01-01 CA $60.00 001S1015 00 G 2020-03-01 9901-01-01 CA $60.00 004S1015 00 G 2019-03-01 2020-03-01 CA $300.00 001S1015 00 G 2019-03-01 2020-03-01 CA $300.00 004S1015 00 G 2018-03-01 2019-03-01 CA $300.00 001S1015 00 G 2018-03-01 2019-03-01 CA $300.00 004S1015 00 G 2018-01-01 2018-03-01 CA $250.00 001S1015 00 G 2018-01-01 2018-03-01 CA $250.00 004S1015 00 G 2017-03-01 2018-01-01 CA $250.00 001S1015 00 G 2017-03-01 2018-01-01 CA $250.00 004S1015 00 G 2016-04-01 2017-03-01 CA $250.00 001S1015 00 G 2016-04-01 2017-03-01 CA $250.00 004S1016 00 G 2020-03-01 9901-01-01 CA $35.00 001S1016 00 G 2020-03-01 9901-01-01 CA $35.00 004S1016 00 G 2019-03-01 2020-03-01 CA $35.00 001S1016 00 G 2019-03-01 2020-03-01 CA $35.00 004S1016 00 G 2018-03-01 2019-03-01 CA $32.72 001S1016 00 G 2018-03-01 2019-03-01 CA $32.72 004S1016 00 G 2018-01-01 2018-03-01 CA $31.33 001S1016 00 G 2018-01-01 2018-03-01 CA $31.33 004S1016 00 G 2017-03-01 2018-01-01 CA $31.33 001S1016 00 G 2017-03-01 2018-01-01 CA $31.33 004S1016 00 G 2016-04-01 2017-03-01 CA $31.33 001S1040 00 G 2021-03-01 9901-01-01 CA $4,200.00 001S1040 00 G 2021-03-01 9901-01-01 CA $4,200.00 004S1040 00 G 2019-03-01 2021-03-01 CA $5,400.00 001S1040 00 G 2019-03-01 2021-03-01 CA $5,400.00 004S1040 00 G 2018-03-01 2019-03-01 CA $5,400.00 001S1040 00 G 2018-03-01 2019-03-01 CA $5,400.00 004S1040 00 G 2018-01-01 2018-03-01 CA $5,400.00 001S1040 00 G 2018-01-01 2018-03-01 CA $5,400.00 004S1040 00 G 2017-03-01 2018-01-01 CA $5,400.00 001S1040 00 G 2017-03-01 2018-01-01 CA $5,400.00 004S1040 00 G 2016-04-01 2017-03-01 CA $4,000.00 001S1040 00 G 2016-04-01 2017-03-01 CA $4,000.00 004S1090 26 P 2018-01-01 9901-01-01 CA $3,822.50 001S1090 26 P 2018-01-01 9901-01-01 CA $3,822.50 004S1090 26 P 2017-07-12 2018-01-01 CA $3,822.50 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 62 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

S1090 26 P 2017-07-12 2018-01-01 CA $3,822.50 004S2066 00 2 2018-01-01 9901-01-01 CA $2,822.82 001S2067 00 2 2018-01-01 9901-01-01 CA $2,822.82 001S2117 00 0 2018-01-01 9901-01-01 CA $6,661.67 001S2117 00 0 2018-01-01 9901-01-01 CA $6,661.67 004S2140 00 6 2018-01-01 9901-01-01 CA $200.00 001S2140 00 6 2018-01-01 9901-01-01 CA $200.00 004S2900 00 2 2018-01-01 9901-01-01 CA $7,761.07 001S2900 00 2 2018-01-01 9901-01-01 CA $2,500.00 004S2900 00 2 2017-03-01 2018-01-01 CA $7,761.07 001S2900 00 2 2016-04-01 2017-03-01 CA $7,761.07 001S3000 00 6 2018-01-01 9901-01-01 CA $45.00 001S3000 00 6 2018-01-01 9901-01-01 CA $45.00 004S3000 00 6 2016-12-01 2018-01-01 CA $45.00 001S3000 00 6 2016-12-01 2018-01-01 CA $45.00 004S3005 00 6 2018-01-05 9901-01-01 CA $60.00 001S3005 00 6 2018-01-05 9901-01-01 CA $60.00 004S3600 00 8 2018-03-01 9901-01-01 CA $27.00 001S3600 00 8 2018-01-01 2018-03-01 CA $27.00 001S3600 00 8 2018-01-01 9901-01-01 CA $27.00 004S3600 00 8 2016-07-29 2018-01-01 CA $27.00 001S3600 00 8 2016-07-29 2018-01-01 CA $27.00 004S4005 00 6 2019-03-01 9901-01-01 CA $454.50 001S4005 00 6 2018-01-01 2019-03-01 CA $166.80 001S4005 00 6 2018-01-01 9901-01-01 CA $166.80 004S4989 00 6 2018-01-01 9901-01-01 CA $2,332.00 001S4989 00 6 2018-01-01 9901-01-01 CA $2,332.00 004S4989 00 6 2016-12-09 2018-01-01 CA $2,332.00 001S4989 00 6 2016-12-09 2018-01-01 CA $2,332.00 004S5001 00 6 2018-01-01 9901-01-01 CA $176.00 001S5001 00 6 2018-01-01 9901-01-01 CA $176.00 004S5012 00 G 2018-01-01 9901-01-01 CA $11.80 001S5012 00 G 2018-01-01 9901-01-01 CA $11.80 004S5105 00 6 2018-03-01 9901-01-01 CA $29.41 001S5105 00 6 2018-01-01 2018-03-01 CA $29.41 001S5105 00 6 2018-01-01 9901-01-01 CA $29.41 004S5105 00 6 2017-08-07 2018-01-01 CA $29.41 001S5105 00 6 2017-08-07 2018-01-01 CA $29.41 004S5108 00 6 2018-01-01 9901-01-01 CA $31.25 001S5108 00 6 2018-01-01 9901-01-01 CA $31.25 004S5110 00 6 2018-01-01 9901-01-01 CA $31.25 001S5110 00 6 2018-01-01 9901-01-01 CA $31.25 004S5110 00 6 2016-04-01 2018-01-01 CA $31.25 001S5115 00 6 2018-01-01 9901-01-01 CA $37.50 001S5115 00 6 2018-01-01 9901-01-01 CA $37.50 004S5115 00 6 2016-04-01 2018-01-01 CA $37.50 001S5115 00 6 2016-04-01 2018-01-01 CA $37.50 004S5498 00 6 2019-03-01 9901-01-01 CA $250.00 001S5498 00 6 2019-03-01 9901-01-01 CA $250.00 004S5498 00 6 2018-07-28 2019-03-01 CA $250.00 001S5501 00 6 2018-03-01 9901-01-01 CA $1,100.00 001S5501 00 6 2018-03-01 9901-01-01 CA $1,100.00 004S5501 00 6 2018-01-01 2018-03-01 CA $1,100.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 63 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

S5501 00 6 2018-01-01 2018-03-01 CA $1,100.00 004S5501 00 6 2016-04-01 2018-01-01 CA $1,100.00 001S5501 00 6 2016-04-01 2018-01-01 CA $1,100.00 004S8100 00 G 2018-01-01 9901-01-01 CA $65.00 001S8100 00 G 2018-01-01 9901-01-01 CA $65.00 004S8100 00 G 2017-03-01 2018-01-01 CA $65.00 001S8100 00 G 2017-03-01 2018-01-01 CA $65.00 004S8101 00 G 2020-03-01 9901-01-01 CA $31.00 001S8101 00 G 2020-03-01 9901-01-01 CA $31.00 004S8101 00 G 2018-01-01 2020-03-01 CA $65.00 001S8101 00 G 2018-01-01 2020-03-01 CA $65.00 004S8101 00 G 2016-04-01 2018-01-01 CA $65.00 001S8101 00 G 2016-04-01 2018-01-01 CA $65.00 004S8265 00 2 2018-01-01 9901-01-01 CA $85.81 001S8265 00 2 2018-01-01 9901-01-01 CA $85.81 004S8270 00 G 2021-03-01 9901-01-01 CA $382.15 001S8270 00 G 2021-03-01 9901-01-01 CA $382.15 004S8270 00 G 2018-03-01 2021-03-01 CA $282.00 001S8270 00 G 2018-03-01 2021-03-01 CA $282.00 004S8270 00 G 2018-01-01 2018-03-01 CA $282.00 001S8270 00 G 2018-01-01 2018-03-01 CA $282.00 004S8270 00 G 2017-03-01 2018-01-01 CA $282.00 001S8270 00 G 2017-03-01 2018-01-01 CA $282.00 004S8270 00 G 2016-04-01 2017-03-01 CA $282.00 001S8270 00 G 2016-04-01 2017-03-01 CA $282.00 004S8415 00 G 2018-01-01 9901-01-01 CA $200.00 001S8415 00 G 2018-01-01 9901-01-01 CA $200.00 004S8424 00 G 2018-01-01 9901-01-01 CA $171.00 001S8424 00 G 2018-01-01 9901-01-01 CA $171.00 004S8424 00 G 2017-12-06 2018-01-01 CA $171.00 001S8424 00 G 2017-12-06 2018-01-01 CA $171.00 004S8431 00 G 2018-01-01 9901-01-01 CA $55.00 001S8431 00 G 2018-01-01 9901-01-01 CA $55.00 004S8431 00 G 2017-03-01 2018-01-01 CA $55.00 001S8431 00 G 2017-03-01 2018-01-01 CA $55.00 004S8450 00 G 2020-03-01 9901-01-01 CA $50.00 001S8450 00 G 2020-03-01 9901-01-01 CA $50.00 004S8450 00 G 2019-03-01 2020-03-01 CA $48.00 001S8450 00 G 2019-03-01 2020-03-01 CA $48.00 004S8450 00 G 2018-03-01 2019-03-01 CA $20.00 001S8450 00 G 2018-03-01 2019-03-01 CA $20.00 004S8450 00 G 2018-01-01 2018-03-01 CA $20.00 001S8450 00 G 2018-01-01 2018-03-01 CA $20.00 004S8450 00 G 2017-03-01 2018-01-01 CA $20.00 001S8450 00 G 2017-03-01 2018-01-01 CA $20.00 004S8450 00 G 2016-04-01 2017-03-01 CA $20.00 001S8451 00 G 2020-03-01 9901-01-01 CA $34.55 001S8451 00 G 2020-03-01 9901-01-01 CA $34.55 004S8451 00 G 2019-03-01 2020-03-01 CA $56.00 001S8451 00 G 2019-03-01 2020-03-01 CA $56.00 004S8451 00 G 2018-03-01 2019-03-01 CA $56.00 001S8451 00 G 2018-03-01 2019-03-01 CA $56.00 004S8451 00 G 2018-01-01 2018-03-01 CA $56.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 64 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

S8451 00 G 2018-01-01 2018-03-01 CA $56.00 004S8451 00 G 2017-03-01 2018-01-01 CA $56.00 001S8451 00 G 2017-03-01 2018-01-01 CA $56.00 004S8451 00 G 2016-04-01 2017-03-01 CA $56.00 001S8451 00 G 2016-04-01 2017-03-01 CA $56.00 004S8940 00 G 2018-01-01 9901-01-01 CA $195.00 001S8940 00 G 2018-01-01 9901-01-01 CA $195.00 004S8999 00 G 2018-01-01 9901-01-01 CA $23.84 001S8999 00 G 2018-01-01 9901-01-01 CA $23.84 004S9083 00 6 2020-03-01 9901-01-01 CA $1,000.00 001S9083 00 6 2019-03-01 2020-03-01 CA $1,000.00 001S9083 00 6 2018-01-01 2019-03-01 CA $150.00 001S9083 00 6 2018-01-01 9901-01-01 CA $125.00 004S9083 00 6 2017-03-01 2018-01-01 CA $150.00 001S9083 00 6 2017-03-01 2018-01-01 CA $125.00 004S9083 00 6 2016-04-01 2017-03-01 CA $150.00 001S9088 00 6 2020-03-01 9901-01-01 CA $88.00 001S9088 00 6 2020-03-01 9901-01-01 CA $88.00 004S9088 00 6 2019-03-01 2020-03-01 CA $110.00 001S9088 00 6 2019-03-01 2020-03-01 CA $110.00 004S9088 00 6 2018-03-01 2019-03-01 CA $110.00 001S9088 00 6 2018-03-01 2019-03-01 CA $110.00 004S9088 00 6 2018-01-01 2018-03-01 CA $110.00 001S9088 00 6 2018-01-01 2018-03-01 CA $110.00 004S9088 00 6 2017-03-01 2018-01-01 CA $110.00 001S9088 00 6 2017-03-01 2018-01-01 CA $110.00 004S9088 00 6 2016-04-01 2017-03-01 CA $110.00 001S9088 00 6 2016-04-01 2017-03-01 CA $110.00 004S9090 00 2 2018-01-01 9901-01-01 CA $145.00 001S9090 00 2 2018-01-01 9901-01-01 CA $60.00 004S9090 00 2 2017-03-01 2018-01-01 CA $145.00 001S9090 00 2 2016-04-01 2017-03-01 CA $70.00 001S9097 00 6 2018-01-01 9901-01-01 CA $180.00 001S9097 00 6 2018-01-01 9901-01-01 CA $180.00 004S9126 00 6 2020-03-01 9901-01-01 CA $193.89 001S9126 00 6 2019-03-01 2020-03-01 CA $350.00 001S9126 00 6 2018-03-01 2019-03-01 CA $223.07 001S9126 00 6 2018-01-01 2018-03-01 CA $184.00 001S9126 00 6 2018-01-01 9901-01-01 CA $184.00 004S9126 00 6 2017-03-01 2018-01-01 CA $184.00 001S9126 00 6 2017-03-01 2018-01-01 CA $184.00 004S9126 00 6 2016-11-30 2017-03-01 CA $184.00 001S9126 00 6 2016-11-30 2017-03-01 CA $184.00 004S9129 00 D 2018-01-01 9901-01-01 CA $319.00 001S9129 00 D 2018-01-01 9901-01-01 CA $319.00 004S9131 00 D 2020-03-01 9901-01-01 CA $200.54 001S9131 00 D 2020-03-01 9901-01-01 CA $200.54 004S9131 00 D 2018-03-01 2020-03-01 CA $319.00 001S9131 00 D 2018-03-01 2020-03-01 CA $319.00 004S9131 00 D 2018-01-01 2018-03-01 CA $319.00 001S9131 00 D 2018-01-01 2018-03-01 CA $319.00 004S9131 00 D 2017-03-01 2018-01-01 CA $319.00 001S9131 00 D 2017-03-01 2018-01-01 CA $319.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 65 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

S9131 00 D 2016-04-01 2017-03-01 CA $319.00 001S9131 00 D 2016-04-01 2017-03-01 CA $319.00 004S9152 00 6 2018-01-01 9901-01-01 CA $175.00 001S9152 00 6 2018-01-01 9901-01-01 CA $175.00 004S9330 00 6 2018-01-01 9901-01-01 CA $586.95 001S9330 00 6 2018-01-01 9901-01-01 CA $586.95 004S9338 00 6 2020-03-01 9901-01-01 CA $250.00 001S9338 00 6 2020-03-01 9901-01-01 CA $250.00 004S9338 00 6 2019-03-01 2020-03-01 CA $478.19 001S9338 00 6 2019-03-01 2020-03-01 CA $350.00 004S9338 00 6 2018-03-01 2019-03-01 CA $478.19 001S9338 00 6 2018-01-01 2018-03-01 CA $400.00 001S9338 00 6 2018-01-01 2019-03-01 CA $350.00 004S9338 00 6 2017-03-01 2018-01-01 CA $400.00 001S9338 00 6 2016-04-01 2017-03-01 CA $400.00 001S9338 00 6 2016-04-01 2018-01-01 CA $350.00 004S9340 00 6 2019-03-01 9901-01-01 CA $250.00 001S9340 00 6 2019-03-01 9901-01-01 CA $136.00 004S9340 00 6 2018-03-01 2019-03-01 CA $250.00 001S9340 00 6 2018-01-01 2018-03-01 CA $136.00 001S9340 00 6 2018-01-01 2019-03-01 CA $136.00 004S9340 00 6 2016-04-01 2018-01-01 CA $136.00 001S9340 00 6 2016-04-01 2018-01-01 CA $136.00 004S9342 00 6 2020-03-01 9901-01-01 CA $15.00 001S9342 00 6 2020-03-01 9901-01-01 CA $15.00 004S9342 00 6 2018-03-01 2020-03-01 CA $72.48 001S9342 00 6 2018-01-01 2018-03-01 CA $66.00 001S9342 00 6 2018-01-01 2020-03-01 CA $60.00 004S9342 00 6 2017-03-01 2018-01-01 CA $66.00 001S9342 00 6 2017-03-01 2018-01-01 CA $60.00 004S9342 00 6 2016-04-01 2017-03-01 CA $66.00 001S9343 00 6 2018-03-01 9901-01-01 CA $218.27 001S9343 00 6 2018-01-01 2018-03-01 CA $218.27 001S9343 00 6 2018-01-01 9901-01-01 CA $218.27 004S9343 00 6 2017-03-01 2018-01-01 CA $218.27 001S9343 00 6 2017-03-01 2018-01-01 CA $218.27 004S9343 00 6 2016-01-08 2017-03-01 CA $218.27 001S9343 00 6 2016-01-08 2017-03-01 CA $218.27 004S9351 00 6 2018-03-01 9901-01-01 CA $321.20 001S9351 00 6 2018-01-01 2018-03-01 CA $321.20 001S9351 00 6 2018-01-01 9901-01-01 CA $321.20 004S9351 00 6 2017-09-06 2018-01-01 CA $321.20 001S9351 00 6 2017-09-06 2018-01-01 CA $321.20 004S9365 00 6 2018-01-01 9901-01-01 CA $136.00 001S9365 00 6 2018-01-01 9901-01-01 CA $136.00 004S9366 00 6 2018-01-01 9901-01-01 CA $650.00 001S9366 00 6 2018-01-01 9901-01-01 CA $649.51 004S9366 00 6 2017-03-01 2018-01-01 CA $650.00 001S9370 00 6 2020-10-03 9901-01-01 CA $306.90 001S9374 00 6 2020-03-01 9901-01-01 CA $130.00 001S9374 00 6 2020-03-01 9901-01-01 CA $130.00 004S9374 00 6 2018-03-01 2020-03-01 CA $332.00 001S9374 00 6 2018-01-01 2018-03-01 CA $332.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 66 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

S9374 00 6 2018-01-01 2020-03-01 CA $332.00 004S9374 00 6 2017-06-13 2018-01-01 CA $332.00 001S9374 00 6 2017-06-13 2018-01-01 CA $332.00 004S9375 00 6 2018-03-01 9901-01-01 CA $2,714.64 001S9375 00 6 2018-03-01 9901-01-01 CA $2,714.64 004S9375 00 6 2018-01-01 2018-03-01 CA $2,714.64 001S9375 00 6 2018-01-01 2018-03-01 CA $2,714.64 004S9375 00 6 2017-03-01 2018-01-01 CA $2,714.64 001S9375 00 6 2017-03-01 2018-01-01 CA $2,714.64 004S9375 00 6 2016-04-01 2017-03-01 CA $2,714.64 001S9375 00 6 2016-04-01 2017-03-01 CA $2,714.64 004S9430 00 6 2021-03-01 9901-01-01 CA $201.25 001S9430 00 6 2020-03-01 2021-03-01 CA $250.00 001S9430 00 6 2019-03-01 2020-03-01 CA $201.25 001S9430 00 6 2018-03-01 2019-03-01 CA $201.25 001S9430 00 6 2018-01-01 2018-03-01 CA $201.25 001S9430 00 6 2018-01-01 9901-01-01 CA $201.25 004S9430 00 6 2017-03-01 2018-01-01 CA $201.25 001S9430 00 6 2017-03-01 2018-01-01 CA $201.25 004S9430 00 6 2016-04-01 2017-03-01 CA $201.25 001S9430 00 6 2016-04-01 2017-03-01 CA $201.25 004S9433 00 G 2019-03-01 9901-01-01 CA $35.00 001S9433 00 G 2019-03-01 9901-01-01 CA $35.00 004S9433 00 G 2018-07-28 2019-03-01 CA $35.00 001S9433 00 G 2018-07-28 2019-03-01 CA $35.00 004S9435 NU G 2020-04-25 9901-01-01 CA $633.67 001S9435 NU G 2020-04-25 9901-01-01 CA $633.67 004S9441 00 6 2018-01-01 9901-01-01 CA $50.00 001S9441 00 6 2018-01-01 9901-01-01 CA $50.00 004S9441 00 6 2017-03-01 2018-01-01 CA $50.00 001S9441 00 6 2016-01-29 2017-03-01 CA $50.00 001S9441 00 6 2016-01-29 2018-01-01 CA $50.00 004S9443 00 6 2020-03-01 9901-01-01 CA $146.00 001S9443 00 6 2019-03-01 2020-03-01 CA $250.00 001S9443 00 6 2018-03-01 2019-03-01 CA $140.00 001S9443 00 6 2018-01-01 2018-03-01 CA $140.00 001S9443 00 6 2018-01-01 9901-01-01 CA $72.00 004S9443 00 6 2017-03-01 2018-01-01 CA $140.00 001S9443 00 6 2016-04-01 2017-03-01 CA $140.00 001S9451 00 6 2018-01-01 9901-01-01 CA $43.99 001S9451 00 6 2018-01-01 9901-01-01 CA $43.99 004S9451 00 6 2017-03-01 2018-01-01 CA $43.99 001S9451 00 6 2017-03-01 2018-01-01 CA $43.99 004S9451 00 6 2016-04-01 2017-03-01 CA $43.99 001S9451 00 6 2016-04-01 2017-03-01 CA $43.99 004S9452 00 6 2018-01-01 9901-01-01 CA $100.00 001S9452 00 6 2018-01-01 9901-01-01 CA $100.00 004S9452 00 6 2017-03-01 2018-01-01 CA $100.00 001S9452 00 6 2017-03-01 2018-01-01 CA $100.00 004S9455 00 6 2018-01-01 9901-01-01 CA $130.20 001S9455 00 6 2018-01-01 9901-01-01 CA $130.20 004S9455 00 6 2016-12-01 2018-01-01 CA $130.20 001S9455 00 6 2016-12-01 2018-01-01 CA $130.20 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 67 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

S9465 00 6 2018-01-01 9901-01-01 CA $86.00 001S9465 00 6 2018-01-01 9901-01-01 CA $86.00 004S9465 00 6 2016-08-09 2018-01-01 CA $86.00 001S9465 00 6 2016-08-09 2018-01-01 CA $86.00 004S9470 00 6 2020-03-01 9901-01-01 CA $493.90 001S9470 00 6 2018-01-01 2020-03-01 CA $185.00 001S9470 00 6 2018-01-01 9901-01-01 CA $185.00 004S9484 00 C 2019-03-01 9901-01-01 CA $1,176.88 001S9484 00 C 2019-03-01 9901-01-01 CA $1,176.88 004S9484 00 C 2018-03-01 2019-03-01 CA $1,176.88 001S9484 00 C 2018-03-01 2019-03-01 CA $1,176.88 004S9484 00 C 2018-01-01 2018-03-01 CA $1,176.88 001S9484 00 C 2018-01-01 2018-03-01 CA $1,176.88 004S9484 00 C 2017-03-01 2018-01-01 CA $1,176.88 001S9484 00 C 2017-03-01 2018-01-01 CA $1,176.88 004S9485 00 C 2018-01-01 9901-01-01 CA $1,915.00 001S9485 00 C 2018-01-01 9901-01-01 CA $1,915.00 004S9485 00 C 2016-01-29 2018-01-01 CA $1,915.00 001S9485 00 C 2016-01-29 2018-01-01 CA $1,915.00 004S9494 00 6 2018-01-01 9901-01-01 CA $395.00 001S9494 00 6 2018-01-01 9901-01-01 CA $395.00 004S9500 00 6 2020-03-01 9901-01-01 CA $300.00 001S9500 00 6 2020-03-01 9901-01-01 CA $300.00 004S9500 00 6 2018-03-01 2020-03-01 CA $4,716.00 001S9500 00 6 2018-03-01 2020-03-01 CA $4,716.00 004S9500 00 6 2018-01-01 2018-03-01 CA $4,716.00 001S9500 00 6 2018-01-01 2018-03-01 CA $4,716.00 004S9500 00 6 2016-04-01 2018-01-01 CA $4,716.00 001S9500 00 6 2016-04-01 2018-01-01 CA $4,716.00 004S9501 00 6 2020-03-01 9901-01-01 CA $513.06 001S9501 00 6 2018-03-01 2020-03-01 CA $397.64 001S9501 00 6 2018-01-01 2018-03-01 CA $266.66 001S9501 00 6 2018-01-01 9901-01-01 CA $266.66 004S9501 00 6 2016-04-01 2018-01-01 CA $266.66 001S9501 00 6 2016-04-01 2018-01-01 CA $266.66 004S9502 00 6 2018-03-01 9901-01-01 CA $944.62 001S9502 00 6 2018-03-01 9901-01-01 CA $944.62 004S9502 00 6 2018-01-01 2018-03-01 CA $944.62 001S9502 00 6 2018-01-01 2018-03-01 CA $944.62 004S9502 00 6 2016-04-01 2018-01-01 CA $944.62 001S9502 00 6 2016-04-01 2018-01-01 CA $944.62 004S9503 00 6 2018-01-01 9901-01-01 CA $235.00 001S9503 00 6 2018-01-01 9901-01-01 CA $235.00 004S9503 00 6 2017-12-12 2018-01-01 CA $235.00 001S9503 00 6 2017-12-12 2018-01-01 CA $235.00 004S9504 00 6 2020-03-01 9901-01-01 CA $250.00 001S9504 00 6 2018-01-01 2020-03-01 CA $250.00 001S9504 00 6 2018-01-01 9901-01-01 CA $250.00 004S9504 00 6 2016-06-01 2018-01-01 CA $250.00 001S9504 00 6 2016-06-01 2018-01-01 CA $250.00 004S9542 00 6 2018-01-01 9901-01-01 CA $2,714.64 001S9542 00 6 2018-01-01 9901-01-01 CA $2,714.64 004S9810 00 6 2020-10-03 9901-01-01 CA $250.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 68 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

T1000 00 6 2018-01-01 9901-01-01 CA $9.04 001T1000 00 6 2018-01-01 9901-01-01 CA $9.04 004T1001 00 6 2018-03-01 9901-01-01 CA $109.27 001T1001 00 6 2018-01-01 2018-03-01 CA $98.68 001T1001 00 6 2018-01-01 9901-01-01 CA $98.68 004T1014 00 6 2020-03-01 9901-01-01 CA $0.27 001T1014 00 6 2020-03-01 9901-01-01 CA $0.27 004T1014 00 6 2019-03-01 2020-03-01 CA $1.25 001T1014 00 6 2018-03-01 2019-03-01 CA $1.25 001T1014 00 6 2018-01-01 2018-03-01 CA $0.50 001T1014 00 6 2018-01-01 2020-03-01 CA $0.50 004T1014 00 6 2017-03-01 2018-01-01 CA $0.50 001T1014 00 6 2017-03-01 2018-01-01 CA $0.50 004T1014 00 6 2017-01-01 2017-03-01 CA $0.50 001T1014 00 6 2016-08-25 2017-01-01 CA $0.50 001T1014 00 6 2016-08-25 2017-03-01 CA $0.50 004T1015 00 6 2019-03-01 9901-01-01 CA $45.00 001T1015 00 6 2018-01-01 2019-03-01 CA $30.00 001T1015 00 6 2018-01-01 9901-01-01 CA $30.00 004T1015 00 6 2017-11-22 2018-01-01 CA $30.00 001T1015 00 6 2017-11-22 2018-01-01 CA $30.00 004T1016 00 6 2018-03-01 9901-01-01 CA $52.63 001T1016 00 6 2018-03-01 9901-01-01 CA $52.63 004T1016 00 6 2018-01-01 2018-03-01 CA $52.63 001T1016 00 6 2018-01-01 2018-03-01 CA $52.63 004T1016 00 6 2017-03-01 2018-01-01 CA $52.63 001T1016 00 6 2017-03-01 2018-01-01 CA $52.63 004T1016 00 6 2016-04-01 2017-03-01 CA $52.63 001T1016 00 6 2016-04-01 2017-03-01 CA $52.63 004T1017 00 6 2018-03-01 9901-01-01 CA $67.50 001T1017 00 6 2018-01-01 2018-03-01 CA $61.50 001T1017 00 6 2018-01-01 9901-01-01 CA $25.40 004T1017 00 6 2016-04-01 2018-01-01 CA $61.50 001T1030 00 6 2018-01-01 9901-01-01 CA $231.42 001T1030 00 6 2018-01-01 9901-01-01 CA $231.42 004T1030 00 6 2016-04-01 2018-01-01 CA $231.42 001T1030 00 6 2016-04-01 2018-01-01 CA $231.42 004T1505 NU 6 2018-01-01 9901-01-01 CA $7,495.00 001T1505 NU 6 2018-01-01 9901-01-01 CA $7,495.00 004T2042 00 6 2020-03-01 9901-01-01 CA $233.75 001T2042 00 6 2019-03-01 2020-03-01 CA $291.56 001T2042 00 6 2018-03-01 2019-03-01 CA $217.07 001T2042 00 6 2018-01-01 2018-03-01 CA $206.79 001T2042 00 6 2018-01-01 9901-01-01 CA $206.79 004T2042 00 6 2017-03-01 2018-01-01 CA $206.79 001T2042 00 6 2017-03-01 2018-01-01 CA $206.79 004T2045 00 6 2020-10-03 9901-01-01 CA $880.35 001T2048 00 C 2018-01-01 9901-01-01 CA $48.47 004T4521 NU G 2021-03-01 9901-01-01 CA $0.88 001T4521 NU G 2021-03-01 9901-01-01 CA $0.88 004T4521 NU G 2020-03-01 2021-03-01 CA $0.48 001T4521 NU G 2020-03-01 2021-03-01 CA $0.48 004T4521 NU G 2019-03-01 2020-03-01 CA $0.48 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 69 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

T4521 NU G 2019-03-01 2020-03-01 CA $0.48 004T4521 NU G 2018-07-28 2019-03-01 CA $0.48 001T4521 NU G 2018-07-28 2019-03-01 CA $0.48 004T4521 00 G 2021-03-01 9901-01-01 CA $1.47 001T4521 00 G 2021-03-01 9901-01-01 CA $1.47 004T4521 00 G 2020-03-01 2021-03-01 CA $1.40 001T4521 00 G 2020-03-01 2021-03-01 CA $1.40 004T4521 00 G 2019-03-01 2020-03-01 CA $0.48 001T4521 00 G 2019-03-01 2020-03-01 CA $0.48 004T4521 00 G 2018-07-28 2019-03-01 CA $0.48 001T4521 00 G 2018-07-28 2019-03-01 CA $0.48 004T4533 00 G 2018-01-01 9901-01-01 CA $0.45 001T4533 00 G 2018-01-01 9901-01-01 CA $0.45 004T4533 00 G 2016-07-01 2018-01-01 CA $0.45 001T4533 00 G 2016-07-01 2018-01-01 CA $0.45 004T4541 00 G 2018-01-01 9901-01-01 CA $0.60 001T4541 00 G 2018-01-01 9901-01-01 CA $0.60 004U0005 00 8 2021-01-23 2021-03-01 CA $25.00 001V2025 00 G 2018-01-01 9901-01-01 CA $147.00 001V2025 00 G 2018-01-01 9901-01-01 CA $147.00 004V2702 00 G 2018-01-01 9901-01-01 CA $8.19 001V2702 00 G 2018-01-01 9901-01-01 CA $8.19 004V2781 00 G 2021-03-01 9901-01-01 CA $400.00 001V2781 00 G 2021-03-01 9901-01-01 CA $400.00 004V2781 00 G 2018-01-01 2021-03-01 CA $200.00 001V2781 00 G 2018-01-01 2021-03-01 CA $200.00 004V2781 00 G 2017-03-01 2018-01-01 CA $200.00 001V2781 00 G 2017-03-01 2018-01-01 CA $200.00 004V2781 00 G 2016-04-01 2017-03-01 CA $200.00 001V2781 00 G 2016-04-01 2017-03-01 CA $200.00 004V2785 00 G 2019-03-01 9901-01-01 CA $13,975.00 001V2785 00 G 2019-03-01 9901-01-01 CA $13,975.00 004V2785 00 G 2018-03-01 2019-03-01 CA $13,975.00 001V2785 00 G 2018-03-01 2019-03-01 CA $13,975.00 004V2785 00 G 2018-01-01 2018-03-01 CA $13,653.00 001V2785 00 G 2018-01-01 2018-03-01 CA $13,653.00 004V2785 00 G 2016-04-01 2018-01-01 CA $13,653.00 001V2785 00 G 2016-04-01 2018-01-01 CA $13,653.00 004V2787 00 G 2019-03-01 9901-01-01 CA $4,685.00 001V2787 00 G 2019-03-01 9901-01-01 CA $4,685.00 004V2787 00 G 2018-03-01 2019-03-01 CA $2,970.00 001V2787 00 G 2018-03-01 2019-03-01 CA $2,970.00 004V2787 00 G 2018-01-01 2018-03-01 CA $1,736.00 001V2787 00 G 2018-01-01 2018-03-01 CA $1,736.00 004V2787 00 G 2017-03-01 2018-01-01 CA $1,736.00 001V2787 00 G 2017-03-01 2018-01-01 CA $1,736.00 004V2787 00 G 2016-04-01 2017-03-01 CA $1,237.50 001V2787 00 G 2016-04-01 2017-03-01 CA $1,237.50 004V2788 00 G 2019-03-01 9901-01-01 CA $3,920.38 001V2788 00 G 2019-03-01 9901-01-01 CA $3,920.38 004V2788 00 G 2018-03-01 2019-03-01 CA $3,920.38 001V2788 00 G 2018-03-01 2019-03-01 CA $3,920.38 004V2788 00 G 2018-01-01 2018-03-01 CA $3,920.38 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 70 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

V2788 00 G 2018-01-01 2018-03-01 CA $3,920.38 004V2788 00 G 2017-03-01 2018-01-01 CA $3,920.38 001V2788 00 G 2017-03-01 2018-01-01 CA $3,920.38 004V2788 00 G 2016-04-01 2017-03-01 CA $3,920.38 001V2788 00 G 2016-04-01 2017-03-01 CA $3,920.38 004V2790 00 G 2020-03-01 9901-01-01 CA $35,000.00 001V2790 00 G 2020-03-01 9901-01-01 CA $35,000.00 004V2790 00 G 2019-03-01 2020-03-01 CA $35,000.00 001V2790 00 G 2019-03-01 2020-03-01 CA $35,000.00 004V2790 00 G 2018-03-01 2019-03-01 CA $12,712.50 001V2790 00 G 2018-03-01 2019-03-01 CA $12,712.50 004V2790 00 G 2018-01-01 2018-03-01 CA $8,000.00 001V2790 00 G 2018-01-01 2018-03-01 CA $8,000.00 004V2790 00 G 2017-03-01 2018-01-01 CA $8,000.00 001V2790 00 G 2017-03-01 2018-01-01 CA $8,000.00 004V5060 00 G 2018-01-01 9901-01-01 CA $6,000.00 001V5060 00 G 2018-01-01 9901-01-01 CA $6,000.00 004V5110 00 G 2018-01-01 9901-01-01 CA $500.00 001V5110 00 G 2018-01-01 9901-01-01 CA $500.00 004V5140 00 G 2018-01-01 9901-01-01 CA $3,942.40 001V5140 00 G 2018-01-01 9901-01-01 CA $3,942.40 004V5160 00 G 2021-03-01 9901-01-01 CA $423.31 001V5160 00 G 2021-03-01 9901-01-01 CA $423.31 004V5160 00 G 2020-03-01 2021-03-01 CA $1,500.00 001V5160 00 G 2020-03-01 2021-03-01 CA $1,500.00 004V5160 00 G 2018-03-01 2020-03-01 CA $1,100.00 001V5160 00 G 2018-03-01 2020-03-01 CA $1,100.00 004V5160 00 G 2018-01-01 2018-03-01 CA $1,100.00 001V5160 00 G 2018-01-01 2018-03-01 CA $1,100.00 004V5160 00 G 2017-03-01 2018-01-01 CA $1,100.00 001V5160 00 G 2017-03-01 2018-01-01 CA $1,100.00 004V5160 00 G 2016-04-01 2017-03-01 CA $1,100.00 001V5160 00 G 2016-04-01 2017-03-01 CA $1,100.00 004V5180 00 G 2018-03-01 9901-01-01 CA $3,225.00 001V5180 00 G 2018-03-01 9901-01-01 CA $3,225.00 004V5180 00 G 2018-01-01 2018-03-01 CA $2,693.12 001V5180 00 G 2018-01-01 2018-03-01 CA $2,693.12 004V5180 00 G 2016-01-08 2018-01-01 CA $2,693.12 001V5180 00 G 2016-01-08 2018-01-01 CA $2,693.12 004V5241 00 G 2018-01-01 9901-01-01 CA $737.28 001V5241 00 G 2018-01-01 9901-01-01 CA $737.28 004V5253 00 G 2018-01-01 9901-01-01 CA $6,500.00 001V5253 00 G 2018-01-01 9901-01-01 CA $6,500.00 004V5254 00 G 2018-01-01 9901-01-01 CA $6,400.00 001V5254 00 G 2018-01-01 9901-01-01 CA $6,400.00 004V5256 00 G 2018-01-01 9901-01-01 CA $2,235.20 001V5256 00 G 2018-01-01 9901-01-01 CA $2,235.20 004V5257 00 G 2021-03-01 9901-01-01 CA $5,195.00 001V5257 00 G 2021-03-01 9901-01-01 CA $5,195.00 004V5257 00 G 2020-03-01 2021-03-01 CA $3,795.00 001V5257 00 G 2020-03-01 2021-03-01 CA $3,795.00 004V5257 00 G 2018-03-01 2020-03-01 CA $3,295.00 001V5257 00 G 2018-03-01 2020-03-01 CA $3,295.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 71 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

V5257 00 G 2018-01-01 2018-03-01 CA $3,295.00 001V5257 00 G 2018-01-01 2018-03-01 CA $3,295.00 004V5257 00 G 2017-03-01 2018-01-01 CA $3,295.00 001V5257 00 G 2017-03-01 2018-01-01 CA $3,295.00 004V5257 00 G 2016-04-01 2017-03-01 CA $3,295.00 001V5257 00 G 2016-04-01 2017-03-01 CA $3,295.00 004V5258 00 G 2021-03-01 9901-01-01 CA $8,388.00 001V5258 00 G 2021-03-01 9901-01-01 CA $8,388.00 004V5258 00 G 2020-03-01 2021-03-01 CA $7,000.00 001V5258 00 G 2020-03-01 2021-03-01 CA $7,000.00 004V5258 00 G 2018-03-01 2020-03-01 CA $6,990.00 001V5258 00 G 2018-03-01 2020-03-01 CA $6,990.00 004V5258 00 G 2018-01-01 2018-03-01 CA $6,990.00 001V5258 00 G 2018-01-01 2018-03-01 CA $6,990.00 004V5258 00 G 2017-03-01 2018-01-01 CA $6,990.00 001V5258 00 G 2017-03-01 2018-01-01 CA $6,990.00 004V5258 00 G 2016-04-01 2017-03-01 CA $6,990.00 001V5258 00 G 2016-04-01 2017-03-01 CA $6,990.00 004V5259 00 G 2018-01-01 9901-01-01 CA $3,990.00 001V5261 00 G 2021-03-01 9901-01-01 CA $9,400.00 001V5261 00 G 2021-03-01 9901-01-01 CA $9,400.00 004V5261 00 G 2020-03-01 2021-03-01 CA $8,645.00 001V5261 00 G 2020-03-01 2021-03-01 CA $8,645.00 004V5261 00 G 2019-03-01 2020-03-01 CA $8,000.00 001V5261 00 G 2019-03-01 2020-03-01 CA $8,000.00 004V5261 00 G 2018-03-01 2019-03-01 CA $7,400.00 001V5261 00 G 2018-03-01 2019-03-01 CA $7,400.00 004V5261 00 G 2018-01-01 2018-03-01 CA $6,890.00 001V5261 00 G 2018-01-01 2018-03-01 CA $6,890.00 004V5261 00 G 2017-03-01 2018-01-01 CA $6,890.00 001V5261 00 G 2017-03-01 2018-01-01 CA $6,890.00 004V5261 00 G 2016-04-01 2017-03-01 CA $6,890.00 001V5261 00 G 2016-04-01 2017-03-01 CA $6,890.00 004V5264 00 G 2021-03-01 9901-01-01 CA $150.00 001V5264 00 G 2021-03-01 9901-01-01 CA $150.00 004V5264 00 G 2020-03-01 2021-03-01 CA $140.00 001V5264 00 G 2020-03-01 2021-03-01 CA $140.00 004V5264 00 G 2019-03-01 2020-03-01 CA $140.00 001V5264 00 G 2019-03-01 2020-03-01 CA $140.00 004V5264 00 G 2018-03-01 2019-03-01 CA $140.00 001V5264 00 G 2018-03-01 2019-03-01 CA $140.00 004V5264 00 G 2018-01-01 2018-03-01 CA $140.00 001V5264 00 G 2018-01-01 2018-03-01 CA $140.00 004V5264 00 G 2017-03-01 2018-01-01 CA $140.00 001V5264 00 G 2017-03-01 2018-01-01 CA $140.00 004V5264 00 G 2016-04-01 2017-03-01 CA $140.00 001V5264 00 G 2016-04-01 2017-03-01 CA $140.00 004V5265 00 G 2021-03-01 9901-01-01 CA $150.00 001V5265 00 G 2021-03-01 9901-01-01 CA $150.00 004V5265 00 G 2018-03-01 2021-03-01 CA $150.00 001V5265 00 G 2018-03-01 2021-03-01 CA $150.00 004V5265 00 G 2018-01-01 2018-03-01 CA $87.04 001V5265 00 G 2018-01-01 2018-03-01 CA $87.04 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 72 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

V5266 00 G 2021-03-01 9901-01-01 CA $7.20 001V5266 00 G 2021-03-01 9901-01-01 CA $7.20 004V5266 00 G 2020-03-01 2021-03-01 CA $8.00 001V5266 00 G 2020-03-01 2021-03-01 CA $8.00 004V5266 00 G 2019-03-01 2020-03-01 CA $8.00 001V5266 00 G 2019-03-01 2020-03-01 CA $8.00 004V5266 00 G 2018-03-01 2019-03-01 CA $8.00 001V5266 00 G 2018-03-01 2019-03-01 CA $8.00 004V5266 00 G 2018-01-01 2018-03-01 CA $8.00 001V5266 00 G 2018-01-01 2018-03-01 CA $8.00 004V5266 00 G 2017-03-01 2018-01-01 CA $8.00 001V5266 00 G 2017-03-01 2018-01-01 CA $8.00 004V5266 00 G 2016-04-01 2017-03-01 CA $8.00 001V5266 00 G 2016-04-01 2017-03-01 CA $8.00 004V5267 00 G 2020-03-01 9901-01-01 CA $229.00 001V5267 00 G 2020-03-01 9901-01-01 CA $229.00 004V5267 00 G 2019-03-01 2020-03-01 CA $147.50 001V5267 00 G 2019-03-01 2020-03-01 CA $147.50 004V5267 00 G 2018-03-01 2019-03-01 CA $147.50 001V5267 00 G 2018-03-01 2019-03-01 CA $147.50 004V5267 00 G 2018-01-01 2018-03-01 CA $147.50 001V5267 00 G 2018-01-01 2018-03-01 CA $147.50 004V5267 00 G 2017-03-01 2018-01-01 CA $147.50 001V5267 00 G 2017-03-01 2018-01-01 CA $147.50 004V5267 00 G 2016-04-01 2017-03-01 CA $147.50 001V5267 00 G 2016-04-01 2017-03-01 CA $147.50 004V5275 00 G 2021-03-01 9901-01-01 CA $180.00 001V5275 00 G 2021-03-01 9901-01-01 CA $180.00 004V5275 00 G 2020-03-01 2021-03-01 CA $180.00 001V5275 00 G 2020-03-01 2021-03-01 CA $180.00 004V5275 00 G 2018-03-01 2020-03-01 CA $150.00 001V5275 00 G 2018-03-01 2020-03-01 CA $150.00 004V5275 00 G 2018-01-01 2018-03-01 CA $100.00 001V5275 00 G 2018-01-01 2018-03-01 CA $100.00 004V5275 00 G 2017-03-01 2018-01-01 CA $100.00 001V5275 00 G 2017-03-01 2018-01-01 CA $100.00 004V5275 00 G 2016-04-01 2017-03-01 CA $100.00 001V5275 00 G 2016-04-01 2017-03-01 CA $100.00 0040009M 00 8 2016-01-01 2018-01-01 CA $1,450.00 0010009M 00 8 2016-01-01 2018-01-01 CA $1,450.00 0040202U 26 P 2020-12-05 2021-01-01 CA $30.00 0010213T 00 2 2018-01-01 9901-01-01 CA $541.00 0010213T 00 2 2018-01-01 9901-01-01 CA $541.00 0040213T 00 2 2017-06-02 2018-01-01 CA $541.00 0010213T 00 2 2017-06-02 2018-01-01 CA $541.00 0040249T 00 2 2018-01-01 9901-01-01 CA $1,800.00 0010249T 00 2 2018-01-01 9901-01-01 CA $1,800.00 0040249T 00 2 2016-07-29 2018-01-01 CA $1,800.00 0010249T 00 2 2016-07-29 2018-01-01 CA $1,800.00 0040295T 00 6 2016-04-01 2018-01-01 CA $1,500.00 0010295T 00 6 2016-04-01 2018-01-01 CA $1,500.00 0040296T 00 6 2016-04-01 2018-01-01 CA $500.00 0010296T 00 6 2016-04-01 2018-01-01 CA $500.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 73 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

0297T 00 6 2016-04-01 2018-01-01 CA $55.00 0010298T 00 6 2016-04-01 2018-01-01 CA $210.00 0010346T 00 5 2018-01-01 2018-03-01 CA $200.00 0010346T 00 5 2018-01-01 2018-03-01 CA $125.00 0040346T 00 5 2017-03-01 2018-01-01 CA $200.00 0010346T 00 5 2016-08-25 2017-03-01 CA $125.00 0010346T 00 5 2016-08-25 2018-01-01 CA $125.00 0040358T 00 6 2021-03-01 9901-01-01 CA $105.00 0010358T 00 6 2021-03-01 9901-01-01 CA $105.00 0040358T 00 6 2020-03-01 2021-03-01 CA $150.00 0010358T 00 6 2018-03-01 2020-03-01 CA $150.00 0010358T 00 6 2018-01-01 2018-03-01 CA $150.00 0010358T 00 6 2018-01-01 2021-03-01 CA $150.00 0040358T 00 6 2017-03-01 2018-01-01 CA $150.00 0010358T 00 6 2017-03-01 2018-01-01 CA $150.00 0040358T 00 6 2016-08-09 2017-03-01 CA $150.00 0010358T 00 6 2016-08-09 2017-03-01 CA $150.00 0040366T 00 6 2018-03-01 9901-01-01 CA $75.00 0010366T 00 6 2018-01-01 2018-03-01 CA $60.00 0010366T 00 6 2018-01-01 9901-01-01 CA $60.00 0040366T 00 6 2017-03-01 2018-01-01 CA $60.00 0010367T 00 6 2018-03-01 9901-01-01 CA $120.00 0010367T 00 6 2018-03-01 9901-01-01 CA $120.00 0040367T 00 6 2018-01-01 2018-03-01 CA $120.00 0010367T 00 6 2018-01-01 2018-03-01 CA $120.00 0040367T 00 6 2017-07-11 2018-01-01 CA $120.00 0010367T 00 6 2017-07-11 2018-01-01 CA $120.00 0040399T 00 6 2018-01-01 9901-01-01 CA $200.00 0010399T 00 6 2018-01-01 9901-01-01 CA $200.00 0040399T 00 6 2017-08-04 2018-01-01 CA $200.00 0010399T 00 6 2017-08-04 2018-01-01 CA $200.00 00415879 00 2 2018-01-01 9901-01-01 CA $7,291.52 00115879 00 2 2018-01-01 9901-01-01 CA $7,291.52 00417380 00 2 2018-01-01 9901-01-01 CA $300.00 00117380 00 2 2018-01-01 9901-01-01 CA $300.00 00436468 00 2 2018-01-01 9901-01-01 CA $350.00 00136468 00 2 2018-01-01 9901-01-01 CA $350.00 00437195 00 2 2018-01-01 9901-01-01 CA $1,535.00 00137195 00 2 2018-01-01 9901-01-01 CA $1,535.00 00437195 00 2 2016-01-15 2018-01-01 CA $1,535.00 00137195 00 2 2016-01-15 2018-01-01 CA $1,535.00 0044019F 00 6 2019-03-30 9901-01-01 CA $15.00 00144705 00 2 2018-02-01 2018-03-01 CA $1,016.67 00144705 00 2 2018-02-01 2018-03-01 CA $1,016.67 00450323 00 2 2018-01-01 2020-03-01 CA $8,860.00 00150323 00 2 2018-01-01 2020-03-01 CA $8,860.00 00458974 00 2 2020-03-01 9901-01-01 CA $963.00 00158974 00 2 2020-03-01 9901-01-01 CA $963.00 00458974 00 2 2018-03-01 2020-03-01 CA $2,110.00 00158974 00 2 2018-01-01 2018-03-01 CA $1,500.00 00158974 00 2 2018-01-01 2020-03-01 CA $1,500.00 00458974 00 2 2016-04-01 2018-01-01 CA $1,500.00 00158974 00 2 2016-04-01 2018-01-01 CA $1,500.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 74 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

69090 00 2 2018-01-01 9901-01-01 CA $75.00 00169090 00 2 2018-01-01 9901-01-01 CA $75.00 00469090 00 2 2016-04-01 2018-01-01 CA $75.00 00169090 00 2 2016-04-01 2018-01-01 CA $75.00 00474300 TC 5 2018-01-01 9901-01-01 CA $738.46 00174300 00 5 2020-03-01 9901-01-01 CA $1,691.43 00174300 00 5 2019-03-01 2020-03-01 CA $1,378.00 00174300 00 5 2018-03-01 2019-03-01 CA $1,277.00 00174300 00 5 2018-01-01 2018-03-01 CA $1,217.00 00174300 00 5 2018-01-01 9901-01-01 CA $1,188.00 00474300 00 5 2017-03-01 2018-01-01 CA $1,217.00 00174300 00 5 2016-04-01 2017-03-01 CA $1,188.00 00174300 00 5 2016-04-01 2018-01-01 CA $1,188.00 00474328 TC 5 2018-01-01 9901-01-01 CA $702.08 00174328 00 5 2018-03-01 9901-01-01 CA $1,924.00 00174328 00 5 2018-01-01 2018-03-01 CA $1,641.00 00174328 00 5 2018-01-01 9901-01-01 CA $1,641.00 00474328 00 5 2017-03-01 2018-01-01 CA $1,641.00 00174328 00 5 2016-04-01 2017-03-01 CA $1,641.00 00174328 00 5 2016-04-01 2018-01-01 CA $1,641.00 00474330 TC 5 2018-01-01 9901-01-01 CA $1,113.00 00174330 00 5 2019-03-01 9901-01-01 CA $3,279.75 00174330 00 5 2018-03-01 2019-03-01 CA $3,279.75 00174330 00 5 2018-01-01 2018-03-01 CA $3,036.75 00174330 00 5 2018-01-01 9901-01-01 CA $1,656.06 00474330 00 5 2017-03-01 2018-01-01 CA $3,036.75 00174330 00 5 2016-04-01 2017-03-01 CA $1,656.06 00174330 00 5 2016-04-01 2018-01-01 CA $1,656.06 00474340 TC 5 2018-01-01 9901-01-01 CA $1,268.74 00174340 00 5 2018-01-01 9901-01-01 CA $91.00 00174360 TC 5 2018-01-01 9901-01-01 CA $971.76 00174360 00 5 2018-01-01 9901-01-01 CA $1,000.75 00175894 TC 5 2018-01-01 9901-01-01 CA $2,894.12 00175894 00 5 2018-01-01 9901-01-01 CA $15,747.50 00175894 00 5 2018-01-01 9901-01-01 CA $15,747.50 00475894 00 5 2016-04-01 2018-01-01 CA $15,747.50 00175894 00 5 2016-04-01 2018-01-01 CA $15,747.50 00475970 00 5 2018-01-01 9901-01-01 CA $142.00 00177013 00 5 2018-01-01 9901-01-01 CA $582.00 00177061 00 5 2019-03-01 2020-03-01 CA $250.00 00177061 00 5 2018-03-01 2019-03-01 CA $199.00 00177061 00 5 2018-03-01 2020-03-01 CA $199.00 00477061 00 5 2018-01-01 2018-03-01 CA $199.00 00177061 00 5 2018-01-01 2018-03-01 CA $199.00 00477061 00 5 2017-03-01 2018-01-01 CA $199.00 00177061 00 5 2017-03-01 2018-01-01 CA $199.00 00477061 00 5 2016-04-01 2017-03-01 CA $199.00 00177061 00 5 2016-04-01 2017-03-01 CA $199.00 00477061 26 P 2019-03-01 2020-03-01 CA $127.00 00177061 26 P 2019-03-01 2020-03-01 CA $127.00 00477061 26 P 2018-03-01 2019-03-01 CA $127.00 00177061 26 P 2018-03-01 2019-03-01 CA $127.00 00477061 26 P 2018-01-01 2018-03-01 CA $127.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 75 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

77061 26 P 2018-01-01 2018-03-01 CA $127.00 00477061 26 P 2017-03-01 2018-01-01 CA $127.00 00177061 26 P 2017-03-01 2018-01-01 CA $127.00 00477062 00 5 2018-03-01 2019-03-01 CA $235.00 00177062 00 5 2018-01-01 2018-03-01 CA $232.00 00177062 00 5 2018-01-01 2019-03-01 CA $232.00 00477062 00 5 2017-03-01 2018-01-01 CA $232.00 00177062 00 5 2017-03-01 2018-01-01 CA $232.00 00477062 00 5 2016-04-01 2017-03-01 CA $232.00 00177062 00 5 2016-04-01 2017-03-01 CA $232.00 00477062 26 P 2018-03-01 2019-03-01 CA $146.00 00177062 26 P 2018-03-01 2019-03-01 CA $146.00 00477062 26 P 2018-01-01 2018-03-01 CA $146.00 00177062 26 P 2018-01-01 2018-03-01 CA $146.00 00477062 26 P 2017-03-01 2018-01-01 CA $146.00 00177062 26 P 2017-03-01 2018-01-01 CA $146.00 00477067 00 5 2017-02-09 2018-01-01 CA $651.00 00177067 00 5 2017-02-09 2018-01-01 CA $651.00 00477371 00 5 2018-03-01 9901-01-01 CA $62,940.00 00177371 00 5 2018-03-01 9901-01-01 CA $62,940.00 00477371 00 5 2018-01-01 2018-03-01 CA $62,940.00 00177371 00 5 2018-01-01 2018-03-01 CA $62,940.00 00477371 00 5 2016-04-01 2018-01-01 CA $62,940.00 00177371 00 5 2016-04-01 2018-01-01 CA $62,940.00 00477520 00 E 2018-01-01 2020-03-01 CA $3,560.00 00180330 00 8 2018-01-01 2018-03-01 CA $869.00 00180330 00 8 2018-01-01 2018-03-01 CA $869.00 00480330 00 8 2016-12-01 2018-01-01 CA $869.00 00180330 00 8 2016-12-01 2018-01-01 CA $869.00 00481203 00 8 2016-12-01 2018-01-01 CA $1,000.00 00181203 00 8 2016-12-01 2018-01-01 CA $1,000.00 00481216 00 8 2018-01-01 2018-03-01 CA $2,090.00 00181216 00 8 2018-01-01 2018-03-01 CA $2,090.00 00481224 00 8 2018-01-01 2018-03-01 CA $800.00 00181224 00 8 2018-01-01 2018-03-01 CA $800.00 00481224 00 8 2016-05-13 2018-01-01 CA $800.00 00181224 00 8 2016-05-13 2018-01-01 CA $800.00 00481244 00 8 2018-01-01 2018-03-01 CA $491.00 00181244 00 8 2018-01-01 2018-03-01 CA $350.00 00481244 00 8 2017-03-01 2018-01-01 CA $491.00 00181244 00 8 2016-04-01 2017-03-01 CA $350.00 00181244 00 8 2016-04-01 2018-01-01 CA $350.00 00481252 00 8 2018-01-01 2018-03-01 CA $1,029.00 00181252 00 8 2018-01-01 2018-03-01 CA $1,029.00 00481252 00 8 2016-02-19 2018-01-01 CA $1,029.00 00181252 00 8 2016-02-19 2018-01-01 CA $1,029.00 00481254 00 8 2018-01-01 2018-03-01 CA $199.00 00181254 00 8 2018-01-01 2018-03-01 CA $199.00 00481254 00 8 2017-02-03 2018-01-01 CA $199.00 00181254 00 8 2017-02-03 2018-01-01 CA $199.00 00481257 00 8 2016-04-01 2018-01-01 CA $597.04 00181302 00 8 2018-01-01 2018-03-01 CA $1,299.50 00181302 00 8 2018-01-01 2018-03-01 CA $1,299.50 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 76 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

81302 00 8 2017-02-03 2018-01-01 CA $1,299.50 00181302 00 8 2017-02-03 2018-01-01 CA $1,299.50 00481324 00 8 2018-01-01 2018-03-01 CA $829.33 00181324 00 8 2018-01-01 2018-03-01 CA $829.33 00481324 00 8 2017-09-07 2018-01-01 CA $829.33 00181324 00 8 2017-09-07 2018-01-01 CA $829.33 00481331 00 8 2018-01-01 2018-03-01 CA $515.92 00181331 00 8 2018-01-01 2018-03-01 CA $515.92 00481331 00 8 2016-07-01 2018-01-01 CA $515.92 00181331 00 8 2016-07-01 2018-01-01 CA $515.92 00481407 00 8 2018-01-01 2018-03-01 CA $6,000.00 00181407 00 8 2018-01-01 2018-03-01 CA $6,000.00 00481407 00 8 2017-03-01 2018-01-01 CA $6,000.00 00181407 00 8 2017-03-01 2018-01-01 CA $6,000.00 00481407 00 8 2016-04-01 2017-03-01 CA $6,000.00 00181407 00 8 2016-04-01 2017-03-01 CA $6,000.00 00481408 00 8 2016-04-01 2018-01-01 CA $3,000.00 00181408 00 8 2016-04-01 2018-01-01 CA $3,000.00 00481415 00 8 2018-01-01 2018-03-01 CA $8,000.00 00181415 00 8 2018-01-01 2018-03-01 CA $8,000.00 00481415 00 8 2017-02-09 2018-01-01 CA $8,000.00 00181415 00 8 2017-02-09 2018-01-01 CA $8,000.00 00481416 00 8 2018-01-01 2018-03-01 CA $5,000.00 00181416 00 8 2018-01-01 2018-03-01 CA $5,000.00 00481416 00 8 2017-06-02 2018-01-01 CA $5,000.00 00181416 00 8 2017-06-02 2018-01-01 CA $5,000.00 00481420 00 8 2016-04-01 2018-01-01 CA $4,750.00 00181420 00 8 2016-04-01 2018-01-01 CA $4,750.00 00481455 00 8 2018-01-01 2018-03-01 CA $7,752.00 00181455 00 8 2018-01-01 2018-03-01 CA $7,752.00 00481455 00 8 2016-11-30 2018-01-01 CA $7,752.00 00181455 00 8 2016-11-30 2018-01-01 CA $7,752.00 00481490 00 8 2016-08-25 2018-01-01 CA $989.00 00181490 00 8 2016-08-25 2018-01-01 CA $989.00 00481500 00 8 2018-01-01 2018-03-01 CA $556.08 00181500 00 8 2018-01-01 2018-03-01 CA $556.08 00481500 00 8 2017-08-07 2018-01-01 CA $556.08 00181500 00 8 2017-08-07 2018-01-01 CA $556.08 00481503 00 8 2018-01-01 2018-03-01 CA $703.04 00181503 00 8 2018-01-01 2018-03-01 CA $703.04 00481503 00 8 2016-04-01 2018-01-01 CA $703.04 00181507 00 8 2018-01-01 2018-03-01 CA $2,495.00 00181507 00 8 2018-01-01 2018-03-01 CA $2,495.00 00481507 00 8 2017-03-01 2018-01-01 CA $2,495.00 00181507 00 8 2017-03-01 2018-01-01 CA $2,495.00 00481507 00 8 2016-04-01 2017-03-01 CA $2,495.00 00181507 00 8 2016-04-01 2017-03-01 CA $2,495.00 00481542 00 8 2020-05-02 2021-03-01 CA $5,150.00 00181545 00 8 2016-12-01 2018-01-01 CA $6,400.00 00181545 00 8 2016-12-01 2018-01-01 CA $6,400.00 00481551 00 8 2018-07-28 2019-03-01 CA $3,300.00 00181595 00 8 2016-03-25 2018-01-01 CA $3,600.00 00181595 00 8 2016-03-25 2018-01-01 CA $3,600.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 77 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

86860 00 8 2018-01-01 9901-01-01 CA $138.00 00186860 00 8 2018-01-01 9901-01-01 CA $138.00 00486860 00 8 2016-04-01 2018-01-01 CA $138.00 00186860 00 8 2016-04-01 2018-01-01 CA $138.00 00486890 00 8 2018-01-01 9901-01-01 CA $539.00 00186890 00 8 2018-01-01 9901-01-01 CA $539.00 00486891 00 8 2018-01-01 2018-03-01 CA $1,175.00 00186891 00 8 2018-01-01 2018-03-01 CA $1,175.00 00486921 00 8 2018-01-01 9901-01-01 CA $195.00 00186921 00 8 2018-01-01 9901-01-01 CA $185.00 00486921 00 8 2016-04-01 2018-01-01 CA $195.00 00186932 00 8 2018-01-01 9901-01-01 CA $75.00 00186932 00 8 2018-01-01 9901-01-01 CA $75.00 00486970 00 8 2018-01-01 9901-01-01 CA $63.90 00186970 00 8 2018-01-01 9901-01-01 CA $63.90 00486971 00 8 2018-01-01 9901-01-01 CA $20.00 00186971 00 8 2018-01-01 9901-01-01 CA $20.00 00486971 00 8 2017-03-03 2018-01-01 CA $20.00 00186971 00 8 2017-03-03 2018-01-01 CA $20.00 00486975 00 8 2019-03-01 9901-01-01 CA $175.52 00186975 00 8 2018-03-01 2019-03-01 CA $167.50 00186975 00 8 2018-01-01 2018-03-01 CA $159.52 00186975 00 8 2018-01-01 9901-01-01 CA $159.52 00486975 00 8 2017-03-01 2018-01-01 CA $159.52 00186976 00 8 2018-01-01 9901-01-01 CA $145.29 00186976 00 8 2018-01-01 9901-01-01 CA $145.29 00486977 00 8 2020-03-01 9901-01-01 CA $104.00 00186977 00 8 2020-03-01 9901-01-01 CA $104.00 00486977 00 8 2019-03-01 2020-03-01 CA $390.00 00186977 00 8 2019-03-01 2020-03-01 CA $390.00 00486977 00 8 2018-03-01 2019-03-01 CA $390.00 00186977 00 8 2018-03-01 2019-03-01 CA $390.00 00486977 00 8 2018-01-01 2018-03-01 CA $390.00 00186977 00 8 2018-01-01 2018-03-01 CA $390.00 00486977 00 8 2017-03-01 2018-01-01 CA $390.00 00186977 00 8 2017-03-01 2018-01-01 CA $390.00 00486977 00 8 2016-04-01 2017-03-01 CA $390.00 00186977 00 8 2016-04-01 2017-03-01 CA $390.00 00486978 00 8 2018-01-01 9901-01-01 CA $172.03 00186978 00 8 2018-01-01 9901-01-01 CA $172.03 00487426 00 8 2020-06-25 2021-03-01 CA $125.00 00187426 00 8 2020-06-25 2021-03-01 CA $125.00 00487428 00 8 2021-01-30 9901-01-01 CA $350.00 00187636 00 8 2020-10-06 9901-01-01 CA $158.37 00187636 00 8 2020-10-06 9901-01-01 CA $158.37 00487637 00 8 2021-03-20 9901-01-01 CA $966.00 00189250 00 8 2018-01-01 9901-01-01 CA $3,500.00 00189250 00 8 2018-01-01 9901-01-01 CA $3,500.00 00489253 00 8 2018-01-01 9901-01-01 CA $630.00 00189253 00 8 2018-01-01 9901-01-01 CA $630.00 00489254 00 8 2018-03-01 9901-01-01 CA $1,800.00 00189254 00 8 2018-03-01 9901-01-01 CA $1,800.00 00489254 00 8 2018-01-01 2018-03-01 CA $1,800.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 78 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

89254 00 8 2018-01-01 2018-03-01 CA $1,800.00 00489255 00 8 2018-03-01 9901-01-01 CA $2,500.00 00189255 00 8 2018-01-01 2018-03-01 CA $1,800.00 00189255 00 8 2018-01-01 9901-01-01 CA $1,800.00 00489258 00 8 2018-01-01 9901-01-01 CA $1,276.00 00189258 00 8 2018-01-01 9901-01-01 CA $1,276.00 00489258 00 8 2016-04-15 2018-01-01 CA $1,276.00 00189258 00 8 2016-04-15 2018-01-01 CA $1,276.00 00489268 00 8 2018-01-01 9901-01-01 CA $2,200.00 00189268 00 8 2018-01-01 9901-01-01 CA $2,200.00 00489268 00 8 2017-07-13 2018-01-01 CA $2,200.00 00189268 00 8 2017-07-13 2018-01-01 CA $2,200.00 00489272 00 8 2018-03-01 9901-01-01 CA $2,729.00 00189272 00 8 2018-01-01 2018-03-01 CA $1,950.00 00189272 00 8 2018-01-01 9901-01-01 CA $1,950.00 00489272 00 8 2016-11-30 2018-01-01 CA $1,950.00 00189272 00 8 2016-11-30 2018-01-01 CA $1,950.00 00489280 00 8 2018-01-01 9901-01-01 CA $3,000.00 00189280 00 8 2018-01-01 9901-01-01 CA $3,000.00 00489342 00 8 2018-01-01 9901-01-01 CA $600.00 00189342 00 8 2018-01-01 9901-01-01 CA $600.00 00489342 00 8 2017-06-14 2018-01-01 CA $600.00 00189342 00 8 2017-06-14 2018-01-01 CA $600.00 00489352 00 8 2018-01-01 9901-01-01 CA $2,800.00 00189352 00 8 2018-01-01 9901-01-01 CA $2,800.00 00489352 00 8 2016-12-01 2018-01-01 CA $2,800.00 00189352 00 8 2016-12-01 2018-01-01 CA $2,800.00 00489353 00 8 2018-01-01 9901-01-01 CA $600.00 00189353 00 8 2018-01-01 9901-01-01 CA $600.00 00490620 00 6 2019-11-01 2020-02-01 CA $181.00 00190620 00 6 2019-11-01 2020-02-01 CA $181.00 00490620 00 6 2019-08-15 2019-11-01 CA $181.00 00190620 00 6 2019-08-15 2019-11-01 CA $181.00 00490621 00 6 2019-11-01 2020-02-01 CA $147.89 00190621 00 6 2019-11-01 2020-02-01 CA $147.89 00490621 00 6 2019-08-15 2019-11-01 CA $147.89 00190621 00 6 2019-08-15 2019-11-01 CA $147.89 00490633 00 6 2019-11-01 2020-02-01 CA $35.08 00190633 00 6 2019-11-01 2020-02-01 CA $35.08 00490633 00 6 2019-08-15 2019-11-01 CA $34.74 00190633 00 6 2019-08-15 2019-11-01 CA $34.74 00490636 00 6 2019-11-01 2020-02-01 CA $110.24 00190636 00 6 2019-11-01 2020-02-01 CA $110.24 00490636 00 6 2019-08-15 2019-11-01 CA $110.24 00190636 00 6 2019-08-15 2019-11-01 CA $110.24 00490647 00 6 2019-11-01 2020-02-01 CA $27.81 00190647 00 6 2019-11-01 2020-02-01 CA $27.81 00490647 00 6 2019-08-15 2019-11-01 CA $27.81 00190647 00 6 2019-08-15 2019-11-01 CA $27.81 00490648 00 6 2019-11-01 2020-02-01 CA $14.50 00190648 00 6 2019-11-01 2020-02-01 CA $14.50 00490648 00 6 2019-08-15 2019-11-01 CA $14.50 00190648 00 6 2019-08-15 2019-11-01 CA $14.50 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 79 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

90651 00 6 2019-11-01 2020-02-01 CA $241.61 00190651 00 6 2019-11-01 2020-02-01 CA $241.61 00490651 00 6 2019-08-15 2019-11-01 CA $230.14 00190651 00 6 2019-08-15 2019-11-01 CA $230.14 00490660 00 6 2018-01-01 9901-01-01 CA $60.00 00190660 00 6 2018-01-01 9901-01-01 CA $60.00 00490680 00 6 2019-11-01 2020-02-01 CA $89.60 00190680 00 6 2019-11-01 2020-02-01 CA $89.60 00490680 00 6 2019-08-15 2019-11-01 CA $87.86 00190680 00 6 2019-08-15 2019-11-01 CA $87.86 00490681 00 6 2019-11-01 2020-02-01 CA $128.21 00190681 00 6 2019-11-01 2020-02-01 CA $128.21 00490681 00 6 2019-08-15 2019-11-01 CA $128.21 00190681 00 6 2019-08-15 2019-11-01 CA $128.21 00490696 00 6 2019-11-01 2020-02-01 CA $55.60 00190696 00 6 2019-11-01 2020-02-01 CA $55.60 00490696 00 6 2019-08-15 2019-11-01 CA $55.60 00190696 00 6 2019-08-15 2019-11-01 CA $55.60 00490698 00 6 2019-11-01 2020-02-01 CA $101.91 00190698 00 6 2019-11-01 2020-02-01 CA $101.91 00490698 00 6 2019-08-15 2019-11-01 CA $101.91 00190698 00 6 2019-08-15 2019-11-01 CA $101.91 00490700 00 6 2019-11-01 2020-02-01 CA $28.36 00190700 00 6 2019-11-01 2020-02-01 CA $28.36 00490700 00 6 2019-08-15 2019-11-01 CA $28.36 00190700 00 6 2019-08-15 2019-11-01 CA $28.36 00490707 00 6 2019-11-01 2020-02-01 CA $83.40 00190707 00 6 2019-11-01 2020-02-01 CA $83.40 00490707 00 6 2019-08-15 2019-11-01 CA $79.54 00190707 00 6 2019-08-15 2019-11-01 CA $79.54 00490710 00 6 2019-11-01 2020-02-01 CA $238.43 00190710 00 6 2019-11-01 2020-02-01 CA $238.43 00490710 00 6 2019-08-15 2019-11-01 CA $227.23 00190710 00 6 2019-08-15 2019-11-01 CA $227.23 00490713 00 6 2019-11-01 2020-02-01 CA $35.54 00190713 00 6 2019-11-01 2020-02-01 CA $35.54 00490713 00 6 2019-08-15 2019-11-01 CA $35.54 00190713 00 6 2019-08-15 2019-11-01 CA $35.54 00490716 00 6 2019-11-01 2020-02-01 CA $143.87 00190716 00 6 2019-11-01 2020-02-01 CA $143.87 00490716 00 6 2019-08-15 2019-11-01 CA $137.06 00190716 00 6 2019-08-15 2019-11-01 CA $137.06 00490723 00 6 2019-11-01 2020-02-01 CA $83.90 00190723 00 6 2019-11-01 2020-02-01 CA $83.90 00490723 00 6 2019-08-15 2019-11-01 CA $83.90 00190723 00 6 2019-08-15 2019-11-01 CA $83.90 00490734 00 6 2019-11-01 2020-02-01 CA $134.12 00190734 00 6 2019-11-01 2020-02-01 CA $134.12 00490734 00 6 2019-08-15 2019-11-01 CA $134.12 00190734 00 6 2019-08-15 2019-11-01 CA $134.12 00490750 00 6 2019-11-01 2020-02-01 CA $152.85 00190750 00 6 2019-11-01 2020-02-01 CA $152.85 00490750 00 6 2019-08-15 2019-11-01 CA $152.85 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 80 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

90750 00 6 2019-08-15 2019-11-01 CA $152.85 00490839 00 C 2018-01-01 2018-03-01 CA $200.00 00190839 00 C 2018-01-01 2018-03-01 CA $200.00 00490840 00 C 2018-01-01 2018-03-01 CA $150.00 00190840 00 C 2018-01-01 2018-03-01 CA $150.00 00490867 00 C 2018-01-01 2018-03-01 CA $195.00 00190867 00 C 2018-01-01 2018-03-01 CA $195.00 00490868 00 C 2018-01-01 2018-03-01 CA $400.00 00190868 00 C 2018-01-01 2018-03-01 CA $400.00 00490869 00 C 2016-12-14 2018-01-01 CA $950.00 00190869 00 C 2016-12-14 2018-01-01 CA $950.00 00490882 00 C 2018-01-01 9901-01-01 CA $191.25 00190882 00 C 2018-01-01 9901-01-01 CA $191.25 00490993 00 6 2021-03-01 9901-01-01 CA $125.00 00190993 00 6 2021-03-01 9901-01-01 CA $125.00 00490993 00 6 2020-03-01 2021-03-01 CA $6,216.00 00190993 00 6 2019-03-01 2020-03-01 CA $6,216.00 00190993 00 6 2018-03-01 2019-03-01 CA $5,864.00 00190993 00 6 2018-01-01 2018-03-01 CA $5,584.00 00190993 00 6 2018-01-01 2021-03-01 CA $3,629.00 00490993 00 6 2017-03-01 2018-01-01 CA $5,584.00 00190993 00 6 2016-04-01 2017-03-01 CA $5,140.00 00192921 00 6 2018-01-01 9901-01-01 CA $13,135.00 00192921 00 6 2018-01-01 9901-01-01 CA $7,608.00 00492921 00 6 2017-03-01 2018-01-01 CA $13,135.00 00192929 00 6 2018-01-01 9901-01-01 CA $1,733.00 00192929 00 6 2018-01-01 9901-01-01 CA $1,733.00 00492978 TC 6 2018-01-01 9901-01-01 CA $3,126.00 00192978 00 6 2019-03-01 9901-01-01 CA $15,246.00 00192978 00 6 2019-03-01 9901-01-01 CA $10,542.35 00492978 00 6 2018-03-01 2019-03-01 CA $15,246.00 00192978 00 6 2018-01-01 2018-03-01 CA $10,619.00 00192978 00 6 2018-01-01 2019-03-01 CA $10,542.35 00492978 00 6 2017-03-01 2018-01-01 CA $10,619.00 00192978 00 6 2016-04-01 2017-03-01 CA $10,542.35 00192978 00 6 2016-04-01 2018-01-01 CA $10,542.35 00492979 00 6 2018-01-01 9901-01-01 CA $200.00 00192992 00 6 2018-01-01 9901-01-01 CA $3,844.00 00192992 00 6 2018-01-01 9901-01-01 CA $3,844.00 00492992 00 6 2016-02-05 2018-01-01 CA $3,844.00 00192992 00 6 2016-02-05 2018-01-01 CA $3,844.00 00493243 00 6 2021-05-22 9901-01-01 CA $995.00 00193245 00 6 2021-07-10 9901-01-01 CA $550.00 00193247 00 6 2021-04-17 9901-01-01 CA $995.00 00193299 00 6 2019-03-01 9901-01-01 CA $242.55 00193299 00 6 2019-03-01 9901-01-01 CA $242.55 00493299 00 6 2018-03-01 2019-03-01 CA $242.55 00193299 00 6 2018-03-01 2019-03-01 CA $242.55 00493299 00 6 2018-01-01 2018-03-01 CA $242.55 00193299 00 6 2018-01-01 2018-03-01 CA $242.55 00493299 00 6 2017-03-01 2018-01-01 CA $242.55 00193299 00 6 2017-03-01 2018-01-01 CA $242.55 00493317 00 6 2018-01-01 9901-01-01 CA $300.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 81 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

93531 TC 6 2018-01-01 9901-01-01 CA $8,417.98 00193531 00 6 2020-03-01 9901-01-01 CA $11,550.00 00193531 00 6 2019-03-01 2020-03-01 CA $17,057.00 00193531 00 6 2018-03-01 2019-03-01 CA $17,057.00 00193531 00 6 2018-01-01 2018-03-01 CA $17,057.00 00193531 00 6 2018-01-01 9901-01-01 CA $10,500.00 00493531 00 6 2017-03-01 2018-01-01 CA $17,057.00 00193531 00 6 2016-04-01 2017-03-01 CA $10,500.00 00193531 00 6 2016-04-01 2018-01-01 CA $10,500.00 00493533 00 6 2018-01-01 9901-01-01 CA $2,819.60 00193561 00 6 2018-01-01 9901-01-01 CA $151.05 00193562 00 6 2018-01-01 9901-01-01 CA $80.56 00193571 TC 6 2018-01-01 9901-01-01 CA $1,067.84 00193571 00 6 2019-03-01 9901-01-01 CA $3,827.00 00193571 00 6 2018-01-01 2019-03-01 CA $1,166.50 00193571 00 6 2018-01-01 9901-01-01 CA $1,166.50 00493571 00 6 2017-03-01 2018-01-01 CA $1,166.50 00193571 00 6 2017-03-01 2018-01-01 CA $1,166.50 00493571 00 6 2016-04-01 2017-03-01 CA $1,166.50 00193571 00 6 2016-04-01 2017-03-01 CA $1,166.50 00493609 TC 6 2018-01-01 9901-01-01 CA $7,395.25 00193609 00 6 2018-01-01 9901-01-01 CA $15,182.00 00193609 00 6 2018-01-01 9901-01-01 CA $15,182.00 00493609 00 6 2017-03-01 2018-01-01 CA $15,182.00 00193609 00 6 2017-03-01 2018-01-01 CA $15,182.00 00493620 TC 6 2018-01-01 9901-01-01 CA $3,505.37 00193620 00 6 2019-03-01 9901-01-01 CA $24,178.50 00193620 00 6 2018-03-01 2019-03-01 CA $24,178.50 00193620 00 6 2018-01-01 2018-03-01 CA $24,178.50 00193620 00 6 2018-01-01 9901-01-01 CA $4,168.12 00493620 00 6 2017-03-01 2018-01-01 CA $24,178.50 00193620 00 6 2016-04-01 2017-03-01 CA $4,168.12 00193620 00 6 2016-04-01 2018-01-01 CA $4,168.12 00493621 TC 6 2018-01-01 9901-01-01 CA $5,012.85 00193621 00 6 2019-03-01 9901-01-01 CA $13,836.00 00193621 00 6 2018-03-01 2019-03-01 CA $13,600.46 00193621 00 6 2018-03-01 9901-01-01 CA $13,600.46 00493621 00 6 2018-01-01 2018-03-01 CA $13,600.46 00193621 00 6 2018-01-01 2018-03-01 CA $13,600.46 00493621 00 6 2017-03-01 2018-01-01 CA $13,600.46 00193621 00 6 2017-03-01 2018-01-01 CA $13,600.46 00493621 00 6 2016-04-01 2017-03-01 CA $13,600.46 00193621 00 6 2016-04-01 2017-03-01 CA $13,600.46 00493623 TC 6 2018-01-01 9901-01-01 CA $1,277.88 00193623 00 6 2021-03-01 9901-01-01 CA $750.00 00193623 00 6 2021-03-01 9901-01-01 CA $750.00 00493623 00 6 2019-03-01 2021-03-01 CA $15,514.00 00193623 00 6 2019-03-01 2021-03-01 CA $15,514.00 00493623 00 6 2018-03-01 2019-03-01 CA $15,514.00 00193623 00 6 2018-03-01 2019-03-01 CA $15,514.00 00493623 00 6 2018-01-01 2018-03-01 CA $15,514.00 00193623 00 6 2018-01-01 2018-03-01 CA $15,514.00 00493623 00 6 2017-03-01 2018-01-01 CA $15,514.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 82 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

93623 00 6 2017-03-01 2018-01-01 CA $15,514.00 00493623 00 6 2016-04-01 2017-03-01 CA $15,514.00 00193623 00 6 2016-04-01 2017-03-01 CA $15,514.00 00493641 00 6 2018-01-01 9901-01-01 CA $1,601.00 00193662 TC 6 2018-01-01 9901-01-01 CA $1,609.29 00193662 00 6 2019-03-01 9901-01-01 CA $20,900.00 00193662 00 6 2018-03-01 2019-03-01 CA $19,801.68 00193662 00 6 2018-03-01 9901-01-01 CA $11,909.00 00493662 00 6 2018-01-01 2018-03-01 CA $19,801.68 00193662 00 6 2018-01-01 2018-03-01 CA $11,909.00 00493662 00 6 2017-03-01 2018-01-01 CA $19,801.68 00193662 00 6 2016-04-01 2017-03-01 CA $11,909.00 00193662 00 6 2016-04-01 2018-01-01 CA $11,909.00 00494776 00 6 2018-01-01 9901-01-01 CA $579.12 00194776 00 6 2018-01-01 9901-01-01 CA $579.12 00495700 00 6 2020-03-21 2021-03-01 CA $1,012.00 00195708 00 6 2020-06-20 2021-03-01 CA $3,071.00 00195711 00 6 2020-10-17 9901-01-01 CA $1,012.00 00195714 00 6 2020-11-07 2021-03-01 CA $4,952.00 00195715 00 6 2020-04-04 2021-03-01 CA $6,000.00 00196377 00 6 2018-01-01 2018-03-01 CA $293.00 00196377 00 6 2018-01-01 2018-03-01 CA $293.00 00496377 00 6 2017-03-03 2018-01-01 CA $293.00 00196377 00 6 2017-03-03 2018-01-01 CA $293.00 00497152 00 6 2020-03-01 9901-01-01 CA $57.50 00197152 00 6 2020-03-01 9901-01-01 CA $57.50 00497152 00 6 2019-04-06 2020-03-01 CA $57.50 00198969 00 6 2018-01-01 9901-01-01 CA $177.63 00198969 00 6 2018-01-01 9901-01-01 CA $177.63 00499000 00 6 2021-03-01 9901-01-01 CA $25.00 00199000 00 6 2020-03-01 2021-03-01 CA $25.00 00199000 00 6 2019-03-01 2020-03-01 CA $25.00 00199000 00 6 2019-03-01 9901-01-01 CA $25.00 00499000 00 6 2018-03-01 2019-03-01 CA $25.00 00199000 00 6 2018-03-01 2019-03-01 CA $25.00 00499000 00 6 2018-01-01 2018-03-01 CA $25.00 00199000 00 6 2018-01-01 2018-03-01 CA $25.00 00499000 00 6 2017-03-01 2018-01-01 CA $25.00 00199000 00 6 2017-03-01 2018-01-01 CA $25.00 00499000 00 6 2016-04-01 2017-03-01 CA $25.00 00199000 00 6 2016-04-01 2017-03-01 CA $25.00 00499001 00 6 2021-03-01 9901-01-01 CA $50.00 00199001 00 6 2021-03-01 9901-01-01 CA $50.00 00499001 00 6 2019-03-01 2021-03-01 CA $61.30 00199001 00 6 2019-03-01 2021-03-01 CA $58.50 00499001 00 6 2018-03-01 2019-03-01 CA $52.61 00199001 00 6 2018-01-01 2018-03-01 CA $45.00 00199001 00 6 2018-01-01 2019-03-01 CA $45.00 00499001 00 6 2017-03-01 2018-01-01 CA $45.00 00199001 00 6 2017-03-01 2018-01-01 CA $45.00 00499001 00 6 2016-04-01 2017-03-01 CA $45.00 00199001 00 6 2016-04-01 2017-03-01 CA $45.00 00499002 00 6 2021-03-01 9901-01-01 CA $25.00 001

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 83 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

99002 00 6 2020-03-01 2021-03-01 CA $25.00 00199002 00 6 2020-03-01 9901-01-01 CA $25.00 00499002 00 6 2019-03-01 2020-03-01 CA $50.00 00199002 00 6 2019-03-01 2020-03-01 CA $50.00 00499002 00 6 2018-03-01 2019-03-01 CA $50.00 00199002 00 6 2018-03-01 2019-03-01 CA $50.00 00499002 00 6 2018-01-01 2018-03-01 CA $50.00 00199002 00 6 2018-01-01 2018-03-01 CA $50.00 00499002 00 6 2017-03-01 2018-01-01 CA $50.00 00199002 00 6 2017-03-01 2018-01-01 CA $50.00 00499002 00 6 2016-04-01 2017-03-01 CA $50.00 00199002 00 6 2016-04-01 2017-03-01 CA $50.00 00499060 00 6 2018-01-01 9901-01-01 CA $1,387.00 00199060 00 6 2018-01-01 9901-01-01 CA $1,387.00 00499060 00 6 2017-03-01 2018-01-01 CA $1,387.00 00199060 00 6 2017-03-01 2018-01-01 CA $1,387.00 00499071 00 6 2020-03-01 9901-01-01 CA $100.00 00199071 00 6 2019-03-01 2020-03-01 CA $100.00 00199071 00 6 2018-03-01 2019-03-01 CA $75.00 00199071 00 6 2018-01-01 2018-03-01 CA $75.00 00199071 00 6 2018-01-01 9901-01-01 CA $30.00 00499071 00 6 2017-03-01 2018-01-01 CA $75.00 00199071 00 6 2017-03-01 2018-01-01 CA $30.00 00499071 00 6 2016-04-01 2017-03-01 CA $15.00 00199071 00 6 2016-04-01 2017-03-01 CA $15.00 00499072 00 6 2020-09-08 9901-01-01 CA $25.00 00199072 00 6 2020-09-08 9901-01-01 CA $25.00 00499177 00 6 2018-01-01 2018-03-01 CA $60.00 00199177 00 6 2018-01-01 2018-03-01 CA $30.00 00499177 00 6 2017-03-01 2018-01-01 CA $60.00 00199177 00 6 2016-03-04 2017-03-01 CA $30.00 00199177 00 6 2016-03-04 2018-01-01 CA $30.00 00499188 00 6 2018-01-01 2018-03-01 CA $125.00 00199188 00 6 2018-01-01 2018-03-01 CA $50.00 00499188 00 6 2017-03-01 2018-01-01 CA $125.00 00199190 00 6 2018-01-01 9901-01-01 CA $508.00 00199190 00 6 2018-01-01 9901-01-01 CA $508.00 00499444 00 6 2019-03-01 9901-01-01 CA $990.00 00199444 00 6 2019-03-01 9901-01-01 CA $990.00 00499444 00 6 2018-03-01 2019-03-01 CA $990.00 00199444 00 6 2018-03-01 2019-03-01 CA $990.00 00499444 00 6 2018-01-01 2018-03-01 CA $990.00 00199444 00 6 2018-01-01 2018-03-01 CA $990.00 00499444 00 6 2017-03-01 2018-01-01 CA $990.00 00199444 00 6 2017-03-01 2018-01-01 CA $990.00 00499444 00 6 2016-04-01 2017-03-01 CA $990.00 00199444 00 6 2016-04-01 2017-03-01 CA $990.00 00499447 00 6 2018-01-01 2018-03-01 CA $222.00 00199447 00 6 2018-01-01 2018-03-01 CA $222.00 00499447 00 6 2017-11-27 2018-01-01 CA $222.00 00199447 00 6 2017-11-27 2018-01-01 CA $222.00 00499450 00 6 2018-01-01 9901-01-01 CA $125.00 00199450 00 6 2018-01-01 9901-01-01 CA $125.00 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 84 of 85

CALIFORNIA State Prevailing RatesTRICARE West Region

CODE MOD TOS EFFECTIVE DATE TERM DATE STATE PREVAILING

AMOUNT001=PHYSICIAN RATE 004=NON-PHYSICIAN

99450 00 6 2016-02-12 2018-01-01 CA $125.00 00199450 00 6 2016-02-12 2018-01-01 CA $125.00 00499455 00 6 2018-01-01 9901-01-01 CA $365.00 00199455 00 6 2018-01-01 9901-01-01 CA $365.00 00499455 00 6 2016-04-01 2018-01-01 CA $365.00 00199455 00 6 2016-04-01 2018-01-01 CA $365.00 00499456 00 6 2021-03-01 9901-01-01 CA $967.31 00199456 00 6 2021-03-01 9901-01-01 CA $967.31 00499456 00 6 2020-03-07 2021-03-01 CA $967.31 00199605 00 6 2018-01-01 9901-01-01 CA $358.55 00199605 00 6 2018-01-01 9901-01-01 CA $283.88 00499605 00 6 2017-03-01 2018-01-01 CA $358.55 00199605 00 6 2016-04-01 2017-03-01 CA $283.88 00199605 00 6 2016-04-01 2018-01-01 CA $283.88 00499606 00 6 2020-03-01 9901-01-01 CA $186.00 00199606 00 6 2020-03-01 9901-01-01 CA $186.00 00499606 00 6 2019-03-01 2020-03-01 CA $306.32 00199606 00 6 2019-03-01 2020-03-01 CA $289.22 00499606 00 6 2018-03-01 2019-03-01 CA $306.32 00199606 00 6 2018-01-01 2018-03-01 CA $306.32 00199606 00 6 2018-01-01 2019-03-01 CA $289.22 00499606 00 6 2017-03-01 2018-01-01 CA $306.32 00199606 00 6 2016-04-01 2017-03-01 CA $289.22 00199606 00 6 2016-04-01 2018-01-01 CA $289.22 00499607 00 6 2020-03-01 9901-01-01 CA $47.00 00199607 00 6 2020-03-01 9901-01-01 CA $47.00 00499607 00 6 2018-03-01 2020-03-01 CA $395.39 00199607 00 6 2018-03-01 2020-03-01 CA $395.39 00499607 00 6 2018-01-01 2018-03-01 CA $395.39 00199607 00 6 2018-01-01 2018-03-01 CA $395.39 00499607 00 6 2017-03-01 2018-01-01 CA $395.39 00199607 00 6 2017-03-01 2018-01-01 CA $395.39 004

Please note: The presence or absence of a State Prevailing rate does not indicate policy coverage, payment approval or payment denial.

Revised: 7/13/2021 Page 85 of 85