DOC Conversion Factor: $60.00 DOC Non-Facility DOC Allowed … · 2019. 7. 11. · RBRVS Physician-Related Services Fee Schedule Effective January 1, 2016 ... DOC Professional Provider

DOC Conversion Factor: $60.00 Link to Legend

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

10021 3.53$ $211.80 1.95$ $117.00 XXX

10022 4.09$ $245.40 1.85$ $111.00 XXX

10030 22.85$ $1,371.00 4.60$ $276.00 XXX

10035 15.86$ $951.60 2.46$ $147.60 XXX

10036 13.86$ $831.60 1.24$ $74.40 XXX

10040 2.89$ $173.40 2.50$ $150.00 010

10060 3.37$ $202.20 2.78$ $166.80 010

10061 5.89$ $353.40 5.12$ $307.20 010

10080 5.21$ $312.60 2.93$ $175.80 010

10081 7.72$ $463.20 4.80$ $288.00 010

10120 4.40$ $264.00 2.98$ $178.80 010

10121 7.85$ $471.00 5.25$ $315.00 010

10140 4.69$ $281.40 3.38$ $202.80 010

10160 3.75$ $225.00 2.74$ $164.40 010

10180 7.01$ $420.60 5.02$ $301.20 010

11000 1.57$ $94.20 0.81$ $48.60 000

11001 0.61$ $36.60 0.40$ $24.00 ZZZ

11004 16.02$ $961.20 16.02$ $961.20 000

11005 21.43$ $1,285.80 21.43$ $1,285.80 000

11006 19.41$ $1,164.60 19.41$ $1,164.60 000

11008 7.53$ $451.80 7.53$ $451.80 ZZZ

11010 14.14$ $848.40 7.86$ $471.60 010

11011 15.27$ $916.20 8.30$ $498.00 000

11012 20.33$ $1,219.80 11.86$ $711.60 000

11042 3.37$ $202.20 1.75$ $105.00 000

11043 6.50$ $390.00 4.36$ $261.60 000

11044 8.89$ $533.40 6.46$ $387.60 000

11045 1.16$ $69.60 0.73$ $43.80 ZZZ

11046 2.05$ $123.00 1.55$ $93.00 ZZZ

11047 3.46$ $207.60 2.75$ $165.00 ZZZ

11055 1.39$ $83.40 0.46$ $27.60 000

11056 1.69$ $101.40 0.65$ $39.00 000

11057 1.90$ $114.00 0.84$ $50.40 000

11100 2.98$ $178.80 1.38$ $82.80 000

11101 0.93$ $55.80 0.71$ $42.60 ZZZ

11200 2.53$ $151.80 2.11$ $126.60 010

Department of Corrections (DOC)

RBRVS Physician-Related Services Fee Schedule

Effective January 1, 2016

CPT® codes and descriptions only are copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

DOC Professional Provider Fee Schedule, Effective 1/1/2016

Page | 1

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

11201 0.53$ $31.80 0.47$ $28.20 ZZZ

11300 2.82$ $169.20 0.99$ $59.40 000

11301 3.46$ $207.60 1.51$ $90.60 000

11302 4.07$ $244.20 1.78$ $106.80 000

11303 4.49$ $269.40 2.10$ $126.00 000

11305 2.88$ $172.80 1.11$ $66.60 000

11306 3.53$ $211.80 1.46$ $87.60 000

11307 4.15$ $249.00 1.88$ $112.80 000

11308 4.35$ $261.00 2.09$ $125.40 000

11310 3.28$ $196.80 1.33$ $79.80 000

11311 3.18$ $190.80 1.85$ $111.00 000

11312 4.62$ $277.20 2.21$ $132.60 000

11313 5.32$ $319.20 2.83$ $169.80 000

11400 3.58$ $214.80 2.30$ $138.00 010

11401 4.28$ $256.80 2.96$ $177.60 010

11402 4.74$ $284.40 3.24$ $194.40 010

11403 5.47$ $328.20 4.19$ $251.40 010

11404 6.19$ $371.40 4.59$ $275.40 010

11406 8.83$ $529.80 6.90$ $414.00 010

11420 3.54$ $212.40 2.34$ $140.40 010

11421 4.50$ $270.00 3.13$ $187.80 010

11422 5.02$ $301.20 3.86$ $231.60 010

11423 5.76$ $345.60 4.47$ $268.20 010

11424 6.63$ $397.80 5.08$ $304.80 010

11426 9.38$ $562.80 7.71$ $462.60 010

11440 3.90$ $234.00 2.98$ $178.80 010

11441 4.81$ $288.60 3.77$ $226.20 010

11442 5.38$ $322.80 4.15$ $249.00 010

11443 6.38$ $382.80 5.07$ $304.20 010

11444 7.98$ $478.80 6.43$ $385.80 010

11446 11.04$ $662.40 9.19$ $551.40 010

11450 10.87$ $652.20 7.08$ $424.80 090

11451 13.81$ $828.60 9.09$ $545.40 090

11462 10.64$ $638.40 6.78$ $406.80 090

11463 13.99$ $839.40 9.14$ $548.40 090

11470 11.78$ $706.80 7.91$ $474.60 090

11471 14.55$ $873.00 9.83$ $589.80 090

11600 5.54$ $332.40 3.39$ $203.40 010

11601 6.56$ $393.60 4.23$ $253.80 010

11602 7.11$ $426.60 4.65$ $279.00 010

11603 8.10$ $486.00 5.55$ $333.00 010

11604 8.98$ $538.80 6.09$ $365.40 010



Page | 2

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

11606 12.76$ $765.60 8.98$ $538.80 010

11620 5.59$ $335.40 3.43$ $205.80 010

11621 6.59$ $395.40 4.27$ $256.20 010

11622 7.34$ $440.40 4.88$ $292.80 010

11623 8.58$ $514.80 6.02$ $361.20 010

11624 9.65$ $579.00 6.79$ $407.40 010

11626 11.56$ $693.60 8.28$ $496.80 010

11640 5.77$ $346.20 3.56$ $213.60 010

11641 6.83$ $409.80 4.45$ $267.00 010

11642 7.77$ $466.20 5.24$ $314.40 010

11643 9.12$ $547.20 6.53$ $391.80 010

11644 11.22$ $673.20 8.06$ $483.60 010

11646 14.58$ $874.80 11.15$ $669.00 010

11719 0.40$ $24.00 0.22$ $13.20 000

11720 0.93$ $55.80 0.42$ $25.20 000

11721 1.29$ $77.40 0.70$ $42.00 000

11730 2.86$ $171.60 1.44$ $86.40 000

11732 1.03$ $61.80 0.57$ $34.20 ZZZ

11740 1.44$ $86.40 0.95$ $57.00 000

11750 5.25$ $315.00 4.09$ $245.40 010

11752 9.31$ $558.60 7.52$ $451.20 010

11755 3.87$ $232.20 2.24$ $134.40 000

11760 5.62$ $337.20 3.34$ $200.40 010

11762 8.09$ $485.40 5.26$ $315.60 010

11765 4.89$ $293.40 2.72$ $163.20 010

11770 7.88$ $472.80 5.16$ $309.60 010

11771 16.15$ $969.00 12.09$ $725.40 090

11772 19.60$ $1,176.00 16.18$ $970.80 090

11900 1.59$ $95.40 0.89$ $53.40 000

11901 1.99$ $119.40 1.37$ $82.20 000

11920 4.86$ $291.60 3.22$ $193.20 000

11921 5.65$ $339.00 3.80$ $228.00 000

11922 1.77$ $106.20 0.83$ $49.80 ZZZ

11950 2.12$ $127.20 1.46$ $87.60 000

11951 2.74$ $164.40 2.00$ $120.00 000

11952 3.69$ $221.40 2.71$ $162.60 000

11954 4.46$ $267.60 3.21$ $192.60 000

11960 26.91$ $1,614.60 26.91$ $1,614.60 090

11970 17.25$ $1,035.00 17.25$ $1,035.00 090

11971 13.56$ $813.60 9.13$ $547.80 090

11976 4.06$ $243.60 2.64$ $158.40 000

11980 2.69$ $161.40 1.58$ $94.80 000



Page | 3

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

11981 3.98$ $238.80 2.28$ $136.80 XXX

11982 4.51$ $270.60 2.78$ $166.80 XXX

11983 6.25$ $375.00 4.86$ $291.60 XXX

12001 2.56$ $153.60 1.24$ $74.40 000

12002 3.10$ $186.00 1.62$ $97.20 000

12004 3.64$ $218.40 2.02$ $121.20 000

12005 4.57$ $274.20 2.62$ $157.20 000

12006 5.41$ $324.60 3.21$ $192.60 000

12007 6.28$ $376.80 4.05$ $243.00 000

12011 3.13$ $187.80 1.53$ $91.80 000

12013 3.26$ $195.60 1.60$ $96.00 000

12014 3.79$ $227.40 2.06$ $123.60 000

12015 4.58$ $274.80 2.59$ $155.40 000

12016 5.80$ $348.00 3.53$ $211.80 000

12017 4.21$ $252.60 4.21$ $252.60 000

12018 4.78$ $286.80 4.78$ $286.80 000

12020 8.25$ $495.00 5.46$ $327.60 010

12021 4.73$ $283.80 3.99$ $239.40 010

12031 6.81$ $408.60 4.36$ $261.60 010

12032 8.73$ $523.80 5.58$ $334.80 010

12034 8.90$ $534.00 5.86$ $351.60 010

12035 10.94$ $656.40 6.79$ $407.40 010

12036 11.97$ $718.20 7.83$ $469.80 010

12037 13.54$ $812.40 9.16$ $549.60 010

12041 6.80$ $408.00 4.28$ $256.80 010

12042 8.27$ $496.20 5.71$ $342.60 010

12044 10.31$ $618.60 6.09$ $365.40 010

12045 11.54$ $692.40 7.68$ $460.80 010

12046 13.55$ $813.00 8.65$ $519.00 010

12047 14.72$ $883.20 9.66$ $579.60 010

12051 7.41$ $444.60 4.89$ $293.40 010

12052 8.42$ $505.20 5.81$ $348.60 010

12053 9.90$ $594.00 6.19$ $371.40 010

12054 10.32$ $619.20 6.29$ $377.40 010

12055 13.39$ $803.40 8.68$ $520.80 010

12056 15.61$ $936.60 10.72$ $643.20 010

12057 15.93$ $955.80 11.42$ $685.20 010

13100 9.60$ $576.00 5.86$ $351.60 010

13101 11.37$ $682.20 7.23$ $433.80 010

13102 3.46$ $207.60 2.09$ $125.40 ZZZ

13120 10.03$ $601.80 6.74$ $404.40 010

13121 12.24$ $734.40 7.60$ $456.00 010



Page | 4

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

13122 3.79$ $227.40 2.40$ $144.00 ZZZ

13131 11.03$ $661.80 7.11$ $426.60 010

13132 13.62$ $817.20 8.95$ $537.00 010

13133 5.07$ $304.20 3.70$ $222.00 ZZZ

13151 12.05$ $723.00 8.16$ $489.60 010

13152 14.47$ $868.20 9.89$ $593.40 010

13153 5.49$ $329.40 3.99$ $239.40 ZZZ

13160 22.63$ $1,357.80 22.63$ $1,357.80 090

14000 17.72$ $1,063.20 14.30$ $858.00 090

14001 22.69$ $1,361.40 18.53$ $1,111.80 090

14020 19.87$ $1,192.20 16.22$ $973.20 090

14021 24.79$ $1,487.40 20.47$ $1,228.20 090

14040 21.71$ $1,302.60 18.05$ $1,083.00 090

14041 26.86$ $1,611.60 22.17$ $1,330.20 090

14060 22.10$ $1,326.00 19.22$ $1,153.20 090

14061 28.91$ $1,734.60 23.74$ $1,424.40 090

14301 30.58$ $1,834.80 25.02$ $1,501.20 090

14302 6.21$ $372.60 6.21$ $372.60 ZZZ

14350 19.84$ $1,190.40 19.84$ $1,190.40 090

15002 9.89$ $593.40 6.37$ $382.20 000

15003 2.15$ $129.00 1.27$ $76.20 ZZZ

15004 11.46$ $687.60 7.65$ $459.00 000

15005 3.51$ $210.60 2.53$ $151.80 ZZZ

15040 7.37$ $442.20 3.58$ $214.80 000

15050 16.14$ $968.40 12.71$ $762.60 090

15100 24.25$ $1,455.00 20.16$ $1,209.60 090

15101 5.30$ $318.00 3.10$ $186.00 ZZZ

15110 22.64$ $1,358.40 19.59$ $1,175.40 090

15111 3.18$ $190.80 2.85$ $171.00 ZZZ

15115 23.32$ $1,399.20 20.25$ $1,215.00 090

15116 4.19$ $251.40 3.74$ $224.40 ZZZ

15120 24.14$ $1,448.40 19.75$ $1,185.00 090

15121 5.95$ $357.00 3.73$ $223.80 ZZZ

15130 19.06$ $1,143.60 15.94$ $956.40 090

15131 2.79$ $167.40 2.55$ $153.00 ZZZ

15135 23.99$ $1,439.40 20.93$ $1,255.80 090

15136 2.65$ $159.00 2.47$ $148.20 ZZZ

15150 19.34$ $1,160.40 17.59$ $1,055.40 090

15151 3.35$ $201.00 3.07$ $184.20 ZZZ

15152 4.10$ $246.00 3.81$ $228.60 ZZZ

15155 20.49$ $1,229.40 18.89$ $1,133.40 090

15156 4.34$ $260.40 4.09$ $245.40 ZZZ



Page | 5

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

15157 4.89$ $293.40 4.55$ $273.00 ZZZ

15200 23.59$ $1,415.40 19.03$ $1,141.80 090

15201 4.24$ $254.40 2.20$ $132.00 ZZZ

15220 21.98$ $1,318.80 17.51$ $1,050.60 090

15221 3.92$ $235.20 2.00$ $120.00 ZZZ

15240 26.59$ $1,595.40 22.87$ $1,372.20 090

15241 5.28$ $316.80 3.13$ $187.80 ZZZ

15260 28.89$ $1,733.40 24.56$ $1,473.60 090

15261 6.18$ $370.80 3.97$ $238.20 ZZZ

15271 4.02$ $241.20 2.38$ $142.80 000

15272 0.77$ $46.20 0.48$ $28.80 ZZZ

15273 8.40$ $504.00 5.63$ $337.80 000

15274 2.01$ $120.60 1.27$ $76.20 ZZZ

15275 4.28$ $256.80 2.71$ $162.60 000

15276 0.98$ $58.80 0.70$ $42.00 ZZZ

15277 9.12$ $547.20 6.29$ $377.40 000

15278 2.39$ $143.40 1.58$ $94.80 ZZZ

15570 25.90$ $1,554.00 20.77$ $1,246.20 090

15572 25.18$ $1,510.80 21.15$ $1,269.00 090

15574 25.97$ $1,558.20 21.79$ $1,307.40 090

15576 22.99$ $1,379.40 19.12$ $1,147.20 090

15600 9.36$ $561.60 5.96$ $357.60 090

15610 10.26$ $615.60 6.92$ $415.20 090

15620 12.65$ $759.00 9.35$ $561.00 090

15630 13.20$ $792.00 9.94$ $596.40 090

15650 14.43$ $865.80 10.91$ $654.60 090

15731 31.99$ $1,919.40 28.64$ $1,718.40 090

15732 36.66$ $2,199.60 31.82$ $1,909.20 090

15734 42.18$ $2,530.80 36.88$ $2,212.80 090

15736 37.22$ $2,233.20 32.01$ $1,920.60 090

15738 39.42$ $2,365.20 34.52$ $2,071.20 090

15740 29.01$ $1,740.60 24.31$ $1,458.60 090

15750 25.95$ $1,557.00 25.95$ $1,557.00 090

15756 65.54$ $3,932.40 65.54$ $3,932.40 090

15757 64.81$ $3,888.60 64.81$ $3,888.60 090

15758 64.88$ $3,892.80 64.88$ $3,892.80 090

15760 24.36$ $1,461.60 20.22$ $1,213.20 090

15770 19.09$ $1,145.40 19.09$ $1,145.40 090

15775 8.54$ $512.40 6.28$ $376.80 000

15776 14.10$ $846.00 10.04$ $602.40 000

15777 5.93$ $355.80 5.93$ $355.80 ZZZ

15780 24.18$ $1,450.80 18.08$ $1,084.80 090



Page | 6

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

15781 15.94$ $956.40 12.42$ $745.20 090

15782 18.46$ $1,107.60 12.90$ $774.00 090

15783 13.39$ $803.40 10.33$ $619.80 090

15786 7.08$ $424.80 3.87$ $232.20 010

15787 1.44$ $86.40 0.50$ $30.00 ZZZ

15788 13.53$ $811.80 7.20$ $432.00 090

15789 15.78$ $946.80 11.84$ $710.40 090

15792 13.01$ $780.60 7.68$ $460.80 090

15793 14.25$ $855.00 10.58$ $634.80 090

15819 20.85$ $1,251.00 20.85$ $1,251.00 090

15820 16.25$ $975.00 14.62$ $877.20 090

15821 17.47$ $1,048.20 15.65$ $939.00 090

15822 12.84$ $770.40 11.23$ $673.80 090

15823 17.51$ $1,050.60 15.66$ $939.60 090

15824 000

15825 000

15826 000

15828 000

15829 000

15830 32.92$ $1,975.20 32.92$ $1,975.20 090

15832 25.90$ $1,554.00 25.90$ $1,554.00 090

15833 24.32$ $1,459.20 24.32$ $1,459.20 090

15834 25.10$ $1,506.00 25.10$ $1,506.00 090

15835 26.18$ $1,570.80 26.18$ $1,570.80 090

15836 21.42$ $1,285.20 21.42$ $1,285.20 090

15837 22.72$ $1,363.20 18.79$ $1,127.40 090

15838 16.26$ $975.60 16.26$ $975.60 090

15839 25.06$ $1,503.60 20.82$ $1,249.20 090

15840 28.65$ $1,719.00 28.65$ $1,719.00 090

15841 45.37$ $2,722.20 45.37$ $2,722.20 090

15842 74.00$ $4,440.00 74.00$ $4,440.00 090

15845 28.91$ $1,734.60 28.91$ $1,734.60 090

15847 By Report By Report YYY

15850 Bundled Bundled XXX

15851 2.87$ $172.20 1.29$ $77.40 000

15852 1.30$ $78.00 1.30$ $78.00 000

15860 3.07$ $184.20 3.07$ $184.20 000

15876 000

15877 000

15878 000

15879 000

15920 16.90$ $1,014.00 16.90$ $1,014.00 090

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered



Page | 7

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

15922 22.11$ $1,326.60 22.11$ $1,326.60 090

15931 19.07$ $1,144.20 19.07$ $1,144.20 090

15933 23.76$ $1,425.60 23.76$ $1,425.60 090

15934 25.84$ $1,550.40 25.84$ $1,550.40 090

15935 30.58$ $1,834.80 30.58$ $1,834.80 090

15936 24.89$ $1,493.40 24.89$ $1,493.40 090

15937 28.93$ $1,735.80 28.93$ $1,735.80 090

15940 19.55$ $1,173.00 19.55$ $1,173.00 090

15941 25.26$ $1,515.60 25.26$ $1,515.60 090

15944 24.87$ $1,492.20 24.87$ $1,492.20 090

15945 27.42$ $1,645.20 27.42$ $1,645.20 090

15946 45.88$ $2,752.80 45.88$ $2,752.80 090

15950 16.56$ $993.60 16.56$ $993.60 090

15951 24.88$ $1,492.80 24.88$ $1,492.80 090

15952 25.34$ $1,520.40 25.34$ $1,520.40 090

15953 28.10$ $1,686.00 28.10$ $1,686.00 090

15956 32.30$ $1,938.00 32.30$ $1,938.00 090

15958 32.93$ $1,975.80 32.93$ $1,975.80 090


16000 1.95$ $117.00 1.29$ $77.40 000

16020 2.36$ $141.60 1.55$ $93.00 000

16025 4.19$ $251.40 3.14$ $188.40 000

16030 5.27$ $316.20 3.76$ $225.60 000

16035 5.45$ $327.00 5.45$ $327.00 000

16036 2.24$ $134.40 2.24$ $134.40 ZZZ

17000 1.92$ $115.20 1.52$ $91.20 010

17003 0.16$ $9.60 0.07$ $4.20 ZZZ

17004 4.31$ $258.60 2.84$ $170.40 010

17106 9.75$ $585.00 7.87$ $472.20 090

17107 12.39$ $743.40 9.88$ $592.80 090

17108 18.16$ $1,089.60 14.91$ $894.60 090

17110 3.22$ $193.20 2.02$ $121.20 010

17111 3.80$ $228.00 2.47$ $148.20 010

17250 2.30$ $138.00 1.06$ $63.60 000

17260 2.71$ $162.60 2.00$ $120.00 010

17261 4.13$ $247.80 2.61$ $156.60 010

17262 5.01$ $300.60 3.31$ $198.60 010

17263 5.47$ $328.20 3.68$ $220.80 010

17264 5.87$ $352.20 3.92$ $235.20 010

17266 6.64$ $398.40 4.58$ $274.80 010

17270 4.32$ $259.20 2.84$ $170.40 010

17271 4.67$ $280.20 3.16$ $189.60 010



Page | 8

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

17272 5.33$ $319.80 3.65$ $219.00 010

17273 5.94$ $356.40 4.11$ $246.60 010

17274 7.00$ $420.00 5.01$ $300.60 010

17276 8.08$ $484.80 6.01$ $360.60 010

17280 4.04$ $242.40 2.58$ $154.80 010

17281 5.08$ $304.80 3.55$ $213.00 010

17282 5.84$ $350.40 4.10$ $246.00 010

17283 6.97$ $418.20 5.11$ $306.60 010

17284 7.95$ $477.00 5.95$ $357.00 010

17286 10.14$ $608.40 7.95$ $477.00 010

17311 18.94$ $1,136.40 10.69$ $641.40 000

17312 11.18$ $670.80 5.68$ $340.80 ZZZ

17313 17.74$ $1,064.40 9.58$ $574.80 000

17314 10.74$ $644.40 5.27$ $316.20 ZZZ

17315 2.27$ $136.20 1.50$ $90.00 ZZZ

17340 1.45$ $87.00 1.39$ $83.40 010

17360 3.67$ $220.20 2.79$ $167.40 010

17380 000


19000 3.29$ $197.40 1.23$ $73.80 000

19001 0.76$ $45.60 0.62$ $37.20 ZZZ

19020 13.50$ $810.00 8.59$ $515.40 090

19030 4.80$ $288.00 2.21$ $132.60 000

19081 20.44$ $1,226.40 4.79$ $287.40 XXX

19082 17.02$ $1,021.20 2.40$ $144.00 XXX

19083 19.79$ $1,187.40 4.50$ $270.00 XXX

19084 16.38$ $982.80 2.26$ $135.60 XXX

19085 30.52$ $1,831.20 5.29$ $317.40 XXX

19086 24.31$ $1,458.60 2.64$ $158.40 XXX

19100 4.29$ $257.40 1.91$ $114.60 000

19101 9.68$ $580.80 6.15$ $369.00 010

19105 63.80$ $3,828.00 5.53$ $331.80 000

19110 13.76$ $825.60 9.56$ $573.60 090

19112 12.99$ $779.40 8.71$ $522.60 090

19120 13.82$ $829.20 11.47$ $688.20 090

19125 15.29$ $917.40 12.72$ $763.20 090

19126 4.40$ $264.00 4.40$ $264.00 ZZZ

19260 33.42$ $2,005.20 33.42$ $2,005.20 090

19271 45.58$ $2,734.80 45.58$ $2,734.80 090

19272 49.72$ $2,983.20 49.72$ $2,983.20 090

19281 6.99$ $419.40 2.90$ $174.00 XXX

19282 4.92$ $295.20 1.45$ $87.00 XXX

Not Covered



Page | 9

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

19283 7.87$ $472.20 2.90$ $174.00 XXX

19284 5.98$ $358.80 1.46$ $87.60 XXX

19285 15.27$ $916.20 2.46$ $147.60 XXX

19286 13.48$ $808.80 1.24$ $74.40 XXX

19287 25.56$ $1,533.60 3.69$ $221.40 XXX

19288 20.71$ $1,242.60 1.85$ $111.00 XXX

19296 117.91$ $7,074.60 5.79$ $347.40 000

19297 2.59$ $155.40 2.59$ $155.40 ZZZ

19298 30.81$ $1,848.60 9.20$ $552.00 000

19300 14.80$ $888.00 11.56$ $693.60 090

19301 18.00$ $1,080.00 18.00$ $1,080.00 090

19302 24.78$ $1,486.80 24.78$ $1,486.80 090

19303 27.84$ $1,670.40 27.84$ $1,670.40 090

19304 15.98$ $958.80 15.98$ $958.80 090

19305 31.15$ $1,869.00 31.15$ $1,869.00 090

19306 33.13$ $1,987.80 33.13$ $1,987.80 090

19307 33.05$ $1,983.00 33.05$ $1,983.00 090

19316 21.64$ $1,298.40 21.64$ $1,298.40 090

19318 31.07$ $1,864.20 31.07$ $1,864.20 090

19324 13.62$ $817.20 13.62$ $817.20 090

19325 18.15$ $1,089.00 18.15$ $1,089.00 090

19328 14.03$ $841.80 14.03$ $841.80 090

19330 17.94$ $1,076.40 17.94$ $1,076.40 090

19340 28.36$ $1,701.60 28.36$ $1,701.60 090

19342 26.11$ $1,566.60 26.11$ $1,566.60 090

19350 23.44$ $1,406.40 19.04$ $1,142.40 090

19355 19.64$ $1,178.40 15.79$ $947.40 090

19357 42.87$ $2,572.20 42.87$ $2,572.20 090

19361 44.37$ $2,662.20 44.37$ $2,662.20 090

19364 77.47$ $4,648.20 77.47$ $4,648.20 090

19366 39.35$ $2,361.00 39.35$ $2,361.00 090

19367 50.42$ $3,025.20 50.42$ $3,025.20 090

19368 61.92$ $3,715.20 61.92$ $3,715.20 090

19369 57.46$ $3,447.60 57.46$ $3,447.60 090

19370 19.42$ $1,165.20 19.42$ $1,165.20 090

19371 22.18$ $1,330.80 22.18$ $1,330.80 090

19380 21.88$ $1,312.80 21.88$ $1,312.80 090

19396 8.02$ $481.20 3.95$ $237.00 000


20005 8.83$ $529.80 6.60$ $396.00 010

20100 16.81$ $1,008.60 16.81$ $1,008.60 010

20101 12.92$ $775.20 5.76$ $345.60 010



Page | 10

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

20102 14.08$ $844.80 7.09$ $425.40 010

20103 16.72$ $1,003.20 9.79$ $587.40 010

20150 25.41$ $1,524.60 25.41$ $1,524.60 090

20200 5.95$ $357.00 2.63$ $157.80 000

20205 8.24$ $494.40 4.28$ $256.80 000

20206 7.00$ $420.00 1.70$ $102.00 000

20220 4.94$ $296.40 2.09$ $125.40 000

20225 15.62$ $937.20 3.12$ $187.20 000

20240 4.36$ $261.60 4.36$ $261.60 000

20245 14.47$ $868.20 14.47$ $868.20 010

20250 10.85$ $651.00 10.85$ $651.00 010

20251 11.78$ $706.80 11.78$ $706.80 010

20500 3.00$ $180.00 2.43$ $145.80 010

20501 3.47$ $208.20 1.09$ $65.40 000

20520 5.87$ $352.20 4.18$ $250.80 010

20525 13.88$ $832.80 7.01$ $420.60 010

20526 2.18$ $130.80 1.61$ $96.60 000

20527 2.37$ $142.20 1.87$ $112.20 000

20550 1.68$ $100.80 1.18$ $70.80 000

20551 1.72$ $103.20 1.21$ $72.60 000

20552 1.59$ $95.40 1.08$ $64.80 000

20553 1.83$ $109.80 1.23$ $73.80 000

20555 9.20$ $552.00 9.20$ $552.00 000

20600 1.35$ $81.00 1.01$ $60.60 000

20604 2.07$ $124.20 1.29$ $77.40 XXX

20605 1.42$ $85.20 1.05$ $63.00 000

20606 2.28$ $136.80 1.48$ $88.80 XXX

20610 1.70$ $102.00 1.29$ $77.40 000

20611 2.60$ $156.00 1.72$ $103.20 XXX

20612 1.73$ $103.80 1.18$ $70.80 000

20615 7.07$ $424.20 4.67$ $280.20 010

20650 5.95$ $357.00 4.46$ $267.60 010

20660 6.61$ $396.60 6.61$ $396.60 000

20661 14.09$ $845.40 14.09$ $845.40 090

20662 12.57$ $754.20 12.57$ $754.20 090

20663 13.27$ $796.20 13.27$ $796.20 090

20664 23.95$ $1,437.00 23.95$ $1,437.00 090

20665 3.05$ $183.00 2.61$ $156.60 010

20670 11.15$ $669.00 4.21$ $252.60 010

20680 17.78$ $1,066.80 11.99$ $719.40 090

20690 16.66$ $999.60 16.66$ $999.60 090

20692 31.58$ $1,894.80 31.58$ $1,894.80 090



Page | 11

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

20693 12.66$ $759.60 12.66$ $759.60 090

20694 12.18$ $730.80 9.61$ $576.60 090

20696 33.84$ $2,030.40 33.84$ $2,030.40 090

20697 59.44$ $3,566.40 59.44$ $3,566.40 000

20802 67.77$ $4,066.20 67.77$ $4,066.20 090

20805 92.27$ $5,536.20 92.27$ $5,536.20 090

20808 112.67$ $6,760.20 112.67$ $6,760.20 090

20816 57.80$ $3,468.00 57.80$ $3,468.00 090

20822 50.70$ $3,042.00 50.70$ $3,042.00 090

20824 56.81$ $3,408.60 56.81$ $3,408.60 090

20827 51.14$ $3,068.40 51.14$ $3,068.40 090

20838 68.49$ $4,109.40 68.49$ $4,109.40 090

20900 12.15$ $729.00 5.33$ $319.80 000

20902 8.00$ $480.00 8.00$ $480.00 000

20910 11.75$ $705.00 11.75$ $705.00 090

20912 13.71$ $822.60 13.71$ $822.60 090

20920 11.25$ $675.00 11.25$ $675.00 090

20922 17.14$ $1,028.40 13.98$ $838.80 090

20924 14.32$ $859.20 14.32$ $859.20 090

20926 12.18$ $730.80 12.18$ $730.80 090


20931 3.04$ $182.40 3.04$ $182.40 ZZZ


20937 4.61$ $276.60 4.61$ $276.60 ZZZ

20938 5.03$ $301.80 5.03$ $301.80 ZZZ

20950 7.40$ $444.00 2.59$ $155.40 000

20955 70.78$ $4,246.80 70.78$ $4,246.80 090

20956 74.06$ $4,443.60 74.06$ $4,443.60 090

20957 69.53$ $4,171.80 69.53$ $4,171.80 090

20962 60.46$ $3,627.60 60.46$ $3,627.60 090

20969 78.26$ $4,695.60 78.26$ $4,695.60 090

20970 80.89$ $4,853.40 80.89$ $4,853.40 090

20972 67.46$ $4,047.60 67.46$ $4,047.60 090

20973 74.46$ $4,467.60 74.46$ $4,467.60 090

20974 2.19$ $131.40 1.42$ $85.20 000

20975 4.94$ $296.40 4.94$ $296.40 000

20979 1.50$ $90.00 0.91$ $54.60 000

20982 90.02$ $5,401.20 10.84$ $650.40 000

20983 217.31$ $13,038.60 11.46$ $687.60 XXX

20985 4.09$ $245.40 4.09$ $245.40 ZZZ


21010 21.13$ $1,267.80 21.13$ $1,267.80 090



Page | 12

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

21011 10.04$ $602.40 7.41$ $444.60 090

21012 9.56$ $573.60 9.56$ $573.60 090

21013 14.85$ $891.00 11.38$ $682.80 090

21014 14.73$ $883.80 14.73$ $883.80 090

21015 20.08$ $1,204.80 20.08$ $1,204.80 090

21016 28.84$ $1,730.40 28.84$ $1,730.40 090

21025 25.82$ $1,549.20 21.65$ $1,299.00 090

21026 18.02$ $1,081.20 14.47$ $868.20 090

21029 22.12$ $1,327.20 18.28$ $1,096.80 090

21030 15.15$ $909.00 12.12$ $727.20 090

21031 11.60$ $696.00 8.60$ $516.00 090

21032 11.79$ $707.40 8.50$ $510.00 090

21034 37.74$ $2,264.40 33.05$ $1,983.00 090

21040 15.26$ $915.60 12.15$ $729.00 090

21044 25.08$ $1,504.80 25.08$ $1,504.80 090

21045 35.07$ $2,104.20 35.07$ $2,104.20 090

21046 32.28$ $1,936.80 32.28$ $1,936.80 090

21047 37.66$ $2,259.60 37.66$ $2,259.60 090

21048 33.08$ $1,984.80 33.08$ $1,984.80 090

21049 34.55$ $2,073.00 34.55$ $2,073.00 090

21050 24.10$ $1,446.00 24.10$ $1,446.00 090

21060 22.83$ $1,369.80 22.83$ $1,369.80 090

21070 17.53$ $1,051.80 17.53$ $1,051.80 090

21073 11.29$ $677.40 7.27$ $436.20 090

21076 28.79$ $1,727.40 23.88$ $1,432.80 010

21077 72.20$ $4,332.00 59.99$ $3,599.40 090

21079 48.64$ $2,918.40 39.94$ $2,396.40 090

21080 54.63$ $3,277.80 44.46$ $2,667.60 090

21081 50.47$ $3,028.20 40.90$ $2,454.00 090

21082 47.81$ $2,868.60 38.45$ $2,307.00 090

21083 45.64$ $2,738.40 35.70$ $2,142.00 090

21084 52.41$ $3,144.60 41.39$ $2,483.40 090

21085 21.99$ $1,319.40 16.20$ $972.00 010

21086 53.72$ $3,223.20 44.45$ $2,667.00 090

21087 53.63$ $3,217.80 44.35$ $2,661.00 090

21088 By Report By Report 090


21100 30.19$ $1,811.40 14.21$ $852.60 090

21110 23.74$ $1,424.40 19.79$ $1,187.40 090

21116 4.30$ $258.00 1.25$ $75.00 000

21120 19.30$ $1,158.00 15.17$ $910.20 090

21121 23.59$ $1,415.40 19.54$ $1,172.40 090



Page | 13

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

21122 18.98$ $1,138.80 18.98$ $1,138.80 090

21123 26.91$ $1,614.60 26.91$ $1,614.60 090

21125 91.08$ $5,464.80 22.50$ $1,350.00 090

21127 132.12$ $7,927.20 25.58$ $1,534.80 090

21137 21.16$ $1,269.60 21.16$ $1,269.60 090

21138 25.62$ $1,537.20 25.62$ $1,537.20 090

21139 27.08$ $1,624.80 27.08$ $1,624.80 090

21141 38.24$ $2,294.40 38.24$ $2,294.40 090

21142 40.06$ $2,403.60 40.06$ $2,403.60 090

21143 40.35$ $2,421.00 40.35$ $2,421.00 090

21145 44.67$ $2,680.20 44.67$ $2,680.20 090

21146 44.06$ $2,643.60 44.06$ $2,643.60 090

21147 49.70$ $2,982.00 49.70$ $2,982.00 090

21150 47.98$ $2,878.80 47.98$ $2,878.80 090

21151 58.16$ $3,489.60 58.16$ $3,489.60 090

21154 58.92$ $3,535.20 58.92$ $3,535.20 090

21155 62.18$ $3,730.80 62.18$ $3,730.80 090

21159 70.97$ $4,258.20 70.97$ $4,258.20 090

21160 90.12$ $5,407.20 90.12$ $5,407.20 090

21172 52.66$ $3,159.60 52.66$ $3,159.60 090

21175 61.55$ $3,693.00 61.55$ $3,693.00 090

21179 42.01$ $2,520.60 42.01$ $2,520.60 090

21180 43.89$ $2,633.40 43.89$ $2,633.40 090

21181 20.96$ $1,257.60 20.96$ $1,257.60 090

21182 54.78$ $3,286.80 54.78$ $3,286.80 090

21183 65.26$ $3,915.60 65.26$ $3,915.60 090

21184 60.26$ $3,615.60 60.26$ $3,615.60 090

21188 46.00$ $2,760.00 46.00$ $2,760.00 090

21193 34.50$ $2,070.00 34.50$ $2,070.00 090

21194 40.90$ $2,454.00 40.90$ $2,454.00 090

21195 38.49$ $2,309.40 38.49$ $2,309.40 090

21196 42.54$ $2,552.40 42.54$ $2,552.40 090

21198 33.61$ $2,016.60 33.61$ $2,016.60 090

21199 30.32$ $1,819.20 30.32$ $1,819.20 090

21206 33.80$ $2,028.00 33.80$ $2,028.00 090

21208 56.01$ $3,360.60 24.07$ $1,444.20 090

21209 23.67$ $1,420.20 17.83$ $1,069.80 090

21210 68.11$ $4,086.60 24.93$ $1,495.80 090

21215 122.18$ $7,330.80 25.91$ $1,554.60 090

21230 20.29$ $1,217.40 20.29$ $1,217.40 090

21235 21.02$ $1,261.20 16.28$ $976.80 090

21240 32.05$ $1,923.00 32.05$ $1,923.00 090



Page | 14

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

21242 29.37$ $1,762.20 29.37$ $1,762.20 090

21243 48.53$ $2,911.80 48.53$ $2,911.80 090

21244 30.76$ $1,845.60 30.76$ $1,845.60 090

21245 32.09$ $1,925.40 25.36$ $1,521.60 090

21246 24.82$ $1,489.20 24.82$ $1,489.20 090

21247 44.21$ $2,652.60 44.21$ $2,652.60 090

21248 32.17$ $1,930.20 26.03$ $1,561.80 090

21249 43.87$ $2,632.20 36.90$ $2,214.00 090

21255 39.85$ $2,391.00 39.85$ $2,391.00 090

21256 34.68$ $2,080.80 34.68$ $2,080.80 090

21260 39.88$ $2,392.80 39.88$ $2,392.80 090

21261 59.95$ $3,597.00 59.95$ $3,597.00 090

21263 55.43$ $3,325.80 55.43$ $3,325.80 090

21267 45.72$ $2,743.20 45.72$ $2,743.20 090

21268 49.60$ $2,976.00 49.60$ $2,976.00 090

21270 27.93$ $1,675.80 20.70$ $1,242.00 090

21275 23.70$ $1,422.00 23.70$ $1,422.00 090

21280 16.38$ $982.80 16.38$ $982.80 090

21282 10.98$ $658.80 10.98$ $658.80 090

21295 5.23$ $313.80 5.23$ $313.80 090

21296 12.49$ $749.40 12.49$ $749.40 090


21310 3.90$ $234.00 0.75$ $45.00 000

21315 8.15$ $489.00 4.37$ $262.20 010

21320 7.53$ $451.80 3.87$ $232.20 010

21325 13.81$ $828.60 13.81$ $828.60 090

21330 16.45$ $987.00 16.45$ $987.00 090

21335 20.95$ $1,257.00 20.95$ $1,257.00 090

21336 18.69$ $1,121.40 18.69$ $1,121.40 090

21337 11.79$ $707.40 8.51$ $510.60 090

21338 20.93$ $1,255.80 20.93$ $1,255.80 090

21339 22.34$ $1,340.40 22.34$ $1,340.40 090

21340 21.56$ $1,293.60 21.56$ $1,293.60 090

21343 34.57$ $2,074.20 34.57$ $2,074.20 090

21344 39.72$ $2,383.20 39.72$ $2,383.20 090

21345 23.42$ $1,405.20 18.71$ $1,122.60 090

21346 26.24$ $1,574.40 26.24$ $1,574.40 090

21347 32.61$ $1,956.60 32.61$ $1,956.60 090

21348 34.17$ $2,050.20 34.17$ $2,050.20 090

21355 12.46$ $747.60 9.20$ $552.00 010

21356 14.53$ $871.80 10.86$ $651.60 010

21360 15.42$ $925.20 15.42$ $925.20 090



Page | 15

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

21365 31.59$ $1,895.40 31.59$ $1,895.40 090

21366 32.82$ $1,969.20 32.82$ $1,969.20 090

21385 19.55$ $1,173.00 19.55$ $1,173.00 090

21386 19.73$ $1,183.80 19.73$ $1,183.80 090

21387 20.37$ $1,222.20 20.37$ $1,222.20 090

21390 22.74$ $1,364.40 22.74$ $1,364.40 090

21395 28.41$ $1,704.60 28.41$ $1,704.60 090

21400 5.62$ $337.20 4.53$ $271.80 090

21401 12.90$ $774.00 8.21$ $492.60 090

21406 14.82$ $889.20 14.82$ $889.20 090

21407 18.46$ $1,107.60 18.46$ $1,107.60 090

21408 24.81$ $1,488.60 24.81$ $1,488.60 090

21421 22.16$ $1,329.60 18.58$ $1,114.80 090

21422 19.33$ $1,159.80 19.33$ $1,159.80 090

21423 23.37$ $1,402.20 23.37$ $1,402.20 090

21431 21.45$ $1,287.00 21.45$ $1,287.00 090

21432 18.80$ $1,128.00 18.80$ $1,128.00 090

21433 49.04$ $2,942.40 49.04$ $2,942.40 090

21435 35.86$ $2,151.60 35.86$ $2,151.60 090

21436 57.63$ $3,457.80 57.63$ $3,457.80 090

21440 17.18$ $1,030.80 13.85$ $831.00 090

21445 22.67$ $1,360.20 18.30$ $1,098.00 090

21450 18.42$ $1,105.20 14.65$ $879.00 090

21451 22.51$ $1,350.60 18.78$ $1,126.80 090

21452 17.92$ $1,075.20 10.43$ $625.80 090

21453 27.00$ $1,620.00 23.02$ $1,381.20 090

21454 17.06$ $1,023.60 17.06$ $1,023.60 090

21461 64.03$ $3,841.80 27.49$ $1,649.40 090

21462 67.77$ $4,066.20 30.52$ $1,831.20 090

21465 27.41$ $1,644.60 27.41$ $1,644.60 090

21470 34.39$ $2,063.40 34.39$ $2,063.40 090

21480 2.91$ $174.60 0.89$ $53.40 000

21485 20.80$ $1,248.00 17.29$ $1,037.40 090

21490 26.10$ $1,566.00 26.10$ $1,566.00 090

21495 20.66$ $1,239.60 20.66$ $1,239.60 090

21497 21.82$ $1,309.20 18.05$ $1,083.00 090


21501 13.09$ $785.40 9.15$ $549.00 090

21502 14.83$ $889.80 14.83$ $889.80 090

21510 12.48$ $748.80 12.48$ $748.80 090

21550 7.66$ $459.60 4.52$ $271.20 010

21552 12.47$ $748.20 12.47$ $748.20 090



Page | 16

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

21554 20.44$ $1,226.40 20.44$ $1,226.40 090

21555 11.90$ $714.00 8.66$ $519.60 090

21556 14.94$ $896.40 14.94$ $896.40 090

21557 26.84$ $1,610.40 26.84$ $1,610.40 090

21558 37.57$ $2,254.20 37.57$ $2,254.20 090

21600 15.76$ $945.60 15.76$ $945.60 090

21610 32.25$ $1,935.00 32.25$ $1,935.00 090

21615 17.06$ $1,023.60 17.06$ $1,023.60 090

21616 20.87$ $1,252.20 20.87$ $1,252.20 090

21620 14.12$ $847.20 14.12$ $847.20 090

21627 15.20$ $912.00 15.20$ $912.00 090

21630 33.76$ $2,025.60 33.76$ $2,025.60 090

21632 33.49$ $2,009.40 33.49$ $2,009.40 090

21685 28.57$ $1,714.20 28.57$ $1,714.20 090

21700 10.26$ $615.60 10.26$ $615.60 090

21705 15.13$ $907.80 15.13$ $907.80 090

21720 12.82$ $769.20 12.82$ $769.20 090

21725 14.70$ $882.00 14.70$ $882.00 090

21740 28.27$ $1,696.20 28.27$ $1,696.20 090



21750 18.88$ $1,132.80 18.88$ $1,132.80 090

21811 16.77$ $1,006.20 16.77$ $1,006.20 XXX

21812 20.08$ $1,204.80 20.08$ $1,204.80 XXX

21813 26.18$ $1,570.80 26.18$ $1,570.80 XXX

21820 4.04$ $242.40 4.15$ $249.00 090

21825 15.13$ $907.80 15.13$ $907.80 090


21920 7.48$ $448.80 4.59$ $275.40 010

21925 12.71$ $762.60 10.00$ $600.00 090

21930 13.45$ $807.00 10.26$ $615.60 090

21931 13.09$ $785.40 13.09$ $785.40 090

21932 18.42$ $1,105.20 18.42$ $1,105.20 090

21933 20.48$ $1,228.80 20.48$ $1,228.80 090

21935 28.53$ $1,711.80 28.53$ $1,711.80 090

21936 39.14$ $2,348.40 39.14$ $2,348.40 090

22010 26.42$ $1,585.20 26.42$ $1,585.20 090

22015 25.66$ $1,539.60 25.66$ $1,539.60 090

22100 24.13$ $1,447.80 24.13$ $1,447.80 090

22101 23.71$ $1,422.60 23.71$ $1,422.60 090

22102 22.24$ $1,334.40 22.24$ $1,334.40 090

22103 3.84$ $230.40 3.84$ $230.40 ZZZ



Page | 17

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

22110 28.87$ $1,732.20 28.87$ $1,732.20 090

22112 27.82$ $1,669.20 27.82$ $1,669.20 090

22114 27.97$ $1,678.20 27.97$ $1,678.20 090

22116 3.85$ $231.00 3.85$ $231.00 ZZZ

22206 67.17$ $4,030.20 67.17$ $4,030.20 090

22207 66.05$ $3,963.00 66.05$ $3,963.00 090

22208 15.99$ $959.40 15.99$ $959.40 ZZZ

22210 49.20$ $2,952.00 49.20$ $2,952.00 090

22212 41.18$ $2,470.80 41.18$ $2,470.80 090

22214 41.31$ $2,478.60 41.31$ $2,478.60 090

22216 9.98$ $598.80 9.98$ $598.80 ZZZ

22220 44.24$ $2,654.40 44.24$ $2,654.40 090

22222 43.64$ $2,618.40 43.64$ $2,618.40 090

22224 44.07$ $2,644.20 44.07$ $2,644.20 090

22226 9.95$ $597.00 9.95$ $597.00 ZZZ

22305 5.44$ $326.40 4.91$ $294.60 090

22310 8.66$ $519.60 7.94$ $476.40 090

22315 24.91$ $1,494.60 21.58$ $1,294.80 090

22318 44.58$ $2,674.80 44.58$ $2,674.80 090

22319 49.20$ $2,952.00 49.20$ $2,952.00 090

22325 39.70$ $2,382.00 39.70$ $2,382.00 090

22326 40.85$ $2,451.00 40.85$ $2,451.00 090

22327 41.38$ $2,482.80 41.38$ $2,482.80 090

22328 7.68$ $460.80 7.68$ $460.80 ZZZ

22505 3.59$ $215.40 3.59$ $215.40 010

22510 52.29$ $3,137.40 12.87$ $772.20 XXX

22511 51.80$ $3,108.00 12.08$ $724.80 XXX

22512 29.01$ $1,740.60 5.90$ $354.00 XXX

22513 219.13$ $13,147.80 15.07$ $904.20 XXX

22514 218.96$ $13,137.60 14.07$ $844.20 XXX

22515 132.70$ $7,962.00 6.29$ $377.40 XXX

22526 70.92$ $4,255.20 9.91$ $594.60 010

22527 59.10$ $3,546.00 4.48$ $268.80 ZZZ

22532 48.96$ $2,937.60 48.96$ $2,937.60 090

22533 46.07$ $2,764.20 46.07$ $2,764.20 090

22534 9.89$ $593.40 9.89$ $593.40 ZZZ

22548 53.29$ $3,197.40 53.29$ $3,197.40 090

22551 46.90$ $2,814.00 46.90$ $2,814.00 090

22552 10.85$ $651.00 10.85$ $651.00 ZZZ

22554 34.61$ $2,076.60 34.61$ $2,076.60 090

22556 45.92$ $2,755.20 45.92$ $2,755.20 090

22558 42.66$ $2,559.60 42.66$ $2,559.60 090



Page | 18

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

22585 9.03$ $541.80 9.03$ $541.80 ZZZ

22586 50.89$ $3,053.40 50.89$ $3,053.40 090

22590 43.21$ $2,592.60 43.21$ $2,592.60 090

22595 41.28$ $2,476.80 41.28$ $2,476.80 090

22600 35.49$ $2,129.40 35.49$ $2,129.40 090

22610 34.92$ $2,095.20 34.92$ $2,095.20 090

22612 43.95$ $2,637.00 43.95$ $2,637.00 090

22614 10.70$ $642.00 10.70$ $642.00 ZZZ

22630 42.99$ $2,579.40 42.99$ $2,579.40 090

22632 8.72$ $523.20 8.72$ $523.20 ZZZ

22633 51.00$ $3,060.00 51.00$ $3,060.00 090

22634 13.57$ $814.20 13.57$ $814.20 ZZZ

22800 37.59$ $2,255.40 37.59$ $2,255.40 090

22802 58.21$ $3,492.60 58.21$ $3,492.60 090

22804 67.17$ $4,030.20 67.17$ $4,030.20 090

22808 50.64$ $3,038.40 50.64$ $3,038.40 090

22810 56.02$ $3,361.20 56.02$ $3,361.20 090

22812 64.78$ $3,886.80 64.78$ $3,886.80 090

22818 60.72$ $3,643.20 60.72$ $3,643.20 090

22819 74.26$ $4,455.60 74.26$ $4,455.60 090

22830 22.59$ $1,355.40 22.59$ $1,355.40 090

22840 20.80$ $1,248.00 20.80$ $1,248.00 ZZZ


22842 20.88$ $1,252.80 20.88$ $1,252.80 ZZZ

22843 22.33$ $1,339.80 22.33$ $1,339.80 ZZZ

22844 27.14$ $1,628.40 27.14$ $1,628.40 ZZZ

22845 19.90$ $1,194.00 19.90$ $1,194.00 ZZZ

22846 20.68$ $1,240.80 20.68$ $1,240.80 ZZZ

22847 22.78$ $1,366.80 22.78$ $1,366.80 ZZZ

22848 9.91$ $594.60 9.91$ $594.60 ZZZ

22849 35.90$ $2,154.00 35.90$ $2,154.00 090

22850 20.09$ $1,205.40 20.09$ $1,205.40 090

22851 11.14$ $668.40 11.14$ $668.40 ZZZ

22852 19.30$ $1,158.00 19.30$ $1,158.00 090

22855 30.53$ $1,831.80 30.53$ $1,831.80 090

22856 44.62$ $2,677.20 44.62$ $2,677.20 090

22857 53.06$ $3,183.60 53.06$ $3,183.60 090

22858 13.63$ $817.80 13.63$ $817.80 XXX

22861 56.23$ $3,373.80 56.23$ $3,373.80 090

22862 53.51$ $3,210.60 53.51$ $3,210.60 090

22864 55.72$ $3,343.20 55.72$ $3,343.20 090

22865 57.38$ $3,442.80 57.38$ $3,442.80 090



Page | 19

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


22900 15.72$ $943.20 15.72$ $943.20 090

22901 18.45$ $1,107.00 18.45$ $1,107.00 090

22902 12.48$ $748.80 9.29$ $557.40 090

22903 12.21$ $732.60 12.21$ $732.60 090

22904 29.05$ $1,743.00 29.05$ $1,743.00 090

22905 36.77$ $2,206.20 36.77$ $2,206.20 090


23000 16.91$ $1,014.60 10.53$ $631.80 090

23020 19.39$ $1,163.40 19.39$ $1,163.40 090

23030 12.73$ $763.80 7.20$ $432.00 010

23031 12.38$ $742.80 6.21$ $372.60 010

23035 19.06$ $1,143.60 19.06$ $1,143.60 090

23040 20.24$ $1,214.40 20.24$ $1,214.40 090

23044 15.99$ $959.40 15.99$ $959.40 090

23065 6.23$ $373.80 4.77$ $286.20 010

23066 16.05$ $963.00 10.09$ $605.40 090

23071 11.72$ $703.20 11.72$ $703.20 090

23073 19.35$ $1,161.00 19.35$ $1,161.00 090

23075 13.42$ $805.20 9.19$ $551.40 090

23076 15.14$ $908.40 15.14$ $908.40 090

23077 31.86$ $1,911.60 31.86$ $1,911.60 090

23078 39.90$ $2,394.00 39.90$ $2,394.00 090

23100 14.07$ $844.20 14.07$ $844.20 090

23101 12.82$ $769.20 12.82$ $769.20 090

23105 17.97$ $1,078.20 17.97$ $1,078.20 090

23106 13.89$ $833.40 13.89$ $833.40 090

23107 18.57$ $1,114.20 18.57$ $1,114.20 090

23120 16.51$ $990.60 16.51$ $990.60 090

23125 19.92$ $1,195.20 19.92$ $1,195.20 090

23130 17.21$ $1,032.60 17.21$ $1,032.60 090

23140 15.01$ $900.60 15.01$ $900.60 090

23145 19.53$ $1,171.80 19.53$ $1,171.80 090

23146 17.49$ $1,049.40 17.49$ $1,049.40 090

23150 18.51$ $1,110.60 18.51$ $1,110.60 090

23155 22.28$ $1,336.80 22.28$ $1,336.80 090

23156 19.03$ $1,141.80 19.03$ $1,141.80 090

23170 15.62$ $937.20 15.62$ $937.20 090

23172 15.97$ $958.20 15.97$ $958.20 090

23174 21.13$ $1,267.80 21.13$ $1,267.80 090

23180 18.71$ $1,122.60 18.71$ $1,122.60 090

23182 18.37$ $1,102.20 18.37$ $1,102.20 090



Page | 20

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

23184 20.68$ $1,240.80 20.68$ $1,240.80 090

23190 16.01$ $960.60 16.01$ $960.60 090

23195 21.14$ $1,268.40 21.14$ $1,268.40 090

23200 41.40$ $2,484.00 41.40$ $2,484.00 090

23210 49.56$ $2,973.60 49.56$ $2,973.60 090

23220 54.27$ $3,256.20 54.27$ $3,256.20 090

23330 6.92$ $415.20 4.29$ $257.40 010

23333 12.82$ $769.20 12.82$ $769.20 XXX

23334 30.20$ $1,812.00 30.20$ $1,812.00 XXX

23335 35.86$ $2,151.60 35.86$ $2,151.60 XXX

23350 3.82$ $229.20 1.45$ $87.00 000

23395 36.10$ $2,166.00 36.10$ $2,166.00 090

23397 31.93$ $1,915.80 31.93$ $1,915.80 090

23400 27.22$ $1,633.20 27.22$ $1,633.20 090

23405 17.59$ $1,055.40 17.59$ $1,055.40 090

23406 21.65$ $1,299.00 21.65$ $1,299.00 090

23410 23.11$ $1,386.60 23.11$ $1,386.60 090

23412 23.96$ $1,437.60 23.96$ $1,437.60 090

23415 19.61$ $1,176.60 19.61$ $1,176.60 090

23420 27.24$ $1,634.40 27.24$ $1,634.40 090

23430 21.01$ $1,260.60 21.01$ $1,260.60 090

23440 21.22$ $1,273.20 21.22$ $1,273.20 090

23450 26.49$ $1,589.40 26.49$ $1,589.40 090

23455 28.03$ $1,681.80 28.03$ $1,681.80 090

23460 30.54$ $1,832.40 30.54$ $1,832.40 090

23462 29.70$ $1,782.00 29.70$ $1,782.00 090

23465 31.24$ $1,874.40 31.24$ $1,874.40 090

23466 31.50$ $1,890.00 31.50$ $1,890.00 090

23470 33.74$ $2,024.40 33.74$ $2,024.40 090

23472 40.84$ $2,450.40 40.84$ $2,450.40 090

23473 45.55$ $2,733.00 45.55$ $2,733.00 090

23474 49.19$ $2,951.40 49.19$ $2,951.40 090

23480 23.03$ $1,381.80 23.03$ $1,381.80 090

23485 26.77$ $1,606.20 26.77$ $1,606.20 090

23490 23.70$ $1,422.00 23.70$ $1,422.00 090

23491 28.37$ $1,702.20 28.37$ $1,702.20 090

23500 6.24$ $374.40 6.36$ $381.60 090

23505 10.04$ $602.40 9.45$ $567.00 090

23515 20.29$ $1,217.40 20.29$ $1,217.40 090

23520 6.39$ $383.40 6.49$ $389.40 090

23525 10.72$ $643.20 9.87$ $592.20 090

23530 15.52$ $931.20 15.52$ $931.20 090



Page | 21

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

23532 17.53$ $1,051.80 17.53$ $1,051.80 090

23540 6.41$ $384.60 6.52$ $391.20 090

23545 9.74$ $584.40 8.82$ $529.20 090

23550 15.92$ $955.20 15.92$ $955.20 090

23552 18.45$ $1,107.00 18.45$ $1,107.00 090

23570 6.61$ $396.60 6.82$ $409.20 090

23575 11.34$ $680.40 10.60$ $636.00 090

23585 27.53$ $1,651.80 27.53$ $1,651.80 090

23600 9.35$ $561.00 8.79$ $527.40 090

23605 13.17$ $790.20 12.01$ $720.60 090

23615 24.88$ $1,492.80 24.88$ $1,492.80 090

23616 34.82$ $2,089.20 34.82$ $2,089.20 090

23620 7.71$ $462.60 7.31$ $438.60 090

23625 10.77$ $646.20 9.98$ $598.80 090

23630 22.01$ $1,320.60 22.01$ $1,320.60 090

23650 8.93$ $535.80 8.17$ $490.20 090

23655 11.36$ $681.60 11.36$ $681.60 090

23660 16.40$ $984.00 16.40$ $984.00 090

23665 12.06$ $723.60 11.19$ $671.40 090

23670 24.61$ $1,476.60 24.61$ $1,476.60 090

23675 15.61$ $936.60 14.15$ $849.00 090

23680 26.08$ $1,564.80 26.08$ $1,564.80 090

23700 5.54$ $332.40 5.54$ $332.40 010

23800 28.75$ $1,725.00 28.75$ $1,725.00 090

23802 35.48$ $2,128.80 35.48$ $2,128.80 090

23900 38.86$ $2,331.60 38.86$ $2,331.60 090

23920 31.47$ $1,888.20 31.47$ $1,888.20 090

23921 13.24$ $794.40 13.24$ $794.40 090


23930 10.13$ $607.80 6.04$ $362.40 010

23931 8.36$ $501.60 4.56$ $273.60 010

23935 14.31$ $858.60 14.31$ $858.60 090

24000 13.47$ $808.20 13.47$ $808.20 090

24006 19.89$ $1,193.40 19.89$ $1,193.40 090

24065 7.43$ $445.80 4.79$ $287.40 010

24066 17.92$ $1,075.20 11.70$ $702.00 090

24071 11.36$ $681.60 11.36$ $681.60 090

24073 19.33$ $1,159.80 19.33$ $1,159.80 090

24075 14.08$ $844.80 9.30$ $558.00 090

24076 15.24$ $914.40 15.24$ $914.40 090

24077 28.82$ $1,729.20 28.82$ $1,729.20 090

24079 36.81$ $2,208.60 36.81$ $2,208.60 090



Page | 22

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

24100 11.81$ $708.60 11.81$ $708.60 090

24101 14.14$ $848.40 14.14$ $848.40 090

24102 17.37$ $1,042.20 17.37$ $1,042.20 090

24105 9.98$ $598.80 9.98$ $598.80 090

24110 16.37$ $982.20 16.37$ $982.20 090

24115 20.71$ $1,242.60 20.71$ $1,242.60 090

24116 24.17$ $1,450.20 24.17$ $1,450.20 090

24120 14.94$ $896.40 14.94$ $896.40 090

24125 17.37$ $1,042.20 17.37$ $1,042.20 090

24126 18.27$ $1,096.20 18.27$ $1,096.20 090

24130 14.35$ $861.00 14.35$ $861.00 090

24134 20.98$ $1,258.80 20.98$ $1,258.80 090

24136 17.79$ $1,067.40 17.79$ $1,067.40 090

24138 18.97$ $1,138.20 18.97$ $1,138.20 090

24140 19.71$ $1,182.60 19.71$ $1,182.60 090

24145 16.66$ $999.60 16.66$ $999.60 090

24147 17.55$ $1,053.00 17.55$ $1,053.00 090

24149 33.12$ $1,987.20 33.12$ $1,987.20 090

24150 43.56$ $2,613.60 43.56$ $2,613.60 090

24152 37.47$ $2,248.20 37.47$ $2,248.20 090

24155 23.66$ $1,419.60 23.66$ $1,419.60 090

24160 35.46$ $2,127.60 35.46$ $2,127.60 090

24164 20.52$ $1,231.20 20.52$ $1,231.20 090

24200 5.97$ $358.20 3.98$ $238.80 010

24201 15.66$ $939.60 10.16$ $609.60 090

24220 4.68$ $280.80 1.96$ $117.60 000

24300 11.98$ $718.80 11.98$ $718.80 090

24301 21.10$ $1,266.00 21.10$ $1,266.00 090

24305 16.30$ $978.00 16.30$ $978.00 090

24310 13.35$ $801.00 13.35$ $801.00 090

24320 21.92$ $1,315.20 21.92$ $1,315.20 090

24330 20.16$ $1,209.60 20.16$ $1,209.60 090

24331 22.06$ $1,323.60 22.06$ $1,323.60 090

24332 17.23$ $1,033.80 17.23$ $1,033.80 090

24340 17.27$ $1,036.20 17.27$ $1,036.20 090

24341 21.10$ $1,266.00 21.10$ $1,266.00 090

24342 21.81$ $1,308.60 21.81$ $1,308.60 090

24343 19.95$ $1,197.00 19.95$ $1,197.00 090

24344 30.77$ $1,846.20 30.77$ $1,846.20 090

24345 19.86$ $1,191.60 19.86$ $1,191.60 090

24346 30.79$ $1,847.40 30.79$ $1,847.40 090

24357 12.21$ $732.60 12.21$ $732.60 090



Page | 23

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

24358 14.76$ $885.60 14.76$ $885.60 090

24359 18.57$ $1,114.20 18.57$ $1,114.20 090

24360 24.86$ $1,491.60 24.86$ $1,491.60 090

24361 27.94$ $1,676.40 27.94$ $1,676.40 090

24362 29.70$ $1,782.00 29.70$ $1,782.00 090

24363 40.82$ $2,449.20 40.82$ $2,449.20 090

24365 17.89$ $1,073.40 17.89$ $1,073.40 090

24366 19.13$ $1,147.80 19.13$ $1,147.80 090

24370 43.41$ $2,604.60 43.41$ $2,604.60 090

24371 49.95$ $2,997.00 49.95$ $2,997.00 090

24400 22.95$ $1,377.00 22.95$ $1,377.00 090

24410 29.64$ $1,778.40 29.64$ $1,778.40 090

24420 27.70$ $1,662.00 27.70$ $1,662.00 090

24430 29.66$ $1,779.60 29.66$ $1,779.60 090

24435 30.30$ $1,818.00 30.30$ $1,818.00 090

24470 16.05$ $963.00 16.05$ $963.00 090

24495 18.32$ $1,099.20 18.32$ $1,099.20 090

24498 24.32$ $1,459.20 24.32$ $1,459.20 090

24500 10.24$ $614.40 9.29$ $557.40 090

24505 14.18$ $850.80 12.76$ $765.60 090

24515 24.64$ $1,478.40 24.64$ $1,478.40 090

24516 24.15$ $1,449.00 24.15$ $1,449.00 090

24530 10.86$ $651.60 9.80$ $588.00 090

24535 17.37$ $1,042.20 15.98$ $958.80 090

24538 20.93$ $1,255.80 20.93$ $1,255.80 090

24545 26.11$ $1,566.60 26.11$ $1,566.60 090

24546 29.18$ $1,750.80 29.18$ $1,750.80 090

24560 9.18$ $550.80 8.19$ $491.40 090

24565 15.01$ $900.60 13.72$ $823.20 090

24566 20.24$ $1,214.40 20.24$ $1,214.40 090

24575 20.59$ $1,235.40 20.59$ $1,235.40 090

24576 9.74$ $584.40 8.71$ $522.60 090

24577 15.42$ $925.20 14.09$ $845.40 090

24579 23.52$ $1,411.20 23.52$ $1,411.20 090

24582 22.78$ $1,366.80 22.78$ $1,366.80 090

24586 30.40$ $1,824.00 30.40$ $1,824.00 090

24587 30.38$ $1,822.80 30.38$ $1,822.80 090

24600 10.33$ $619.80 9.42$ $565.20 090

24605 13.30$ $798.00 13.30$ $798.00 090

24615 20.03$ $1,201.80 20.03$ $1,201.80 090

24620 15.51$ $930.60 15.51$ $930.60 090

24635 18.98$ $1,138.80 18.98$ $1,138.80 090



Page | 24

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

24640 3.87$ $232.20 2.60$ $156.00 010

24650 7.50$ $450.00 6.87$ $412.20 090

24655 12.39$ $743.40 11.23$ $673.80 090

24665 18.41$ $1,104.60 18.41$ $1,104.60 090

24666 20.65$ $1,239.00 20.65$ $1,239.00 090

24670 8.33$ $499.80 7.49$ $449.40 090

24675 12.90$ $774.00 11.72$ $703.20 090

24685 18.47$ $1,108.20 18.47$ $1,108.20 090

24800 23.30$ $1,398.00 23.30$ $1,398.00 090

24802 27.50$ $1,650.00 27.50$ $1,650.00 090

24900 20.53$ $1,231.80 20.53$ $1,231.80 090

24920 20.54$ $1,232.40 20.54$ $1,232.40 090

24925 15.41$ $924.60 15.41$ $924.60 090

24930 21.53$ $1,291.80 21.53$ $1,291.80 090

24931 22.63$ $1,357.80 22.63$ $1,357.80 090

24935 30.84$ $1,850.40 30.84$ $1,850.40 090



25000 9.60$ $576.00 9.60$ $576.00 090

25001 9.74$ $584.40 9.74$ $584.40 090

25020 16.40$ $984.00 16.40$ $984.00 090

25023 31.11$ $1,866.60 31.11$ $1,866.60 090

25024 21.68$ $1,300.80 21.68$ $1,300.80 090

25025 33.81$ $2,028.60 33.81$ $2,028.60 090

25028 14.92$ $895.20 14.92$ $895.20 090

25031 10.16$ $609.60 10.16$ $609.60 090

25035 16.32$ $979.20 16.32$ $979.20 090

25040 15.87$ $952.20 15.87$ $952.20 090

25065 7.37$ $442.20 4.68$ $280.80 010

25066 10.17$ $610.20 10.17$ $610.20 090

25071 11.93$ $715.80 11.93$ $715.80 090

25073 14.97$ $898.20 14.97$ $898.20 090

25075 13.75$ $825.00 8.94$ $536.40 090

25076 14.58$ $874.80 14.58$ $874.80 090

25077 24.72$ $1,483.20 24.72$ $1,483.20 090

25078 32.44$ $1,946.40 32.44$ $1,946.40 090

25085 12.71$ $762.60 12.71$ $762.60 090

25100 9.77$ $586.20 9.77$ $586.20 090

25101 11.43$ $685.80 11.43$ $685.80 090

25105 13.65$ $819.00 13.65$ $819.00 090

25107 17.42$ $1,045.20 17.42$ $1,045.20 090

25109 15.21$ $912.60 15.21$ $912.60 090



Page | 25

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

25110 9.70$ $582.00 9.70$ $582.00 090

25111 9.10$ $546.00 9.10$ $546.00 090

25112 10.93$ $655.80 10.93$ $655.80 090

25115 21.40$ $1,284.00 21.40$ $1,284.00 090

25116 16.98$ $1,018.80 16.98$ $1,018.80 090

25118 10.82$ $649.20 10.82$ $649.20 090

25119 13.99$ $839.40 13.99$ $839.40 090

25120 14.06$ $843.60 14.06$ $843.60 090

25125 16.33$ $979.80 16.33$ $979.80 090

25126 16.71$ $1,002.60 16.71$ $1,002.60 090

25130 12.66$ $759.60 12.66$ $759.60 090

25135 15.58$ $934.80 15.58$ $934.80 090

25136 13.79$ $827.40 13.79$ $827.40 090

25145 14.57$ $874.20 14.57$ $874.20 090

25150 15.95$ $957.00 15.95$ $957.00 090

25151 16.41$ $984.60 16.41$ $984.60 090

25170 41.39$ $2,483.40 41.39$ $2,483.40 090

25210 13.81$ $828.60 13.81$ $828.60 090

25215 17.43$ $1,045.80 17.43$ $1,045.80 090

25230 12.24$ $734.40 12.24$ $734.40 090

25240 12.13$ $727.80 12.13$ $727.80 090

25246 4.72$ $283.20 2.14$ $128.40 000

25248 11.71$ $702.60 11.71$ $702.60 090

25250 14.87$ $892.20 14.87$ $892.20 090

25251 20.11$ $1,206.60 20.11$ $1,206.60 090

25259 11.89$ $713.40 11.89$ $713.40 090

25260 17.81$ $1,068.60 17.81$ $1,068.60 090

25263 17.56$ $1,053.60 17.56$ $1,053.60 090

25265 21.01$ $1,260.60 21.01$ $1,260.60 090

25270 13.85$ $831.00 13.85$ $831.00 090

25272 15.59$ $935.40 15.59$ $935.40 090

25274 18.71$ $1,122.60 18.71$ $1,122.60 090

25275 18.95$ $1,137.00 18.95$ $1,137.00 090

25280 15.92$ $955.20 15.92$ $955.20 090

25290 12.35$ $741.00 12.35$ $741.00 090

25295 14.78$ $886.80 14.78$ $886.80 090

25300 19.25$ $1,155.00 19.25$ $1,155.00 090

25301 18.12$ $1,087.20 18.12$ $1,087.20 090

25310 17.51$ $1,050.60 17.51$ $1,050.60 090

25312 20.16$ $1,209.60 20.16$ $1,209.60 090

25315 21.62$ $1,297.20 21.62$ $1,297.20 090

25316 25.61$ $1,536.60 25.61$ $1,536.60 090



Page | 26

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

25320 27.90$ $1,674.00 27.90$ $1,674.00 090

25332 23.69$ $1,421.40 23.69$ $1,421.40 090

25335 22.79$ $1,367.40 22.79$ $1,367.40 090

25337 25.11$ $1,506.60 25.11$ $1,506.60 090

25350 19.00$ $1,140.00 19.00$ $1,140.00 090

25355 21.12$ $1,267.20 21.12$ $1,267.20 090

25360 18.42$ $1,105.20 18.42$ $1,105.20 090

25365 25.59$ $1,535.40 25.59$ $1,535.40 090

25370 28.28$ $1,696.80 28.28$ $1,696.80 090

25375 26.69$ $1,601.40 26.69$ $1,601.40 090

25390 21.66$ $1,299.60 21.66$ $1,299.60 090

25391 27.89$ $1,673.40 27.89$ $1,673.40 090

25392 24.54$ $1,472.40 24.54$ $1,472.40 090

25393 31.95$ $1,917.00 31.95$ $1,917.00 090

25394 21.87$ $1,312.20 21.87$ $1,312.20 090

25400 22.59$ $1,355.40 22.59$ $1,355.40 090

25405 29.12$ $1,747.20 29.12$ $1,747.20 090

25415 26.97$ $1,618.20 26.97$ $1,618.20 090

25420 32.67$ $1,960.20 32.67$ $1,960.20 090

25425 26.98$ $1,618.80 26.98$ $1,618.80 090

25426 31.45$ $1,887.00 31.45$ $1,887.00 090

25430 20.57$ $1,234.20 20.57$ $1,234.20 090

25431 22.09$ $1,325.40 22.09$ $1,325.40 090

25440 21.58$ $1,294.80 21.58$ $1,294.80 090

25441 26.44$ $1,586.40 26.44$ $1,586.40 090

25442 22.73$ $1,363.80 22.73$ $1,363.80 090

25443 21.94$ $1,316.40 21.94$ $1,316.40 090

25444 23.18$ $1,390.80 23.18$ $1,390.80 090

25445 20.31$ $1,218.60 20.31$ $1,218.60 090

25446 32.89$ $1,973.40 32.89$ $1,973.40 090

25447 23.35$ $1,401.00 23.35$ $1,401.00 090

25449 29.05$ $1,743.00 29.05$ $1,743.00 090

25450 14.68$ $880.80 14.68$ $880.80 090

25455 17.36$ $1,041.60 17.36$ $1,041.60 090

25490 20.19$ $1,211.40 20.19$ $1,211.40 090

25491 20.76$ $1,245.60 20.76$ $1,245.60 090

25492 25.36$ $1,521.60 25.36$ $1,521.60 090

25500 7.83$ $469.80 7.16$ $429.60 090

25505 14.31$ $858.60 13.05$ $783.00 090

25515 18.86$ $1,131.60 18.86$ $1,131.60 090

25520 15.81$ $948.60 14.96$ $897.60 090

25525 22.10$ $1,326.00 22.10$ $1,326.00 090



Page | 27

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

25526 26.75$ $1,605.00 26.75$ $1,605.00 090

25530 7.53$ $451.80 6.80$ $408.00 090

25535 13.88$ $832.80 12.81$ $768.60 090

25545 17.59$ $1,055.40 17.59$ $1,055.40 090

25560 7.96$ $477.60 7.17$ $430.20 090

25565 14.74$ $884.40 13.27$ $796.20 090

25574 18.95$ $1,137.00 18.95$ $1,137.00 090

25575 25.34$ $1,520.40 25.34$ $1,520.40 090

25600 9.43$ $565.80 8.90$ $534.00 090

25605 15.48$ $928.80 14.52$ $871.20 090

25606 18.70$ $1,122.00 18.70$ $1,122.00 090

25607 20.73$ $1,243.80 20.73$ $1,243.80 090

25608 23.20$ $1,392.00 23.20$ $1,392.00 090

25609 29.47$ $1,768.20 29.47$ $1,768.20 090

25622 8.72$ $523.20 7.92$ $475.20 090

25624 13.54$ $812.40 12.29$ $737.40 090

25628 20.32$ $1,219.20 20.32$ $1,219.20 090

25630 8.71$ $522.60 7.98$ $478.80 090

25635 12.17$ $730.20 10.82$ $649.20 090

25645 15.96$ $957.60 15.96$ $957.60 090

25650 9.14$ $548.40 8.55$ $513.00 090

25651 13.75$ $825.00 13.75$ $825.00 090

25652 17.60$ $1,056.00 17.60$ $1,056.00 090

25660 11.57$ $694.20 11.57$ $694.20 090

25670 17.08$ $1,024.80 17.08$ $1,024.80 090

25671 14.98$ $898.80 14.98$ $898.80 090

25675 12.35$ $741.00 11.22$ $673.20 090

25676 17.67$ $1,060.20 17.67$ $1,060.20 090

25680 13.40$ $804.00 13.40$ $804.00 090

25685 20.57$ $1,234.20 20.57$ $1,234.20 090

25690 13.46$ $807.60 13.46$ $807.60 090

25695 17.80$ $1,068.00 17.80$ $1,068.00 090

25800 20.62$ $1,237.20 20.62$ $1,237.20 090

25805 23.70$ $1,422.00 23.70$ $1,422.00 090

25810 24.46$ $1,467.60 24.46$ $1,467.60 090

25820 17.41$ $1,044.60 17.41$ $1,044.60 090

25825 21.43$ $1,285.80 21.43$ $1,285.80 090

25830 26.90$ $1,614.00 26.90$ $1,614.00 090

25900 19.93$ $1,195.80 19.93$ $1,195.80 090

25905 17.86$ $1,071.60 17.86$ $1,071.60 090

25907 16.32$ $979.20 16.32$ $979.20 090

25909 19.23$ $1,153.80 19.23$ $1,153.80 090



Page | 28

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

25915 33.09$ $1,985.40 33.09$ $1,985.40 090

25920 19.53$ $1,171.80 19.53$ $1,171.80 090

25922 16.09$ $965.40 16.09$ $965.40 090

25924 17.07$ $1,024.20 17.07$ $1,024.20 090

25927 23.05$ $1,383.00 23.05$ $1,383.00 090

25929 16.58$ $994.80 16.58$ $994.80 090

25931 18.58$ $1,114.80 18.58$ $1,114.80 090


26010 7.70$ $462.00 3.93$ $235.80 010

26011 11.34$ $680.40 5.25$ $315.00 010

26020 12.30$ $738.00 12.30$ $738.00 090

26025 11.97$ $718.20 11.97$ $718.20 090

26030 13.91$ $834.60 13.91$ $834.60 090

26034 15.19$ $911.40 15.19$ $911.40 090

26035 24.20$ $1,452.00 24.20$ $1,452.00 090

26037 15.98$ $958.80 15.98$ $958.80 090

26040 8.87$ $532.20 8.87$ $532.20 090

26045 13.24$ $794.40 13.24$ $794.40 090

26055 16.24$ $974.40 8.86$ $531.60 090

26060 7.54$ $452.40 7.54$ $452.40 090

26070 8.92$ $535.20 8.92$ $535.20 090

26075 9.44$ $566.40 9.44$ $566.40 090

26080 11.09$ $665.40 11.09$ $665.40 090

26100 9.45$ $567.00 9.45$ $567.00 090

26105 9.46$ $567.60 9.46$ $567.60 090

26110 9.13$ $547.80 9.13$ $547.80 090

26111 11.80$ $708.00 11.80$ $708.00 090

26113 15.49$ $929.40 15.49$ $929.40 090

26115 14.53$ $871.80 9.44$ $566.40 090

26116 14.90$ $894.00 14.90$ $894.00 090

26117 21.11$ $1,266.60 21.11$ $1,266.60 090

26118 29.56$ $1,773.60 29.56$ $1,773.60 090

26121 16.85$ $1,011.00 16.85$ $1,011.00 090

26123 23.54$ $1,412.40 23.54$ $1,412.40 090

26125 7.65$ $459.00 7.65$ $459.00 ZZZ

26130 13.06$ $783.60 13.06$ $783.60 090

26135 15.52$ $931.20 15.52$ $931.20 090

26140 14.25$ $855.00 14.25$ $855.00 090

26145 14.44$ $866.40 14.44$ $866.40 090

26160 16.66$ $999.60 9.51$ $570.60 090

26170 11.48$ $688.80 11.48$ $688.80 090

26180 12.56$ $753.60 12.56$ $753.60 090



Page | 29

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

26185 15.50$ $930.00 15.50$ $930.00 090

26200 12.73$ $763.80 12.73$ $763.80 090

26205 16.94$ $1,016.40 16.94$ $1,016.40 090

26210 12.52$ $751.20 12.52$ $751.20 090

26215 15.85$ $951.00 15.85$ $951.00 090

26230 14.09$ $845.40 14.09$ $845.40 090

26235 13.95$ $837.00 13.95$ $837.00 090

26236 12.49$ $749.40 12.49$ $749.40 090

26250 30.45$ $1,827.00 30.45$ $1,827.00 090

26260 22.63$ $1,357.80 22.63$ $1,357.80 090

26262 17.79$ $1,067.40 17.79$ $1,067.40 090

26320 9.84$ $590.40 9.84$ $590.40 090

26340 9.62$ $577.20 9.62$ $577.20 090

26341 2.83$ $169.80 2.12$ $127.20 010

26350 20.19$ $1,211.40 20.19$ $1,211.40 090

26352 23.09$ $1,385.40 23.09$ $1,385.40 090

26356 24.96$ $1,497.60 24.96$ $1,497.60 090

26357 24.26$ $1,455.60 24.26$ $1,455.60 090

26358 26.88$ $1,612.80 26.88$ $1,612.80 090

26370 21.41$ $1,284.60 21.41$ $1,284.60 090

26372 24.79$ $1,487.40 24.79$ $1,487.40 090

26373 23.82$ $1,429.20 23.82$ $1,429.20 090

26390 23.46$ $1,407.60 23.46$ $1,407.60 090

26392 27.18$ $1,630.80 27.18$ $1,630.80 090

26410 16.06$ $963.60 16.06$ $963.60 090

26412 19.26$ $1,155.60 19.26$ $1,155.60 090

26415 21.61$ $1,296.60 21.61$ $1,296.60 090

26416 20.24$ $1,214.40 20.24$ $1,214.40 090

26418 16.46$ $987.60 16.46$ $987.60 090

26420 19.98$ $1,198.80 19.98$ $1,198.80 090

26426 14.15$ $849.00 14.15$ $849.00 090

26428 21.29$ $1,277.40 21.29$ $1,277.40 090

26432 14.17$ $850.20 14.17$ $850.20 090

26433 15.06$ $903.60 15.06$ $903.60 090

26434 18.25$ $1,095.00 18.25$ $1,095.00 090

26437 17.59$ $1,055.40 17.59$ $1,055.40 090

26440 17.59$ $1,055.40 17.59$ $1,055.40 090

26442 27.22$ $1,633.20 27.22$ $1,633.20 090

26445 16.42$ $985.20 16.42$ $985.20 090

26449 19.68$ $1,180.80 19.68$ $1,180.80 090

26450 11.56$ $693.60 11.56$ $693.60 090

26455 11.40$ $684.00 11.40$ $684.00 090



Page | 30

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

26460 11.17$ $670.20 11.17$ $670.20 090

26471 17.36$ $1,041.60 17.36$ $1,041.60 090

26474 17.00$ $1,020.00 17.00$ $1,020.00 090

26476 16.43$ $985.80 16.43$ $985.80 090

26477 16.44$ $986.40 16.44$ $986.40 090

26478 17.54$ $1,052.40 17.54$ $1,052.40 090

26479 17.37$ $1,042.20 17.37$ $1,042.20 090

26480 21.31$ $1,278.60 21.31$ $1,278.60 090

26483 23.79$ $1,427.40 23.79$ $1,427.40 090

26485 22.82$ $1,369.20 22.82$ $1,369.20 090

26489 25.76$ $1,545.60 25.76$ $1,545.60 090

26490 22.14$ $1,328.40 22.14$ $1,328.40 090

26492 24.58$ $1,474.80 24.58$ $1,474.80 090

26494 22.20$ $1,332.00 22.20$ $1,332.00 090

26496 24.11$ $1,446.60 24.11$ $1,446.60 090

26497 24.28$ $1,456.80 24.28$ $1,456.80 090

26498 31.93$ $1,915.80 31.93$ $1,915.80 090

26499 23.30$ $1,398.00 23.30$ $1,398.00 090

26500 17.58$ $1,054.80 17.58$ $1,054.80 090

26502 19.69$ $1,181.40 19.69$ $1,181.40 090

26508 18.11$ $1,086.60 18.11$ $1,086.60 090

26510 16.83$ $1,009.80 16.83$ $1,009.80 090

26516 19.73$ $1,183.80 19.73$ $1,183.80 090

26517 23.13$ $1,387.80 23.13$ $1,387.80 090

26518 23.26$ $1,395.60 23.26$ $1,395.60 090

26520 18.48$ $1,108.80 18.48$ $1,108.80 090

26525 18.49$ $1,109.40 18.49$ $1,109.40 090

26530 15.16$ $909.60 15.16$ $909.60 090

26531 17.62$ $1,057.20 17.62$ $1,057.20 090

26535 11.95$ $717.00 11.95$ $717.00 090

26536 20.21$ $1,212.60 20.21$ $1,212.60 090

26540 18.53$ $1,111.80 18.53$ $1,111.80 090

26541 22.51$ $1,350.60 22.51$ $1,350.60 090

26542 19.10$ $1,146.00 19.10$ $1,146.00 090

26545 19.45$ $1,167.00 19.45$ $1,167.00 090

26546 27.95$ $1,677.00 27.95$ $1,677.00 090

26548 21.38$ $1,282.80 21.38$ $1,282.80 090

26550 43.37$ $2,602.20 43.37$ $2,602.20 090

26551 79.97$ $4,798.20 79.97$ $4,798.20 090

26553 91.27$ $5,476.20 91.27$ $5,476.20 090

26554 92.93$ $5,575.80 92.93$ $5,575.80 090

26555 37.68$ $2,260.80 37.68$ $2,260.80 090



Page | 31

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

26556 94.88$ $5,692.80 94.88$ $5,692.80 090

26560 15.86$ $951.60 15.86$ $951.60 090

26561 26.15$ $1,569.00 26.15$ $1,569.00 090

26562 37.57$ $2,254.20 37.57$ $2,254.20 090

26565 19.08$ $1,144.80 19.08$ $1,144.80 090

26567 19.20$ $1,152.00 19.20$ $1,152.00 090

26568 25.35$ $1,521.00 25.35$ $1,521.00 090

26580 41.13$ $2,467.80 41.13$ $2,467.80 090

26587 25.64$ $1,538.40 25.64$ $1,538.40 090

26590 37.48$ $2,248.80 37.48$ $2,248.80 090

26591 12.42$ $745.20 12.42$ $745.20 090

26593 16.98$ $1,018.80 16.98$ $1,018.80 090

26596 21.22$ $1,273.20 21.22$ $1,273.20 090

26600 8.44$ $506.40 7.93$ $475.80 090

26605 9.20$ $552.00 8.35$ $501.00 090

26607 12.87$ $772.20 12.87$ $772.20 090

26608 13.51$ $810.60 13.51$ $810.60 090

26615 16.31$ $978.60 16.31$ $978.60 090

26641 10.47$ $628.20 9.52$ $571.20 090

26645 11.96$ $717.60 10.95$ $657.00 090

26650 13.57$ $814.20 13.57$ $814.20 090

26665 17.82$ $1,069.20 17.82$ $1,069.20 090

26670 9.64$ $578.40 8.71$ $522.60 090

26675 12.79$ $767.40 11.70$ $702.00 090

26676 14.20$ $852.00 14.20$ $852.00 090

26685 16.32$ $979.20 16.32$ $979.20 090

26686 17.54$ $1,052.40 17.54$ $1,052.40 090

26700 9.15$ $549.00 8.57$ $514.20 090

26705 11.86$ $711.60 10.82$ $649.20 090

26706 12.46$ $747.60 12.46$ $747.60 090

26715 16.21$ $972.60 16.21$ $972.60 090

26720 5.69$ $341.40 5.27$ $316.20 090

26725 9.59$ $575.40 8.61$ $516.60 090

26727 13.30$ $798.00 13.30$ $798.00 090

26735 16.87$ $1,012.20 16.87$ $1,012.20 090

26740 6.59$ $395.40 6.18$ $370.80 090

26742 10.46$ $627.60 9.46$ $567.60 090

26746 20.92$ $1,255.20 20.92$ $1,255.20 090

26750 5.27$ $316.20 5.28$ $316.80 090

26755 8.95$ $537.00 7.73$ $463.80 090

26756 11.88$ $712.80 11.88$ $712.80 090

26765 14.22$ $853.20 14.22$ $853.20 090



Page | 32

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

26770 7.83$ $469.80 7.23$ $433.80 090

26775 10.91$ $654.60 9.83$ $589.80 090

26776 12.56$ $753.60 12.56$ $753.60 090

26785 15.51$ $930.60 15.51$ $930.60 090

26820 22.10$ $1,326.00 22.10$ $1,326.00 090

26841 20.46$ $1,227.60 20.46$ $1,227.60 090

26842 22.07$ $1,324.20 22.07$ $1,324.20 090

26843 20.76$ $1,245.60 20.76$ $1,245.60 090

26844 22.85$ $1,371.00 22.85$ $1,371.00 090

26850 19.49$ $1,169.40 19.49$ $1,169.40 090

26852 22.36$ $1,341.60 22.36$ $1,341.60 090

26860 16.02$ $961.20 16.02$ $961.20 090

26861 2.88$ $172.80 2.88$ $172.80 ZZZ

26862 20.45$ $1,227.00 20.45$ $1,227.00 090

26863 6.38$ $382.80 6.38$ $382.80 ZZZ

26910 20.22$ $1,213.20 20.22$ $1,213.20 090

26951 18.50$ $1,110.00 18.50$ $1,110.00 090

26952 18.20$ $1,092.00 18.20$ $1,092.00 090


26990 17.60$ $1,056.00 17.60$ $1,056.00 090

26991 20.07$ $1,204.20 14.68$ $880.80 090

26992 26.98$ $1,618.80 26.98$ $1,618.80 090

27000 11.80$ $708.00 11.80$ $708.00 090

27001 15.12$ $907.20 15.12$ $907.20 090

27003 16.77$ $1,006.20 16.77$ $1,006.20 090

27005 20.35$ $1,221.00 20.35$ $1,221.00 090

27006 20.69$ $1,241.40 20.69$ $1,241.40 090

27025 25.73$ $1,543.80 25.73$ $1,543.80 090

27027 25.23$ $1,513.80 25.23$ $1,513.80 090

27030 26.24$ $1,574.40 26.24$ $1,574.40 090

27033 27.25$ $1,635.00 27.25$ $1,635.00 090

27035 32.23$ $1,933.80 32.23$ $1,933.80 090

27036 28.35$ $1,701.00 28.35$ $1,701.00 090

27040 9.96$ $597.60 5.66$ $339.60 010

27041 19.36$ $1,161.60 19.36$ $1,161.60 090

27043 13.07$ $784.20 13.07$ $784.20 090

27045 20.91$ $1,254.60 20.91$ $1,254.60 090

27047 13.25$ $795.00 10.15$ $609.00 090

27048 17.06$ $1,023.60 17.06$ $1,023.60 090

27049 37.46$ $2,247.60 37.46$ $2,247.60 090

27050 10.91$ $654.60 10.91$ $654.60 090

27052 16.26$ $975.60 16.26$ $975.60 090



Page | 33

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

27054 19.29$ $1,157.40 19.29$ $1,157.40 090

27057 28.35$ $1,701.00 28.35$ $1,701.00 090

27059 50.57$ $3,034.20 50.57$ $3,034.20 090

27060 13.06$ $783.60 13.06$ $783.60 090

27062 12.89$ $773.40 12.89$ $773.40 090

27065 14.45$ $867.00 14.45$ $867.00 090

27066 22.81$ $1,368.60 22.81$ $1,368.60 090

27067 28.80$ $1,728.00 28.80$ $1,728.00 090

27070 23.85$ $1,431.00 23.85$ $1,431.00 090

27071 25.80$ $1,548.00 25.80$ $1,548.00 090

27075 58.54$ $3,512.40 58.54$ $3,512.40 090

27076 70.55$ $4,233.00 70.55$ $4,233.00 090

27077 79.21$ $4,752.60 79.21$ $4,752.60 090

27078 57.67$ $3,460.20 57.67$ $3,460.20 090

27080 14.37$ $862.20 14.37$ $862.20 090

27086 8.41$ $504.60 4.71$ $282.60 010

27087 17.59$ $1,055.40 17.59$ $1,055.40 090

27090 23.32$ $1,399.20 23.32$ $1,399.20 090

27091 44.75$ $2,685.00 44.75$ $2,685.00 090

27093 5.50$ $330.00 1.99$ $119.40 000

27095 7.08$ $424.80 2.33$ $139.80 000

27096 4.70$ $282.00 2.42$ $145.20 000

27097 18.92$ $1,135.20 18.92$ $1,135.20 090

27098 18.86$ $1,131.60 18.86$ $1,131.60 090

27100 23.04$ $1,382.40 23.04$ $1,382.40 090

27105 24.33$ $1,459.80 24.33$ $1,459.80 090

27110 27.14$ $1,628.40 27.14$ $1,628.40 090

27111 25.25$ $1,515.00 25.25$ $1,515.00 090

27120 36.40$ $2,184.00 36.40$ $2,184.00 090

27122 30.83$ $1,849.80 30.83$ $1,849.80 090

27125 31.79$ $1,907.40 31.79$ $1,907.40 090

27130 37.99$ $2,279.40 37.99$ $2,279.40 090

27132 46.91$ $2,814.60 46.91$ $2,814.60 090

27134 53.59$ $3,215.40 53.59$ $3,215.40 090

27137 41.25$ $2,475.00 41.25$ $2,475.00 090

27138 42.85$ $2,571.00 42.85$ $2,571.00 090

27140 25.12$ $1,507.20 25.12$ $1,507.20 090

27146 36.02$ $2,161.20 36.02$ $2,161.20 090

27147 41.18$ $2,470.80 41.18$ $2,470.80 090

27151 44.47$ $2,668.20 44.47$ $2,668.20 090

27156 47.99$ $2,879.40 47.99$ $2,879.40 090

27158 39.57$ $2,374.20 39.57$ $2,374.20 090



Page | 34

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

27161 34.09$ $2,045.40 34.09$ $2,045.40 090

27165 38.58$ $2,314.80 38.58$ $2,314.80 090

27170 32.94$ $1,976.40 32.94$ $1,976.40 090

27175 18.72$ $1,123.20 18.72$ $1,123.20 090

27176 25.28$ $1,516.80 25.28$ $1,516.80 090

27177 31.24$ $1,874.40 31.24$ $1,874.40 090

27178 25.77$ $1,546.20 25.77$ $1,546.20 090

27179 27.37$ $1,642.20 27.37$ $1,642.20 090

27181 27.26$ $1,635.60 27.26$ $1,635.60 090

27185 17.24$ $1,034.40 17.24$ $1,034.40 090

27187 27.83$ $1,669.80 27.83$ $1,669.80 090

27193 13.27$ $796.20 13.46$ $807.60 090

27194 19.87$ $1,192.20 19.87$ $1,192.20 090

27200 5.15$ $309.00 5.39$ $323.40 090

27202 14.92$ $895.20 14.92$ $895.20 090

27215 17.64$ $1,058.40 17.64$ $1,058.40 090

27216 26.11$ $1,566.60 26.11$ $1,566.60 090

27217 24.51$ $1,470.60 24.51$ $1,470.60 090

27218 33.79$ $2,027.40 33.79$ $2,027.40 090

27220 14.96$ $897.60 14.82$ $889.20 090

27222 27.39$ $1,643.40 27.39$ $1,643.40 090

27226 29.63$ $1,777.80 29.63$ $1,777.80 090

27227 46.43$ $2,785.80 46.43$ $2,785.80 090

27228 52.88$ $3,172.80 52.88$ $3,172.80 090

27230 13.42$ $805.20 13.33$ $799.80 090

27232 21.04$ $1,262.40 21.04$ $1,262.40 090

27235 25.51$ $1,530.60 25.51$ $1,530.60 090

27236 33.57$ $2,014.20 33.57$ $2,014.20 090

27238 13.00$ $780.00 13.00$ $780.00 090

27240 26.84$ $1,610.40 26.84$ $1,610.40 090

27244 34.53$ $2,071.80 34.53$ $2,071.80 090

27245 34.53$ $2,071.80 34.53$ $2,071.80 090

27246 10.87$ $652.20 10.93$ $655.80 090

27248 20.84$ $1,250.40 20.84$ $1,250.40 090

27250 4.97$ $298.20 4.97$ $298.20 000

27252 21.27$ $1,276.20 21.27$ $1,276.20 090

27253 26.38$ $1,582.80 26.38$ $1,582.80 090

27254 35.52$ $2,131.20 35.52$ $2,131.20 090

27256 8.43$ $505.80 6.52$ $391.20 010

27257 10.16$ $609.60 10.16$ $609.60 010

27258 31.12$ $1,867.20 31.12$ $1,867.20 090

27259 43.49$ $2,609.40 43.49$ $2,609.40 090



Page | 35

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

27265 11.30$ $678.00 11.30$ $678.00 090

27266 16.36$ $981.60 16.36$ $981.60 090

27267 12.28$ $736.80 12.28$ $736.80 090

27268 15.01$ $900.60 15.01$ $900.60 090

27269 34.73$ $2,083.80 34.73$ $2,083.80 090

27275 5.14$ $308.40 5.14$ $308.40 010

27279 19.31$ $1,158.60 19.31$ $1,158.60 XXX

27280 37.56$ $2,253.60 37.56$ $2,253.60 090

27282 23.25$ $1,395.00 23.25$ $1,395.00 090

27284 43.65$ $2,619.00 43.65$ $2,619.00 090

27286 45.98$ $2,758.80 45.98$ $2,758.80 090

27290 44.97$ $2,698.20 44.97$ $2,698.20 090

27295 35.12$ $2,107.20 35.12$ $2,107.20 090


27301 19.13$ $1,147.80 14.08$ $844.80 090

27303 17.93$ $1,075.80 17.93$ $1,075.80 090

27305 13.60$ $816.00 13.60$ $816.00 090

27306 10.16$ $609.60 10.16$ $609.60 090

27307 13.03$ $781.80 13.03$ $781.80 090

27310 20.57$ $1,234.20 20.57$ $1,234.20 090

27323 7.82$ $469.20 5.06$ $303.60 010

27324 11.20$ $672.00 11.20$ $672.00 090

27325 15.43$ $925.80 15.43$ $925.80 090

27326 14.58$ $874.80 14.58$ $874.80 090

27327 13.18$ $790.80 8.86$ $531.60 090

27328 17.35$ $1,041.00 17.35$ $1,041.00 090

27329 28.88$ $1,732.80 28.88$ $1,732.80 090

27330 11.83$ $709.80 11.83$ $709.80 090

27331 13.41$ $804.60 13.41$ $804.60 090

27332 18.04$ $1,082.40 18.04$ $1,082.40 090

27333 16.51$ $990.60 16.51$ $990.60 090

27334 19.24$ $1,154.40 19.24$ $1,154.40 090

27335 21.46$ $1,287.60 21.46$ $1,287.60 090

27337 11.69$ $701.40 11.69$ $701.40 090

27339 21.02$ $1,261.20 21.02$ $1,261.20 090

27340 10.54$ $632.40 10.54$ $632.40 090

27345 13.58$ $814.80 13.58$ $814.80 090

27347 14.96$ $897.60 14.96$ $897.60 090

27350 18.35$ $1,101.00 18.35$ $1,101.00 090

27355 16.95$ $1,017.00 16.95$ $1,017.00 090

27356 20.71$ $1,242.60 20.71$ $1,242.60 090

27357 22.87$ $1,372.20 22.87$ $1,372.20 090



Page | 36

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

27358 7.74$ $464.40 7.74$ $464.40 ZZZ

27360 23.96$ $1,437.60 23.96$ $1,437.60 090

27364 43.50$ $2,610.00 43.50$ $2,610.00 090

27365 57.88$ $3,472.80 57.88$ $3,472.80 090

27370 4.55$ $273.00 1.43$ $85.80 000

27372 17.44$ $1,046.40 11.39$ $683.40 090

27380 16.78$ $1,006.80 16.78$ $1,006.80 090

27381 22.43$ $1,345.80 22.43$ $1,345.80 090

27385 16.29$ $977.40 16.29$ $977.40 090

27386 23.36$ $1,401.60 23.36$ $1,401.60 090

27390 12.66$ $759.60 12.66$ $759.60 090

27391 16.25$ $975.00 16.25$ $975.00 090

27392 20.03$ $1,201.80 20.03$ $1,201.80 090

27393 14.30$ $858.00 14.30$ $858.00 090

27394 18.13$ $1,087.80 18.13$ $1,087.80 090

27395 24.66$ $1,479.60 24.66$ $1,479.60 090

27396 17.33$ $1,039.80 17.33$ $1,039.80 090

27397 25.34$ $1,520.40 25.34$ $1,520.40 090

27400 19.52$ $1,171.20 19.52$ $1,171.20 090

27403 18.02$ $1,081.20 18.02$ $1,081.20 090

27405 18.99$ $1,139.40 18.99$ $1,139.40 090

27407 21.83$ $1,309.80 21.83$ $1,309.80 090

27409 26.77$ $1,606.20 26.77$ $1,606.20 090

27412 46.32$ $2,779.20 46.32$ $2,779.20 090

27415 38.45$ $2,307.00 38.45$ $2,307.00 090

27416 27.45$ $1,647.00 27.45$ $1,647.00 090

27418 23.30$ $1,398.00 23.30$ $1,398.00 090

27420 20.92$ $1,255.20 20.92$ $1,255.20 090

27422 20.87$ $1,252.20 20.87$ $1,252.20 090

27424 21.02$ $1,261.20 21.02$ $1,261.20 090

27425 12.68$ $760.80 12.68$ $760.80 090

27427 20.04$ $1,202.40 20.04$ $1,202.40 090

27428 31.32$ $1,879.20 31.32$ $1,879.20 090

27429 35.07$ $2,104.20 35.07$ $2,104.20 090

27430 20.81$ $1,248.60 20.81$ $1,248.60 090

27435 22.74$ $1,364.40 22.74$ $1,364.40 090

27437 18.57$ $1,114.20 18.57$ $1,114.20 090

27438 23.62$ $1,417.20 23.62$ $1,417.20 090

27440 22.41$ $1,344.60 22.41$ $1,344.60 090

27441 23.11$ $1,386.60 23.11$ $1,386.60 090

27442 24.41$ $1,464.60 24.41$ $1,464.60 090

27443 22.67$ $1,360.20 22.67$ $1,360.20 090



Page | 37

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

27445 34.98$ $2,098.80 34.98$ $2,098.80 090

27446 32.50$ $1,950.00 32.50$ $1,950.00 090

27447 37.98$ $2,278.80 37.98$ $2,278.80 090

27448 21.88$ $1,312.80 21.88$ $1,312.80 090

27450 28.37$ $1,702.20 28.37$ $1,702.20 090

27454 36.42$ $2,185.20 36.42$ $2,185.20 090

27455 26.42$ $1,585.20 26.42$ $1,585.20 090

27457 26.58$ $1,594.80 26.58$ $1,594.80 090

27465 34.64$ $2,078.40 34.64$ $2,078.40 090

27466 33.09$ $1,985.40 33.09$ $1,985.40 090

27468 34.67$ $2,080.20 34.67$ $2,080.20 090

27470 33.00$ $1,980.00 33.00$ $1,980.00 090

27472 35.40$ $2,124.00 35.40$ $2,124.00 090

27475 18.61$ $1,116.60 18.61$ $1,116.60 090

27477 20.55$ $1,233.00 20.55$ $1,233.00 090

27479 22.30$ $1,338.00 22.30$ $1,338.00 090

27485 18.84$ $1,130.40 18.84$ $1,130.40 090

27486 39.46$ $2,367.60 39.46$ $2,367.60 090

27487 49.24$ $2,954.40 49.24$ $2,954.40 090

27488 33.71$ $2,022.60 33.71$ $2,022.60 090

27495 31.62$ $1,897.20 31.62$ $1,897.20 090

27496 15.29$ $917.40 15.29$ $917.40 090

27497 16.33$ $979.80 16.33$ $979.80 090

27498 18.16$ $1,089.60 18.16$ $1,089.60 090

27499 19.65$ $1,179.00 19.65$ $1,179.00 090

27500 14.68$ $880.80 13.53$ $811.80 090

27501 14.19$ $851.40 14.07$ $844.20 090

27502 21.45$ $1,287.00 21.45$ $1,287.00 090

27503 22.54$ $1,352.40 22.54$ $1,352.40 090

27506 37.53$ $2,251.80 37.53$ $2,251.80 090

27507 27.26$ $1,635.60 27.26$ $1,635.60 090

27508 14.89$ $893.40 13.97$ $838.20 090

27509 18.17$ $1,090.20 18.17$ $1,090.20 090

27510 19.18$ $1,150.80 19.18$ $1,150.80 090

27511 27.90$ $1,674.00 27.90$ $1,674.00 090

27513 34.68$ $2,080.80 34.68$ $2,080.80 090

27514 27.07$ $1,624.20 27.07$ $1,624.20 090

27516 14.43$ $865.80 13.51$ $810.60 090

27517 18.93$ $1,135.80 18.93$ $1,135.80 090

27519 24.94$ $1,496.40 24.94$ $1,496.40 090

27520 9.25$ $555.00 8.41$ $504.60 090

27524 21.16$ $1,269.60 21.16$ $1,269.60 090



Page | 38

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

27530 8.67$ $520.20 8.03$ $481.80 090

27532 17.37$ $1,042.20 16.25$ $975.00 090

27535 25.13$ $1,507.80 25.13$ $1,507.80 090

27536 33.40$ $2,004.00 33.40$ $2,004.00 090

27538 13.44$ $806.40 12.55$ $753.00 090

27540 22.77$ $1,366.20 22.77$ $1,366.20 090

27550 14.33$ $859.80 13.24$ $794.40 090

27552 17.63$ $1,057.80 17.63$ $1,057.80 090

27556 24.51$ $1,470.60 24.51$ $1,470.60 090

27557 29.28$ $1,756.80 29.28$ $1,756.80 090

27558 33.29$ $1,997.40 33.29$ $1,997.40 090

27560 10.31$ $618.60 9.47$ $568.20 090

27562 13.25$ $795.00 13.25$ $795.00 090

27566 25.04$ $1,502.40 25.04$ $1,502.40 090

27570 4.29$ $257.40 4.29$ $257.40 010

27580 40.31$ $2,418.60 40.31$ $2,418.60 090

27590 22.32$ $1,339.20 22.32$ $1,339.20 090

27591 27.03$ $1,621.80 27.03$ $1,621.80 090

27592 19.06$ $1,143.60 19.06$ $1,143.60 090

27594 14.27$ $856.20 14.27$ $856.20 090

27596 20.24$ $1,214.40 20.24$ $1,214.40 090

27598 20.24$ $1,214.40 20.24$ $1,214.40 090


27600 11.55$ $693.00 11.55$ $693.00 090

27601 12.48$ $748.80 12.48$ $748.80 090

27602 13.71$ $822.60 13.71$ $822.60 090

27603 15.20$ $912.00 10.97$ $658.20 090

27604 14.31$ $858.60 9.85$ $591.00 090

27605 10.02$ $601.20 5.29$ $317.40 010

27606 8.01$ $480.60 8.01$ $480.60 010

27607 17.13$ $1,027.80 17.13$ $1,027.80 090

27610 18.40$ $1,104.00 18.40$ $1,104.00 090

27612 15.86$ $951.60 15.86$ $951.60 090

27613 7.33$ $439.80 4.65$ $279.00 010

27614 16.68$ $1,000.80 11.48$ $688.80 090

27615 28.58$ $1,714.80 28.58$ $1,714.80 090

27616 35.46$ $2,127.60 35.46$ $2,127.60 090

27618 12.93$ $775.80 8.69$ $521.40 090

27619 13.29$ $797.40 13.29$ $797.40 090

27620 12.92$ $775.20 12.92$ $775.20 090

27625 16.62$ $997.20 16.62$ $997.20 090

27626 17.52$ $1,051.20 17.52$ $1,051.20 090



Page | 39

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

27630 16.30$ $978.00 10.44$ $626.40 090

27632 11.63$ $697.80 11.63$ $697.80 090

27634 19.25$ $1,155.00 19.25$ $1,155.00 090

27635 16.61$ $996.60 16.61$ $996.60 090

27637 21.17$ $1,270.20 21.17$ $1,270.20 090

27638 21.53$ $1,291.80 21.53$ $1,291.80 090

27640 23.49$ $1,409.40 23.49$ $1,409.40 090

27641 18.90$ $1,134.00 18.90$ $1,134.00 090

27645 49.63$ $2,977.80 49.63$ $2,977.80 090

27646 42.98$ $2,578.80 42.98$ $2,578.80 090

27647 29.32$ $1,759.20 29.32$ $1,759.20 090

27648 4.81$ $288.60 1.48$ $88.80 000

27650 18.74$ $1,124.40 18.74$ $1,124.40 090

27652 19.43$ $1,165.80 19.43$ $1,165.80 090

27654 20.15$ $1,209.00 20.15$ $1,209.00 090

27656 18.41$ $1,104.60 11.24$ $674.40 090

27658 10.66$ $639.60 10.66$ $639.60 090

27659 13.73$ $823.80 13.73$ $823.80 090

27664 10.31$ $618.60 10.31$ $618.60 090

27665 11.76$ $705.60 11.76$ $705.60 090

27675 13.88$ $832.80 13.88$ $832.80 090

27676 17.10$ $1,026.00 17.10$ $1,026.00 090

27680 12.21$ $732.60 12.21$ $732.60 090

27681 15.36$ $921.60 15.36$ $921.60 090

27685 19.30$ $1,158.00 13.27$ $796.20 090

27686 15.80$ $948.00 15.80$ $948.00 090

27687 12.94$ $776.40 12.94$ $776.40 090

27690 17.97$ $1,078.20 17.97$ $1,078.20 090

27691 21.23$ $1,273.80 21.23$ $1,273.80 090

27692 2.93$ $175.80 2.93$ $175.80 ZZZ

27695 13.55$ $813.00 13.55$ $813.00 090

27696 15.85$ $951.00 15.85$ $951.00 090

27698 18.19$ $1,091.40 18.19$ $1,091.40 090

27700 16.96$ $1,017.60 16.96$ $1,017.60 090

27702 27.21$ $1,632.60 27.21$ $1,632.60 090

27703 31.24$ $1,874.40 31.24$ $1,874.40 090

27704 16.32$ $979.20 16.32$ $979.20 090

27705 21.41$ $1,284.60 21.41$ $1,284.60 090

27707 11.49$ $689.40 11.49$ $689.40 090

27709 32.78$ $1,966.80 32.78$ $1,966.80 090

27712 30.95$ $1,857.00 30.95$ $1,857.00 090

27715 30.02$ $1,801.20 30.02$ $1,801.20 090



Page | 40

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

27720 24.62$ $1,477.20 24.62$ $1,477.20 090

27722 24.69$ $1,481.40 24.69$ $1,481.40 090

27724 35.41$ $2,124.60 35.41$ $2,124.60 090

27725 33.93$ $2,035.80 33.93$ $2,035.80 090

27726 27.13$ $1,627.80 27.13$ $1,627.80 090

27727 29.08$ $1,744.80 29.08$ $1,744.80 090

27730 16.07$ $964.20 16.07$ $964.20 090

27732 11.51$ $690.60 11.51$ $690.60 090

27734 18.45$ $1,107.00 18.45$ $1,107.00 090

27740 19.91$ $1,194.60 19.91$ $1,194.60 090

27742 21.99$ $1,319.40 21.99$ $1,319.40 090

27745 21.26$ $1,275.60 21.26$ $1,275.60 090

27750 9.90$ $594.00 9.06$ $543.60 090

27752 15.23$ $913.80 14.00$ $840.00 090

27756 16.19$ $971.40 16.19$ $971.40 090

27758 25.04$ $1,502.40 25.04$ $1,502.40 090

27759 28.03$ $1,681.80 28.03$ $1,681.80 090

27760 9.57$ $574.20 8.71$ $522.60 090

27762 13.52$ $811.20 12.28$ $736.80 090

27766 17.27$ $1,036.20 17.27$ $1,036.20 090

27767 8.07$ $484.20 8.12$ $487.20 090

27768 12.47$ $748.20 12.47$ $748.20 090

27769 20.53$ $1,231.80 20.53$ $1,231.80 090

27780 8.80$ $528.00 7.97$ $478.20 090

27781 12.02$ $721.20 11.10$ $666.00 090

27784 20.19$ $1,211.40 20.19$ $1,211.40 090

27786 9.08$ $544.80 8.18$ $490.80 090

27788 11.99$ $719.40 10.92$ $655.20 090

27792 18.44$ $1,106.40 18.44$ $1,106.40 090

27808 9.60$ $576.00 8.59$ $515.40 090

27810 13.28$ $796.80 12.00$ $720.00 090

27814 21.76$ $1,305.60 21.76$ $1,305.60 090

27816 9.18$ $550.80 8.20$ $492.00 090

27818 13.76$ $825.60 12.27$ $736.20 090

27822 23.76$ $1,425.60 23.76$ $1,425.60 090

27823 26.92$ $1,615.20 26.92$ $1,615.20 090

27824 8.95$ $537.00 8.69$ $521.40 090

27825 15.42$ $925.20 13.91$ $834.60 090

27826 23.51$ $1,410.60 23.51$ $1,410.60 090

27827 30.47$ $1,828.20 30.47$ $1,828.20 090

27828 36.43$ $2,185.80 36.43$ $2,185.80 090

27829 19.37$ $1,162.20 19.37$ $1,162.20 090



Page | 41

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

27830 10.83$ $649.80 10.06$ $603.60 090

27831 11.08$ $664.80 11.08$ $664.80 090

27832 21.29$ $1,277.40 21.29$ $1,277.40 090

27840 10.45$ $627.00 10.45$ $627.00 090

27842 14.01$ $840.60 14.01$ $840.60 090

27846 20.48$ $1,228.80 20.48$ $1,228.80 090

27848 22.85$ $1,371.00 22.85$ $1,371.00 090

27860 4.97$ $298.20 4.97$ $298.20 010

27870 29.05$ $1,743.00 29.05$ $1,743.00 090

27871 19.31$ $1,158.60 19.31$ $1,158.60 090

27880 25.58$ $1,534.80 25.58$ $1,534.80 090

27881 24.45$ $1,467.00 24.45$ $1,467.00 090

27882 16.81$ $1,008.60 16.81$ $1,008.60 090

27884 16.21$ $972.60 16.21$ $972.60 090

27886 18.52$ $1,111.20 18.52$ $1,111.20 090

27888 19.25$ $1,155.00 19.25$ $1,155.00 090

27889 18.15$ $1,089.00 18.15$ $1,089.00 090

27892 15.57$ $934.20 15.57$ $934.20 090

27893 17.03$ $1,021.80 17.03$ $1,021.80 090

27894 23.94$ $1,436.40 23.94$ $1,436.40 090


28001 8.15$ $489.00 4.88$ $292.80 010

28002 12.92$ $775.20 9.13$ $547.80 010

28003 20.58$ $1,234.80 16.26$ $975.60 090

28005 16.60$ $996.00 16.60$ $996.00 090

28008 12.71$ $762.60 8.46$ $507.60 090

28010 6.76$ $405.60 6.06$ $363.60 090

28011 9.34$ $560.40 8.30$ $498.00 090

28020 15.86$ $951.60 10.38$ $622.80 090

28022 14.37$ $862.20 9.37$ $562.20 090

28024 13.60$ $816.00 8.80$ $528.00 090

28035 15.44$ $926.40 10.19$ $611.40 090

28039 14.92$ $895.20 10.05$ $603.00 090

28041 13.21$ $792.60 13.21$ $792.60 090

28043 11.79$ $707.40 7.58$ $454.80 090

28045 14.57$ $874.20 10.03$ $601.80 090

28046 20.83$ $1,249.80 20.83$ $1,249.80 090

28047 30.18$ $1,810.80 30.18$ $1,810.80 090

28050 12.56$ $753.60 8.11$ $486.60 090

28052 13.20$ $792.00 8.22$ $493.20 090

28054 11.60$ $696.00 7.09$ $425.40 090

28055 10.81$ $648.60 10.81$ $648.60 090



Page | 42

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

28060 15.24$ $914.40 10.28$ $616.80 090

28062 17.22$ $1,033.20 11.73$ $703.80 090

28070 15.66$ $939.60 10.22$ $613.20 090

28072 14.88$ $892.80 9.53$ $571.80 090

28080 15.47$ $928.20 10.64$ $638.40 090

28086 16.08$ $964.80 10.35$ $621.00 090

28088 13.21$ $792.60 8.14$ $488.40 090

28090 13.88$ $832.80 8.89$ $533.40 090

28092 12.51$ $750.60 7.78$ $466.80 090

28100 17.78$ $1,066.80 11.82$ $709.20 090

28102 17.08$ $1,024.80 17.08$ $1,024.80 090

28103 11.31$ $678.60 11.31$ $678.60 090

28104 15.51$ $930.60 10.15$ $609.00 090

28106 13.31$ $798.60 13.31$ $798.60 090

28107 16.45$ $987.00 10.78$ $646.80 090

28108 13.02$ $781.20 8.34$ $500.40 090

28110 13.69$ $821.40 8.37$ $502.20 090

28111 14.48$ $868.80 9.36$ $561.60 090

28112 14.43$ $865.80 9.03$ $541.80 090

28113 17.42$ $1,045.20 12.30$ $738.00 090

28114 31.25$ $1,875.00 23.98$ $1,438.80 090

28116 22.01$ $1,320.60 16.35$ $981.00 090

28118 17.39$ $1,043.40 11.84$ $710.40 090

28119 15.47$ $928.20 10.42$ $625.20 090

28120 19.78$ $1,186.80 14.26$ $855.60 090

28122 17.54$ $1,052.40 12.67$ $760.20 090

28124 14.07$ $844.20 9.56$ $573.60 090

28126 11.72$ $703.20 7.19$ $431.40 090

28130 18.28$ $1,096.80 18.28$ $1,096.80 090

28140 17.39$ $1,043.40 12.57$ $754.20 090

28150 12.62$ $757.20 8.11$ $486.60 090

28153 12.18$ $730.80 7.64$ $458.40 090

28160 12.47$ $748.20 7.82$ $469.20 090

28171 24.33$ $1,459.80 24.33$ $1,459.80 090

28173 21.84$ $1,310.40 21.84$ $1,310.40 090

28175 14.07$ $844.20 14.07$ $844.20 090

28190 7.62$ $457.20 3.87$ $232.20 010

28192 13.89$ $833.40 9.07$ $544.20 090

28193 15.59$ $935.40 10.62$ $637.20 090

28200 14.43$ $865.80 9.26$ $555.60 090

28202 17.51$ $1,050.60 12.27$ $736.20 090

28208 13.97$ $838.20 8.98$ $538.80 090



Page | 43

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

28210 16.80$ $1,008.00 11.74$ $704.40 090

28220 13.28$ $796.80 8.72$ $523.20 090

28222 14.91$ $894.60 10.07$ $604.20 090

28225 12.12$ $727.20 7.50$ $450.00 090

28226 17.74$ $1,064.40 11.14$ $668.40 090

28230 12.85$ $771.00 8.18$ $490.80 090

28232 11.48$ $688.80 7.04$ $422.40 090

28234 12.11$ $726.60 7.65$ $459.00 090

28238 19.61$ $1,176.60 13.96$ $837.60 090

28240 13.04$ $782.40 8.38$ $502.80 090

28250 17.02$ $1,021.20 11.62$ $697.20 090

28260 20.00$ $1,200.00 14.59$ $875.40 090

28261 28.43$ $1,705.80 22.15$ $1,329.00 090

28262 41.94$ $2,516.40 33.19$ $1,991.40 090

28264 28.75$ $1,725.00 21.48$ $1,288.80 090

28270 14.49$ $869.40 9.63$ $577.80 090

28272 11.69$ $701.40 7.38$ $442.80 090

28280 15.23$ $913.80 10.08$ $604.80 090

28285 15.73$ $943.80 10.90$ $654.00 090

28286 13.37$ $802.20 8.67$ $520.20 090

28288 17.80$ $1,068.00 12.42$ $745.20 090

28289 21.38$ $1,282.80 15.67$ $940.20 090

28290 17.30$ $1,038.00 11.36$ $681.60 090

28292 23.14$ $1,388.40 17.37$ $1,042.20 090

28293 30.88$ $1,852.80 20.51$ $1,230.60 090

28294 22.45$ $1,347.00 15.66$ $939.60 090

28296 20.91$ $1,254.60 15.01$ $900.60 090

28297 23.69$ $1,421.40 16.63$ $997.80 090

28298 21.13$ $1,267.80 14.50$ $870.00 090

28299 26.12$ $1,567.20 19.38$ $1,162.80 090

28300 18.50$ $1,110.00 18.50$ $1,110.00 090

28302 20.12$ $1,207.20 20.12$ $1,207.20 090

28304 24.01$ $1,440.60 17.27$ $1,036.20 090

28305 19.00$ $1,140.00 19.00$ $1,140.00 090

28306 18.01$ $1,080.60 11.56$ $693.60 090

28307 19.95$ $1,197.00 12.86$ $771.60 090

28308 16.66$ $999.60 10.87$ $652.20 090

28309 25.66$ $1,539.60 25.66$ $1,539.60 090

28310 16.12$ $967.20 10.31$ $618.60 090

28312 15.04$ $902.40 9.21$ $552.60 090

28313 15.53$ $931.80 10.30$ $618.00 090

28315 14.19$ $851.40 9.38$ $562.80 090



Page | 44

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

28320 17.37$ $1,042.20 17.37$ $1,042.20 090

28322 22.96$ $1,377.60 16.47$ $988.20 090

28340 17.02$ $1,021.20 11.92$ $715.20 090

28341 19.70$ $1,182.00 14.18$ $850.80 090

28344 13.69$ $821.40 8.92$ $535.20 090

28345 15.40$ $924.00 10.55$ $633.00 090

28360 26.11$ $1,566.60 26.11$ $1,566.60 090

28400 7.21$ $432.60 6.57$ $394.20 090

28405 11.31$ $678.60 10.21$ $612.60 090

28406 14.89$ $893.40 14.89$ $893.40 090

28415 31.28$ $1,876.80 31.28$ $1,876.80 090

28420 35.27$ $2,116.20 35.27$ $2,116.20 090

28430 6.87$ $412.20 6.07$ $364.20 090

28435 9.18$ $550.80 8.15$ $489.00 090

28436 12.81$ $768.60 12.81$ $768.60 090

28445 30.00$ $1,800.00 30.00$ $1,800.00 090

28446 33.98$ $2,038.80 33.98$ $2,038.80 090

28450 6.28$ $376.80 5.57$ $334.20 090

28455 8.40$ $504.00 7.52$ $451.20 090

28456 9.20$ $552.00 9.20$ $552.00 090

28465 17.76$ $1,065.60 17.76$ $1,065.60 090

28470 6.37$ $382.20 5.93$ $355.80 090

28475 7.43$ $445.80 6.55$ $393.00 090

28476 10.17$ $610.20 10.17$ $610.20 090

28485 15.07$ $904.20 15.07$ $904.20 090

28490 4.26$ $255.60 3.65$ $219.00 090

28495 5.20$ $312.00 4.35$ $261.00 090

28496 13.03$ $781.80 6.77$ $406.20 090

28505 19.45$ $1,167.00 14.30$ $858.00 090

28510 3.61$ $216.60 3.52$ $211.20 090

28515 4.73$ $283.80 4.15$ $249.00 090

28525 16.63$ $997.80 11.48$ $688.80 090

28530 3.38$ $202.80 2.99$ $179.40 090

28531 10.31$ $618.60 5.36$ $321.60 090

28540 6.04$ $362.40 5.43$ $325.80 090

28545 8.43$ $505.80 7.44$ $446.40 090

28546 16.47$ $988.20 9.46$ $567.60 090

28555 25.49$ $1,529.40 19.01$ $1,140.60 090

28570 6.46$ $387.60 5.44$ $326.40 090

28575 10.48$ $628.80 9.43$ $565.80 090

28576 11.09$ $665.40 11.09$ $665.40 090

28585 24.87$ $1,492.20 19.23$ $1,153.80 090



Page | 45

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

28600 6.36$ $381.60 5.44$ $326.40 090

28605 9.39$ $563.40 8.41$ $504.60 090

28606 11.27$ $676.20 11.27$ $676.20 090

28615 22.47$ $1,348.20 22.47$ $1,348.20 090

28630 4.54$ $272.40 3.12$ $187.20 010

28635 5.08$ $304.80 3.77$ $226.20 010

28636 8.39$ $503.40 5.28$ $316.80 010

28645 19.21$ $1,152.60 13.94$ $836.40 090

28660 3.37$ $202.20 2.53$ $151.80 010

28665 4.45$ $267.00 3.76$ $225.60 010

28666 5.35$ $321.00 5.35$ $321.00 010

28675 17.12$ $1,027.20 11.84$ $710.40 090

28705 35.39$ $2,123.40 35.39$ $2,123.40 090

28715 26.58$ $1,594.80 26.58$ $1,594.80 090

28725 22.08$ $1,324.80 22.08$ $1,324.80 090

28730 20.85$ $1,251.00 20.85$ $1,251.00 090

28735 22.22$ $1,333.20 22.22$ $1,333.20 090

28737 19.69$ $1,181.40 19.69$ $1,181.40 090

28740 24.64$ $1,478.40 17.79$ $1,067.40 090

28750 23.72$ $1,423.20 16.90$ $1,014.00 090

28755 14.99$ $899.40 9.52$ $571.20 090

28760 23.08$ $1,384.80 16.56$ $993.60 090

28800 15.46$ $927.60 15.46$ $927.60 090

28805 20.72$ $1,243.20 20.72$ $1,243.20 090

28810 12.25$ $735.00 12.25$ $735.00 090

28820 16.57$ $994.20 11.37$ $682.20 090

28825 15.83$ $949.80 10.68$ $640.80 090

28890 9.47$ $568.20 6.47$ $388.20 090


29000 8.20$ $492.00 4.80$ $288.00 000

29010 6.89$ $413.40 4.18$ $250.80 000

29015 8.27$ $496.20 5.09$ $305.40 000

29035 5.66$ $339.60 3.42$ $205.20 000

29040 6.55$ $393.00 4.15$ $249.00 000

29044 8.30$ $498.00 4.34$ $260.40 000

29046 7.04$ $422.40 4.50$ $270.00 000

29049 2.41$ $144.60 1.76$ $105.60 000

29055 6.44$ $386.40 3.93$ $235.80 000

29058 3.50$ $210.00 2.63$ $157.80 000

29065 2.77$ $166.20 1.95$ $117.00 000

29075 2.50$ $150.00 1.77$ $106.20 000

29085 2.76$ $165.60 1.92$ $115.20 000



Page | 46

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

29086 2.29$ $137.40 1.48$ $88.80 000

29105 2.54$ $152.40 1.68$ $100.80 000

29125 1.88$ $112.80 1.13$ $67.80 000

29126 2.23$ $133.80 1.38$ $82.80 000

29130 1.17$ $70.20 0.80$ $48.00 000

29131 1.47$ $88.20 0.93$ $55.80 000

29200 0.86$ $51.60 0.52$ $31.20 000

29240 0.84$ $50.40 0.53$ $31.80 000

29260 0.84$ $50.40 0.55$ $33.00 000

29280 0.85$ $51.00 0.57$ $34.20 000

29305 7.15$ $429.00 4.52$ $271.20 000

29325 7.84$ $470.40 5.03$ $301.80 000

29345 3.90$ $234.00 2.85$ $171.00 000

29355 4.02$ $241.20 3.00$ $180.00 000

29358 4.63$ $277.80 2.93$ $175.80 000

29365 3.53$ $211.80 2.48$ $148.80 000

29405 2.37$ $142.20 1.71$ $102.60 000

29425 2.28$ $136.80 1.62$ $97.20 000

29435 3.35$ $201.00 2.34$ $140.40 000

29440 1.27$ $76.20 0.83$ $49.80 000

29445 3.87$ $232.20 2.96$ $177.60 000

29450 4.12$ $247.20 3.20$ $192.00 000

29505 2.42$ $145.20 1.42$ $85.20 000

29515 2.08$ $124.80 1.41$ $84.60 000

29520 0.91$ $54.60 0.53$ $31.80 000

29530 0.83$ $49.80 0.52$ $31.20 000

29540 0.75$ $45.00 0.51$ $30.60 000

29550 0.55$ $33.00 0.33$ $19.80 000

29580 1.52$ $91.20 1.01$ $60.60 000

29581 1.83$ $109.80 0.36$ $21.60 000

29582 2.08$ $124.80 0.45$ $27.00 000

29583 1.29$ $77.40 0.32$ $19.20 000

29584 2.08$ $124.80 0.45$ $27.00 000

29700 1.81$ $108.60 0.93$ $55.80 000

29705 1.91$ $114.60 1.33$ $79.80 000

29710 3.47$ $208.20 2.31$ $138.60 000

29720 2.45$ $147.00 1.24$ $74.40 000

29730 1.85$ $111.00 1.27$ $76.20 000

29740 2.83$ $169.80 1.96$ $117.60 000

29750 2.55$ $153.00 1.89$ $113.40 000


29800 14.49$ $869.40 14.49$ $869.40 090



Page | 47

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

29804 18.34$ $1,100.40 18.34$ $1,100.40 090

29805 13.35$ $801.00 13.35$ $801.00 090

29806 29.82$ $1,789.20 29.82$ $1,789.20 090

29807 29.10$ $1,746.00 29.10$ $1,746.00 090

29819 16.53$ $991.80 16.53$ $991.80 090

29820 15.15$ $909.00 15.15$ $909.00 090

29821 16.56$ $993.60 16.56$ $993.60 090

29822 16.11$ $966.60 16.11$ $966.60 090

29823 17.58$ $1,054.80 17.58$ $1,054.80 090

29824 18.96$ $1,137.60 18.96$ $1,137.60 090

29825 16.41$ $984.60 16.41$ $984.60 090

29826 4.89$ $293.40 4.89$ $293.40 ZZZ

29827 29.88$ $1,792.80 29.88$ $1,792.80 090

29828 25.78$ $1,546.80 25.78$ $1,546.80 090

29830 12.85$ $771.00 12.85$ $771.00 090

29834 13.81$ $828.60 13.81$ $828.60 090

29835 14.27$ $856.20 14.27$ $856.20 090

29836 16.16$ $969.60 16.16$ $969.60 090

29837 14.83$ $889.80 14.83$ $889.80 090

29838 16.60$ $996.00 16.60$ $996.00 090

29840 12.80$ $768.00 12.80$ $768.00 090

29843 13.69$ $821.40 13.69$ $821.40 090

29844 14.07$ $844.20 14.07$ $844.20 090

29845 16.34$ $980.40 16.34$ $980.40 090

29846 14.74$ $884.40 14.74$ $884.40 090

29847 15.16$ $909.60 15.16$ $909.60 090

29848 14.49$ $869.40 14.49$ $869.40 090

29850 17.45$ $1,047.00 17.45$ $1,047.00 090

29851 24.93$ $1,495.80 24.93$ $1,495.80 090

29855 22.04$ $1,322.40 22.04$ $1,322.40 090

29856 27.97$ $1,678.20 27.97$ $1,678.20 090

29860 18.63$ $1,117.80 18.63$ $1,117.80 090

29861 20.34$ $1,220.40 20.34$ $1,220.40 090

29862 22.88$ $1,372.80 22.88$ $1,372.80 090

29863 22.87$ $1,372.20 22.87$ $1,372.20 090

29866 29.34$ $1,760.40 29.34$ $1,760.40 090

29867 35.46$ $2,127.60 35.46$ $2,127.60 090

29868 45.02$ $2,701.20 45.02$ $2,701.20 090

29870 16.81$ $1,008.60 11.68$ $700.80 090

29871 14.54$ $872.40 14.54$ $872.40 090

29873 14.91$ $894.60 14.91$ $894.60 090

29874 15.18$ $910.80 15.18$ $910.80 090



Page | 48

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

29875 14.01$ $840.60 14.01$ $840.60 090

29876 18.55$ $1,113.00 18.55$ $1,113.00 090

29877 17.58$ $1,054.80 17.58$ $1,054.80 090

29879 18.69$ $1,121.40 18.69$ $1,121.40 090

29880 15.90$ $954.00 15.90$ $954.00 090

29881 15.33$ $919.80 15.33$ $919.80 090

29882 19.73$ $1,183.80 19.73$ $1,183.80 090

29883 23.69$ $1,421.40 23.69$ $1,421.40 090

29884 17.44$ $1,046.40 17.44$ $1,046.40 090

29885 21.19$ $1,271.40 21.19$ $1,271.40 090

29886 17.97$ $1,078.20 17.97$ $1,078.20 090

29887 21.04$ $1,262.40 21.04$ $1,262.40 090

29888 27.71$ $1,662.60 27.71$ $1,662.60 090

29889 34.34$ $2,060.40 34.34$ $2,060.40 090

29891 19.22$ $1,153.20 19.22$ $1,153.20 090

29892 16.79$ $1,007.40 16.79$ $1,007.40 090

29893 18.03$ $1,081.80 12.42$ $745.20 090

29894 14.23$ $853.80 14.23$ $853.80 090

29895 13.58$ $814.80 13.58$ $814.80 090

29897 14.39$ $863.40 14.39$ $863.40 090

29898 16.08$ $964.80 16.08$ $964.80 090

29899 29.17$ $1,750.20 29.17$ $1,750.20 090

29900 13.19$ $791.40 13.19$ $791.40 090

29901 15.09$ $905.40 15.09$ $905.40 090

29902 16.02$ $961.20 16.02$ $961.20 090

29904 17.98$ $1,078.80 17.98$ $1,078.80 090

29905 19.34$ $1,160.40 19.34$ $1,160.40 090

29906 20.34$ $1,220.40 20.34$ $1,220.40 090

29907 24.66$ $1,479.60 24.66$ $1,479.60 090

29914 28.11$ $1,686.60 28.11$ $1,686.60 090

29915 28.61$ $1,716.60 28.61$ $1,716.60 090

29916 28.66$ $1,719.60 28.66$ $1,719.60 090


30000 6.76$ $405.60 3.39$ $203.40 010

30020 6.85$ $411.00 3.42$ $205.20 010

30100 4.15$ $249.00 1.97$ $118.20 000

30110 6.76$ $405.60 3.73$ $223.80 010

30115 12.51$ $750.60 12.51$ $750.60 090

30117 26.11$ $1,566.60 9.90$ $594.00 090

30118 21.97$ $1,318.20 21.97$ $1,318.20 090

30120 14.95$ $897.00 12.53$ $751.80 090

30124 8.24$ $494.40 8.24$ $494.40 090



Page | 49

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

30125 17.43$ $1,045.80 17.43$ $1,045.80 090

30130 11.07$ $664.20 11.07$ $664.20 090

30140 12.86$ $771.60 12.86$ $771.60 090

30150 21.99$ $1,319.40 21.99$ $1,319.40 090

30160 22.03$ $1,321.80 22.03$ $1,321.80 090

30200 3.34$ $200.40 1.71$ $102.60 000

30210 4.39$ $263.40 2.86$ $171.60 010

30220 8.96$ $537.60 3.58$ $214.80 010

30300 5.49$ $329.40 3.07$ $184.20 010

30310 5.99$ $359.40 5.99$ $359.40 010

30320 12.82$ $769.20 12.82$ $769.20 090

30400 29.14$ $1,748.40 29.14$ $1,748.40 090

30410 33.94$ $2,036.40 33.94$ $2,036.40 090

30420 39.20$ $2,352.00 39.20$ $2,352.00 090

30430 27.87$ $1,672.20 27.87$ $1,672.20 090

30435 31.92$ $1,915.20 31.92$ $1,915.20 090

30450 42.68$ $2,560.80 42.68$ $2,560.80 090

30460 20.28$ $1,216.80 20.28$ $1,216.80 090

30462 44.17$ $2,650.20 44.17$ $2,650.20 090

30465 28.02$ $1,681.20 28.02$ $1,681.20 090

30520 17.94$ $1,076.40 17.94$ $1,076.40 090

30540 19.93$ $1,195.80 19.93$ $1,195.80 090

30545 25.14$ $1,508.40 25.14$ $1,508.40 090

30560 7.95$ $477.00 3.99$ $239.40 010

30580 18.84$ $1,130.40 14.60$ $876.00 090

30600 16.99$ $1,019.40 12.68$ $760.80 090

30620 18.05$ $1,083.00 18.05$ $1,083.00 090

30630 17.87$ $1,072.20 17.87$ $1,072.20 090

30801 6.79$ $407.40 3.99$ $239.40 010

30802 8.52$ $511.20 5.49$ $329.40 010

30901 2.73$ $163.80 1.58$ $94.80 000

30903 6.47$ $388.20 2.25$ $135.00 000

30905 7.92$ $475.20 2.99$ $179.40 000

30906 10.21$ $612.60 3.86$ $231.60 000

30915 16.46$ $987.60 16.46$ $987.60 090

30920 23.82$ $1,429.20 23.82$ $1,429.20 090

30930 3.56$ $213.60 3.56$ $213.60 010


31000 5.40$ $324.00 3.06$ $183.60 010

31002 5.62$ $337.20 5.62$ $337.20 010

31020 14.26$ $855.60 10.48$ $628.80 090

31030 20.13$ $1,207.80 15.23$ $913.80 090



Page | 50

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

31032 16.51$ $990.60 16.51$ $990.60 090

31040 21.77$ $1,306.20 21.77$ $1,306.20 090

31050 14.02$ $841.20 14.02$ $841.20 090

31051 18.57$ $1,114.20 18.57$ $1,114.20 090

31070 12.72$ $763.20 12.72$ $763.20 090

31075 22.48$ $1,348.80 22.48$ $1,348.80 090

31080 29.73$ $1,783.80 29.73$ $1,783.80 090

31081 40.86$ $2,451.60 40.86$ $2,451.60 090

31084 33.13$ $1,987.80 33.13$ $1,987.80 090

31085 43.38$ $2,602.80 43.38$ $2,602.80 090

31086 32.31$ $1,938.60 32.31$ $1,938.60 090

31087 30.78$ $1,846.80 30.78$ $1,846.80 090

31090 29.55$ $1,773.00 29.55$ $1,773.00 090

31200 16.64$ $998.40 16.64$ $998.40 090

31201 21.27$ $1,276.20 21.27$ $1,276.20 090

31205 25.90$ $1,554.00 25.90$ $1,554.00 090

31225 53.30$ $3,198.00 53.30$ $3,198.00 090

31230 58.97$ $3,538.20 58.97$ $3,538.20 090

31231 6.20$ $372.00 1.84$ $110.40 000

31233 7.66$ $459.60 3.88$ $232.80 000

31235 8.72$ $523.20 4.59$ $275.40 000

31237 7.49$ $449.40 4.59$ $275.40 000

31238 7.46$ $447.60 4.80$ $288.00 000

31239 17.63$ $1,057.80 17.63$ $1,057.80 010

31240 4.57$ $274.20 4.57$ $274.20 000

31254 7.72$ $463.20 7.72$ $463.20 000

31255 11.29$ $677.40 11.29$ $677.40 000

31256 5.60$ $336.00 5.60$ $336.00 000

31267 8.97$ $538.20 8.97$ $538.20 000

31276 14.24$ $854.40 14.24$ $854.40 000

31287 6.57$ $394.20 6.57$ $394.20 000

31288 7.60$ $456.00 7.60$ $456.00 000

31290 32.63$ $1,957.80 32.63$ $1,957.80 010

31291 34.61$ $2,076.60 34.61$ $2,076.60 010

31292 28.35$ $1,701.00 28.35$ $1,701.00 010

31293 30.76$ $1,845.60 30.76$ $1,845.60 010

31294 35.10$ $2,106.00 35.10$ $2,106.00 010

31295 61.34$ $3,680.40 4.65$ $279.00 000

31296 62.46$ $3,747.60 5.57$ $334.20 000

31297 61.43$ $3,685.80 4.56$ $273.60 000


31300 37.61$ $2,256.60 37.61$ $2,256.60 090



Page | 51

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

31320 20.25$ $1,215.00 20.25$ $1,215.00 090

31360 60.52$ $3,631.20 60.52$ $3,631.20 090

31365 74.42$ $4,465.20 74.42$ $4,465.20 090

31367 64.33$ $3,859.80 64.33$ $3,859.80 090

31368 71.72$ $4,303.20 71.72$ $4,303.20 090

31370 60.75$ $3,645.00 60.75$ $3,645.00 090

31375 57.27$ $3,436.20 57.27$ $3,436.20 090

31380 56.79$ $3,407.40 56.79$ $3,407.40 090

31382 62.47$ $3,748.20 62.47$ $3,748.20 090

31390 83.14$ $4,988.40 83.14$ $4,988.40 090

31395 88.03$ $5,281.80 88.03$ $5,281.80 090

31400 28.36$ $1,701.60 28.36$ $1,701.60 090

31420 23.85$ $1,431.00 23.85$ $1,431.00 090

31500 3.06$ $183.60 3.06$ $183.60 000

31502 0.99$ $59.40 0.99$ $59.40 000

31505 2.44$ $146.40 1.42$ $85.20 000

31510 6.13$ $367.80 3.45$ $207.00 000

31511 6.13$ $367.80 3.68$ $220.80 000

31512 5.94$ $356.40 3.68$ $220.80 000

31513 3.76$ $225.60 3.76$ $225.60 000

31515 5.40$ $324.00 3.01$ $180.60 000

31520 4.46$ $267.60 4.46$ $267.60 000

31525 7.34$ $440.40 4.57$ $274.20 000

31526 4.49$ $269.40 4.49$ $269.40 000

31527 5.52$ $331.20 5.52$ $331.20 000

31528 4.13$ $247.80 4.13$ $247.80 000

31529 4.61$ $276.60 4.61$ $276.60 000

31530 5.63$ $337.80 5.63$ $337.80 000

31531 6.06$ $363.60 6.06$ $363.60 000

31535 5.40$ $324.00 5.40$ $324.00 000

31536 6.01$ $360.60 6.01$ $360.60 000

31540 6.88$ $412.80 6.88$ $412.80 000

31541 7.52$ $451.20 7.52$ $451.20 000

31545 10.31$ $618.60 10.31$ $618.60 000

31546 15.64$ $938.40 15.64$ $938.40 000

31560 8.91$ $534.60 8.91$ $534.60 000

31561 9.75$ $585.00 9.75$ $585.00 000

31570 9.78$ $586.80 6.53$ $391.80 000

31571 7.12$ $427.20 7.12$ $427.20 000

31575 3.32$ $199.20 2.20$ $132.00 000

31576 6.54$ $392.40 3.53$ $211.80 000

31577 7.01$ $420.60 4.26$ $255.60 000



Page | 52

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

31578 8.09$ $485.40 4.90$ $294.00 000

31579 6.09$ $365.40 4.02$ $241.20 000

31580 35.19$ $2,111.40 35.19$ $2,111.40 090

31582 54.56$ $3,273.60 54.56$ $3,273.60 090

31584 43.23$ $2,593.80 43.23$ $2,593.80 090

31587 28.44$ $1,706.40 28.44$ $1,706.40 090

31588 32.67$ $1,960.20 32.67$ $1,960.20 090

31590 26.12$ $1,567.20 26.12$ $1,567.20 090

31595 22.07$ $1,324.20 22.07$ $1,324.20 090


31600 11.03$ $661.80 11.03$ $661.80 000

31601 7.23$ $433.80 7.23$ $433.80 000

31603 6.23$ $373.80 6.23$ $373.80 000

31605 5.07$ $304.20 5.07$ $304.20 000

31610 20.47$ $1,228.20 20.47$ $1,228.20 090

31611 15.62$ $937.20 15.62$ $937.20 090

31612 2.42$ $145.20 1.36$ $81.60 000

31613 13.15$ $789.00 13.15$ $789.00 090

31614 21.79$ $1,307.40 21.79$ $1,307.40 090

31615 5.25$ $315.00 3.66$ $219.60 000

31622 8.85$ $531.00 4.08$ $244.80 000

31623 9.68$ $580.80 4.18$ $250.80 000

31624 9.15$ $549.00 4.22$ $253.20 000

31625 11.58$ $694.80 4.81$ $288.60 000

31626 26.89$ $1,613.40 5.97$ $358.20 000

31627 42.26$ $2,535.60 2.75$ $165.00 ZZZ

31628 12.20$ $732.00 5.38$ $322.80 000

31629 14.57$ $874.20 5.67$ $340.20 000

31630 5.65$ $339.00 5.65$ $339.00 000

31631 6.47$ $388.20 6.47$ $388.20 000

31632 2.15$ $129.00 1.40$ $84.00 ZZZ

31633 2.65$ $159.00 1.81$ $108.60 ZZZ

31634 55.44$ $3,326.40 5.82$ $349.20 000

31635 10.10$ $606.00 5.34$ $320.40 000

31636 6.25$ $375.00 6.25$ $375.00 000

31637 2.12$ $127.20 2.12$ $127.20 ZZZ

31638 7.13$ $427.80 7.13$ $427.80 000

31640 7.18$ $430.80 7.18$ $430.80 000

31641 7.31$ $438.60 7.31$ $438.60 000

31643 5.04$ $302.40 5.04$ $302.40 000

31645 9.43$ $565.80 4.60$ $276.00 000

31646 8.47$ $508.20 3.98$ $238.80 000



Page | 53

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

31647 6.30$ $378.00 6.30$ $378.00 000

31648 5.83$ $349.80 5.83$ $349.80 000

31649 1.97$ $118.20 1.97$ $118.20 ZZZ

31651 2.22$ $133.20 2.22$ $133.20 ZZZ

31652 26.70$ $1,602.00 6.66$ $399.60 XXX

31653 28.36$ $1,701.60 7.34$ $440.40 XXX

31654 4.19$ $251.40 1.92$ $115.20 XXX

31660 6.00$ $360.00 6.00$ $360.00 000

31661 6.30$ $378.00 6.30$ $378.00 000

31717 7.65$ $459.00 3.10$ $186.00 000

31720 1.46$ $87.60 1.46$ $87.60 000

31725 2.53$ $151.80 2.53$ $151.80 000

31730 36.59$ $2,195.40 4.10$ $246.00 000

31750 40.79$ $2,447.40 40.79$ $2,447.40 090

31755 51.50$ $3,090.00 51.50$ $3,090.00 090

31760 38.32$ $2,299.20 38.32$ $2,299.20 090

31766 48.91$ $2,934.60 48.91$ $2,934.60 090

31770 36.74$ $2,204.40 36.74$ $2,204.40 090

31775 37.12$ $2,227.20 37.12$ $2,227.20 090

31780 33.10$ $1,986.00 33.10$ $1,986.00 090

31781 40.84$ $2,450.40 40.84$ $2,450.40 090

31785 30.61$ $1,836.60 30.61$ $1,836.60 090

31786 39.54$ $2,372.40 39.54$ $2,372.40 090

31800 21.29$ $1,277.40 21.29$ $1,277.40 090

31805 22.86$ $1,371.60 22.86$ $1,371.60 090

31820 12.56$ $753.60 9.37$ $562.20 090

31825 17.28$ $1,036.80 13.66$ $819.60 090

31830 12.81$ $768.60 9.80$ $588.00 090


32035 19.98$ $1,198.80 19.98$ $1,198.80 090

32036 21.56$ $1,293.60 21.56$ $1,293.60 090

32096 22.21$ $1,332.60 22.21$ $1,332.60 090

32097 22.21$ $1,332.60 22.21$ $1,332.60 090

32098 21.08$ $1,264.80 21.08$ $1,264.80 090

32100 22.31$ $1,338.60 22.31$ $1,338.60 090

32110 40.28$ $2,416.80 40.28$ $2,416.80 090

32120 24.09$ $1,445.40 24.09$ $1,445.40 090

32124 25.59$ $1,535.40 25.59$ $1,535.40 090

32140 27.49$ $1,649.40 27.49$ $1,649.40 090

32141 41.89$ $2,513.40 41.89$ $2,513.40 090

32150 27.75$ $1,665.00 27.75$ $1,665.00 090

32151 27.75$ $1,665.00 27.75$ $1,665.00 090



Page | 54

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

32160 21.87$ $1,312.20 21.87$ $1,312.20 090

32200 31.50$ $1,890.00 31.50$ $1,890.00 090

32215 22.19$ $1,331.40 22.19$ $1,331.40 090

32220 43.75$ $2,625.00 43.75$ $2,625.00 090

32225 27.47$ $1,648.20 27.47$ $1,648.20 090

32310 25.23$ $1,513.80 25.23$ $1,513.80 090

32320 44.09$ $2,645.40 44.09$ $2,645.40 090

32400 4.39$ $263.40 2.49$ $149.40 000

32405 13.34$ $800.40 2.98$ $178.80 000

32440 43.11$ $2,586.60 43.11$ $2,586.60 090

32442 87.78$ $5,266.80 87.78$ $5,266.80 090

32445 97.49$ $5,849.40 97.49$ $5,849.40 090

32480 40.67$ $2,440.20 40.67$ $2,440.20 090

32482 43.60$ $2,616.00 43.60$ $2,616.00 090

32484 39.49$ $2,369.40 39.49$ $2,369.40 090

32486 64.43$ $3,865.80 64.43$ $3,865.80 090

32488 65.74$ $3,944.40 65.74$ $3,944.40 090

32491 40.61$ $2,436.60 40.61$ $2,436.60 090

32501 6.69$ $401.40 6.69$ $401.40 ZZZ

32503 49.71$ $2,982.60 49.71$ $2,982.60 090

32504 56.68$ $3,400.80 56.68$ $3,400.80 090

32505 25.74$ $1,544.40 25.74$ $1,544.40 090

32506 4.28$ $256.80 4.28$ $256.80 ZZZ

32507 4.28$ $256.80 4.28$ $256.80 ZZZ

32540 47.76$ $2,865.60 47.76$ $2,865.60 090

32550 22.96$ $1,377.60 6.23$ $373.80 000

32551 4.73$ $283.80 4.73$ $283.80 000

32552 5.27$ $316.20 4.52$ $271.20 010

32553 17.43$ $1,045.80 5.56$ $333.60 000

32554 5.83$ $349.80 2.54$ $152.40 000

32555 8.49$ $509.40 3.21$ $192.60 000

32556 15.99$ $959.40 3.51$ $210.60 000

32557 15.20$ $912.00 4.38$ $262.80 000

32560 7.14$ $428.40 2.17$ $130.20 000

32561 2.64$ $158.40 1.93$ $115.80 000

32562 2.37$ $142.20 1.73$ $103.80 000

32601 8.50$ $510.00 8.50$ $510.00 000

32604 13.22$ $793.20 13.22$ $793.20 000

32606 12.69$ $761.40 12.69$ $761.40 000

32607 8.50$ $510.00 8.50$ $510.00 000

32608 10.41$ $624.60 10.41$ $624.60 000

32609 7.16$ $429.60 7.16$ $429.60 000



Page | 55

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

32650 18.47$ $1,108.20 18.47$ $1,108.20 090

32651 30.22$ $1,813.20 30.22$ $1,813.20 090

32652 45.73$ $2,743.80 45.73$ $2,743.80 090

32653 29.22$ $1,753.20 29.22$ $1,753.20 090

32654 32.56$ $1,953.60 32.56$ $1,953.60 090

32655 26.40$ $1,584.00 26.40$ $1,584.00 090

32656 22.22$ $1,333.20 22.22$ $1,333.20 090

32658 19.75$ $1,185.00 19.75$ $1,185.00 090

32659 20.27$ $1,216.20 20.27$ $1,216.20 090

32661 22.11$ $1,326.60 22.11$ $1,326.60 090

32662 24.66$ $1,479.60 24.66$ $1,479.60 090

32663 38.55$ $2,313.00 38.55$ $2,313.00 090

32664 23.55$ $1,413.00 23.55$ $1,413.00 090

32665 33.75$ $2,025.00 33.75$ $2,025.00 090

32666 24.09$ $1,445.40 24.09$ $1,445.40 090

32667 4.29$ $257.40 4.29$ $257.40 ZZZ

32668 4.28$ $256.80 4.28$ $256.80 ZZZ

32669 37.05$ $2,223.00 37.05$ $2,223.00 090

32670 44.02$ $2,641.20 44.02$ $2,641.20 090

32671 48.65$ $2,919.00 48.65$ $2,919.00 090

32672 41.88$ $2,512.80 41.88$ $2,512.80 090

32673 33.60$ $2,016.00 33.60$ $2,016.00 090

32674 5.89$ $353.40 5.89$ $353.40 ZZZ

32701 5.94$ $356.40 5.94$ $356.40 XXX

32800 26.10$ $1,566.00 26.10$ $1,566.00 090

32810 24.90$ $1,494.00 24.90$ $1,494.00 090

32815 76.92$ $4,615.20 76.92$ $4,615.20 090

32820 36.88$ $2,212.80 36.88$ $2,212.80 090

32850 By Report By Report XXX

32851 90.32$ $5,419.20 90.32$ $5,419.20 090

32852 98.68$ $5,920.80 98.68$ $5,920.80 090

32853 125.65$ $7,539.00 125.65$ $7,539.00 090

32854 133.62$ $8,017.20 133.62$ $8,017.20 090



32900 38.82$ $2,329.20 38.82$ $2,329.20 090

32905 36.91$ $2,214.60 36.91$ $2,214.60 090

32906 45.52$ $2,731.20 45.52$ $2,731.20 090

32940 33.94$ $2,036.40 33.94$ $2,036.40 090

32960 3.99$ $239.40 2.77$ $166.20 000

32997 9.78$ $586.80 9.78$ $586.80 000

32998 71.34$ $4,280.40 8.14$ $488.40 000



Page | 56

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


33010 3.30$ $198.00 3.30$ $198.00 000

33011 3.31$ $198.60 3.31$ $198.60 000

33015 14.20$ $852.00 14.20$ $852.00 090

33020 24.29$ $1,457.40 24.29$ $1,457.40 090

33025 22.03$ $1,321.80 22.03$ $1,321.80 090

33030 55.00$ $3,300.00 55.00$ $3,300.00 090

33031 67.89$ $4,073.40 67.89$ $4,073.40 090

33050 27.62$ $1,657.20 27.62$ $1,657.20 090

33120 57.58$ $3,454.80 57.58$ $3,454.80 090

33130 38.02$ $2,281.20 38.02$ $2,281.20 090

33140 43.09$ $2,585.40 43.09$ $2,585.40 090

33141 3.60$ $216.00 3.60$ $216.00 ZZZ

33202 21.39$ $1,283.40 21.39$ $1,283.40 090

33203 22.18$ $1,330.80 22.18$ $1,330.80 090

33206 12.81$ $768.60 12.81$ $768.60 090

33207 13.62$ $817.20 13.62$ $817.20 090

33208 14.74$ $884.40 14.74$ $884.40 090

33210 4.91$ $294.60 4.91$ $294.60 000

33211 5.02$ $301.20 5.02$ $301.20 000

33212 9.26$ $555.60 9.26$ $555.60 090

33213 9.65$ $579.00 9.65$ $579.00 090

33214 13.59$ $815.40 13.59$ $815.40 090

33215 8.59$ $515.40 8.59$ $515.40 090

33216 10.65$ $639.00 10.65$ $639.00 090

33217 10.44$ $626.40 10.44$ $626.40 090

33218 11.16$ $669.60 11.16$ $669.60 090

33220 11.17$ $670.20 11.17$ $670.20 090

33221 10.36$ $621.60 10.36$ $621.60 090

33222 9.75$ $585.00 9.75$ $585.00 090

33223 11.67$ $700.20 11.67$ $700.20 090

33224 14.15$ $849.00 14.15$ $849.00 000

33225 12.84$ $770.40 12.84$ $770.40 ZZZ

33226 13.58$ $814.80 13.58$ $814.80 000

33227 9.73$ $583.80 9.73$ $583.80 090

33228 10.15$ $609.00 10.15$ $609.00 090

33229 10.70$ $642.00 10.70$ $642.00 090

33230 10.99$ $659.40 10.99$ $659.40 090

33231 11.44$ $686.40 11.44$ $686.40 090

33233 6.80$ $408.00 6.80$ $408.00 090

33234 13.76$ $825.60 13.76$ $825.60 090

33235 17.97$ $1,078.20 17.97$ $1,078.20 090



Page | 57

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

33236 21.68$ $1,300.80 21.68$ $1,300.80 090

33237 23.30$ $1,398.00 23.30$ $1,398.00 090

33238 25.87$ $1,552.20 25.87$ $1,552.20 090

33240 10.48$ $628.80 10.48$ $628.80 090

33241 6.38$ $382.80 6.38$ $382.80 090

33243 37.73$ $2,263.80 37.73$ $2,263.80 090

33244 24.07$ $1,444.20 24.07$ $1,444.20 090

33249 25.64$ $1,538.40 25.64$ $1,538.40 090

33250 40.25$ $2,415.00 40.25$ $2,415.00 090

33251 44.73$ $2,683.80 44.73$ $2,683.80 090

33254 37.79$ $2,267.40 37.79$ $2,267.40 090

33255 44.66$ $2,679.60 44.66$ $2,679.60 090

33256 53.67$ $3,220.20 53.67$ $3,220.20 090

33257 16.15$ $969.00 16.15$ $969.00 ZZZ

33258 18.12$ $1,087.20 18.12$ $1,087.20 ZZZ

33259 23.39$ $1,403.40 23.39$ $1,403.40 ZZZ

33261 45.11$ $2,706.60 45.11$ $2,706.60 090

33262 10.69$ $641.40 10.69$ $641.40 090

33263 11.10$ $666.00 11.10$ $666.00 090

33264 11.57$ $694.20 11.57$ $694.20 090

33265 37.56$ $2,253.60 37.56$ $2,253.60 090

33266 50.78$ $3,046.80 50.78$ $3,046.80 090

33270 16.43$ $985.80 16.43$ $985.80 XXX

33271 13.86$ $831.60 13.86$ $831.60 XXX

33272 9.75$ $585.00 9.75$ $585.00 XXX

33273 11.46$ $687.60 11.46$ $687.60 XXX

33282 6.67$ $400.20 6.67$ $400.20 090

33284 5.91$ $354.60 5.91$ $354.60 090

33300 67.19$ $4,031.40 67.19$ $4,031.40 090

33305 112.28$ $6,736.80 112.28$ $6,736.80 090

33310 32.37$ $1,942.20 32.37$ $1,942.20 090

33315 52.52$ $3,151.20 52.52$ $3,151.20 090

33320 29.29$ $1,757.40 29.29$ $1,757.40 090

33321 33.91$ $2,034.60 33.91$ $2,034.60 090

33322 38.27$ $2,296.20 38.27$ $2,296.20 090

33335 51.60$ $3,096.00 51.60$ $3,096.00 090

33361 37.24$ $2,234.40 37.24$ $2,234.40 000

33362 40.66$ $2,439.60 40.66$ $2,439.60 000

33363 42.29$ $2,537.40 42.29$ $2,537.40 000

33364 44.28$ $2,656.80 44.28$ $2,656.80 000

33365 48.75$ $2,925.00 48.75$ $2,925.00 000

33366 52.71$ $3,162.60 52.71$ $3,162.60 XXX



Page | 58

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

33367 17.13$ $1,027.80 17.13$ $1,027.80 ZZZ

33368 20.37$ $1,222.20 20.37$ $1,222.20 ZZZ

33369 26.92$ $1,615.20 26.92$ $1,615.20 ZZZ

33400 62.63$ $3,757.80 62.63$ $3,757.80 090

33401 39.82$ $2,389.20 39.82$ $2,389.20 090

33403 40.85$ $2,451.00 40.85$ $2,451.00 090

33404 48.33$ $2,899.80 48.33$ $2,899.80 090

33405 62.38$ $3,742.80 62.38$ $3,742.80 090

33406 79.00$ $4,740.00 79.00$ $4,740.00 090

33410 69.74$ $4,184.40 69.74$ $4,184.40 090

33411 92.11$ $5,526.60 92.11$ $5,526.60 090

33412 86.73$ $5,203.80 86.73$ $5,203.80 090

33413 89.00$ $5,340.00 89.00$ $5,340.00 090

33414 59.24$ $3,554.40 59.24$ $3,554.40 090

33415 55.87$ $3,352.20 55.87$ $3,352.20 090

33416 55.88$ $3,352.80 55.88$ $3,352.80 090

33417 46.11$ $2,766.60 46.11$ $2,766.60 090

33418 49.68$ $2,980.80 49.68$ $2,980.80 XXX

33419 11.69$ $701.40 11.69$ $701.40 XXX

33420 40.10$ $2,406.00 40.10$ $2,406.00 090

33422 46.12$ $2,767.20 46.12$ $2,767.20 090

33425 75.09$ $4,505.40 75.09$ $4,505.40 090

33426 65.49$ $3,929.40 65.49$ $3,929.40 090

33427 67.15$ $4,029.00 67.15$ $4,029.00 090

33430 76.90$ $4,614.00 76.90$ $4,614.00 090

33460 66.81$ $4,008.60 66.81$ $4,008.60 090

33463 84.86$ $5,091.60 84.86$ $5,091.60 090

33464 67.16$ $4,029.60 67.16$ $4,029.60 090

33465 75.71$ $4,542.60 75.71$ $4,542.60 090

33468 67.50$ $4,050.00 67.50$ $4,050.00 090

33470 35.86$ $2,151.60 35.86$ $2,151.60 090

33471 38.35$ $2,301.00 38.35$ $2,301.00 090

33475 64.08$ $3,844.80 64.08$ $3,844.80 090

33476 42.13$ $2,527.80 42.13$ $2,527.80 090

33477 36.32$ $2,179.20 36.32$ $2,179.20 XXX

33478 43.51$ $2,610.60 43.51$ $2,610.60 090

33496 45.95$ $2,757.00 45.95$ $2,757.00 090

33500 43.28$ $2,596.80 43.28$ $2,596.80 090

33501 31.21$ $1,872.60 31.21$ $1,872.60 090

33502 35.39$ $2,123.40 35.39$ $2,123.40 090

33503 36.82$ $2,209.20 36.82$ $2,209.20 090

33504 40.59$ $2,435.40 40.59$ $2,435.40 090



Page | 59

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

33505 56.74$ $3,404.40 56.74$ $3,404.40 090

33506 56.57$ $3,394.20 56.57$ $3,394.20 090

33507 47.52$ $2,851.20 47.52$ $2,851.20 090

33508 0.44$ $26.40 0.44$ $26.40 ZZZ

33510 53.16$ $3,189.60 53.16$ $3,189.60 090

33511 58.41$ $3,504.60 58.41$ $3,504.60 090

33512 66.34$ $3,980.40 66.34$ $3,980.40 090

33513 68.24$ $4,094.40 68.24$ $4,094.40 090

33514 71.86$ $4,311.60 71.86$ $4,311.60 090

33516 74.74$ $4,484.40 74.74$ $4,484.40 090

33517 5.12$ $307.20 5.12$ $307.20 ZZZ

33518 11.26$ $675.60 11.26$ $675.60 ZZZ

33519 14.89$ $893.40 14.89$ $893.40 ZZZ

33521 17.86$ $1,071.60 17.86$ $1,071.60 ZZZ

33522 20.04$ $1,202.40 20.04$ $1,202.40 ZZZ

33523 22.80$ $1,368.00 22.80$ $1,368.00 ZZZ

33530 14.38$ $862.80 14.38$ $862.80 ZZZ

33533 51.41$ $3,084.60 51.41$ $3,084.60 090

33534 60.46$ $3,627.60 60.46$ $3,627.60 090

33535 67.40$ $4,044.00 67.40$ $4,044.00 090

33536 72.65$ $4,359.00 72.65$ $4,359.00 090

33542 72.14$ $4,328.40 72.14$ $4,328.40 090

33545 84.93$ $5,095.80 84.93$ $5,095.80 090

33548 81.41$ $4,884.60 81.41$ $4,884.60 090

33572 6.30$ $378.00 6.30$ $378.00 ZZZ

33600 47.52$ $2,851.20 47.52$ $2,851.20 090

33602 46.13$ $2,767.80 46.13$ $2,767.80 090

33606 51.65$ $3,099.00 51.65$ $3,099.00 090

33608 49.76$ $2,985.60 49.76$ $2,985.60 090

33610 49.07$ $2,944.20 49.07$ $2,944.20 090

33611 56.89$ $3,413.40 56.89$ $3,413.40 090

33612 55.24$ $3,314.40 55.24$ $3,314.40 090

33615 55.11$ $3,306.60 55.11$ $3,306.60 090

33617 59.68$ $3,580.80 59.68$ $3,580.80 090

33619 75.29$ $4,517.40 75.29$ $4,517.40 090

33620 45.51$ $2,730.60 45.51$ $2,730.60 090

33621 25.80$ $1,548.00 25.80$ $1,548.00 090

33622 100.32$ $6,019.20 100.32$ $6,019.20 090

33641 45.26$ $2,715.60 45.26$ $2,715.60 090

33645 47.75$ $2,865.00 47.75$ $2,865.00 090

33647 50.15$ $3,009.00 50.15$ $3,009.00 090

33660 48.48$ $2,908.80 48.48$ $2,908.80 090



Page | 60

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

33665 52.79$ $3,167.40 52.79$ $3,167.40 090

33670 54.31$ $3,258.60 54.31$ $3,258.60 090

33675 54.39$ $3,263.40 54.39$ $3,263.40 090

33676 59.03$ $3,541.80 59.03$ $3,541.80 090

33677 61.32$ $3,679.20 61.32$ $3,679.20 090

33681 50.88$ $3,052.80 50.88$ $3,052.80 090

33684 55.06$ $3,303.60 55.06$ $3,303.60 090

33688 51.89$ $3,113.40 51.89$ $3,113.40 090

33690 33.31$ $1,998.60 33.31$ $1,998.60 090

33692 57.14$ $3,428.40 57.14$ $3,428.40 090

33694 56.89$ $3,413.40 56.89$ $3,413.40 090

33697 56.67$ $3,400.20 56.67$ $3,400.20 090

33702 42.76$ $2,565.60 42.76$ $2,565.60 090

33710 59.84$ $3,590.40 59.84$ $3,590.40 090

33720 42.78$ $2,566.80 42.78$ $2,566.80 090

33722 44.88$ $2,692.80 44.88$ $2,692.80 090

33724 42.51$ $2,550.60 42.51$ $2,550.60 090

33726 56.06$ $3,363.60 56.06$ $3,363.60 090

33730 55.34$ $3,320.40 55.34$ $3,320.40 090

33732 45.59$ $2,735.40 45.59$ $2,735.40 090

33735 35.94$ $2,156.40 35.94$ $2,156.40 090

33736 38.96$ $2,337.60 38.96$ $2,337.60 090

33737 37.61$ $2,256.60 37.61$ $2,256.60 090

33750 34.90$ $2,094.00 34.90$ $2,094.00 090

33755 36.50$ $2,190.00 36.50$ $2,190.00 090

33762 37.21$ $2,232.60 37.21$ $2,232.60 090

33764 36.50$ $2,190.00 36.50$ $2,190.00 090

33766 36.82$ $2,209.20 36.82$ $2,209.20 090

33767 39.29$ $2,357.40 39.29$ $2,357.40 090

33768 11.42$ $685.20 11.42$ $685.20 ZZZ

33770 61.81$ $3,708.60 61.81$ $3,708.60 090

33771 63.66$ $3,819.60 63.66$ $3,819.60 090

33774 49.76$ $2,985.60 49.76$ $2,985.60 090

33775 53.87$ $3,232.20 53.87$ $3,232.20 090

33776 56.94$ $3,416.40 56.94$ $3,416.40 090

33777 55.07$ $3,304.20 55.07$ $3,304.20 090

33778 68.45$ $4,107.00 68.45$ $4,107.00 090

33779 67.95$ $4,077.00 67.95$ $4,077.00 090

33780 65.20$ $3,912.00 65.20$ $3,912.00 090

33781 67.60$ $4,056.00 67.60$ $4,056.00 090

33782 88.84$ $5,330.40 88.84$ $5,330.40 090

33783 101.97$ $6,118.20 101.97$ $6,118.20 090



Page | 61

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

33786 62.67$ $3,760.20 62.67$ $3,760.20 090

33788 44.57$ $2,674.20 44.57$ $2,674.20 090

33800 27.34$ $1,640.40 27.34$ $1,640.40 090

33802 30.09$ $1,805.40 30.09$ $1,805.40 090

33803 31.81$ $1,908.60 31.81$ $1,908.60 090

33813 35.90$ $2,154.00 35.90$ $2,154.00 090

33814 42.18$ $2,530.80 42.18$ $2,530.80 090

33820 26.87$ $1,612.20 26.87$ $1,612.20 090

33822 29.62$ $1,777.20 29.62$ $1,777.20 090

33824 32.70$ $1,962.00 32.70$ $1,962.00 090

33840 34.34$ $2,060.40 34.34$ $2,060.40 090

33845 36.98$ $2,218.80 36.98$ $2,218.80 090

33851 35.25$ $2,115.00 35.25$ $2,115.00 090

33852 38.71$ $2,322.60 38.71$ $2,322.60 090

33853 50.66$ $3,039.60 50.66$ $3,039.60 090

33860 88.16$ $5,289.60 88.16$ $5,289.60 090

33863 86.39$ $5,183.40 86.39$ $5,183.40 090

33864 88.30$ $5,298.00 88.30$ $5,298.00 090

33870 69.21$ $4,152.60 69.21$ $4,152.60 090

33875 75.49$ $4,529.40 75.49$ $4,529.40 090

33877 99.83$ $5,989.80 99.83$ $5,989.80 090

33880 49.80$ $2,988.00 49.80$ $2,988.00 090

33881 42.80$ $2,568.00 42.80$ $2,568.00 090

33883 31.10$ $1,866.00 31.10$ $1,866.00 090

33884 11.28$ $676.80 11.28$ $676.80 ZZZ

33886 26.83$ $1,609.80 26.83$ $1,609.80 090

33889 21.67$ $1,300.20 21.67$ $1,300.20 000

33891 26.57$ $1,594.20 26.57$ $1,594.20 000

33910 72.29$ $4,337.40 72.29$ $4,337.40 090

33915 34.86$ $2,091.60 34.86$ $2,091.60 090

33916 115.23$ $6,913.80 115.23$ $6,913.80 090

33917 40.36$ $2,421.60 40.36$ $2,421.60 090

33920 52.69$ $3,161.40 52.69$ $3,161.40 090

33922 38.45$ $2,307.00 38.45$ $2,307.00 090

33924 7.83$ $469.80 7.83$ $469.80 ZZZ

33925 47.37$ $2,842.20 47.37$ $2,842.20 090

33926 70.58$ $4,234.80 70.58$ $4,234.80 090



33935 137.77$ $8,266.20 137.77$ $8,266.20 090





Page | 62

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

33945 133.27$ $7,996.20 133.27$ $7,996.20 090

33946 8.48$ $508.80 8.48$ $508.80 XXX

33947 9.37$ $562.20 9.37$ $562.20 XXX

33948 6.72$ $403.20 6.72$ $403.20 XXX

33949 6.54$ $392.40 6.54$ $392.40 XXX

33951 11.75$ $705.00 11.75$ $705.00 XXX

33952 11.75$ $705.00 11.75$ $705.00 XXX

33953 13.12$ $787.20 13.12$ $787.20 XXX

33954 13.14$ $788.40 13.14$ $788.40 XXX

33955 23.73$ $1,423.80 23.73$ $1,423.80 XXX

33956 22.95$ $1,377.00 22.95$ $1,377.00 XXX

33957 5.28$ $316.80 5.28$ $316.80 XXX

33958 5.17$ $310.20 5.17$ $310.20 XXX

33959 6.70$ $402.00 6.70$ $402.00 XXX

33962 6.58$ $394.80 6.58$ $394.80 XXX

33963 13.39$ $803.40 13.39$ $803.40 XXX

33964 13.87$ $832.20 13.87$ $832.20 XXX

33965 5.28$ $316.80 5.28$ $316.80 XXX

33966 6.47$ $388.20 6.47$ $388.20 XXX

33967 7.11$ $426.60 7.11$ $426.60 000

33968 0.93$ $55.80 0.93$ $55.80 000

33969 7.80$ $468.00 7.80$ $468.00 XXX

33970 9.72$ $583.20 9.72$ $583.20 000

33971 19.70$ $1,182.00 19.70$ $1,182.00 090

33973 14.11$ $846.60 14.11$ $846.60 000

33974 24.68$ $1,480.80 24.68$ $1,480.80 090

33975 36.08$ $2,164.80 36.08$ $2,164.80 XXX

33976 43.86$ $2,631.60 43.86$ $2,631.60 XXX

33977 31.03$ $1,861.80 31.03$ $1,861.80 XXX

33978 36.67$ $2,200.20 36.67$ $2,200.20 XXX

33979 53.44$ $3,206.40 53.44$ $3,206.40 XXX

33980 49.01$ $2,940.60 49.01$ $2,940.60 XXX

33981 22.83$ $1,369.80 22.83$ $1,369.80 XXX

33982 54.37$ $3,262.20 54.37$ $3,262.20 XXX

33983 63.44$ $3,806.40 63.44$ $3,806.40 XXX

33984 7.83$ $469.80 7.83$ $469.80 XXX

33985 14.71$ $882.60 14.71$ $882.60 XXX

33986 14.60$ $876.00 14.60$ $876.00 XXX

33987 5.71$ $342.60 5.71$ $342.60 XXX

33988 21.30$ $1,278.00 21.30$ $1,278.00 XXX

33989 13.84$ $830.40 13.84$ $830.40 XXX

33990 12.05$ $723.00 12.05$ $723.00 XXX



Page | 63

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

33991 17.55$ $1,053.00 17.55$ $1,053.00 XXX

33992 5.67$ $340.20 5.67$ $340.20 XXX

33993 4.99$ $299.40 4.99$ $299.40 XXX


34001 27.09$ $1,625.40 27.09$ $1,625.40 090

34051 27.40$ $1,644.00 27.40$ $1,644.00 090

34101 16.79$ $1,007.40 16.79$ $1,007.40 090

34111 16.75$ $1,005.00 16.75$ $1,005.00 090

34151 38.91$ $2,334.60 38.91$ $2,334.60 090

34201 28.69$ $1,721.40 28.69$ $1,721.40 090

34203 26.63$ $1,597.80 26.63$ $1,597.80 090

34401 40.46$ $2,427.60 40.46$ $2,427.60 090

34421 20.40$ $1,224.00 20.40$ $1,224.00 090

34451 40.06$ $2,403.60 40.06$ $2,403.60 090

34471 29.89$ $1,793.40 29.89$ $1,793.40 090

34490 17.02$ $1,021.20 17.02$ $1,021.20 090

34501 27.29$ $1,637.40 27.29$ $1,637.40 090

34502 42.65$ $2,559.00 42.65$ $2,559.00 090

34510 33.15$ $1,989.00 33.15$ $1,989.00 090

34520 27.86$ $1,671.60 27.86$ $1,671.60 090

34530 30.73$ $1,843.80 30.73$ $1,843.80 090

34800 31.45$ $1,887.00 31.45$ $1,887.00 090

34802 34.73$ $2,083.80 34.73$ $2,083.80 090

34803 35.85$ $2,151.00 35.85$ $2,151.00 090

34804 34.66$ $2,079.60 34.66$ $2,079.60 090

34805 33.12$ $1,987.20 33.12$ $1,987.20 090

34806 2.76$ $165.60 2.76$ $165.60 ZZZ

34808 5.70$ $342.00 5.70$ $342.00 ZZZ

34812 9.31$ $558.60 9.31$ $558.60 000

34813 6.52$ $391.20 6.52$ $391.20 ZZZ

34820 13.58$ $814.80 13.58$ $814.80 000

34825 19.48$ $1,168.80 19.48$ $1,168.80 090

34826 5.68$ $340.80 5.68$ $340.80 ZZZ

34830 48.91$ $2,934.60 48.91$ $2,934.60 090

34831 52.48$ $3,148.80 52.48$ $3,148.80 090

34832 52.37$ $3,142.20 52.37$ $3,142.20 090

34833 16.83$ $1,009.80 16.83$ $1,009.80 000

34834 7.56$ $453.60 7.56$ $453.60 000







Page | 64

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL






34900 24.99$ $1,499.40 24.99$ $1,499.40 090

35001 31.22$ $1,873.20 31.22$ $1,873.20 090

35002 31.46$ $1,887.60 31.46$ $1,887.60 090

35005 30.69$ $1,841.40 30.69$ $1,841.40 090

35011 27.93$ $1,675.80 27.93$ $1,675.80 090

35013 34.94$ $2,096.40 34.94$ $2,096.40 090

35021 34.76$ $2,085.60 34.76$ $2,085.60 090

35022 39.14$ $2,348.40 39.14$ $2,348.40 090

35045 27.76$ $1,665.60 27.76$ $1,665.60 090

35081 48.54$ $2,912.40 48.54$ $2,912.40 090

35082 60.96$ $3,657.60 60.96$ $3,657.60 090

35091 49.66$ $2,979.60 49.66$ $2,979.60 090

35092 72.09$ $4,325.40 72.09$ $4,325.40 090

35102 52.49$ $3,149.40 52.49$ $3,149.40 090

35103 62.32$ $3,739.20 62.32$ $3,739.20 090

35111 42.55$ $2,553.00 42.55$ $2,553.00 090

35112 51.42$ $3,085.20 51.42$ $3,085.20 090

35121 45.61$ $2,736.60 45.61$ $2,736.60 090

35122 59.82$ $3,589.20 59.82$ $3,589.20 090

35131 38.64$ $2,318.40 38.64$ $2,318.40 090

35132 45.22$ $2,713.20 45.22$ $2,713.20 090

35141 30.81$ $1,848.60 30.81$ $1,848.60 090

35142 36.82$ $2,209.20 36.82$ $2,209.20 090

35151 34.58$ $2,074.80 34.58$ $2,074.80 090

35152 38.79$ $2,327.40 38.79$ $2,327.40 090

35180 26.63$ $1,597.80 26.63$ $1,597.80 090

35182 49.37$ $2,962.20 49.37$ $2,962.20 090

35184 29.04$ $1,742.40 29.04$ $1,742.40 090

35188 33.06$ $1,983.60 33.06$ $1,983.60 090

35189 42.51$ $2,550.60 42.51$ $2,550.60 090

35190 21.26$ $1,275.60 21.26$ $1,275.60 090

35201 26.54$ $1,592.40 26.54$ $1,592.40 090

35206 21.68$ $1,300.80 21.68$ $1,300.80 090

35207 21.44$ $1,286.40 21.44$ $1,286.40 090

35211 38.14$ $2,288.40 38.14$ $2,288.40 090

35216 56.67$ $3,400.20 56.67$ $3,400.20 090

35221 40.33$ $2,419.80 40.33$ $2,419.80 090



Page | 65

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

35226 23.21$ $1,392.60 23.21$ $1,392.60 090

35231 34.40$ $2,064.00 34.40$ $2,064.00 090

35236 27.36$ $1,641.60 27.36$ $1,641.60 090

35241 38.94$ $2,336.40 38.94$ $2,336.40 090

35246 43.61$ $2,616.60 43.61$ $2,616.60 090

35251 47.09$ $2,825.40 47.09$ $2,825.40 090

35256 28.38$ $1,702.80 28.38$ $1,702.80 090

35261 29.52$ $1,771.20 29.52$ $1,771.20 090

35266 24.30$ $1,458.00 24.30$ $1,458.00 090

35271 38.05$ $2,283.00 38.05$ $2,283.00 090

35276 40.21$ $2,412.60 40.21$ $2,412.60 090

35281 44.94$ $2,696.40 44.94$ $2,696.40 090

35286 26.10$ $1,566.00 26.10$ $1,566.00 090

35301 31.53$ $1,891.80 31.53$ $1,891.80 090

35302 31.36$ $1,881.60 31.36$ $1,881.60 090

35303 34.70$ $2,082.00 34.70$ $2,082.00 090

35304 35.75$ $2,145.00 35.75$ $2,145.00 090

35305 34.23$ $2,053.80 34.23$ $2,053.80 090

35306 12.64$ $758.40 12.64$ $758.40 ZZZ

35311 40.28$ $2,416.80 40.28$ $2,416.80 090

35321 24.81$ $1,488.60 24.81$ $1,488.60 090

35331 40.33$ $2,419.80 40.33$ $2,419.80 090

35341 38.02$ $2,281.20 38.02$ $2,281.20 090

35351 35.61$ $2,136.60 35.61$ $2,136.60 090

35355 28.83$ $1,729.80 28.83$ $1,729.80 090

35361 42.61$ $2,556.60 42.61$ $2,556.60 090

35363 48.66$ $2,919.60 48.66$ $2,919.60 090

35371 22.86$ $1,371.60 22.86$ $1,371.60 090

35372 27.36$ $1,641.60 27.36$ $1,641.60 090

35390 4.40$ $264.00 4.40$ $264.00 ZZZ

35400 4.11$ $246.60 4.11$ $246.60 ZZZ

35450 13.96$ $837.60 13.96$ $837.60 000

35452 9.42$ $565.20 9.42$ $565.20 000

35458 13.64$ $818.40 13.64$ $818.40 000

35460 8.70$ $522.00 8.70$ $522.00 000

35471 75.35$ $4,521.00 14.55$ $873.00 000

35472 54.29$ $3,257.40 9.86$ $591.60 000

35475 46.11$ $2,766.60 9.45$ $567.00 000

35476 42.39$ $2,543.40 7.66$ $459.60 000

35500 8.80$ $528.00 8.80$ $528.00 ZZZ

35501 41.49$ $2,489.40 41.49$ $2,489.40 090

35506 35.29$ $2,117.40 35.29$ $2,117.40 090



Page | 66

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

35508 37.53$ $2,251.80 37.53$ $2,251.80 090

35509 39.11$ $2,346.60 39.11$ $2,346.60 090

35510 34.08$ $2,044.80 34.08$ $2,044.80 090

35511 31.04$ $1,862.40 31.04$ $1,862.40 090

35512 33.81$ $2,028.60 33.81$ $2,028.60 090

35515 41.49$ $2,489.40 41.49$ $2,489.40 090

35516 33.81$ $2,028.60 33.81$ $2,028.60 090

35518 32.14$ $1,928.40 32.14$ $1,928.40 090

35521 34.27$ $2,056.20 34.27$ $2,056.20 090

35522 33.65$ $2,019.00 33.65$ $2,019.00 090

35523 35.84$ $2,150.40 35.84$ $2,150.40 090

35525 31.92$ $1,915.20 31.92$ $1,915.20 090

35526 47.34$ $2,840.40 47.34$ $2,840.40 090

35531 56.22$ $3,373.20 56.22$ $3,373.20 090

35533 41.56$ $2,493.60 41.56$ $2,493.60 090

35535 53.00$ $3,180.00 53.00$ $3,180.00 090

35536 46.76$ $2,805.60 46.76$ $2,805.60 090

35537 60.83$ $3,649.80 60.83$ $3,649.80 090

35538 65.02$ $3,901.20 65.02$ $3,901.20 090

35539 60.88$ $3,652.80 60.88$ $3,652.80 090

35540 67.84$ $4,070.40 67.84$ $4,070.40 090

35556 39.07$ $2,344.20 39.07$ $2,344.20 090

35558 34.46$ $2,067.60 34.46$ $2,067.60 090

35560 47.63$ $2,857.80 47.63$ $2,857.80 090

35563 37.01$ $2,220.60 37.01$ $2,220.60 090

35565 36.91$ $2,214.60 36.91$ $2,214.60 090

35566 46.54$ $2,792.40 46.54$ $2,792.40 090

35570 42.31$ $2,538.60 42.31$ $2,538.60 090

35571 37.07$ $2,224.20 37.07$ $2,224.20 090

35572 9.55$ $573.00 9.55$ $573.00 ZZZ

35583 40.36$ $2,421.60 40.36$ $2,421.60 090

35585 46.77$ $2,806.20 46.77$ $2,806.20 090

35587 38.08$ $2,284.80 38.08$ $2,284.80 090

35600 7.00$ $420.00 7.00$ $420.00 ZZZ

35601 39.04$ $2,342.40 39.04$ $2,342.40 090

35606 32.71$ $1,962.60 32.71$ $1,962.60 090

35612 29.87$ $1,792.20 29.87$ $1,792.20 090

35616 30.56$ $1,833.60 30.56$ $1,833.60 090

35621 30.62$ $1,837.20 30.62$ $1,837.20 090

35623 36.44$ $2,186.40 36.44$ $2,186.40 090

35626 43.79$ $2,627.40 43.79$ $2,627.40 090

35631 51.42$ $3,085.20 51.42$ $3,085.20 090



Page | 67

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

35632 50.00$ $3,000.00 50.00$ $3,000.00 090

35633 55.75$ $3,345.00 55.75$ $3,345.00 090

35634 48.97$ $2,938.20 48.97$ $2,938.20 090

35636 44.35$ $2,661.00 44.35$ $2,661.00 090

35637 48.11$ $2,886.60 48.11$ $2,886.60 090

35638 49.10$ $2,946.00 49.10$ $2,946.00 090

35642 27.42$ $1,645.20 27.42$ $1,645.20 090

35645 28.41$ $1,704.60 28.41$ $1,704.60 090

35646 47.85$ $2,871.00 47.85$ $2,871.00 090

35647 43.37$ $2,602.20 43.37$ $2,602.20 090

35650 30.17$ $1,810.20 30.17$ $1,810.20 090

35654 38.18$ $2,290.80 38.18$ $2,290.80 090

35656 30.29$ $1,817.40 30.29$ $1,817.40 090

35661 30.33$ $1,819.80 30.33$ $1,819.80 090

35663 35.08$ $2,104.80 35.08$ $2,104.80 090

35665 32.75$ $1,965.00 32.75$ $1,965.00 090

35666 35.44$ $2,126.40 35.44$ $2,126.40 090

35671 31.29$ $1,877.40 31.29$ $1,877.40 090

35681 2.22$ $133.20 2.22$ $133.20 ZZZ

35682 9.77$ $586.20 9.77$ $586.20 ZZZ

35683 11.36$ $681.60 11.36$ $681.60 ZZZ

35685 5.49$ $329.40 5.49$ $329.40 ZZZ

35686 4.44$ $266.40 4.44$ $266.40 ZZZ

35691 26.76$ $1,605.60 26.76$ $1,605.60 090

35693 22.97$ $1,378.20 22.97$ $1,378.20 090

35694 27.47$ $1,648.20 27.47$ $1,648.20 090

35695 29.25$ $1,755.00 29.25$ $1,755.00 090

35697 4.07$ $244.20 4.07$ $244.20 ZZZ

35700 4.23$ $253.80 4.23$ $253.80 ZZZ

35701 16.13$ $967.80 16.13$ $967.80 090

35721 12.82$ $769.20 12.82$ $769.20 090

35741 14.52$ $871.20 14.52$ $871.20 090

35761 11.07$ $664.20 11.07$ $664.20 090

35800 20.12$ $1,207.20 20.12$ $1,207.20 090

35820 55.32$ $3,319.20 55.32$ $3,319.20 090

35840 32.98$ $1,978.80 32.98$ $1,978.80 090

35860 23.48$ $1,408.80 23.48$ $1,408.80 090

35870 34.51$ $2,070.60 34.51$ $2,070.60 090

35875 16.65$ $999.00 16.65$ $999.00 090

35876 26.38$ $1,582.80 26.38$ $1,582.80 090

35879 25.78$ $1,546.80 25.78$ $1,546.80 090

35881 28.47$ $1,708.20 28.47$ $1,708.20 090



Page | 68

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

35883 33.68$ $2,020.80 33.68$ $2,020.80 090

35884 34.33$ $2,059.80 34.33$ $2,059.80 090

35901 13.27$ $796.20 13.27$ $796.20 090

35903 15.92$ $955.20 15.92$ $955.20 090

35905 46.66$ $2,799.60 46.66$ $2,799.60 090

35907 53.09$ $3,185.40 53.09$ $3,185.40 090


36002 4.65$ $279.00 3.02$ $181.20 000

36005 9.62$ $577.20 1.36$ $81.60 000

36010 14.77$ $886.20 3.42$ $205.20 XXX

36011 24.69$ $1,481.40 4.42$ $265.20 XXX

36012 25.48$ $1,528.80 4.91$ $294.60 XXX

36013 23.33$ $1,399.80 3.54$ $212.40 XXX

36014 24.05$ $1,443.00 4.25$ $255.00 XXX

36015 25.79$ $1,547.40 4.90$ $294.00 XXX

36100 14.61$ $876.60 4.29$ $257.40 XXX

36120 12.45$ $747.00 2.79$ $167.40 XXX

36140 12.86$ $771.60 2.85$ $171.00 XXX

36147 24.78$ $1,486.80 5.26$ $315.60 XXX

36148 7.77$ $466.20 1.39$ $83.40 ZZZ

36160 14.58$ $874.80 3.51$ $210.60 XXX

36200 18.28$ $1,096.80 4.22$ $253.20 000

36215 33.24$ $1,994.40 6.61$ $396.60 XXX

36216 35.08$ $2,104.80 7.65$ $459.00 XXX

36217 58.12$ $3,487.20 9.10$ $546.00 XXX

36218 5.64$ $338.40 1.48$ $88.80 ZZZ

36221 32.36$ $1,941.60 5.95$ $357.00 000

36222 38.70$ $2,322.00 8.16$ $489.60 000

36223 45.34$ $2,720.40 8.93$ $535.80 000

36224 53.47$ $3,208.20 9.92$ $595.20 000

36225 44.33$ $2,659.80 8.81$ $528.60 000

36226 54.28$ $3,256.80 9.94$ $596.40 000

36227 7.23$ $433.80 3.14$ $188.40 ZZZ

36228 35.89$ $2,153.40 6.42$ $385.20 ZZZ

36245 40.54$ $2,432.40 7.07$ $424.20 XXX

36246 26.02$ $1,561.20 7.46$ $447.60 000

36247 46.62$ $2,797.20 8.87$ $532.20 000

36248 4.50$ $270.00 1.41$ $84.60 ZZZ

36251 42.06$ $2,523.60 7.81$ $468.60 000

36252 45.35$ $2,721.00 10.34$ $620.40 000

36253 67.38$ $4,042.80 10.73$ $643.80 000

36254 64.96$ $3,897.60 12.01$ $720.60 000



Page | 69

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

36260 17.40$ $1,044.00 17.40$ $1,044.00 090

36261 11.20$ $672.00 11.20$ $672.00 090

36262 8.60$ $516.00 8.60$ $516.00 090


36400 0.85$ $51.00 0.57$ $34.20 XXX

36405 0.76$ $45.60 0.46$ $27.60 XXX

36406 0.48$ $28.80 0.23$ $13.80 XXX

36410 0.49$ $29.40 0.27$ $16.20 XXX

36415 $3 per unit $3 per unit XXX


36420 1.47$ $88.20 1.47$ $88.20 XXX

36425 1.12$ $67.20 1.12$ $67.20 XXX

36430 1.02$ $61.20 1.02$ $61.20 XXX

36440 1.64$ $98.40 1.64$ $98.40 XXX

36450 3.29$ $197.40 3.29$ $197.40 XXX

36455 3.46$ $207.60 3.46$ $207.60 XXX

36460 9.68$ $580.80 9.68$ $580.80 XXX

36468 000

36470 4.34$ $260.40 2.39$ $143.40 010

36471 5.02$ $301.20 2.82$ $169.20 010

36475 45.40$ $2,724.00 7.78$ $466.80 000

36476 8.54$ $512.40 3.75$ $225.00 ZZZ

36478 35.49$ $2,129.40 7.76$ $465.60 000

36479 8.90$ $534.00 3.78$ $226.80 ZZZ

36481 60.63$ $3,637.80 9.99$ $599.40 000

36500 5.10$ $306.00 5.10$ $306.00 000

36510 2.62$ $157.20 1.58$ $94.80 000

36511 2.69$ $161.40 2.69$ $161.40 000

36512 2.71$ $162.60 2.71$ $162.60 000

36513 2.73$ $163.80 2.73$ $163.80 000

36514 16.01$ $960.60 2.65$ $159.00 000

36515 61.87$ $3,712.20 2.46$ $147.60 000

36516 62.31$ $3,738.60 1.89$ $113.40 000

36522 41.90$ $2,514.00 2.95$ $177.00 000

36555 7.49$ $449.40 3.35$ $201.00 000

36556 6.75$ $405.00 3.40$ $204.00 000

36557 29.44$ $1,766.40 9.15$ $549.00 010

36558 22.97$ $1,378.20 7.88$ $472.80 010

36560 39.41$ $2,364.60 10.83$ $649.80 010

36561 34.53$ $2,071.80 9.97$ $598.20 010

36563 38.93$ $2,335.80 10.60$ $636.00 010

36565 28.31$ $1,698.60 9.69$ $581.40 010

Not Covered



Page | 70

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

36566 162.89$ $9,773.40 10.76$ $645.60 010

36568 8.88$ $532.80 2.78$ $166.80 000

36569 7.36$ $441.60 2.62$ $157.20 000

36570 34.27$ $2,056.20 8.93$ $535.80 010

36571 38.44$ $2,306.40 9.06$ $543.60 010

36575 4.94$ $296.40 0.99$ $59.40 000

36576 11.23$ $673.80 5.56$ $333.60 010

36578 15.19$ $911.40 6.15$ $369.00 010

36580 6.33$ $379.80 1.90$ $114.00 000

36581 22.77$ $1,366.20 5.61$ $336.60 010

36582 32.42$ $1,945.20 8.63$ $517.80 010

36583 40.19$ $2,411.40 9.41$ $564.60 010

36584 6.05$ $363.00 1.92$ $115.20 000

36585 34.02$ $2,041.20 8.05$ $483.00 010

36589 4.70$ $282.00 3.92$ $235.20 010

36590 8.37$ $502.20 5.77$ $346.20 010

36591 0.69$ $41.40 0.69$ $41.40 XXX

36592 0.78$ $46.80 0.78$ $46.80 XXX

36593 0.92$ $55.20 0.92$ $55.20 XXX

36595 17.25$ $1,035.00 5.25$ $315.00 000

36596 3.92$ $235.20 1.28$ $76.80 000

36597 3.71$ $222.60 1.75$ $105.00 000

36598 3.25$ $195.00 1.05$ $63.00 000

36600 0.92$ $55.20 0.44$ $26.40 XXX

36620 1.44$ $86.40 1.44$ $86.40 000

36625 2.89$ $173.40 2.89$ $173.40 000

36640 3.42$ $205.20 3.42$ $205.20 000

36660 1.82$ $109.20 1.82$ $109.20 000

36680 1.62$ $97.20 1.62$ $97.20 000

36800 3.46$ $207.60 3.46$ $207.60 000

36810 6.05$ $363.00 6.05$ $363.00 000

36815 4.03$ $241.80 4.03$ $241.80 000

36818 19.40$ $1,164.00 19.40$ $1,164.00 090

36819 20.47$ $1,228.20 20.47$ $1,228.20 090

36820 20.44$ $1,226.40 20.44$ $1,226.40 090

36821 18.59$ $1,115.40 18.59$ $1,115.40 090

36823 37.27$ $2,236.20 37.27$ $2,236.20 090

36825 22.44$ $1,346.40 22.44$ $1,346.40 090

36830 18.69$ $1,121.40 18.69$ $1,121.40 090

36831 17.28$ $1,036.80 17.28$ $1,036.80 090

36832 21.22$ $1,273.20 21.22$ $1,273.20 090

36833 22.74$ $1,364.40 22.74$ $1,364.40 090



Page | 71

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

36835 13.85$ $831.00 13.85$ $831.00 090

36838 31.81$ $1,908.60 31.81$ $1,908.60 090

36860 6.08$ $364.80 3.18$ $190.80 000

36861 3.63$ $217.80 3.63$ $217.80 000

36870 54.67$ $3,280.20 8.59$ $515.40 090

37140 63.11$ $3,786.60 63.11$ $3,786.60 090

37145 59.07$ $3,544.20 59.07$ $3,544.20 090

37160 60.68$ $3,640.80 60.68$ $3,640.80 090

37180 56.86$ $3,411.60 56.86$ $3,411.60 090

37181 63.88$ $3,832.80 63.88$ $3,832.80 090

37182 23.95$ $1,437.00 23.95$ $1,437.00 000

37183 177.38$ $10,642.80 11.31$ $678.60 000

37184 67.23$ $4,033.80 12.80$ $768.00 000

37185 21.23$ $1,273.80 4.64$ $278.40 ZZZ

37186 40.78$ $2,446.80 6.92$ $415.20 ZZZ

37187 61.08$ $3,664.80 11.45$ $687.00 000

37188 52.84$ $3,170.40 8.31$ $498.60 000

37191 78.71$ $4,722.60 6.74$ $404.40 000

37192 45.65$ $2,739.00 10.26$ $615.60 000

37193 47.31$ $2,838.60 10.34$ $620.40 000


37197 44.97$ $2,698.20 8.88$ $532.80 000

37200 6.31$ $378.60 6.31$ $378.60 000

37211 11.18$ $670.80 11.18$ $670.80 000

37212 9.85$ $591.00 9.85$ $591.00 000

37213 6.97$ $418.20 6.97$ $418.20 000

37214 3.82$ $229.20 3.82$ $229.20 000

37215 27.82$ $1,669.20 27.82$ $1,669.20 090

37216 -$ $0.00 -$ $0.00 090

37217 30.46$ $1,827.60 30.46$ $1,827.60 XXX

37218 22.95$ $1,377.00 22.95$ $1,377.00 XXX

37220 93.83$ $5,629.80 11.51$ $690.60 000

37221 138.70$ $8,322.00 14.17$ $850.20 000

37222 26.10$ $1,566.00 5.17$ $310.20 ZZZ

37223 77.35$ $4,641.00 5.95$ $357.00 ZZZ

37224 114.05$ $6,843.00 12.72$ $763.20 000

37225 329.85$ $19,791.00 17.18$ $1,030.80 000

37226 271.19$ $16,271.40 14.90$ $894.00 000

37227 445.80$ $26,748.00 20.65$ $1,239.00 000

37228 162.31$ $9,738.60 15.50$ $930.00 000

37229 324.80$ $19,488.00 20.04$ $1,202.40 000

37230 247.75$ $14,865.00 19.74$ $1,184.40 000



Page | 72

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

37231 400.03$ $24,001.80 21.49$ $1,289.40 000

37232 35.88$ $2,152.80 5.63$ $337.80 ZZZ

37233 43.05$ $2,583.00 9.15$ $549.00 ZZZ

37234 115.90$ $6,954.00 7.88$ $472.80 ZZZ

37235 121.76$ $7,305.60 11.27$ $676.20 ZZZ

37236 122.73$ $7,363.80 12.72$ $763.20 XXX

37237 73.47$ $4,408.20 5.93$ $355.80 XXX

37238 125.64$ $7,538.40 8.86$ $531.60 XXX

37239 60.73$ $3,643.80 4.16$ $249.60 XXX

37241 142.66$ $8,559.60 12.70$ $762.00 XXX

37242 229.93$ $13,795.80 14.06$ $843.60 XXX

37243 292.26$ $17,535.60 16.73$ $1,003.80 XXX

37244 202.99$ $12,179.40 19.56$ $1,173.60 XXX

37252 41.77$ $2,506.20 2.54$ $152.40 XXX

37253 6.28$ $376.80 2.02$ $121.20 XXX

37500 21.33$ $1,279.80 21.33$ $1,279.80 090


37565 20.46$ $1,227.60 20.46$ $1,227.60 090

37600 19.86$ $1,191.60 19.86$ $1,191.60 090

37605 22.14$ $1,328.40 22.14$ $1,328.40 090

37606 16.29$ $977.40 16.29$ $977.40 090

37607 10.57$ $634.20 10.57$ $634.20 090

37609 8.92$ $535.20 5.86$ $351.60 010

37615 14.63$ $877.80 14.63$ $877.80 090

37616 30.48$ $1,828.80 30.48$ $1,828.80 090

37617 37.02$ $2,221.20 37.02$ $2,221.20 090

37618 10.80$ $648.00 10.80$ $648.00 090

37619 45.23$ $2,713.80 45.23$ $2,713.80 090

37650 14.21$ $852.60 14.21$ $852.60 090

37660 31.89$ $1,913.40 31.89$ $1,913.40 090

37700 7.05$ $423.00 7.05$ $423.00 090

37718 12.27$ $736.20 12.27$ $736.20 090

37722 13.42$ $805.20 13.42$ $805.20 090

37735 19.27$ $1,156.20 19.27$ $1,156.20 090

37760 17.20$ $1,032.00 17.20$ $1,032.00 090

37761 15.49$ $929.40 15.49$ $929.40 090

37765 18.67$ $1,120.20 12.65$ $759.00 090

37766 22.13$ $1,327.80 15.43$ $925.80 090

37780 7.18$ $430.80 7.18$ $430.80 090

37785 10.18$ $610.80 7.42$ $445.20 090

37788 36.54$ $2,192.40 36.54$ $2,192.40 090

37790 14.22$ $853.20 14.22$ $853.20 090



Page | 73

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


38100 31.81$ $1,908.60 31.81$ $1,908.60 090

38101 31.98$ $1,918.80 31.98$ $1,918.80 090

38102 7.19$ $431.40 7.19$ $431.40 ZZZ

38115 35.01$ $2,100.60 35.01$ $2,100.60 090

38120 29.12$ $1,747.20 29.12$ $1,747.20 090


38200 3.30$ $198.00 3.30$ $198.00 000


38205 2.38$ $142.80 2.38$ $142.80 000

38206 2.40$ $144.00 2.40$ $144.00 000

38207 1.31$ $78.60 1.31$ $78.60 XXX

38208 0.82$ $49.20 0.82$ $49.20 XXX

38209 0.35$ $21.00 0.35$ $21.00 XXX

38210 2.32$ $139.20 2.32$ $139.20 XXX

38211 2.09$ $125.40 2.09$ $125.40 XXX

38212 1.39$ $83.40 1.39$ $83.40 XXX

38213 0.35$ $21.00 0.35$ $21.00 XXX

38214 1.20$ $72.00 1.20$ $72.00 XXX

38215 1.39$ $83.40 1.39$ $83.40 XXX

38220 4.81$ $288.60 1.74$ $104.40 XXX

38221 4.91$ $294.60 2.15$ $129.00 XXX

38230 5.62$ $337.20 5.62$ $337.20 000

38232 5.60$ $336.00 5.60$ $336.00 000

38240 6.45$ $387.00 6.45$ $387.00 XXX

38241 4.84$ $290.40 4.84$ $290.40 XXX

38242 3.39$ $203.40 3.39$ $203.40 000

38243 3.38$ $202.80 3.38$ $202.80 000

38300 7.97$ $478.20 5.25$ $315.00 010

38305 13.33$ $799.80 13.33$ $799.80 090

38308 12.40$ $744.00 12.40$ $744.00 090

38380 16.27$ $976.20 16.27$ $976.20 090

38381 22.16$ $1,329.60 22.16$ $1,329.60 090

38382 17.06$ $1,023.60 17.06$ $1,023.60 090

38500 9.37$ $562.20 7.08$ $424.80 010

38505 3.71$ $222.60 2.06$ $123.60 000

38510 14.72$ $883.20 11.78$ $706.80 010

38520 12.98$ $778.80 12.98$ $778.80 090

38525 12.14$ $728.40 12.14$ $728.40 090

38530 15.35$ $921.00 15.35$ $921.00 090

38542 14.66$ $879.60 14.66$ $879.60 090

38550 14.14$ $848.40 14.14$ $848.40 090



Page | 74

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

38555 27.80$ $1,668.00 27.80$ $1,668.00 090

38562 19.63$ $1,177.80 19.63$ $1,177.80 090

38564 19.52$ $1,171.20 19.52$ $1,171.20 090

38570 14.12$ $847.20 14.12$ $847.20 010

38571 18.84$ $1,130.40 18.84$ $1,130.40 010

38572 25.87$ $1,552.20 25.87$ $1,552.20 010


38700 22.91$ $1,374.60 22.91$ $1,374.60 090

38720 38.01$ $2,280.60 38.01$ $2,280.60 090

38724 41.25$ $2,475.00 41.25$ $2,475.00 090

38740 19.24$ $1,154.40 19.24$ $1,154.40 090

38745 24.24$ $1,454.40 24.24$ $1,454.40 090

38746 5.88$ $352.80 5.88$ $352.80 ZZZ

38747 7.31$ $438.60 7.31$ $438.60 ZZZ

38760 23.34$ $1,400.40 23.34$ $1,400.40 090

38765 35.78$ $2,146.80 35.78$ $2,146.80 090

38770 22.70$ $1,362.00 22.70$ $1,362.00 090

38780 28.76$ $1,725.60 28.76$ $1,725.60 090

38790 2.35$ $141.00 2.35$ $141.00 000

38792 1.15$ $69.00 1.15$ $69.00 000

38794 8.66$ $519.60 8.66$ $519.60 090

38900 3.77$ $226.20 3.77$ $226.20 ZZZ


39000 13.92$ $835.20 13.92$ $835.20 090

39010 21.78$ $1,306.80 21.78$ $1,306.80 090

39200 24.31$ $1,458.60 24.31$ $1,458.60 090

39220 31.49$ $1,889.40 31.49$ $1,889.40 090

39401 8.56$ $513.60 8.56$ $513.60 XXX

39402 11.15$ $669.00 11.15$ $669.00 XXX


39501 23.49$ $1,409.40 23.49$ $1,409.40 090

39503 167.93$ $10,075.80 167.93$ $10,075.80 090

39540 23.91$ $1,434.60 23.91$ $1,434.60 090

39541 26.04$ $1,562.40 26.04$ $1,562.40 090

39545 24.75$ $1,485.00 24.75$ $1,485.00 090

39560 22.04$ $1,322.40 22.04$ $1,322.40 090

39561 34.33$ $2,059.80 34.33$ $2,059.80 090


40490 3.73$ $223.80 2.08$ $124.80 000

40500 14.79$ $887.40 10.55$ $633.00 090

40510 14.10$ $846.00 10.28$ $616.80 090

40520 14.25$ $855.00 10.34$ $620.40 090



Page | 75

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

40525 15.82$ $949.20 15.82$ $949.20 090

40527 17.73$ $1,063.80 17.73$ $1,063.80 090

40530 15.67$ $940.20 11.60$ $696.00 090

40650 12.92$ $775.20 8.66$ $519.60 090

40652 14.21$ $852.60 10.15$ $609.00 090

40654 16.55$ $993.00 12.24$ $734.40 090

40700 25.85$ $1,551.00 25.85$ $1,551.00 090

40701 28.89$ $1,733.40 28.89$ $1,733.40 090

40702 24.91$ $1,494.60 24.91$ $1,494.60 090

40720 29.07$ $1,744.20 29.07$ $1,744.20 090

40761 30.72$ $1,843.20 30.72$ $1,843.20 090


40800 6.38$ $382.80 3.92$ $235.20 010

40801 9.36$ $561.60 6.53$ $391.80 010

40804 5.69$ $341.40 3.45$ $207.00 010

40805 11.11$ $666.60 6.69$ $401.40 010

40806 3.45$ $207.00 0.96$ $57.60 000

40808 5.62$ $337.20 3.23$ $193.80 010

40810 6.19$ $371.40 3.78$ $226.80 010

40812 8.58$ $514.80 5.81$ $348.60 010

40814 11.42$ $685.20 9.00$ $540.00 090

40816 11.92$ $715.20 9.33$ $559.80 090

40818 10.69$ $641.40 8.09$ $485.40 090

40819 9.42$ $565.20 7.11$ $426.60 090

40820 8.01$ $480.60 5.17$ $310.20 010

40830 7.94$ $476.40 4.88$ $292.80 010

40831 10.03$ $601.80 6.61$ $396.60 010

40840 23.67$ $1,420.20 18.13$ $1,087.80 090

40842 22.77$ $1,366.20 17.38$ $1,042.80 090

40843 31.43$ $1,885.80 24.40$ $1,464.00 090

40844 37.75$ $2,265.00 30.16$ $1,809.60 090

40845 42.21$ $2,532.60 35.10$ $2,106.00 090


41000 4.82$ $289.20 3.30$ $198.00 010

41005 6.83$ $409.80 3.71$ $222.60 010

41006 10.60$ $636.00 7.37$ $442.20 090

41007 10.39$ $623.40 7.11$ $426.60 090

41008 11.21$ $672.60 7.89$ $473.40 090

41009 11.90$ $714.00 8.57$ $514.20 090

41010 6.10$ $366.00 3.20$ $192.00 010

41015 13.38$ $802.80 10.30$ $618.00 090

41016 13.04$ $782.40 10.35$ $621.00 090



Page | 76

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

41017 13.16$ $789.60 10.39$ $623.40 090

41018 14.90$ $894.00 12.11$ $726.60 090

41019 13.47$ $808.20 13.47$ $808.20 000

41100 4.98$ $298.80 3.14$ $188.40 010

41105 5.06$ $303.60 3.25$ $195.00 010

41108 4.41$ $264.60 2.66$ $159.60 010

41110 6.33$ $379.80 3.87$ $232.20 010

41112 9.95$ $597.00 7.48$ $448.80 090

41113 10.85$ $651.00 8.25$ $495.00 090

41114 18.43$ $1,105.80 18.43$ $1,105.80 090

41115 7.38$ $442.80 4.49$ $269.40 010

41116 9.89$ $593.40 6.50$ $390.00 090

41120 32.07$ $1,924.20 32.07$ $1,924.20 090

41130 39.18$ $2,350.80 39.18$ $2,350.80 090

41135 63.60$ $3,816.00 63.60$ $3,816.00 090

41140 64.44$ $3,866.40 64.44$ $3,866.40 090

41145 81.54$ $4,892.40 81.54$ $4,892.40 090

41150 64.72$ $3,883.20 64.72$ $3,883.20 090

41153 70.33$ $4,219.80 70.33$ $4,219.80 090

41155 87.71$ $5,262.60 87.71$ $5,262.60 090

41250 7.97$ $478.20 4.48$ $268.80 010

41251 8.64$ $518.40 5.32$ $319.20 010

41252 9.27$ $556.20 6.09$ $365.40 010

41500 12.35$ $741.00 12.35$ $741.00 090

41510 12.63$ $757.80 12.63$ $757.80 090

41512 19.66$ $1,179.60 19.66$ $1,179.60 090

41520 10.54$ $632.40 7.63$ $457.80 090

41530 11.20$ $672.00 11.20$ $672.00 000


41800 8.18$ $490.80 4.38$ $262.80 010

41805 7.78$ $466.80 5.24$ $314.40 010

41806 10.56$ $633.60 7.70$ $462.00 010



41822 8.71$ $522.60 5.33$ $319.80 010

41823 12.71$ $762.60 9.54$ $572.40 090

41825 6.34$ $380.40 3.60$ $216.00 010

41826 9.42$ $565.20 6.29$ $377.40 010

41827 13.10$ $786.00 9.03$ $541.80 090

41828 9.11$ $546.60 6.17$ $370.20 010

41830 11.71$ $702.60 8.39$ $503.40 010




Page | 77

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


41872 10.93$ $655.80 7.59$ $455.40 090

41874 11.20$ $672.00 7.53$ $451.80 090


42000 4.72$ $283.20 3.04$ $182.40 010

42100 4.44$ $266.40 3.22$ $193.20 010

42104 6.43$ $385.80 4.09$ $245.40 010

42106 8.16$ $489.60 5.25$ $315.00 010

42107 13.64$ $818.40 10.14$ $608.40 090

42120 30.02$ $1,801.20 30.02$ $1,801.20 090

42140 7.57$ $454.20 4.56$ $273.60 090

42145 20.39$ $1,223.40 20.39$ $1,223.40 090

42160 6.90$ $414.00 4.30$ $258.00 010

42180 7.18$ $430.80 5.35$ $321.00 010

42182 9.33$ $559.80 7.38$ $442.80 010

42200 24.53$ $1,471.80 24.53$ $1,471.80 090

42205 25.48$ $1,528.80 25.48$ $1,528.80 090

42210 28.44$ $1,706.40 28.44$ $1,706.40 090

42215 19.00$ $1,140.00 19.00$ $1,140.00 090

42220 14.39$ $863.40 14.39$ $863.40 090

42225 25.77$ $1,546.20 25.77$ $1,546.20 090

42226 26.30$ $1,578.00 26.30$ $1,578.00 090

42227 24.80$ $1,488.00 24.80$ $1,488.00 090

42235 21.59$ $1,295.40 21.59$ $1,295.40 090

42260 23.68$ $1,420.80 19.10$ $1,146.00 090

42280 4.87$ $292.20 3.18$ $190.80 010

42281 6.05$ $363.00 4.40$ $264.00 010


42300 6.18$ $370.80 4.45$ $267.00 010

42305 12.42$ $745.20 12.42$ $745.20 090

42310 4.74$ $284.40 3.60$ $216.00 010

42320 7.37$ $442.20 5.09$ $305.40 010

42330 6.84$ $410.40 4.79$ $287.40 010

42335 11.08$ $664.80 7.51$ $450.60 090

42340 13.65$ $819.00 9.73$ $583.80 090

42400 3.15$ $189.00 1.60$ $96.00 000

42405 8.72$ $523.20 6.52$ $391.20 010

42408 13.27$ $796.20 9.43$ $565.80 090

42409 9.84$ $590.40 6.45$ $387.00 090

42410 17.76$ $1,065.60 17.76$ $1,065.60 090

42415 30.14$ $1,808.40 30.14$ $1,808.40 090

42420 33.81$ $2,028.60 33.81$ $2,028.60 090



Page | 78

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

42425 23.86$ $1,431.60 23.86$ $1,431.60 090

42426 38.37$ $2,302.20 38.37$ $2,302.20 090

42440 11.84$ $710.40 11.84$ $710.40 090

42450 13.25$ $795.00 10.40$ $624.00 090

42500 12.74$ $764.40 9.97$ $598.20 090

42505 16.24$ $974.40 13.14$ $788.40 090

42507 15.00$ $900.00 15.00$ $900.00 090

42509 24.44$ $1,466.40 24.44$ $1,466.40 090

42510 18.64$ $1,118.40 18.64$ $1,118.40 090

42550 3.97$ $238.20 1.81$ $108.60 000

42600 14.05$ $843.00 10.07$ $604.20 090

42650 2.47$ $148.20 1.71$ $102.60 000

42660 3.68$ $220.80 2.51$ $150.60 000

42665 9.13$ $547.80 5.95$ $357.00 090


42700 5.60$ $336.00 3.96$ $237.60 010

42720 13.11$ $786.60 11.24$ $674.40 010

42725 23.46$ $1,407.60 23.46$ $1,407.60 090

42800 4.68$ $280.80 3.25$ $195.00 010

42804 5.83$ $349.80 3.32$ $199.20 010

42806 6.53$ $391.80 3.85$ $231.00 010

42808 6.67$ $400.20 4.69$ $281.40 010

42809 5.96$ $357.60 3.52$ $211.20 010

42810 11.45$ $687.00 8.45$ $507.00 090

42815 16.22$ $973.20 16.22$ $973.20 090

42820 8.37$ $502.20 8.37$ $502.20 090

42821 8.69$ $521.40 8.69$ $521.40 090

42825 7.60$ $456.00 7.60$ $456.00 090

42826 7.28$ $436.80 7.28$ $436.80 090

42830 6.02$ $361.20 6.02$ $361.20 090

42831 6.52$ $391.20 6.52$ $391.20 090

42835 5.61$ $336.60 5.61$ $336.60 090

42836 6.98$ $418.80 6.98$ $418.80 090

42842 29.94$ $1,796.40 29.94$ $1,796.40 090

42844 40.91$ $2,454.60 40.91$ $2,454.60 090

42845 65.37$ $3,922.20 65.37$ $3,922.20 090

42860 5.49$ $329.40 5.49$ $329.40 090

42870 17.89$ $1,073.40 17.89$ $1,073.40 090

42890 42.10$ $2,526.00 42.10$ $2,526.00 090

42892 55.46$ $3,327.60 55.46$ $3,327.60 090

42894 69.56$ $4,173.60 69.56$ $4,173.60 090

42900 9.69$ $581.40 9.69$ $581.40 010



Page | 79

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

42950 24.35$ $1,461.00 24.35$ $1,461.00 090

42953 29.36$ $1,761.60 29.36$ $1,761.60 090

42955 23.00$ $1,380.00 23.00$ $1,380.00 090

42960 4.91$ $294.60 4.91$ $294.60 010

42961 12.27$ $736.20 12.27$ $736.20 090

42962 14.97$ $898.20 14.97$ $898.20 090

42970 11.78$ $706.80 11.78$ $706.80 090

42971 13.15$ $789.00 13.15$ $789.00 090

42972 14.72$ $883.20 14.72$ $883.20 090


43020 14.81$ $888.60 14.81$ $888.60 090

43030 14.83$ $889.80 14.83$ $889.80 090

43045 36.07$ $2,164.20 36.07$ $2,164.20 090

43100 17.87$ $1,072.20 17.87$ $1,072.20 090

43101 28.10$ $1,686.00 28.10$ $1,686.00 090

43107 70.39$ $4,223.40 70.39$ $4,223.40 090

43108 126.78$ $7,606.80 126.78$ $7,606.80 090

43112 74.14$ $4,448.40 74.14$ $4,448.40 090

43113 125.42$ $7,525.20 125.42$ $7,525.20 090

43116 143.48$ $8,608.80 143.48$ $8,608.80 090

43117 67.92$ $4,075.20 67.92$ $4,075.20 090

43118 101.39$ $6,083.40 101.39$ $6,083.40 090

43121 78.88$ $4,732.80 78.88$ $4,732.80 090

43122 70.81$ $4,248.60 70.81$ $4,248.60 090

43123 130.10$ $7,806.00 130.10$ $7,806.00 090

43124 105.43$ $6,325.80 105.43$ $6,325.80 090

43130 22.33$ $1,339.80 22.33$ $1,339.80 090

43135 41.02$ $2,461.20 41.02$ $2,461.20 090

43180 15.71$ $942.60 15.71$ $942.60 XXX

43191 4.40$ $264.00 4.40$ $264.00 XXX

43192 4.87$ $292.20 4.87$ $292.20 XXX

43193 4.83$ $289.80 4.83$ $289.80 XXX

43194 5.43$ $325.80 5.43$ $325.80 XXX

43195 5.26$ $315.60 5.26$ $315.60 XXX

43196 5.61$ $336.60 5.61$ $336.60 XXX

43197 5.51$ $330.60 2.34$ $140.40 XXX

43198 6.10$ $366.00 2.80$ $168.00 XXX

43200 7.97$ $478.20 2.68$ $160.80 000

43201 8.07$ $484.20 3.12$ $187.20 000

43202 10.65$ $639.00 3.12$ $187.20 000

43204 4.06$ $243.60 4.06$ $243.60 000

43205 4.22$ $253.20 4.22$ $253.20 000



Page | 80

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

43206 9.62$ $577.20 4.03$ $241.80 000

43210 12.16$ $729.60 12.16$ $729.60 XXX

43211 6.94$ $416.40 6.94$ $416.40 XXX

43212 5.54$ $332.40 5.54$ $332.40 XXX

43213 36.13$ $2,167.80 7.57$ $454.20 XXX

43214 5.67$ $340.20 5.67$ $340.20 XXX

43215 12.23$ $733.80 4.21$ $252.60 000

43216 12.13$ $727.80 4.02$ $241.20 000

43217 13.03$ $781.80 4.75$ $285.00 000

43220 33.71$ $2,022.60 3.55$ $213.00 000

43226 11.11$ $666.60 3.90$ $234.00 000

43227 20.47$ $1,228.20 4.91$ $294.60 000

43229 21.21$ $1,272.60 5.83$ $349.80 XXX

43231 11.68$ $700.80 4.78$ $286.80 000

43232 13.93$ $835.80 5.88$ $352.80 000

43233 6.69$ $401.40 6.69$ $401.40 XXX

43235 9.06$ $543.60 3.68$ $220.80 000

43236 11.31$ $678.60 4.16$ $249.60 000

43237 5.80$ $348.00 5.80$ $348.00 000

43238 6.86$ $411.60 6.86$ $411.60 000

43239 11.61$ $696.60 4.15$ $249.00 000

43240 11.46$ $687.60 11.46$ $687.60 000

43241 4.25$ $255.00 4.25$ $255.00 000

43242 7.75$ $465.00 7.75$ $465.00 000

43243 6.98$ $418.80 6.98$ $418.80 000

43244 7.24$ $434.40 7.24$ $434.40 000

43245 17.98$ $1,078.80 5.19$ $311.40 000

43246 5.87$ $352.20 5.87$ $352.20 000

43247 12.08$ $724.80 5.25$ $315.00 000

43248 11.89$ $713.40 4.96$ $297.60 000

43249 31.85$ $1,911.00 4.58$ $274.80 000

43250 13.26$ $795.60 5.02$ $301.20 000

43251 14.52$ $871.20 5.81$ $348.60 000

43252 10.63$ $637.80 4.98$ $298.80 000

43253 7.74$ $464.40 7.74$ $464.40 XXX

43254 7.95$ $477.00 7.95$ $477.00 XXX

43255 21.44$ $1,286.40 5.94$ $356.40 000

43257 6.86$ $411.60 6.86$ $411.60 000

43259 6.69$ $401.40 6.69$ $401.40 000

43260 9.46$ $567.60 9.46$ $567.60 000

43261 9.92$ $595.20 9.92$ $595.20 000

43262 10.46$ $627.60 10.46$ $627.60 000



Page | 81

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

43263 10.47$ $628.20 10.47$ $628.20 000

43264 10.66$ $639.60 10.66$ $639.60 000

43265 12.64$ $758.40 12.64$ $758.40 000

43266 6.64$ $398.40 6.64$ $398.40 XXX

43270 22.02$ $1,321.20 6.86$ $411.60 XXX

43273 3.43$ $205.80 3.43$ $205.80 ZZZ

43274 13.50$ $810.00 13.50$ $810.00 XXX

43275 11.02$ $661.20 11.02$ $661.20 XXX

43276 14.05$ $843.00 14.05$ $843.00 XXX

43277 11.08$ $664.80 11.08$ $664.80 XXX

43278 12.63$ $757.80 12.63$ $757.80 XXX

43279 35.60$ $2,136.00 35.60$ $2,136.00 090

43280 29.84$ $1,790.40 29.84$ $1,790.40 090

43281 42.51$ $2,550.60 42.51$ $2,550.60 090

43282 47.77$ $2,866.20 47.77$ $2,866.20 090

43283 4.34$ $260.40 4.34$ $260.40 ZZZ


43300 17.71$ $1,062.60 17.71$ $1,062.60 090

43305 31.24$ $1,874.40 31.24$ $1,874.40 090

43310 40.89$ $2,453.40 40.89$ $2,453.40 090

43312 44.40$ $2,664.00 44.40$ $2,664.00 090

43313 76.89$ $4,613.40 76.89$ $4,613.40 090

43314 86.35$ $5,181.00 86.35$ $5,181.00 090

43320 38.36$ $2,301.60 38.36$ $2,301.60 090

43325 36.97$ $2,218.20 36.97$ $2,218.20 090

43327 22.70$ $1,362.00 22.70$ $1,362.00 090

43328 31.25$ $1,875.00 31.25$ $1,875.00 090

43330 36.67$ $2,200.20 36.67$ $2,200.20 090

43331 37.14$ $2,228.40 37.14$ $2,228.40 090

43332 32.01$ $1,920.60 32.01$ $1,920.60 090

43333 34.87$ $2,092.20 34.87$ $2,092.20 090

43334 34.48$ $2,068.80 34.48$ $2,068.80 090

43335 36.89$ $2,213.40 36.89$ $2,213.40 090

43336 41.77$ $2,506.20 41.77$ $2,506.20 090

43337 44.95$ $2,697.00 44.95$ $2,697.00 090

43338 3.18$ $190.80 3.18$ $190.80 ZZZ

43340 37.59$ $2,255.40 37.59$ $2,255.40 090

43341 38.75$ $2,325.00 38.75$ $2,325.00 090

43351 35.85$ $2,151.00 35.85$ $2,151.00 090

43352 29.63$ $1,777.80 29.63$ $1,777.80 090

43360 65.31$ $3,918.60 65.31$ $3,918.60 090

43361 70.26$ $4,215.60 70.26$ $4,215.60 090



Page | 82

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

43400 42.38$ $2,542.80 42.38$ $2,542.80 090

43401 42.83$ $2,569.80 42.83$ $2,569.80 090

43405 40.31$ $2,418.60 40.31$ $2,418.60 090

43410 29.22$ $1,753.20 29.22$ $1,753.20 090

43415 70.95$ $4,257.00 70.95$ $4,257.00 090

43420 29.01$ $1,740.60 29.01$ $1,740.60 090

43425 39.90$ $2,394.00 39.90$ $2,394.00 090

43450 6.18$ $370.80 2.45$ $147.00 000

43453 28.84$ $1,730.40 2.64$ $158.40 000

43460 6.14$ $368.40 6.14$ $368.40 000



43500 21.72$ $1,303.20 21.72$ $1,303.20 090

43501 37.07$ $2,224.20 37.07$ $2,224.20 090

43502 41.90$ $2,514.00 41.90$ $2,514.00 090

43510 26.04$ $1,562.40 26.04$ $1,562.40 090

43520 18.98$ $1,138.80 18.98$ $1,138.80 090

43605 23.11$ $1,386.60 23.11$ $1,386.60 090

43610 27.03$ $1,621.80 27.03$ $1,621.80 090

43611 33.73$ $2,023.80 33.73$ $2,023.80 090

43620 53.84$ $3,230.40 53.84$ $3,230.40 090

43621 62.34$ $3,740.40 62.34$ $3,740.40 090

43622 63.53$ $3,811.80 63.53$ $3,811.80 090

43631 39.93$ $2,395.80 39.93$ $2,395.80 090

43632 55.85$ $3,351.00 55.85$ $3,351.00 090

43633 52.79$ $3,167.40 52.79$ $3,167.40 090

43634 58.18$ $3,490.80 58.18$ $3,490.80 090

43635 3.07$ $184.20 3.07$ $184.20 ZZZ

43640 32.53$ $1,951.80 32.53$ $1,951.80 090

43641 32.95$ $1,977.00 32.95$ $1,977.00 090

43644 47.73$ $2,863.80 47.73$ $2,863.80 090

43645 50.95$ $3,057.00 50.95$ $3,057.00 090



43651 18.16$ $1,089.60 18.16$ $1,089.60 090

43652 21.17$ $1,270.20 21.17$ $1,270.20 090

43653 15.96$ $957.60 15.96$ $957.60 090


43752 1.16$ $69.60 1.16$ $69.60 000

43753 0.61$ $36.60 0.61$ $36.60 000

43754 3.15$ $189.00 0.96$ $57.60 000

43755 4.07$ $244.20 1.72$ $103.20 000



Page | 83

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

43756 6.08$ $364.80 1.47$ $88.20 000

43757 8.57$ $514.20 2.22$ $133.20 000

43760 14.51$ $870.60 1.32$ $79.20 000

43761 3.32$ $199.20 2.92$ $175.20 000

43770 30.96$ $1,857.60 30.96$ $1,857.60 090

43771 35.18$ $2,110.80 35.18$ $2,110.80 090

43772 26.22$ $1,573.20 26.22$ $1,573.20 090

43773 35.12$ $2,107.20 35.12$ $2,107.20 090

43774 26.51$ $1,590.60 26.51$ $1,590.60 090

43775 30.30$ $1,818.00 30.30$ $1,818.00 090

43800 25.64$ $1,538.40 25.64$ $1,538.40 090

43810 28.06$ $1,683.60 28.06$ $1,683.60 090

43820 36.96$ $2,217.60 36.96$ $2,217.60 090

43825 35.96$ $2,157.60 35.96$ $2,157.60 090

43830 19.44$ $1,166.40 19.44$ $1,166.40 090

43831 16.24$ $974.40 16.24$ $974.40 090

43832 28.74$ $1,724.40 28.74$ $1,724.40 090

43840 37.45$ $2,247.00 37.45$ $2,247.00 090

43842 33.75$ $2,025.00 33.75$ $2,025.00 090

43843 35.25$ $2,115.00 35.25$ $2,115.00 090

43845 54.05$ $3,243.00 54.05$ $3,243.00 090

43846 44.42$ $2,665.20 44.42$ $2,665.20 090

43847 49.11$ $2,946.60 49.11$ $2,946.60 090

43848 53.01$ $3,180.60 53.01$ $3,180.60 090

43850 44.97$ $2,698.20 44.97$ $2,698.20 090

43855 45.74$ $2,744.40 45.74$ $2,744.40 090

43860 45.04$ $2,702.40 45.04$ $2,702.40 090

43865 46.85$ $2,811.00 46.85$ $2,811.00 090

43870 19.72$ $1,183.20 19.72$ $1,183.20 090

43880 44.03$ $2,641.80 44.03$ $2,641.80 090



43886 10.20$ $612.00 10.20$ $612.00 090

43887 9.08$ $544.80 9.08$ $544.80 090

43888 12.82$ $769.20 12.82$ $769.20 090


44005 30.17$ $1,810.20 30.17$ $1,810.20 090

44010 24.02$ $1,441.20 24.02$ $1,441.20 090

44015 3.89$ $233.40 3.89$ $233.40 ZZZ

44020 26.90$ $1,614.00 26.90$ $1,614.00 090

44021 26.94$ $1,616.40 26.94$ $1,616.40 090

44025 27.25$ $1,635.00 27.25$ $1,635.00 090



Page | 84

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

44050 25.85$ $1,551.00 25.85$ $1,551.00 090

44055 41.11$ $2,466.60 41.11$ $2,466.60 090

44100 3.09$ $185.40 3.09$ $185.40 000

44110 23.58$ $1,414.80 23.58$ $1,414.80 090

44111 27.29$ $1,637.40 27.29$ $1,637.40 090

44120 33.73$ $2,023.80 33.73$ $2,023.80 090

44121 6.65$ $399.00 6.65$ $399.00 ZZZ

44125 32.66$ $1,959.60 32.66$ $1,959.60 090

44126 67.75$ $4,065.00 67.75$ $4,065.00 090

44127 78.02$ $4,681.20 78.02$ $4,681.20 090

44128 6.69$ $401.40 6.69$ $401.40 ZZZ

44130 36.27$ $2,176.20 36.27$ $2,176.20 090






44139 3.33$ $199.80 3.33$ $199.80 ZZZ

44140 37.05$ $2,223.00 37.05$ $2,223.00 090

44141 50.60$ $3,036.00 50.60$ $3,036.00 090

44143 46.05$ $2,763.00 46.05$ $2,763.00 090

44144 48.93$ $2,935.80 48.93$ $2,935.80 090

44145 45.90$ $2,754.00 45.90$ $2,754.00 090

44146 58.90$ $3,534.00 58.90$ $3,534.00 090

44147 53.64$ $3,218.40 53.64$ $3,218.40 090

44150 52.03$ $3,121.80 52.03$ $3,121.80 090

44151 59.31$ $3,558.60 59.31$ $3,558.60 090

44155 58.13$ $3,487.80 58.13$ $3,487.80 090

44156 63.72$ $3,823.20 63.72$ $3,823.20 090

44157 59.87$ $3,592.20 59.87$ $3,592.20 090

44158 60.29$ $3,617.40 60.29$ $3,617.40 090

44160 34.34$ $2,060.40 34.34$ $2,060.40 090

44180 25.41$ $1,524.60 25.41$ $1,524.60 090

44186 18.07$ $1,084.20 18.07$ $1,084.20 090

44187 30.99$ $1,859.40 30.99$ $1,859.40 090

44188 34.21$ $2,052.60 34.21$ $2,052.60 090

44202 38.32$ $2,299.20 38.32$ $2,299.20 090

44203 6.63$ $397.80 6.63$ $397.80 ZZZ

44204 42.63$ $2,557.80 42.63$ $2,557.80 090

44205 37.11$ $2,226.60 37.11$ $2,226.60 090

44206 48.60$ $2,916.00 48.60$ $2,916.00 090

44207 50.54$ $3,032.40 50.54$ $3,032.40 090



Page | 85

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

44208 55.32$ $3,319.20 55.32$ $3,319.20 090

44210 49.77$ $2,986.20 49.77$ $2,986.20 090

44211 61.11$ $3,666.60 61.11$ $3,666.60 090

44212 57.45$ $3,447.00 57.45$ $3,447.00 090

44213 5.20$ $312.00 5.20$ $312.00 ZZZ

44227 46.10$ $2,766.00 46.10$ $2,766.00 090


44300 23.28$ $1,396.80 23.28$ $1,396.80 090

44310 28.97$ $1,738.20 28.97$ $1,738.20 090

44312 16.53$ $991.80 16.53$ $991.80 090

44314 27.98$ $1,678.80 27.98$ $1,678.80 090

44316 38.97$ $2,338.20 38.97$ $2,338.20 090

44320 33.29$ $1,997.40 33.29$ $1,997.40 090

44322 28.10$ $1,686.00 28.10$ $1,686.00 090

44340 17.49$ $1,049.40 17.49$ $1,049.40 090

44345 29.24$ $1,754.40 29.24$ $1,754.40 090

44346 32.86$ $1,971.60 32.86$ $1,971.60 090

44360 4.30$ $258.00 4.30$ $258.00 000

44361 4.74$ $284.40 4.74$ $284.40 000

44363 5.67$ $340.20 5.67$ $340.20 000

44364 6.05$ $363.00 6.05$ $363.00 000

44365 5.36$ $321.60 5.36$ $321.60 000

44366 7.09$ $425.40 7.09$ $425.40 000

44369 7.25$ $435.00 7.25$ $435.00 000

44370 7.84$ $470.40 7.84$ $470.40 000

44372 7.05$ $423.00 7.05$ $423.00 000

44373 5.67$ $340.20 5.67$ $340.20 000

44376 8.32$ $499.20 8.32$ $499.20 000

44377 8.78$ $526.80 8.78$ $526.80 000

44378 11.26$ $675.60 11.26$ $675.60 000

44379 11.97$ $718.20 11.97$ $718.20 000

44380 6.49$ $389.40 1.79$ $107.40 000

44381 29.78$ $1,786.80 2.59$ $155.40 XXX

44382 9.43$ $565.80 2.27$ $136.20 000

44384 4.51$ $270.60 4.51$ $270.60 XXX

44385 7.13$ $427.80 2.20$ $132.00 000

44386 10.06$ $603.60 2.70$ $162.00 000

44388 10.20$ $612.00 4.61$ $276.60 000

44388 53 5.09$ $305.40 2.29$ $137.40 XXX

44389 12.95$ $777.00 5.08$ $304.80 000

44390 12.86$ $771.60 6.23$ $373.80 000

44391 22.48$ $1,348.80 6.79$ $407.40 000



Page | 86

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

44392 12.07$ $724.20 5.83$ $349.80 000

44394 13.58$ $814.80 6.63$ $397.80 000

44401 97.06$ $5,823.60 7.08$ $424.80 XXX

44402 7.67$ $460.20 7.67$ $460.20 XXX

44403 8.82$ $529.20 8.82$ $529.20 XXX

44404 12.37$ $742.20 5.08$ $304.80 XXX

44405 17.90$ $1,074.00 5.40$ $324.00 XXX

44406 6.72$ $403.20 6.72$ $403.20 XXX

44407 8.03$ $481.80 8.03$ $481.80 XXX

44408 6.79$ $407.40 6.79$ $407.40 XXX

44500 0.70$ $42.00 0.70$ $42.00 000

44602 38.84$ $2,330.40 38.84$ $2,330.40 090

44603 44.63$ $2,677.80 44.63$ $2,677.80 090

44604 29.17$ $1,750.20 29.17$ $1,750.20 090

44605 36.08$ $2,164.80 36.08$ $2,164.80 090

44615 29.75$ $1,785.00 29.75$ $1,785.00 090

44620 24.12$ $1,447.20 24.12$ $1,447.20 090

44625 28.28$ $1,696.80 28.28$ $1,696.80 090

44626 44.25$ $2,655.00 44.25$ $2,655.00 090

44640 38.76$ $2,325.60 38.76$ $2,325.60 090

44650 40.09$ $2,405.40 40.09$ $2,405.40 090

44660 37.19$ $2,231.40 37.19$ $2,231.40 090

44661 43.02$ $2,581.20 43.02$ $2,581.20 090

44680 29.45$ $1,767.00 29.45$ $1,767.00 090

44700 28.47$ $1,708.20 28.47$ $1,708.20 090

44701 4.64$ $278.40 4.64$ $278.40 ZZZ



44720 7.52$ $451.20 7.52$ $451.20 XXX

44721 10.52$ $631.20 10.52$ $631.20 XXX


44800 21.23$ $1,273.80 21.23$ $1,273.80 090

44820 23.27$ $1,396.20 23.27$ $1,396.20 090

44850 20.83$ $1,249.80 20.83$ $1,249.80 090


44900 21.38$ $1,282.80 21.38$ $1,282.80 090

44950 17.74$ $1,064.40 17.74$ $1,064.40 090

44955 2.31$ $138.60 2.31$ $138.60 ZZZ

44960 24.12$ $1,447.20 24.12$ $1,447.20 090

44970 16.66$ $999.60 16.66$ $999.60 090


45000 11.92$ $715.20 11.92$ $715.20 090



Page | 87

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

45005 7.95$ $477.00 4.57$ $274.20 010

45020 16.00$ $960.00 16.00$ $960.00 090

45100 8.49$ $509.40 8.49$ $509.40 090

45108 10.25$ $615.00 10.25$ $615.00 090

45110 51.55$ $3,093.00 51.55$ $3,093.00 090

45111 30.23$ $1,813.80 30.23$ $1,813.80 090

45112 52.36$ $3,141.60 52.36$ $3,141.60 090

45113 53.49$ $3,209.40 53.49$ $3,209.40 090

45114 49.95$ $2,997.00 49.95$ $2,997.00 090

45116 45.41$ $2,724.60 45.41$ $2,724.60 090

45119 54.49$ $3,269.40 54.49$ $3,269.40 090

45120 42.53$ $2,551.80 42.53$ $2,551.80 090

45121 47.91$ $2,874.60 47.91$ $2,874.60 090

45123 31.40$ $1,884.00 31.40$ $1,884.00 090

45126 77.91$ $4,674.60 77.91$ $4,674.60 090

45130 30.52$ $1,831.20 30.52$ $1,831.20 090

45135 37.84$ $2,270.40 37.84$ $2,270.40 090

45136 51.27$ $3,076.20 51.27$ $3,076.20 090

45150 11.14$ $668.40 11.14$ $668.40 090

45160 28.25$ $1,695.00 28.25$ $1,695.00 090

45171 17.03$ $1,021.80 17.03$ $1,021.80 090

45172 22.84$ $1,370.40 22.84$ $1,370.40 090

45190 19.62$ $1,177.20 19.62$ $1,177.20 090

45300 3.59$ $215.40 1.53$ $91.80 000

45303 28.60$ $1,716.00 2.59$ $155.40 000

45305 5.68$ $340.80 2.22$ $133.20 000

45307 6.72$ $403.20 2.94$ $176.40 000

45308 6.25$ $375.00 2.47$ $148.20 000

45309 6.53$ $391.80 2.63$ $157.80 000

45315 6.63$ $397.80 3.03$ $181.80 000

45317 7.04$ $422.40 3.31$ $198.60 000

45320 7.01$ $420.60 3.05$ $183.00 000

45321 3.00$ $180.00 3.00$ $180.00 000

45327 3.38$ $202.80 3.38$ $202.80 000

45330 4.90$ $294.00 1.61$ $96.60 000

45331 7.54$ $452.40 2.08$ $124.80 000

45332 9.07$ $544.20 3.17$ $190.20 000

45333 10.24$ $614.40 2.84$ $170.40 000

45334 18.01$ $1,080.60 3.55$ $213.00 000

45335 8.52$ $511.20 2.07$ $124.20 000

45337 3.44$ $206.40 3.44$ $206.40 000

45338 9.46$ $567.60 3.61$ $216.60 000



Page | 88

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

45340 14.51$ $870.60 2.39$ $143.40 000

45341 3.73$ $223.80 3.73$ $223.80 000

45342 5.06$ $303.60 5.06$ $303.60 000

45346 93.12$ $5,587.20 4.76$ $285.60 XXX

45347 4.60$ $276.00 4.60$ $276.00 XXX

45349 5.83$ $349.80 5.83$ $349.80 XXX

45350 17.27$ $1,036.20 3.04$ $182.40 XXX

45378 10.94$ $656.40 5.46$ $327.60 000

45378 53 5.47$ $328.20 2.73$ $163.80 000

45379 13.79$ $827.40 7.02$ $421.20 000

45380 13.61$ $816.60 5.93$ $355.80 000

45381 13.07$ $784.20 5.94$ $356.40 000

45382 23.21$ $1,392.60 7.63$ $457.80 000

45384 14.88$ $892.80 6.68$ $400.80 000

45385 14.16$ $849.60 7.48$ $448.80 000

45386 19.15$ $1,149.00 6.24$ $374.40 000

45388 97.57$ $5,854.20 7.92$ $475.20 XXX

45389 8.49$ $509.40 8.49$ $509.40 XXX

45390 9.66$ $579.60 9.66$ $579.60 XXX

45391 7.59$ $455.40 7.59$ $455.40 000

45392 8.92$ $535.20 8.92$ $535.20 000

45393 7.38$ $442.80 7.38$ $442.80 XXX

45395 55.43$ $3,325.80 55.43$ $3,325.80 090

45397 60.52$ $3,631.20 60.52$ $3,631.20 090

45398 21.38$ $1,282.80 6.87$ $412.20 XXX


45400 31.97$ $1,918.20 31.97$ $1,918.20 090

45402 42.46$ $2,547.60 42.46$ $2,547.60 090


45500 14.87$ $892.20 14.87$ $892.20 090

45505 16.76$ $1,005.60 16.76$ $1,005.60 090

45520 4.66$ $279.60 1.16$ $69.60 000

45540 29.61$ $1,776.60 29.61$ $1,776.60 090

45541 26.36$ $1,581.60 26.36$ $1,581.60 090

45550 40.85$ $2,451.00 40.85$ $2,451.00 090

45560 19.52$ $1,171.20 19.52$ $1,171.20 090

45562 31.23$ $1,873.80 31.23$ $1,873.80 090

45563 45.59$ $2,735.40 45.59$ $2,735.40 090

45800 33.65$ $2,019.00 33.65$ $2,019.00 090

45805 40.43$ $2,425.80 40.43$ $2,425.80 090

45820 33.73$ $2,023.80 33.73$ $2,023.80 090

45825 39.23$ $2,353.80 39.23$ $2,353.80 090



Page | 89

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

45900 5.71$ $342.60 5.71$ $342.60 010

45905 4.79$ $287.40 4.79$ $287.40 010

45910 5.50$ $330.00 5.50$ $330.00 010

45915 9.58$ $574.80 6.46$ $387.60 010

45990 3.00$ $180.00 3.00$ $180.00 000


46020 7.89$ $473.40 6.66$ $399.60 010

46030 4.01$ $240.60 2.55$ $153.00 010

46040 15.29$ $917.40 11.72$ $703.20 090

46045 12.22$ $733.20 12.22$ $733.20 090

46050 5.87$ $352.20 2.77$ $166.20 010

46060 13.49$ $809.40 13.49$ $809.40 090

46070 6.55$ $393.00 6.55$ $393.00 090

46080 7.07$ $424.20 4.44$ $266.40 010

46083 5.10$ $306.00 3.03$ $181.80 010

46200 12.87$ $772.20 9.33$ $559.80 090

46220 5.96$ $357.60 3.36$ $201.60 010

46221 7.76$ $465.60 5.45$ $327.00 010

46230 7.84$ $470.40 4.85$ $291.00 010

46250 13.31$ $798.60 8.90$ $534.00 090

46255 14.50$ $870.00 9.97$ $598.20 090

46257 11.92$ $715.20 11.92$ $715.20 090

46258 13.03$ $781.80 13.03$ $781.80 090

46260 13.38$ $802.80 13.38$ $802.80 090

46261 14.71$ $882.60 14.71$ $882.60 090

46262 15.59$ $935.40 15.59$ $935.40 090

46270 14.54$ $872.40 11.11$ $666.60 090

46275 15.42$ $925.20 11.75$ $705.00 090

46280 13.31$ $798.60 13.31$ $798.60 090

46285 15.28$ $916.80 11.72$ $703.20 090

46288 15.56$ $933.60 15.56$ $933.60 090

46320 5.29$ $317.40 3.12$ $187.20 010

46500 5.66$ $339.60 3.54$ $212.40 010

46505 8.15$ $489.00 6.78$ $406.80 010

46600 2.58$ $154.80 1.17$ $70.20 000

46601 3.97$ $238.20 2.71$ $162.60 XXX

46604 18.43$ $1,105.80 1.88$ $112.80 000

46606 6.62$ $397.20 2.15$ $129.00 000

46607 5.54$ $332.40 3.62$ $217.20 XXX

46608 6.78$ $406.80 2.27$ $136.20 000

46610 6.59$ $395.40 2.26$ $135.60 000

46611 5.11$ $306.60 2.29$ $137.40 000



Page | 90

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

46612 7.50$ $450.00 2.60$ $156.00 000

46614 3.73$ $223.80 1.84$ $110.40 000

46615 4.11$ $246.60 2.60$ $156.00 000

46700 18.47$ $1,108.20 18.47$ $1,108.20 090

46705 14.31$ $858.60 14.31$ $858.60 090

46706 4.73$ $283.80 4.73$ $283.80 010

46707 13.44$ $806.40 13.44$ $806.40 090

46710 29.74$ $1,784.40 29.74$ $1,784.40 090

46712 60.06$ $3,603.60 60.06$ $3,603.60 090

46715 15.11$ $906.60 15.11$ $906.60 090

46716 31.57$ $1,894.20 31.57$ $1,894.20 090

46730 51.71$ $3,102.60 51.71$ $3,102.60 090

46735 59.82$ $3,589.20 59.82$ $3,589.20 090

46740 59.33$ $3,559.80 59.33$ $3,559.80 090

46742 67.78$ $4,066.80 67.78$ $4,066.80 090

46744 96.95$ $5,817.00 96.95$ $5,817.00 090

46746 103.26$ $6,195.60 103.26$ $6,195.60 090

46748 112.11$ $6,726.60 112.11$ $6,726.60 090

46750 21.34$ $1,280.40 21.34$ $1,280.40 090

46751 16.99$ $1,019.40 16.99$ $1,019.40 090

46753 16.98$ $1,018.80 16.98$ $1,018.80 090

46754 8.45$ $507.00 6.54$ $392.40 010

46760 31.01$ $1,860.60 31.01$ $1,860.60 090

46761 26.09$ $1,565.40 26.09$ $1,565.40 090

46762 26.22$ $1,573.20 26.22$ $1,573.20 090

46900 7.05$ $423.00 3.92$ $235.20 010

46910 7.45$ $447.00 3.79$ $227.40 010

46916 6.67$ $400.20 4.11$ $246.60 010

46917 13.30$ $798.00 3.76$ $225.60 010

46922 7.74$ $464.40 3.82$ $229.20 010

46924 15.63$ $937.80 5.19$ $311.40 010

46930 5.99$ $359.40 4.25$ $255.00 090

46940 6.56$ $393.60 4.13$ $247.80 010

46942 6.23$ $373.80 3.71$ $222.60 010

46945 8.97$ $538.20 6.51$ $390.60 090

46946 9.07$ $544.20 6.45$ $387.00 090

46947 10.71$ $642.60 10.71$ $642.60 090


47000 10.73$ $643.80 2.96$ $177.60 000

47001 2.84$ $170.40 2.84$ $170.40 ZZZ

47010 33.39$ $2,003.40 33.39$ $2,003.40 090

47015 31.83$ $1,909.80 31.83$ $1,909.80 090



Page | 91

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

47100 23.46$ $1,407.60 23.46$ $1,407.60 090

47120 64.16$ $3,849.60 64.16$ $3,849.60 090

47122 94.21$ $5,652.60 94.21$ $5,652.60 090

47125 84.36$ $5,061.60 84.36$ $5,061.60 090

47130 90.57$ $5,434.20 90.57$ $5,434.20 090


47135 147.96$ $8,877.60 147.96$ $8,877.60 090

47140 98.35$ $5,901.00 98.35$ $5,901.00 090

47141 117.47$ $7,048.20 117.47$ $7,048.20 090

47142 129.40$ $7,764.00 129.40$ $7,764.00 090




47146 8.99$ $539.40 8.99$ $539.40 XXX

47147 10.49$ $629.40 10.49$ $629.40 XXX

47300 31.32$ $1,879.20 31.32$ $1,879.20 090

47350 37.88$ $2,272.80 37.88$ $2,272.80 090

47360 51.32$ $3,079.20 51.32$ $3,079.20 090

47361 83.24$ $4,994.40 83.24$ $4,994.40 090

47362 40.00$ $2,400.00 40.00$ $2,400.00 090

47370 34.37$ $2,062.20 34.37$ $2,062.20 090

47371 32.50$ $1,950.00 32.50$ $1,950.00 090


47380 39.79$ $2,387.40 39.79$ $2,387.40 090

47381 38.40$ $2,304.00 38.40$ $2,304.00 090

47382 149.25$ $8,955.00 22.10$ $1,326.00 010

47383 225.48$ $13,528.80 13.82$ $829.20 XXX


47400 59.28$ $3,556.80 59.28$ $3,556.80 090

47420 37.05$ $2,223.00 37.05$ $2,223.00 090

47425 37.36$ $2,241.60 37.36$ $2,241.60 090

47460 34.64$ $2,078.40 34.64$ $2,078.40 090

47480 24.37$ $1,462.20 24.37$ $1,462.20 090

47490 9.67$ $580.20 9.67$ $580.20 010

47531 11.01$ $660.60 2.75$ $165.00 XXX

47532 24.18$ $1,450.80 6.17$ $370.20 XXX

47533 39.49$ $2,369.40 8.68$ $520.80 XXX

47534 48.61$ $2,916.60 11.52$ $691.20 XXX

47535 32.68$ $1,960.80 6.61$ $396.60 XXX

47536 24.23$ $1,453.80 4.23$ $253.80 XXX

47537 11.90$ $714.00 2.83$ $169.80 XXX

47538 134.67$ $8,080.20 9.44$ $566.40 XXX



Page | 92

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

47539 146.99$ $8,819.40 12.75$ $765.00 XXX

47540 152.68$ $9,160.80 15.22$ $913.20 XXX

47541 34.89$ $2,093.40 8.07$ $484.20 XXX

47542 15.08$ $904.80 3.64$ $218.40 XXX

47543 39.28$ $2,356.80 4.59$ $275.40 XXX

47544 24.01$ $1,440.60 6.08$ $364.80 XXX

47550 4.53$ $271.80 4.53$ $271.80 ZZZ

47552 8.94$ $536.40 8.94$ $536.40 000

47553 8.80$ $528.00 8.80$ $528.00 000

47554 13.48$ $808.80 13.48$ $808.80 000

47555 10.54$ $632.40 10.54$ $632.40 000

47556 11.99$ $719.40 11.99$ $719.40 000

47562 18.20$ $1,092.00 18.20$ $1,092.00 090

47563 19.76$ $1,185.60 19.76$ $1,185.60 090

47564 30.77$ $1,846.20 30.77$ $1,846.20 090

47570 21.14$ $1,268.40 21.14$ $1,268.40 090


47600 29.48$ $1,768.80 29.48$ $1,768.80 090

47605 31.01$ $1,860.60 31.01$ $1,860.60 090

47610 34.58$ $2,074.80 34.58$ $2,074.80 090

47612 35.00$ $2,100.00 35.00$ $2,100.00 090

47620 37.87$ $2,272.20 37.87$ $2,272.20 090

47700 28.85$ $1,731.00 28.85$ $1,731.00 090

47701 47.24$ $2,834.40 47.24$ $2,834.40 090

47711 42.86$ $2,571.60 42.86$ $2,571.60 090

47712 54.80$ $3,288.00 54.80$ $3,288.00 090

47715 36.75$ $2,205.00 36.75$ $2,205.00 090

47720 31.83$ $1,909.80 31.83$ $1,909.80 090

47721 37.42$ $2,245.20 37.42$ $2,245.20 090

47740 36.04$ $2,162.40 36.04$ $2,162.40 090

47741 40.56$ $2,433.60 40.56$ $2,433.60 090

47760 62.10$ $3,726.00 62.10$ $3,726.00 090

47765 83.35$ $5,001.00 83.35$ $5,001.00 090

47780 67.96$ $4,077.60 67.96$ $4,077.60 090

47785 89.13$ $5,347.80 89.13$ $5,347.80 090

47800 43.41$ $2,604.60 43.41$ $2,604.60 090

47801 28.31$ $1,698.60 28.31$ $1,698.60 090

47802 41.81$ $2,508.60 41.81$ $2,508.60 090

47900 37.82$ $2,269.20 37.82$ $2,269.20 090


48000 51.54$ $3,092.40 51.54$ $3,092.40 090

48001 62.96$ $3,777.60 62.96$ $3,777.60 090



Page | 93

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

48020 32.37$ $1,942.20 32.37$ $1,942.20 090

48100 24.53$ $1,471.80 24.53$ $1,471.80 090

48102 15.62$ $937.20 6.96$ $417.60 010

48105 78.38$ $4,702.80 78.38$ $4,702.80 090

48120 30.57$ $1,834.20 30.57$ $1,834.20 090

48140 43.03$ $2,581.80 43.03$ $2,581.80 090

48145 44.77$ $2,686.20 44.77$ $2,686.20 090

48146 51.84$ $3,110.40 51.84$ $3,110.40 090

48148 34.41$ $2,064.60 34.41$ $2,064.60 090

48150 85.57$ $5,134.20 85.57$ $5,134.20 090

48152 79.02$ $4,741.20 79.02$ $4,741.20 090

48153 85.13$ $5,107.80 85.13$ $5,107.80 090

48154 79.85$ $4,791.00 79.85$ $4,791.00 090

48155 50.19$ $3,011.40 50.19$ $3,011.40 090


48400 2.99$ $179.40 2.99$ $179.40 ZZZ

48500 31.46$ $1,887.60 31.46$ $1,887.60 090

48510 30.20$ $1,812.00 30.20$ $1,812.00 090

48520 30.16$ $1,809.60 30.16$ $1,809.60 090

48540 35.77$ $2,146.20 35.77$ $2,146.20 090

48545 36.78$ $2,206.80 36.78$ $2,206.80 090

48547 49.25$ $2,955.00 49.25$ $2,955.00 090

48548 45.80$ $2,748.00 45.80$ $2,748.00 090



48552 6.42$ $385.20 6.42$ $385.20 XXX

48554 71.28$ $4,276.80 71.28$ $4,276.80 090

48556 35.26$ $2,115.60 35.26$ $2,115.60 090


49000 21.36$ $1,281.60 21.36$ $1,281.60 090

49002 28.87$ $1,732.20 28.87$ $1,732.20 090

49010 25.81$ $1,548.60 25.81$ $1,548.60 090

49020 43.97$ $2,638.20 43.97$ $2,638.20 090

49040 27.66$ $1,659.60 27.66$ $1,659.60 090

49060 30.44$ $1,826.40 30.44$ $1,826.40 090

49062 20.38$ $1,222.80 20.38$ $1,222.80 090

49082 5.62$ $337.20 2.12$ $127.20 000

49083 8.63$ $517.80 3.13$ $187.80 000

49084 2.98$ $178.80 2.98$ $178.80 000

49180 4.75$ $285.00 2.45$ $147.00 000

49185 29.63$ $1,777.80 3.52$ $211.20 XXX

49203 33.17$ $1,990.20 33.17$ $1,990.20 090



Page | 94

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

49204 42.36$ $2,541.60 42.36$ $2,541.60 090

49205 48.51$ $2,910.60 48.51$ $2,910.60 090

49215 61.45$ $3,687.00 61.45$ $3,687.00 090

49220 25.38$ $1,522.80 25.38$ $1,522.80 090

49250 16.33$ $979.80 16.33$ $979.80 090

49255 22.01$ $1,320.60 22.01$ $1,320.60 090

49320 9.09$ $545.40 9.09$ $545.40 010

49321 9.62$ $577.20 9.62$ $577.20 010

49322 10.28$ $616.80 10.28$ $616.80 010

49323 17.79$ $1,067.40 17.79$ $1,067.40 090

49324 10.82$ $649.20 10.82$ $649.20 010

49325 11.51$ $690.60 11.51$ $690.60 010

49326 5.17$ $310.20 5.17$ $310.20 ZZZ

49327 3.58$ $214.80 3.58$ $214.80 ZZZ


49400 3.89$ $233.40 2.66$ $159.60 000

49402 23.67$ $1,420.20 23.67$ $1,420.20 090

49405 25.91$ $1,554.60 6.07$ $364.20 XXX

49406 25.92$ $1,555.20 6.07$ $364.20 XXX

49407 21.49$ $1,289.40 6.47$ $388.20 XXX

49411 16.11$ $966.60 5.67$ $340.20 000

49412 2.26$ $135.60 2.26$ $135.60 ZZZ

49418 42.77$ $2,566.20 6.24$ $374.40 000

49419 12.44$ $746.40 12.44$ $746.40 090

49421 6.32$ $379.20 6.32$ $379.20 000

49422 10.53$ $631.80 10.53$ $631.80 010

49423 16.39$ $983.40 2.06$ $123.60 000

49424 4.33$ $259.80 1.10$ $66.00 000

49425 20.41$ $1,224.60 20.41$ $1,224.60 090

49426 16.95$ $1,017.00 16.95$ $1,017.00 090

49427 1.30$ $78.00 1.30$ $78.00 000

49428 11.93$ $715.80 11.93$ $715.80 010

49429 12.64$ $758.40 12.64$ $758.40 010

49435 3.28$ $196.80 3.28$ $196.80 ZZZ

49436 5.22$ $313.20 5.22$ $313.20 010

49440 30.87$ $1,852.20 6.36$ $381.60 010

49441 34.72$ $2,083.20 7.30$ $438.00 010

49442 28.72$ $1,723.20 6.39$ $383.40 010

49446 29.79$ $1,787.40 4.65$ $279.00 000

49450 19.96$ $1,197.60 1.92$ $115.20 000

49451 21.74$ $1,304.40 2.60$ $156.00 000

49452 26.83$ $1,609.80 4.01$ $240.60 000



Page | 95

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

49460 22.01$ $1,320.60 1.38$ $82.80 000

49465 4.85$ $291.00 0.89$ $53.40 000

49491 21.95$ $1,317.00 21.95$ $1,317.00 090

49492 26.41$ $1,584.60 26.41$ $1,584.60 090

49495 10.74$ $644.40 10.74$ $644.40 090

49496 17.03$ $1,021.80 17.03$ $1,021.80 090

49500 10.28$ $616.80 10.28$ $616.80 090

49501 16.33$ $979.80 16.33$ $979.80 090

49505 14.46$ $867.60 14.46$ $867.60 090

49507 16.22$ $973.20 16.22$ $973.20 090

49520 17.49$ $1,049.40 17.49$ $1,049.40 090

49521 19.79$ $1,187.40 19.79$ $1,187.40 090

49525 15.88$ $952.80 15.88$ $952.80 090

49540 18.58$ $1,114.80 18.58$ $1,114.80 090

49550 15.94$ $956.40 15.94$ $956.40 090

49553 17.47$ $1,048.20 17.47$ $1,048.20 090

49555 16.55$ $993.00 16.55$ $993.00 090

49557 19.99$ $1,199.40 19.99$ $1,199.40 090

49560 20.39$ $1,223.40 20.39$ $1,223.40 090

49561 25.65$ $1,539.00 25.65$ $1,539.00 090

49565 21.25$ $1,275.00 21.25$ $1,275.00 090

49566 25.89$ $1,553.40 25.89$ $1,553.40 090

49568 7.32$ $439.20 7.32$ $439.20 ZZZ

49570 11.61$ $696.60 11.61$ $696.60 090

49572 14.32$ $859.20 14.32$ $859.20 090

49580 9.31$ $558.60 9.31$ $558.60 090

49582 13.43$ $805.80 13.43$ $805.80 090

49585 12.38$ $742.80 12.38$ $742.80 090

49587 13.23$ $793.80 13.23$ $793.80 090

49590 15.87$ $952.20 15.87$ $952.20 090

49600 19.62$ $1,177.20 19.62$ $1,177.20 090

49605 135.33$ $8,119.80 135.33$ $8,119.80 090

49606 30.86$ $1,851.60 30.86$ $1,851.60 090

49610 19.02$ $1,141.20 19.02$ $1,141.20 090

49611 16.78$ $1,006.80 16.78$ $1,006.80 090

49650 11.92$ $715.20 11.92$ $715.20 090

49651 15.47$ $928.20 15.47$ $928.20 090

49652 20.59$ $1,235.40 20.59$ $1,235.40 090

49653 25.66$ $1,539.60 25.66$ $1,539.60 090

49654 23.35$ $1,401.00 23.35$ $1,401.00 090

49655 28.51$ $1,710.60 28.51$ $1,710.60 090

49656 25.35$ $1,521.00 25.35$ $1,521.00 090



Page | 96

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

49657 36.36$ $2,181.60 36.36$ $2,181.60 090


49900 22.69$ $1,361.40 22.69$ $1,361.40 090

49904 39.80$ $2,388.00 39.80$ $2,388.00 090

49905 9.72$ $583.20 9.72$ $583.20 ZZZ



50010 20.70$ $1,242.00 20.70$ $1,242.00 090

50020 28.82$ $1,729.20 28.82$ $1,729.20 090

50040 26.25$ $1,575.00 26.25$ $1,575.00 090

50045 27.06$ $1,623.60 27.06$ $1,623.60 090

50060 32.33$ $1,939.80 32.33$ $1,939.80 090

50065 34.21$ $2,052.60 34.21$ $2,052.60 090

50070 33.55$ $2,013.00 33.55$ $2,013.00 090

50075 41.23$ $2,473.80 41.23$ $2,473.80 090

50080 24.64$ $1,478.40 24.64$ $1,478.40 090

50081 36.13$ $2,167.80 36.13$ $2,167.80 090

50100 29.78$ $1,786.80 29.78$ $1,786.80 090

50120 26.90$ $1,614.00 26.90$ $1,614.00 090

50125 29.08$ $1,744.80 29.08$ $1,744.80 090

50130 29.25$ $1,755.00 29.25$ $1,755.00 090

50135 32.08$ $1,924.80 32.08$ $1,924.80 090

50200 18.21$ $1,092.60 4.07$ $244.20 000

50205 20.87$ $1,252.20 20.87$ $1,252.20 090

50220 29.45$ $1,767.00 29.45$ $1,767.00 090

50225 33.92$ $2,035.20 33.92$ $2,035.20 090

50230 36.17$ $2,170.20 36.17$ $2,170.20 090

50234 36.75$ $2,205.00 36.75$ $2,205.00 090

50236 41.51$ $2,490.60 41.51$ $2,490.60 090

50240 37.46$ $2,247.60 37.46$ $2,247.60 090

50250 34.47$ $2,068.20 34.47$ $2,068.20 090

50280 26.96$ $1,617.60 26.96$ $1,617.60 090

50290 25.46$ $1,527.60 25.46$ $1,527.60 090


50320 40.41$ $2,424.60 40.41$ $2,424.60 090



50327 5.94$ $356.40 5.94$ $356.40 XXX

50328 5.22$ $313.20 5.22$ $313.20 XXX

50329 4.92$ $295.20 4.92$ $295.20 XXX

50340 26.08$ $1,564.80 26.08$ $1,564.80 090

50360 66.85$ $4,011.00 66.85$ $4,011.00 090



Page | 97

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

50365 78.54$ $4,712.40 78.54$ $4,712.40 090

50370 33.34$ $2,000.40 33.34$ $2,000.40 090

50380 55.10$ $3,306.00 55.10$ $3,306.00 090

50382 35.18$ $2,110.80 7.73$ $463.80 000

50384 28.00$ $1,680.00 7.02$ $421.20 000

50385 33.89$ $2,033.40 6.62$ $397.20 000

50386 22.03$ $1,321.80 5.02$ $301.20 000

50387 16.20$ $972.00 2.78$ $166.80 000

50389 8.82$ $529.20 1.55$ $93.00 000

50390 2.77$ $166.20 2.77$ $166.20 000

50391 3.47$ $208.20 2.77$ $166.20 000

50395 5.12$ $307.20 5.12$ $307.20 000

50396 3.40$ $204.00 3.40$ $204.00 000

50400 32.75$ $1,965.00 32.75$ $1,965.00 090

50405 39.52$ $2,371.20 39.52$ $2,371.20 090

50430 15.35$ $921.00 4.80$ $288.00 XXX

50431 4.76$ $285.60 1.92$ $115.20 XXX

50432 24.98$ $1,498.80 6.34$ $380.40 XXX

50433 33.65$ $2,019.00 7.81$ $468.60 XXX

50434 26.65$ $1,599.00 5.99$ $359.40 XXX

50435 14.01$ $840.60 2.93$ $175.80 XXX

50500 35.11$ $2,106.60 35.11$ $2,106.60 090

50520 31.28$ $1,876.80 31.28$ $1,876.80 090

50525 39.72$ $2,383.20 39.72$ $2,383.20 090

50526 41.81$ $2,508.60 41.81$ $2,508.60 090

50540 32.38$ $1,942.80 32.38$ $1,942.80 090

50541 26.02$ $1,561.20 26.02$ $1,561.20 090

50542 33.03$ $1,981.80 33.03$ $1,981.80 090

50543 42.09$ $2,525.40 42.09$ $2,525.40 090

50544 35.20$ $2,112.00 35.20$ $2,112.00 090

50545 37.87$ $2,272.20 37.87$ $2,272.20 090

50546 33.98$ $2,038.80 33.98$ $2,038.80 090

50547 44.74$ $2,684.40 44.74$ $2,684.40 090

50548 38.07$ $2,284.20 38.07$ $2,284.20 090


50551 10.26$ $615.60 8.34$ $500.40 000

50553 10.90$ $654.00 8.82$ $529.20 000

50555 11.70$ $702.00 9.62$ $577.20 000

50557 11.94$ $716.40 9.80$ $588.00 000

50561 13.55$ $813.00 11.18$ $670.80 000

50562 16.45$ $987.00 16.45$ $987.00 090

50570 13.90$ $834.00 13.90$ $834.00 000



Page | 98

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

50572 15.04$ $902.40 15.04$ $902.40 000

50574 15.99$ $959.40 15.99$ $959.40 000

50575 20.19$ $1,211.40 20.19$ $1,211.40 000

50576 15.96$ $957.60 15.96$ $957.60 000

50580 17.20$ $1,032.00 17.20$ $1,032.00 000

50590 20.59$ $1,235.40 16.14$ $968.40 090

50592 75.77$ $4,546.20 10.37$ $622.20 010

50593 138.45$ $8,307.00 13.74$ $824.40 010

50600 26.61$ $1,596.60 26.61$ $1,596.60 090

50605 27.36$ $1,641.60 27.36$ $1,641.60 090

50606 15.52$ $931.20 4.46$ $267.60 XXX

50610 27.58$ $1,654.80 27.58$ $1,654.80 090

50620 25.67$ $1,540.20 25.67$ $1,540.20 090

50630 25.23$ $1,513.80 25.23$ $1,513.80 090

50650 29.31$ $1,758.60 29.31$ $1,758.60 090

50660 32.46$ $1,947.60 32.46$ $1,947.60 090

50684 3.11$ $186.60 1.45$ $87.00 000

50686 4.14$ $248.40 2.51$ $150.60 000

50688 2.31$ $138.60 2.31$ $138.60 010

50690 2.85$ $171.00 2.03$ $121.80 000

50693 31.40$ $1,884.00 6.27$ $376.20 XXX

50694 34.49$ $2,069.40 8.09$ $485.40 XXX

50695 42.02$ $2,521.20 10.27$ $616.20 XXX

50700 26.34$ $1,580.40 26.34$ $1,580.40 090

50705 50.75$ $3,045.00 5.70$ $342.00 XXX

50706 22.59$ $1,355.40 5.35$ $321.00 XXX

50715 33.92$ $2,035.20 33.92$ $2,035.20 090

50722 28.93$ $1,735.80 28.93$ $1,735.80 090

50725 31.75$ $1,905.00 31.75$ $1,905.00 090

50727 14.41$ $864.60 14.41$ $864.60 090

50728 19.90$ $1,194.00 19.90$ $1,194.00 090

50740 33.69$ $2,021.40 33.69$ $2,021.40 090

50750 32.65$ $1,959.00 32.65$ $1,959.00 090

50760 31.69$ $1,901.40 31.69$ $1,901.40 090

50770 32.53$ $1,951.80 32.53$ $1,951.80 090

50780 31.22$ $1,873.20 31.22$ $1,873.20 090

50782 28.72$ $1,723.20 28.72$ $1,723.20 090

50783 31.99$ $1,919.40 31.99$ $1,919.40 090

50785 34.28$ $2,056.80 34.28$ $2,056.80 090

50800 26.16$ $1,569.60 26.16$ $1,569.60 090

50810 35.57$ $2,134.20 35.57$ $2,134.20 090

50815 34.66$ $2,079.60 34.66$ $2,079.60 090



Page | 99

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

50820 37.13$ $2,227.80 37.13$ $2,227.80 090

50825 46.80$ $2,808.00 46.80$ $2,808.00 090

50830 51.14$ $3,068.40 51.14$ $3,068.40 090

50840 34.87$ $2,092.20 34.87$ $2,092.20 090

50845 35.43$ $2,125.80 35.43$ $2,125.80 090

50860 26.79$ $1,607.40 26.79$ $1,607.40 090

50900 24.22$ $1,453.20 24.22$ $1,453.20 090

50920 25.09$ $1,505.40 25.09$ $1,505.40 090

50930 32.56$ $1,953.60 32.56$ $1,953.60 090

50940 25.18$ $1,510.80 25.18$ $1,510.80 090

50945 27.54$ $1,652.40 27.54$ $1,652.40 090

50947 39.27$ $2,356.20 39.27$ $2,356.20 090

50948 36.09$ $2,165.40 36.09$ $2,165.40 090


50951 10.70$ $642.00 8.68$ $520.80 000

50953 11.30$ $678.00 9.21$ $552.60 000

50955 12.10$ $726.00 9.98$ $598.80 000

50957 12.22$ $733.20 10.04$ $602.40 000

50961 11.02$ $661.20 8.99$ $539.40 000

50970 10.54$ $632.40 10.54$ $632.40 000

50972 10.20$ $612.00 10.20$ $612.00 000

50974 13.38$ $802.80 13.38$ $802.80 000

50976 13.18$ $790.80 13.18$ $790.80 000

50980 10.02$ $601.20 10.02$ $601.20 000

51020 13.37$ $802.20 13.37$ $802.20 090

51030 13.59$ $815.40 13.59$ $815.40 090

51040 8.26$ $495.60 8.26$ $495.60 090

51045 13.87$ $832.20 13.87$ $832.20 090

51050 13.43$ $805.80 13.43$ $805.80 090

51060 16.60$ $996.00 16.60$ $996.00 090

51065 16.43$ $985.80 16.43$ $985.80 090

51080 11.66$ $699.60 11.66$ $699.60 090

51100 1.75$ $105.00 1.10$ $66.00 000

51101 3.61$ $216.60 1.47$ $88.20 000

51102 6.53$ $391.80 4.11$ $246.60 000

51500 18.10$ $1,086.00 18.10$ $1,086.00 090

51520 16.96$ $1,017.60 16.96$ $1,017.60 090

51525 24.33$ $1,459.80 24.33$ $1,459.80 090

51530 22.39$ $1,343.40 22.39$ $1,343.40 090

51535 22.10$ $1,326.00 22.10$ $1,326.00 090

51550 27.18$ $1,630.80 27.18$ $1,630.80 090

51555 35.78$ $2,146.80 35.78$ $2,146.80 090



Page | 100

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

51565 36.70$ $2,202.00 36.70$ $2,202.00 090

51570 41.75$ $2,505.00 41.75$ $2,505.00 090

51575 51.53$ $3,091.80 51.53$ $3,091.80 090

51580 53.61$ $3,216.60 53.61$ $3,216.60 090

51585 59.60$ $3,576.00 59.60$ $3,576.00 090

51590 54.62$ $3,277.20 54.62$ $3,277.20 090

51595 61.85$ $3,711.00 61.85$ $3,711.00 090

51596 66.47$ $3,988.20 66.47$ $3,988.20 090

51597 64.82$ $3,889.20 64.82$ $3,889.20 090

51600 5.41$ $324.60 1.26$ $75.60 000

51605 1.09$ $65.40 1.09$ $65.40 000

51610 3.09$ $185.40 1.85$ $111.00 000

51700 2.39$ $143.40 1.26$ $75.60 000

51701 1.58$ $94.80 0.79$ $47.40 000

51702 2.04$ $122.40 0.86$ $51.60 000

51703 3.73$ $223.80 2.31$ $138.60 000

51705 2.63$ $157.80 1.47$ $88.20 000

51710 3.71$ $222.60 2.28$ $136.80 000

51715 8.32$ $499.20 5.65$ $339.00 000

51720 3.11$ $186.60 2.27$ $136.20 000

51725 5.45$ $327.00 5.45$ $327.00 000

51725 26 2.17$ $130.20 2.17$ $130.20 000

51725 TC 3.28$ $196.80 3.28$ $196.80 000

51726 7.69$ $461.40 7.69$ $461.40 000

51726 26 2.43$ $145.80 2.43$ $145.80 000

51726 TC 5.26$ $315.60 5.26$ $315.60 000

51727 9.09$ $545.40 9.09$ $545.40 000

51727 26 3.04$ $182.40 3.04$ $182.40 000

51727 TC 6.06$ $363.60 6.06$ $363.60 000

51728 9.18$ $550.80 9.18$ $550.80 000

51728 26 2.97$ $178.20 2.97$ $178.20 000

51728 TC 6.21$ $372.60 6.21$ $372.60 000

51729 9.90$ $594.00 9.90$ $594.00 000

51729 26 3.59$ $215.40 3.59$ $215.40 000

51729 TC 6.31$ $378.60 6.31$ $378.60 000

51736 0.45$ $27.00 0.45$ $27.00 XXX

51736 26 0.24$ $14.40 0.24$ $14.40 XXX

51736 TC 0.21$ $12.60 0.21$ $12.60 XXX

51741 0.46$ $27.60 0.46$ $27.60 XXX

51741 26 0.24$ $14.40 0.24$ $14.40 XXX

51741 TC 0.22$ $13.20 0.22$ $13.20 XXX

51784 5.59$ $335.40 5.59$ $335.40 000



Page | 101

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

51784 26 2.18$ $130.80 2.18$ $130.80 000

51784 TC 3.41$ $204.60 3.41$ $204.60 000

51785 7.61$ $456.60 7.61$ $456.60 000

51785 26 2.39$ $143.40 2.39$ $143.40 000

51785 TC 5.22$ $313.20 5.22$ $313.20 000

51792 6.20$ $372.00 6.20$ $372.00 000

51792 26 1.57$ $94.20 1.57$ $94.20 000

51792 TC 4.63$ $277.80 4.63$ $277.80 000

51797 3.26$ $195.60 3.26$ $195.60 ZZZ

51797 26 1.14$ $68.40 1.14$ $68.40 ZZZ

51797 TC 2.12$ $127.20 2.12$ $127.20 ZZZ

51798 0.56$ $33.60 0.56$ $33.60 XXX

51800 29.47$ $1,768.20 29.47$ $1,768.20 090

51820 31.19$ $1,871.40 31.19$ $1,871.40 090

51840 18.60$ $1,116.00 18.60$ $1,116.00 090

51841 22.02$ $1,321.20 22.02$ $1,321.20 090

51845 16.62$ $997.20 16.62$ $997.20 090

51860 20.98$ $1,258.80 20.98$ $1,258.80 090

51865 25.25$ $1,515.00 25.25$ $1,515.00 090

51880 13.26$ $795.60 13.26$ $795.60 090

51900 23.64$ $1,418.40 23.64$ $1,418.40 090

51920 23.82$ $1,429.20 23.82$ $1,429.20 090

51925 29.88$ $1,792.80 29.88$ $1,792.80 090

51940 46.36$ $2,781.60 46.36$ $2,781.60 090

51960 39.35$ $2,361.00 39.35$ $2,361.00 090

51980 20.23$ $1,213.80 20.23$ $1,213.80 090

51990 21.23$ $1,273.80 21.23$ $1,273.80 090

51992 23.78$ $1,426.80 23.78$ $1,426.80 090


52000 5.88$ $352.80 3.58$ $214.80 000

52001 10.58$ $634.80 8.13$ $487.80 000

52005 7.69$ $461.40 3.78$ $226.80 000

52007 12.91$ $774.60 4.70$ $282.00 000

52010 10.78$ $646.80 4.72$ $283.20 000

52204 10.73$ $643.80 4.02$ $241.20 000

52214 19.31$ $1,158.60 4.97$ $298.20 000

52224 20.16$ $1,209.60 5.75$ $345.00 000

52234 6.97$ $418.20 6.97$ $418.20 000

52235 8.18$ $490.80 8.18$ $490.80 000

52240 11.09$ $665.40 11.09$ $665.40 000

52250 6.79$ $407.40 6.79$ $407.40 000

52260 5.96$ $357.60 5.96$ $357.60 000



Page | 102

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

52265 10.61$ $636.60 4.62$ $277.20 000

52270 10.27$ $616.20 5.15$ $309.00 000

52275 13.82$ $829.20 7.04$ $422.40 000

52276 7.50$ $450.00 7.50$ $450.00 000

52277 9.15$ $549.00 9.15$ $549.00 000

52281 7.85$ $471.00 4.32$ $259.20 000

52282 9.52$ $571.20 9.52$ $571.20 000

52283 7.89$ $473.40 5.71$ $342.60 000

52285 7.98$ $478.80 5.55$ $333.00 000

52287 8.97$ $538.20 4.78$ $286.80 000

52290 6.91$ $414.60 6.91$ $414.60 000

52300 7.95$ $477.00 7.95$ $477.00 000

52301 8.22$ $493.20 8.22$ $493.20 000

52305 7.89$ $473.40 7.89$ $473.40 000

52310 6.98$ $418.80 4.30$ $258.00 000

52315 11.81$ $708.60 7.77$ $466.20 000

52317 23.28$ $1,396.80 9.83$ $589.80 000

52318 13.40$ $804.00 13.40$ $804.00 000

52320 6.99$ $419.40 6.99$ $419.40 000

52325 9.08$ $544.80 9.08$ $544.80 000

52327 7.39$ $443.40 7.39$ $443.40 000

52330 14.22$ $853.20 7.46$ $447.60 000

52332 14.27$ $856.20 4.41$ $264.60 000

52334 7.26$ $435.60 7.26$ $435.60 000

52341 8.05$ $483.00 8.05$ $483.00 000

52342 8.76$ $525.60 8.76$ $525.60 000

52343 9.74$ $584.40 9.74$ $584.40 000

52344 10.46$ $627.60 10.46$ $627.60 000

52345 11.17$ $670.20 11.17$ $670.20 000

52346 12.63$ $757.80 12.63$ $757.80 000

52351 8.58$ $514.80 8.58$ $514.80 000

52352 10.03$ $601.80 10.03$ $601.80 000

52353 11.09$ $665.40 11.09$ $665.40 000

52354 11.80$ $708.00 11.80$ $708.00 000

52355 13.22$ $793.20 13.22$ $793.20 000

52356 11.77$ $706.20 11.77$ $706.20 XXX

52400 13.55$ $813.00 13.55$ $813.00 090

52402 7.53$ $451.80 7.53$ $451.80 000

52441 36.61$ $2,196.60 6.42$ $385.20 XXX

52442 28.26$ $1,695.60 1.71$ $102.60 XXX

52450 13.39$ $803.40 13.39$ $803.40 090

52500 13.90$ $834.00 13.90$ $834.00 090



Page | 103

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

52601 23.96$ $1,437.60 23.96$ $1,437.60 090

52630 11.39$ $683.40 11.39$ $683.40 090

52640 9.02$ $541.20 9.02$ $541.20 090

52647 51.92$ $3,115.20 18.38$ $1,102.80 090

52648 53.40$ $3,204.00 19.59$ $1,175.40 090

52649 23.35$ $1,401.00 23.35$ $1,401.00 090

52700 12.54$ $752.40 12.54$ $752.40 090

53000 4.23$ $253.80 4.23$ $253.80 010

53010 8.46$ $507.60 8.46$ $507.60 090

53020 2.75$ $165.00 2.75$ $165.00 000

53025 2.05$ $123.00 2.05$ $123.00 000

53040 11.17$ $670.20 11.17$ $670.20 090

53060 5.22$ $313.20 4.67$ $280.20 010

53080 11.96$ $717.60 11.96$ $717.60 090

53085 19.03$ $1,141.80 19.03$ $1,141.80 090

53200 4.42$ $265.20 4.02$ $241.20 000

53210 21.84$ $1,310.40 21.84$ $1,310.40 090

53215 26.31$ $1,578.60 26.31$ $1,578.60 090

53220 12.92$ $775.20 12.92$ $775.20 090

53230 17.20$ $1,032.00 17.20$ $1,032.00 090

53235 17.96$ $1,077.60 17.96$ $1,077.60 090

53240 12.14$ $728.40 12.14$ $728.40 090

53250 11.65$ $699.00 11.65$ $699.00 090

53260 5.73$ $343.80 5.12$ $307.20 010

53265 6.21$ $372.60 5.28$ $316.80 010

53270 5.91$ $354.60 5.27$ $316.20 010

53275 7.45$ $447.00 7.45$ $447.00 010

53400 22.72$ $1,363.20 22.72$ $1,363.20 090

53405 24.76$ $1,485.60 24.76$ $1,485.60 090

53410 27.71$ $1,662.60 27.71$ $1,662.60 090

53415 31.99$ $1,919.40 31.99$ $1,919.40 090

53420 24.20$ $1,452.00 24.20$ $1,452.00 090

53425 26.52$ $1,591.20 26.52$ $1,591.20 090

53430 27.26$ $1,635.60 27.26$ $1,635.60 090

53431 32.73$ $1,963.80 32.73$ $1,963.80 090

53440 21.35$ $1,281.00 21.35$ $1,281.00 090

53442 22.24$ $1,334.40 22.24$ $1,334.40 090

53444 22.47$ $1,348.20 22.47$ $1,348.20 090

53445 21.38$ $1,282.80 21.38$ $1,282.80 090

53446 18.25$ $1,095.00 18.25$ $1,095.00 090

53447 22.93$ $1,375.80 22.93$ $1,375.80 090

53448 36.34$ $2,180.40 36.34$ $2,180.40 090



Page | 104

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

53449 17.36$ $1,041.60 17.36$ $1,041.60 090

53450 11.64$ $698.40 11.64$ $698.40 090

53460 13.01$ $780.60 13.01$ $780.60 090

53500 21.21$ $1,272.60 21.21$ $1,272.60 090

53502 13.83$ $829.80 13.83$ $829.80 090

53505 13.86$ $831.60 13.86$ $831.60 090

53510 17.93$ $1,075.80 17.93$ $1,075.80 090

53515 22.55$ $1,353.00 22.55$ $1,353.00 090

53520 15.82$ $949.20 15.82$ $949.20 090

53600 2.37$ $142.20 1.80$ $108.00 000

53601 2.32$ $139.20 1.52$ $91.20 000

53605 1.82$ $109.20 1.82$ $109.20 000

53620 3.31$ $198.60 2.47$ $148.20 000

53621 3.13$ $187.80 2.05$ $123.00 000

53660 2.03$ $121.80 1.19$ $71.40 000

53661 1.99$ $119.40 1.14$ $68.40 000

53665 1.08$ $64.80 1.08$ $64.80 000

53850 60.74$ $3,644.40 17.28$ $1,036.80 090

53852 55.82$ $3,349.20 17.67$ $1,060.20 090

53855 22.95$ $1,377.00 2.33$ $139.80 000

53860 45.67$ $2,740.20 6.43$ $385.80 090


54000 4.27$ $256.20 3.10$ $186.00 010

54001 5.30$ $318.00 3.94$ $236.40 010

54015 8.79$ $527.40 8.79$ $527.40 010

54050 3.80$ $228.00 3.02$ $181.20 010

54055 3.41$ $204.60 2.65$ $159.00 010

54056 4.10$ $246.00 3.19$ $191.40 010

54057 3.92$ $235.20 2.73$ $163.80 010

54060 5.16$ $309.60 3.72$ $223.20 010

54065 6.27$ $376.20 4.94$ $296.40 010

54100 5.72$ $343.20 3.58$ $214.80 000

54105 7.56$ $453.60 6.06$ $363.60 010

54110 17.91$ $1,074.60 17.91$ $1,074.60 090

54111 22.68$ $1,360.80 22.68$ $1,360.80 090

54112 26.60$ $1,596.00 26.60$ $1,596.00 090

54115 12.89$ $773.40 12.10$ $726.00 090

54120 17.94$ $1,076.40 17.94$ $1,076.40 090

54125 22.99$ $1,379.40 22.99$ $1,379.40 090

54130 33.75$ $2,025.00 33.75$ $2,025.00 090

54135 42.61$ $2,556.60 42.61$ $2,556.60 090

54150 4.40$ $264.00 2.74$ $164.40 000



Page | 105

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

54160 6.40$ $384.00 4.13$ $247.80 010

54161 5.59$ $335.40 5.59$ $335.40 010

54162 7.37$ $442.20 5.66$ $339.60 010

54163 6.26$ $375.60 6.26$ $375.60 010

54164 5.53$ $331.80 5.53$ $331.80 010

54200 3.09$ $185.40 2.41$ $144.60 010

54205 15.15$ $909.00 15.15$ $909.00 090

54220 5.85$ $351.00 3.79$ $227.40 000

54230 2.77$ $166.20 2.27$ $136.20 000

54231 4.00$ $240.00 3.30$ $198.00 000

54235 2.58$ $154.80 2.10$ $126.00 000

54240 2.91$ $174.60 2.91$ $174.60 000

54240 26 1.87$ $112.20 1.87$ $112.20 000

54240 TC 1.04$ $62.40 1.04$ $62.40 000

54250 3.44$ $206.40 3.44$ $206.40 000

54250 26 3.12$ $187.20 3.12$ $187.20 000

54250 TC 0.32$ $19.20 0.32$ $19.20 000

54300 18.20$ $1,092.00 18.20$ $1,092.00 090

54304 21.28$ $1,276.80 21.28$ $1,276.80 090

54308 20.30$ $1,218.00 20.30$ $1,218.00 090

54312 24.28$ $1,456.80 24.28$ $1,456.80 090

54316 29.55$ $1,773.00 29.55$ $1,773.00 090

54318 21.13$ $1,267.80 21.13$ $1,267.80 090

54322 21.83$ $1,309.80 21.83$ $1,309.80 090

54324 28.35$ $1,701.00 28.35$ $1,701.00 090

54326 26.81$ $1,608.60 26.81$ $1,608.60 090

54328 26.64$ $1,598.40 26.64$ $1,598.40 090

54332 30.18$ $1,810.80 30.18$ $1,810.80 090

54336 35.21$ $2,112.60 35.21$ $2,112.60 090

54340 16.21$ $972.60 16.21$ $972.60 090

54344 28.68$ $1,720.80 28.68$ $1,720.80 090

54348 28.73$ $1,723.80 28.73$ $1,723.80 090

54352 40.10$ $2,406.00 40.10$ $2,406.00 090

54360 20.44$ $1,226.40 20.44$ $1,226.40 090

54380 22.67$ $1,360.20 22.67$ $1,360.20 090

54385 27.52$ $1,651.20 27.52$ $1,651.20 090

54390 36.69$ $2,201.40 36.69$ $2,201.40 090

54400 15.04$ $902.40 15.04$ $902.40 090

54401 18.73$ $1,123.80 18.73$ $1,123.80 090

54405 22.92$ $1,375.20 22.92$ $1,375.20 090

54406 20.73$ $1,243.80 20.73$ $1,243.80 090

54408 22.42$ $1,345.20 22.42$ $1,345.20 090



Page | 106

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

54410 24.38$ $1,462.80 24.38$ $1,462.80 090

54411 29.07$ $1,744.20 29.07$ $1,744.20 090

54415 15.02$ $901.20 15.02$ $901.20 090

54416 20.19$ $1,211.40 20.19$ $1,211.40 090

54417 25.47$ $1,528.20 25.47$ $1,528.20 090

54420 20.00$ $1,200.00 20.00$ $1,200.00 090

54430 18.19$ $1,091.40 18.19$ $1,091.40 090

54435 11.85$ $711.00 11.85$ $711.00 090

54437 19.31$ $1,158.60 19.31$ $1,158.60 XXX

54438 38.59$ $2,315.40 38.59$ $2,315.40 XXX


54450 1.98$ $118.80 1.62$ $97.20 000

54500 2.12$ $127.20 2.12$ $127.20 000

54505 5.99$ $359.40 5.99$ $359.40 010

54512 15.31$ $918.60 15.31$ $918.60 090

54520 9.26$ $555.60 9.26$ $555.60 090

54522 17.38$ $1,042.80 17.38$ $1,042.80 090

54530 14.37$ $862.20 14.37$ $862.20 090

54535 21.11$ $1,266.60 21.11$ $1,266.60 090

54550 14.02$ $841.20 14.02$ $841.20 090

54560 19.49$ $1,169.40 19.49$ $1,169.40 090

54600 12.97$ $778.20 12.97$ $778.20 090

54620 8.57$ $514.20 8.57$ $514.20 010

54640 13.62$ $817.20 13.62$ $817.20 090

54650 20.18$ $1,210.80 20.18$ $1,210.80 090

54660 10.19$ $611.40 10.19$ $611.40 090

54670 11.54$ $692.40 11.54$ $692.40 090

54680 22.45$ $1,347.00 22.45$ $1,347.00 090

54690 20.38$ $1,222.80 20.38$ $1,222.80 090

54692 23.46$ $1,407.60 23.46$ $1,407.60 090


54700 6.08$ $364.80 6.08$ $364.80 010

54800 3.61$ $216.60 3.61$ $216.60 000

54830 10.62$ $637.20 10.62$ $637.20 090

54840 9.15$ $549.00 9.15$ $549.00 090

54860 11.93$ $715.80 11.93$ $715.80 090

54861 16.10$ $966.00 16.10$ $966.00 090

54865 10.24$ $614.40 10.24$ $614.40 090

54900 23.76$ $1,425.60 23.76$ $1,425.60 090

54901 31.28$ $1,876.80 31.28$ $1,876.80 090

55000 3.36$ $201.60 2.42$ $145.20 000

55040 9.63$ $577.80 9.63$ $577.80 090



Page | 107

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

55041 14.49$ $869.40 14.49$ $869.40 090

55060 10.84$ $650.40 10.84$ $650.40 090

55100 6.21$ $372.60 4.75$ $285.00 010

55110 11.03$ $661.80 11.03$ $661.80 090

55120 10.16$ $609.60 10.16$ $609.60 090

55150 13.97$ $838.20 13.97$ $838.20 090

55175 10.34$ $620.40 10.34$ $620.40 090

55180 19.65$ $1,179.00 19.65$ $1,179.00 090

55200 12.58$ $754.80 7.94$ $476.40 090

55250 11.15$ $669.00 6.51$ $390.60 090

55300 5.30$ $318.00 5.30$ $318.00 000

55400 14.39$ $863.40 14.39$ $863.40 090

55450 10.29$ $617.40 7.31$ $438.60 010

55500 11.21$ $672.60 11.21$ $672.60 090

55520 12.64$ $758.40 12.64$ $758.40 090

55530 10.01$ $600.60 10.01$ $600.60 090

55535 12.25$ $735.00 12.25$ $735.00 090

55540 15.06$ $903.60 15.06$ $903.60 090

55550 12.22$ $733.20 12.22$ $733.20 090


55600 12.01$ $720.60 12.01$ $720.60 090

55605 15.55$ $933.00 15.55$ $933.00 090

55650 20.38$ $1,222.80 20.38$ $1,222.80 090

55680 10.11$ $606.60 10.11$ $606.60 090

55700 6.25$ $375.00 3.95$ $237.00 000

55705 7.56$ $453.60 7.56$ $453.60 010

55706 10.62$ $637.20 10.62$ $637.20 010

55720 12.89$ $773.40 12.89$ $773.40 090

55725 16.87$ $1,012.20 16.87$ $1,012.20 090

55801 31.10$ $1,866.00 31.10$ $1,866.00 090

55810 37.25$ $2,235.00 37.25$ $2,235.00 090

55812 45.54$ $2,732.40 45.54$ $2,732.40 090

55815 50.02$ $3,001.20 50.02$ $3,001.20 090

55821 24.76$ $1,485.60 24.76$ $1,485.60 090

55831 26.78$ $1,606.80 26.78$ $1,606.80 090

55840 33.19$ $1,991.40 33.19$ $1,991.40 090

55842 33.18$ $1,990.80 33.18$ $1,990.80 090

55845 38.61$ $2,316.60 38.61$ $2,316.60 090

55860 24.81$ $1,488.60 24.81$ $1,488.60 090

55862 32.45$ $1,947.00 32.45$ $1,947.00 090

55865 37.77$ $2,266.20 37.77$ $2,266.20 090

55866 40.19$ $2,411.40 40.19$ $2,411.40 090



Page | 108

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

55870 5.00$ $300.00 4.04$ $242.40 000

55873 210.40$ $12,624.00 21.75$ $1,305.00 090

55875 21.69$ $1,301.40 21.69$ $1,301.40 090

55876 3.89$ $233.40 2.87$ $172.20 000


55920 12.76$ $765.60 12.76$ $765.60 000



56405 3.08$ $184.80 3.06$ $183.60 010

56420 3.46$ $207.60 2.56$ $153.60 010

56440 5.12$ $307.20 5.12$ $307.20 010

56441 4.08$ $244.80 3.92$ $235.20 010

56442 1.36$ $81.60 1.36$ $81.60 000

56501 3.72$ $223.20 3.25$ $195.00 010

56515 6.38$ $382.80 5.65$ $339.00 010

56605 2.33$ $139.80 1.68$ $100.80 000

56606 1.06$ $63.60 0.83$ $49.80 ZZZ

56620 14.55$ $873.00 14.55$ $873.00 090

56625 17.46$ $1,047.60 17.46$ $1,047.60 090

56630 25.65$ $1,539.00 25.65$ $1,539.00 090

56631 32.70$ $1,962.00 32.70$ $1,962.00 090

56632 38.06$ $2,283.60 38.06$ $2,283.60 090

56633 33.48$ $2,008.80 33.48$ $2,008.80 090

56634 35.89$ $2,153.40 35.89$ $2,153.40 090

56637 41.58$ $2,494.80 41.58$ $2,494.80 090

56640 41.70$ $2,502.00 41.70$ $2,502.00 090

56700 5.25$ $315.00 5.25$ $315.00 010

56740 8.40$ $504.00 8.40$ $504.00 010

56800 6.75$ $405.00 6.75$ $405.00 010

56805 32.30$ $1,938.00 32.30$ $1,938.00 090

56810 7.29$ $437.40 7.29$ $437.40 010

56820 3.16$ $189.60 2.41$ $144.60 000

56821 4.17$ $250.20 3.21$ $192.60 000

57000 5.29$ $317.40 5.29$ $317.40 010

57010 12.18$ $730.80 12.18$ $730.80 090

57020 2.60$ $156.00 2.25$ $135.00 000

57022 4.77$ $286.20 4.77$ $286.20 010

57023 8.69$ $521.40 8.69$ $521.40 010

57061 3.24$ $194.40 2.79$ $167.40 010

57065 5.48$ $328.80 4.89$ $293.40 010

57100 2.51$ $150.60 1.86$ $111.60 000

57105 3.86$ $231.60 3.56$ $213.60 010



Page | 109

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

57106 13.82$ $829.20 13.82$ $829.20 090

57107 40.19$ $2,411.40 40.19$ $2,411.40 090

57109 47.50$ $2,850.00 47.50$ $2,850.00 090

57110 24.95$ $1,497.00 24.95$ $1,497.00 090

57111 44.89$ $2,693.40 44.89$ $2,693.40 090

57112 50.79$ $3,047.40 50.79$ $3,047.40 090

57120 14.29$ $857.40 14.29$ $857.40 090

57130 5.00$ $300.00 4.47$ $268.20 010

57135 5.41$ $324.60 4.86$ $291.60 010

57150 1.28$ $76.80 0.81$ $48.60 000

57155 12.41$ $744.60 8.25$ $495.00 000

57156 5.69$ $341.40 4.18$ $250.80 000

57160 2.17$ $130.20 1.30$ $78.00 000

57170 1.71$ $102.60 1.35$ $81.00 000

57180 4.00$ $240.00 2.97$ $178.20 010

57200 8.49$ $509.40 8.49$ $509.40 090

57210 10.31$ $618.60 10.31$ $618.60 090

57220 8.98$ $538.80 8.98$ $538.80 090

57230 11.08$ $664.80 11.08$ $664.80 090

57240 18.79$ $1,127.40 18.79$ $1,127.40 090

57250 18.90$ $1,134.00 18.90$ $1,134.00 090

57260 23.26$ $1,395.60 23.26$ $1,395.60 090

57265 25.45$ $1,527.00 25.45$ $1,527.00 090

57267 7.14$ $428.40 7.14$ $428.40 ZZZ

57268 13.59$ $815.40 13.59$ $815.40 090

57270 22.31$ $1,338.60 22.31$ $1,338.60 090

57280 26.62$ $1,597.20 26.62$ $1,597.20 090

57282 14.08$ $844.80 14.08$ $844.80 090

57283 19.26$ $1,155.60 19.26$ $1,155.60 090

57284 22.79$ $1,367.40 22.79$ $1,367.40 090

57285 18.82$ $1,129.20 18.82$ $1,129.20 090

57287 19.16$ $1,149.60 19.16$ $1,149.60 090

57288 20.10$ $1,206.00 20.10$ $1,206.00 090

57289 20.68$ $1,240.80 20.68$ $1,240.80 090

57291 17.24$ $1,034.40 17.24$ $1,034.40 090

57292 22.98$ $1,378.80 22.98$ $1,378.80 090

57295 13.41$ $804.60 13.41$ $804.60 090

57296 26.44$ $1,586.40 26.44$ $1,586.40 090

57300 15.70$ $942.00 15.70$ $942.00 090

57305 25.86$ $1,551.60 25.86$ $1,551.60 090

57307 29.55$ $1,773.00 29.55$ $1,773.00 090

57308 18.44$ $1,106.40 18.44$ $1,106.40 090



Page | 110

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

57310 13.10$ $786.00 13.10$ $786.00 090

57311 14.93$ $895.80 14.93$ $895.80 090

57320 15.07$ $904.20 15.07$ $904.20 090

57330 20.93$ $1,255.80 20.93$ $1,255.80 090

57335 31.86$ $1,911.60 31.86$ $1,911.60 090

57400 3.75$ $225.00 3.75$ $225.00 000

57410 3.02$ $181.20 3.02$ $181.20 000

57415 4.51$ $270.60 4.51$ $270.60 010

57420 3.31$ $198.60 2.55$ $153.00 000

57421 4.43$ $265.80 3.46$ $207.60 000

57423 25.44$ $1,526.40 25.44$ $1,526.40 090

57425 27.07$ $1,624.20 27.07$ $1,624.20 090

57426 23.61$ $1,416.60 23.61$ $1,416.60 090

57452 3.08$ $184.80 2.59$ $155.40 000

57454 4.30$ $258.00 3.80$ $228.00 000

57455 4.03$ $241.80 3.09$ $185.40 000

57456 3.80$ $228.00 2.87$ $172.20 000

57460 8.11$ $486.60 4.55$ $273.00 000

57461 9.13$ $547.80 5.23$ $313.80 000

57500 3.67$ $220.20 2.14$ $128.40 000

57505 2.90$ $174.00 2.62$ $157.20 010

57510 3.70$ $222.00 3.24$ $194.40 010

57511 4.11$ $246.60 3.73$ $223.80 010

57513 4.09$ $245.40 3.77$ $226.20 010

57520 8.67$ $520.20 7.74$ $464.40 090

57522 7.42$ $445.20 6.85$ $411.00 090

57530 9.75$ $585.00 9.75$ $585.00 090

57531 50.14$ $3,008.40 50.14$ $3,008.40 090

57540 21.81$ $1,308.60 21.81$ $1,308.60 090

57545 23.41$ $1,404.60 23.41$ $1,404.60 090

57550 11.45$ $687.00 11.45$ $687.00 090

57555 16.79$ $1,007.40 16.79$ $1,007.40 090

57556 15.89$ $953.40 15.89$ $953.40 090

57558 3.52$ $211.20 3.19$ $191.40 010

57700 8.94$ $536.40 8.94$ $536.40 090

57720 8.65$ $519.00 8.65$ $519.00 090

57800 1.71$ $102.60 1.36$ $81.60 000

58100 3.08$ $184.80 2.45$ $147.00 000

58110 1.35$ $81.00 1.14$ $68.40 ZZZ

58120 7.28$ $436.80 6.12$ $367.20 010

58140 25.65$ $1,539.00 25.65$ $1,539.00 090

58145 15.32$ $919.20 15.32$ $919.20 090



Page | 111

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

58146 32.05$ $1,923.00 32.05$ $1,923.00 090

58150 28.14$ $1,688.40 28.14$ $1,688.40 090

58152 34.75$ $2,085.00 34.75$ $2,085.00 090

58180 26.81$ $1,608.60 26.81$ $1,608.60 090

58200 37.76$ $2,265.60 37.76$ $2,265.60 090

58210 50.80$ $3,048.00 50.80$ $3,048.00 090

58240 80.32$ $4,819.20 80.32$ $4,819.20 090

58260 23.05$ $1,383.00 23.05$ $1,383.00 090

58262 25.70$ $1,542.00 25.70$ $1,542.00 090

58263 27.57$ $1,654.20 27.57$ $1,654.20 090

58267 29.36$ $1,761.60 29.36$ $1,761.60 090

58270 24.56$ $1,473.60 24.56$ $1,473.60 090

58275 27.42$ $1,645.20 27.42$ $1,645.20 090

58280 29.25$ $1,755.00 29.25$ $1,755.00 090

58285 36.97$ $2,218.20 36.97$ $2,218.20 090

58290 32.01$ $1,920.60 32.01$ $1,920.60 090

58291 34.59$ $2,075.40 34.59$ $2,075.40 090

58292 36.51$ $2,190.60 36.51$ $2,190.60 090

58293 37.95$ $2,277.00 37.95$ $2,277.00 090

58294 33.94$ $2,036.40 33.94$ $2,036.40 090

58300 2.05$ $123.00 1.50$ $90.00 XXX

58301 2.68$ $160.80 1.88$ $112.80 000

58321 2.19$ $131.40 1.36$ $81.60 000

58322 2.43$ $145.80 1.63$ $97.80 000

58323 0.43$ $25.80 0.34$ $20.40 000

58340 3.45$ $207.00 1.65$ $99.00 000

58345 7.61$ $456.60 7.61$ $456.60 010

58346 12.76$ $765.60 12.76$ $765.60 090

58350 2.74$ $164.40 2.23$ $133.80 010

58353 29.54$ $1,772.40 6.13$ $367.80 010

58356 55.30$ $3,318.00 9.60$ $576.00 010

58400 12.35$ $741.00 12.35$ $741.00 090

58410 22.69$ $1,361.40 22.69$ $1,361.40 090

58520 23.15$ $1,389.00 23.15$ $1,389.00 090

58540 25.29$ $1,517.40 25.29$ $1,517.40 090

58541 20.02$ $1,201.20 20.02$ $1,201.20 090

58542 22.85$ $1,371.00 22.85$ $1,371.00 090

58543 23.13$ $1,387.80 23.13$ $1,387.80 090

58544 25.13$ $1,507.80 25.13$ $1,507.80 090

58545 25.08$ $1,504.80 25.08$ $1,504.80 090

58546 31.26$ $1,875.60 31.26$ $1,875.60 090

58548 52.33$ $3,139.80 52.33$ $3,139.80 090



Page | 112

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

58550 24.61$ $1,476.60 24.61$ $1,476.60 090

58552 27.48$ $1,648.80 27.48$ $1,648.80 090

58553 31.60$ $1,896.00 31.60$ $1,896.00 090

58554 36.87$ $2,212.20 36.87$ $2,212.20 090

58555 8.91$ $534.60 5.28$ $316.80 000

58558 11.52$ $691.20 7.42$ $445.20 000

58559 9.50$ $570.00 9.50$ $570.00 000

58560 10.73$ $643.80 10.73$ $643.80 000

58561 15.18$ $910.80 15.18$ $910.80 000

58562 11.89$ $713.40 8.06$ $483.60 000

58563 48.97$ $2,938.20 9.50$ $570.00 000

58565 54.75$ $3,285.00 12.12$ $727.20 090

58570 21.72$ $1,303.20 21.72$ $1,303.20 090

58571 24.82$ $1,489.20 24.82$ $1,489.20 090

58572 28.35$ $1,701.00 28.35$ $1,701.00 090

58573 33.57$ $2,014.20 33.57$ $2,014.20 090



58600 10.20$ $612.00 10.20$ $612.00 090

58605 9.25$ $555.00 9.25$ $555.00 090

58611 2.15$ $129.00 2.15$ $129.00 ZZZ

58615 6.81$ $408.60 6.81$ $408.60 010

58660 18.74$ $1,124.40 18.74$ $1,124.40 090

58661 18.03$ $1,081.80 18.03$ $1,081.80 010

58662 19.74$ $1,184.40 19.74$ $1,184.40 090

58670 10.23$ $613.80 10.23$ $613.80 090

58671 10.21$ $612.60 10.21$ $612.60 090

58672 20.44$ $1,226.40 20.44$ $1,226.40 090

58673 22.21$ $1,332.60 22.21$ $1,332.60 090


58700 21.66$ $1,299.60 21.66$ $1,299.60 090

58720 20.42$ $1,225.20 20.42$ $1,225.20 090

58740 24.53$ $1,471.80 24.53$ $1,471.80 090

58750 26.40$ $1,584.00 26.40$ $1,584.00 090

58752 25.60$ $1,536.00 25.60$ $1,536.00 090

58760 22.79$ $1,367.40 22.79$ $1,367.40 090

58770 25.03$ $1,501.80 25.03$ $1,501.80 090

58800 8.94$ $536.40 8.37$ $502.20 090

58805 11.32$ $679.20 11.32$ $679.20 090

58820 8.78$ $526.80 8.78$ $526.80 090

58822 20.55$ $1,233.00 20.55$ $1,233.00 090

58825 19.45$ $1,167.00 19.45$ $1,167.00 090



Page | 113

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

58900 12.58$ $754.80 12.58$ $754.80 090

58920 20.84$ $1,250.40 20.84$ $1,250.40 090

58925 20.75$ $1,245.00 20.75$ $1,245.00 090

58940 14.62$ $877.20 14.62$ $877.20 090

58943 32.40$ $1,944.00 32.40$ $1,944.00 090

58950 31.15$ $1,869.00 31.15$ $1,869.00 090

58951 40.01$ $2,400.60 40.01$ $2,400.60 090

58952 45.23$ $2,713.80 45.23$ $2,713.80 090

58953 55.92$ $3,355.20 55.92$ $3,355.20 090

58954 60.72$ $3,643.20 60.72$ $3,643.20 090

58956 38.10$ $2,286.00 38.10$ $2,286.00 090

58957 43.70$ $2,622.00 43.70$ $2,622.00 090

58958 48.08$ $2,884.80 48.08$ $2,884.80 090

58960 26.83$ $1,609.80 26.83$ $1,609.80 090

58970 6.24$ $374.40 5.59$ $335.40 000


58976 7.11$ $426.60 6.09$ $365.40 000


59000 3.55$ $213.00 2.22$ $133.20 000

59001 4.91$ $294.60 4.91$ $294.60 000

59012 5.53$ $331.80 5.53$ $331.80 000

59015 4.30$ $258.00 3.61$ $216.60 000

59020 2.02$ $121.20 2.02$ $121.20 000

59020 26 1.01$ $60.60 1.01$ $60.60 000

59020 TC 1.01$ $60.60 1.01$ $60.60 000

59025 1.36$ $81.60 1.36$ $81.60 000

59025 26 0.81$ $48.60 0.81$ $48.60 000

59025 TC 0.54$ $32.40 0.54$ $32.40 000

59030 2.88$ $172.80 2.88$ $172.80 000

59050 1.38$ $82.80 1.38$ $82.80 XXX

59051 1.14$ $68.40 1.14$ $68.40 XXX

59070 11.22$ $673.20 8.36$ $501.60 000

59072 13.46$ $807.60 13.46$ $807.60 000

59074 10.76$ $645.60 8.32$ $499.20 000

59076 13.46$ $807.60 13.46$ $807.60 000

59100 22.19$ $1,331.40 22.19$ $1,331.40 090

59120 21.72$ $1,303.20 21.72$ $1,303.20 090

59121 21.76$ $1,305.60 21.76$ $1,305.60 090

59130 25.38$ $1,522.80 25.38$ $1,522.80 090

59135 23.89$ $1,433.40 23.89$ $1,433.40 090

59136 23.61$ $1,416.60 23.61$ $1,416.60 090

59140 11.29$ $677.40 11.29$ $677.40 090



Page | 114

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

59150 21.07$ $1,264.20 21.07$ $1,264.20 090

59151 20.44$ $1,226.40 20.44$ $1,226.40 090

59160 5.65$ $339.00 4.74$ $284.40 010

59200 2.02$ $121.20 1.22$ $73.20 000

59300 5.39$ $323.40 4.07$ $244.20 000

59320 4.18$ $250.80 4.18$ $250.80 000

59325 6.63$ $397.80 6.63$ $397.80 000

59350 7.35$ $441.00 7.35$ $441.00 000

59400 57.54$ $3,452.40 57.54$ $3,452.40 MMM

59409 22.21$ $1,332.60 22.21$ $1,332.60 MMM

59410 28.36$ $1,701.60 28.36$ $1,701.60 MMM

59412 2.83$ $169.80 2.83$ $169.80 MMM

59414 2.49$ $149.40 2.49$ $149.40 MMM

59425 12.63$ $757.80 9.70$ $582.00 MMM

59426 22.64$ $1,358.40 17.15$ $1,029.00 MMM

59430 5.14$ $308.40 3.80$ $228.00 MMM

59510 63.59$ $3,815.40 63.59$ $3,815.40 MMM

59514 24.95$ $1,497.00 24.95$ $1,497.00 MMM

59515 34.39$ $2,063.40 34.39$ $2,063.40 MMM

59525 13.15$ $789.00 13.15$ $789.00 ZZZ

59610 60.23$ $3,613.80 60.23$ $3,613.80 MMM

59612 24.90$ $1,494.00 24.90$ $1,494.00 MMM

59614 31.02$ $1,861.20 31.02$ $1,861.20 MMM

59618 64.40$ $3,864.00 64.40$ $3,864.00 MMM

59620 25.64$ $1,538.40 25.64$ $1,538.40 MMM

59622 35.29$ $2,117.40 35.29$ $2,117.40 MMM

59812 8.80$ $528.00 8.14$ $488.40 090

59820 10.56$ $633.60 9.88$ $592.80 090

59821 10.62$ $637.20 9.88$ $592.80 090

59830 12.01$ $720.60 12.01$ $720.60 090

59840 6.01$ $360.60 5.75$ $345.00 010

59841 10.53$ $631.80 9.90$ $594.00 010

59850 10.04$ $602.40 10.04$ $602.40 090

59851 10.69$ $641.40 10.69$ $641.40 090

59852 14.56$ $873.60 14.56$ $873.60 090

59855 11.39$ $683.40 11.39$ $683.40 090

59856 13.35$ $801.00 13.35$ $801.00 090

59857 14.88$ $892.80 14.88$ $892.80 090

59866 6.22$ $373.20 6.22$ $373.20 000

59870 13.07$ $784.20 13.07$ $784.20 090

59871 3.66$ $219.60 3.66$ $219.60 000




Page | 115

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



60000 4.95$ $297.00 4.43$ $265.80 010

60100 3.24$ $194.40 2.25$ $135.00 000

60200 18.59$ $1,115.40 18.59$ $1,115.40 090

60210 19.80$ $1,188.00 19.80$ $1,188.00 090

60212 28.11$ $1,686.60 28.11$ $1,686.60 090

60220 19.87$ $1,192.20 19.87$ $1,192.20 090

60225 26.11$ $1,566.60 26.11$ $1,566.60 090

60240 25.68$ $1,540.80 25.68$ $1,540.80 090

60252 36.86$ $2,211.60 36.86$ $2,211.60 090

60254 46.86$ $2,811.60 46.86$ $2,811.60 090

60260 30.59$ $1,835.40 30.59$ $1,835.40 090

60270 38.04$ $2,282.40 38.04$ $2,282.40 090

60271 29.58$ $1,774.80 29.58$ $1,774.80 090

60280 12.69$ $761.40 12.69$ $761.40 090

60281 16.77$ $1,006.20 16.77$ $1,006.20 090

60300 3.46$ $207.60 1.41$ $84.60 000

60500 26.88$ $1,612.80 26.88$ $1,612.80 090

60502 35.75$ $2,145.00 35.75$ $2,145.00 090

60505 38.64$ $2,318.40 38.64$ $2,318.40 090

60512 6.73$ $403.80 6.73$ $403.80 ZZZ

60520 28.83$ $1,729.80 28.83$ $1,729.80 090

60521 30.97$ $1,858.20 30.97$ $1,858.20 090

60522 37.42$ $2,245.20 37.42$ $2,245.20 090

60540 29.52$ $1,771.20 29.52$ $1,771.20 090

60545 33.82$ $2,029.20 33.82$ $2,029.20 090

60600 38.58$ $2,314.80 38.58$ $2,314.80 090

60605 47.45$ $2,847.00 47.45$ $2,847.00 090

60650 33.08$ $1,984.80 33.08$ $1,984.80 090



61000 3.10$ $186.00 3.10$ $186.00 000

61001 2.40$ $144.00 2.40$ $144.00 000

61020 2.79$ $167.40 2.79$ $167.40 000

61026 2.92$ $175.20 2.92$ $175.20 000

61050 2.44$ $146.40 2.44$ $146.40 000

61055 3.38$ $202.80 3.38$ $202.80 000

61070 1.63$ $97.80 1.63$ $97.80 000

61105 12.58$ $754.80 12.58$ $754.80 090

61107 8.45$ $507.00 8.45$ $507.00 000

61108 24.88$ $1,492.80 24.88$ $1,492.80 090



Page | 116

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

61120 20.36$ $1,221.60 20.36$ $1,221.60 090

61140 34.43$ $2,065.80 34.43$ $2,065.80 090

61150 36.34$ $2,180.40 36.34$ $2,180.40 090

61151 27.10$ $1,626.00 27.10$ $1,626.00 090

61154 34.63$ $2,077.80 34.63$ $2,077.80 090

61156 33.75$ $2,025.00 33.75$ $2,025.00 090

61210 9.89$ $593.40 9.89$ $593.40 000

61215 14.01$ $840.60 14.01$ $840.60 090

61250 22.48$ $1,348.80 22.48$ $1,348.80 090

61253 23.25$ $1,395.00 23.25$ $1,395.00 090

61304 44.60$ $2,676.00 44.60$ $2,676.00 090

61305 54.21$ $3,252.60 54.21$ $3,252.60 090

61312 56.24$ $3,374.40 56.24$ $3,374.40 090

61313 53.82$ $3,229.20 53.82$ $3,229.20 090

61314 49.47$ $2,968.20 49.47$ $2,968.20 090

61315 55.96$ $3,357.60 55.96$ $3,357.60 090

61316 2.35$ $141.00 2.35$ $141.00 ZZZ

61320 51.50$ $3,090.00 51.50$ $3,090.00 090

61321 56.86$ $3,411.60 56.86$ $3,411.60 090

61322 64.30$ $3,858.00 64.30$ $3,858.00 090

61323 64.80$ $3,888.00 64.80$ $3,888.00 090

61330 46.58$ $2,794.80 46.58$ $2,794.80 090

61332 51.71$ $3,102.60 51.71$ $3,102.60 090

61333 52.94$ $3,176.40 52.94$ $3,176.40 090

61340 38.93$ $2,335.80 38.93$ $2,335.80 090

61343 59.40$ $3,564.00 59.40$ $3,564.00 090

61345 55.04$ $3,302.40 55.04$ $3,302.40 090

61450 51.97$ $3,118.20 51.97$ $3,118.20 090

61458 54.30$ $3,258.00 54.30$ $3,258.00 090

61460 57.03$ $3,421.80 57.03$ $3,421.80 090

61480 45.84$ $2,750.40 45.84$ $2,750.40 090

61500 36.34$ $2,180.40 36.34$ $2,180.40 090

61501 31.86$ $1,911.60 31.86$ $1,911.60 090

61510 59.24$ $3,554.40 59.24$ $3,554.40 090

61512 68.85$ $4,131.00 68.85$ $4,131.00 090

61514 51.48$ $3,088.80 51.48$ $3,088.80 090

61516 50.28$ $3,016.80 50.28$ $3,016.80 090

61517 2.35$ $141.00 2.35$ $141.00 ZZZ

61518 74.53$ $4,471.80 74.53$ $4,471.80 090

61519 79.13$ $4,747.80 79.13$ $4,747.80 090

61520 102.07$ $6,124.20 102.07$ $6,124.20 090

61521 84.92$ $5,095.20 84.92$ $5,095.20 090



Page | 117

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

61522 58.66$ $3,519.60 58.66$ $3,519.60 090

61524 55.93$ $3,355.80 55.93$ $3,355.80 090

61526 98.58$ $5,914.80 98.58$ $5,914.80 090

61530 83.10$ $4,986.00 83.10$ $4,986.00 090

61531 33.12$ $1,987.20 33.12$ $1,987.20 090

61533 41.18$ $2,470.80 41.18$ $2,470.80 090

61534 44.30$ $2,658.00 44.30$ $2,658.00 090

61535 27.18$ $1,630.80 27.18$ $1,630.80 090

61536 69.76$ $4,185.60 69.76$ $4,185.60 090

61537 66.35$ $3,981.00 66.35$ $3,981.00 090

61538 71.97$ $4,318.20 71.97$ $4,318.20 090

61539 63.52$ $3,811.20 63.52$ $3,811.20 090

61540 59.14$ $3,548.40 59.14$ $3,548.40 090

61541 58.21$ $3,492.60 58.21$ $3,492.60 090

61543 57.86$ $3,471.60 57.86$ $3,471.60 090

61544 51.54$ $3,092.40 51.54$ $3,092.40 090

61545 86.15$ $5,169.00 86.15$ $5,169.00 090

61546 62.47$ $3,748.20 62.47$ $3,748.20 090

61548 42.90$ $2,574.00 42.90$ $2,574.00 090

61550 27.44$ $1,646.40 27.44$ $1,646.40 090

61552 32.87$ $1,972.20 32.87$ $1,972.20 090

61556 43.44$ $2,606.40 43.44$ $2,606.40 090

61557 43.76$ $2,625.60 43.76$ $2,625.60 090

61558 50.98$ $3,058.80 50.98$ $3,058.80 090

61559 58.94$ $3,536.40 58.94$ $3,536.40 090

61563 51.76$ $3,105.60 51.76$ $3,105.60 090

61564 63.38$ $3,802.80 63.38$ $3,802.80 090

61566 60.70$ $3,642.00 60.70$ $3,642.00 090

61567 69.40$ $4,164.00 69.40$ $4,164.00 090

61570 50.52$ $3,031.20 50.52$ $3,031.20 090

61571 53.74$ $3,224.40 53.74$ $3,224.40 090

61575 60.54$ $3,632.40 60.54$ $3,632.40 090

61576 102.14$ $6,128.40 102.14$ $6,128.40 090

61580 70.45$ $4,227.00 70.45$ $4,227.00 090

61581 76.11$ $4,566.60 76.11$ $4,566.60 090

61582 80.42$ $4,825.20 80.42$ $4,825.20 090

61583 79.03$ $4,741.80 79.03$ $4,741.80 090

61584 78.10$ $4,686.00 78.10$ $4,686.00 090

61585 87.87$ $5,272.20 87.87$ $5,272.20 090

61586 66.68$ $4,000.80 66.68$ $4,000.80 090

61590 85.86$ $5,151.60 85.86$ $5,151.60 090

61591 86.91$ $5,214.60 86.91$ $5,214.60 090



Page | 118

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

61592 86.79$ $5,207.40 86.79$ $5,207.40 090

61595 66.31$ $3,978.60 66.31$ $3,978.60 090

61596 69.50$ $4,170.00 69.50$ $4,170.00 090

61597 76.95$ $4,617.00 76.95$ $4,617.00 090

61598 77.60$ $4,656.00 77.60$ $4,656.00 090

61600 60.26$ $3,615.60 60.26$ $3,615.60 090

61601 66.44$ $3,986.40 66.44$ $3,986.40 090

61605 61.90$ $3,714.00 61.90$ $3,714.00 090

61606 81.68$ $4,900.80 81.68$ $4,900.80 090

61607 75.39$ $4,523.40 75.39$ $4,523.40 090

61608 88.47$ $5,308.20 88.47$ $5,308.20 090

61611 10.95$ $657.00 10.95$ $657.00 ZZZ

61612 41.13$ $2,467.80 41.13$ $2,467.80 ZZZ

61613 88.30$ $5,298.00 88.30$ $5,298.00 090

61615 64.86$ $3,891.60 64.86$ $3,891.60 090

61616 91.38$ $5,482.80 91.38$ $5,482.80 090

61618 35.58$ $2,134.80 35.58$ $2,134.80 090

61619 39.95$ $2,397.00 39.95$ $2,397.00 090

61623 15.58$ $934.80 15.58$ $934.80 000

61624 31.21$ $1,872.60 31.21$ $1,872.60 000

61626 24.16$ $1,449.60 24.16$ $1,449.60 000

61630 36.53$ $2,191.80 36.53$ $2,191.80 XXX

61635 39.43$ $2,365.80 39.43$ $2,365.80 XXX

61640 18.21$ $1,092.60 18.21$ $1,092.60 000

61641 6.39$ $383.40 6.39$ $383.40 ZZZ

61642 12.80$ $768.00 12.80$ $768.00 ZZZ

61645 21.39$ $1,283.40 21.39$ $1,283.40 XXX

61650 14.40$ $864.00 14.40$ $864.00 XXX

61651 6.11$ $366.60 6.11$ $366.60 XXX

61680 60.69$ $3,641.40 60.69$ $3,641.40 090

61682 111.92$ $6,715.20 111.92$ $6,715.20 090

61684 76.92$ $4,615.20 76.92$ $4,615.20 090

61686 120.63$ $7,237.80 120.63$ $7,237.80 090

61690 58.70$ $3,522.00 58.70$ $3,522.00 090

61692 98.29$ $5,897.40 98.29$ $5,897.40 090

61697 113.72$ $6,823.20 113.72$ $6,823.20 090

61698 124.41$ $7,464.60 124.41$ $7,464.60 090

61700 91.74$ $5,504.40 91.74$ $5,504.40 090

61702 108.01$ $6,480.60 108.01$ $6,480.60 090

61703 36.97$ $2,218.20 36.97$ $2,218.20 090

61705 69.82$ $4,189.20 69.82$ $4,189.20 090

61708 59.99$ $3,599.40 59.99$ $3,599.40 090



Page | 119

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

61710 58.22$ $3,493.20 58.22$ $3,493.20 090

61711 70.09$ $4,205.40 70.09$ $4,205.40 090

61720 34.55$ $2,073.00 34.55$ $2,073.00 090

61735 42.68$ $2,560.80 42.68$ $2,560.80 090

61750 38.08$ $2,284.80 38.08$ $2,284.80 090

61751 37.56$ $2,253.60 37.56$ $2,253.60 090

61760 42.89$ $2,573.40 42.89$ $2,573.40 090

61770 43.77$ $2,626.20 43.77$ $2,626.20 090

61781 6.33$ $379.80 6.33$ $379.80 ZZZ

61782 4.96$ $297.60 4.96$ $297.60 ZZZ

61783 6.29$ $377.40 6.29$ $377.40 ZZZ

61790 24.05$ $1,443.00 24.05$ $1,443.00 090

61791 29.20$ $1,752.00 29.20$ $1,752.00 090

61796 27.61$ $1,656.60 27.61$ $1,656.60 090

61797 5.91$ $354.60 5.91$ $354.60 ZZZ

61798 37.50$ $2,250.00 37.50$ $2,250.00 090

61799 8.15$ $489.00 8.15$ $489.00 ZZZ

61800 4.18$ $250.80 4.18$ $250.80 ZZZ

61850 26.75$ $1,605.00 26.75$ $1,605.00 090

61860 42.44$ $2,546.40 42.44$ $2,546.40 090

61863 40.82$ $2,449.20 40.82$ $2,449.20 090

61864 7.63$ $457.80 7.63$ $457.80 ZZZ

61867 61.61$ $3,696.60 61.61$ $3,696.60 090

61868 13.40$ $804.00 13.40$ $804.00 ZZZ

61880 15.74$ $944.40 15.74$ $944.40 090

61885 14.31$ $858.60 14.31$ $858.60 090

61886 23.36$ $1,401.60 23.36$ $1,401.60 090

61888 10.83$ $649.80 10.83$ $649.80 010

62000 28.09$ $1,685.40 28.09$ $1,685.40 090

62005 33.83$ $2,029.80 33.83$ $2,029.80 090

62010 41.49$ $2,489.40 41.49$ $2,489.40 090

62100 43.56$ $2,613.60 43.56$ $2,613.60 090

62115 37.06$ $2,223.60 37.06$ $2,223.60 090

62117 46.35$ $2,781.00 46.35$ $2,781.00 090

62120 47.73$ $2,863.80 47.73$ $2,863.80 090

62121 44.67$ $2,680.20 44.67$ $2,680.20 090

62140 28.27$ $1,696.20 28.27$ $1,696.20 090

62141 31.10$ $1,866.00 31.10$ $1,866.00 090

62142 24.27$ $1,456.20 24.27$ $1,456.20 090

62143 28.30$ $1,698.00 28.30$ $1,698.00 090

62145 38.34$ $2,300.40 38.34$ $2,300.40 090

62146 33.74$ $2,024.40 33.74$ $2,024.40 090



Page | 120

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

62147 38.77$ $2,326.20 38.77$ $2,326.20 090

62148 3.41$ $204.60 3.41$ $204.60 ZZZ

62160 5.10$ $306.00 5.10$ $306.00 ZZZ

62161 41.26$ $2,475.60 41.26$ $2,475.60 090

62162 51.07$ $3,064.20 51.07$ $3,064.20 090

62163 31.01$ $1,860.60 31.01$ $1,860.60 090

62164 56.35$ $3,381.00 56.35$ $3,381.00 090

62165 42.51$ $2,550.60 42.51$ $2,550.60 090

62180 43.29$ $2,597.40 43.29$ $2,597.40 090

62190 24.20$ $1,452.00 24.20$ $1,452.00 090

62192 26.61$ $1,596.60 26.61$ $1,596.60 090

62194 12.74$ $764.40 12.74$ $764.40 010

62200 37.30$ $2,238.00 37.30$ $2,238.00 090

62201 32.89$ $1,973.40 32.89$ $1,973.40 090

62220 28.05$ $1,683.00 28.05$ $1,683.00 090

62223 28.70$ $1,722.00 28.70$ $1,722.00 090

62225 14.47$ $868.20 14.47$ $868.20 090

62230 23.00$ $1,380.00 23.00$ $1,380.00 090

62252 2.41$ $144.60 2.41$ $144.60 XXX

62252 26 1.25$ $75.00 1.25$ $75.00 XXX

62252 TC 1.16$ $69.60 1.16$ $69.60 XXX

62256 16.44$ $986.40 16.44$ $986.40 090

62258 30.66$ $1,839.60 30.66$ $1,839.60 090

62263 19.20$ $1,152.00 9.86$ $591.60 010

62264 12.31$ $738.60 6.84$ $410.40 010

62267 7.21$ $432.60 4.57$ $274.20 000

62268 7.41$ $444.60 7.41$ $444.60 000

62269 7.69$ $461.40 7.69$ $461.40 000

62270 4.62$ $277.20 2.20$ $132.00 000

62272 5.85$ $351.00 2.32$ $139.20 000

62273 5.02$ $301.20 3.25$ $195.00 000

62280 8.91$ $534.60 4.60$ $276.00 010

62281 6.95$ $417.00 4.46$ $267.60 010

62282 8.56$ $513.60 4.15$ $249.00 010

62284 5.33$ $319.80 2.45$ $147.00 000

62287 16.28$ $976.80 16.28$ $976.80 090

62290 9.76$ $585.60 4.95$ $297.00 000

62291 9.69$ $581.40 4.92$ $295.20 000

62292 16.85$ $1,011.00 16.85$ $1,011.00 090

62294 22.73$ $1,363.80 22.73$ $1,363.80 090

62302 7.04$ $422.40 3.51$ $210.60 XXX

62303 7.32$ $439.20 3.57$ $214.20 XXX



Page | 121

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

62304 6.97$ $418.20 3.46$ $207.60 XXX

62305 7.61$ $456.60 3.61$ $216.60 XXX

62310 7.05$ $423.00 3.12$ $187.20 000

62311 6.52$ $391.20 2.57$ $154.20 000

62318 6.74$ $404.40 2.83$ $169.80 000

62319 4.88$ $292.80 2.73$ $163.80 000

62350 11.33$ $679.80 11.33$ $679.80 010

62351 24.09$ $1,445.40 24.09$ $1,445.40 090

62355 7.64$ $458.40 7.64$ $458.40 010

62360 8.79$ $527.40 8.79$ $527.40 010

62361 10.13$ $607.80 10.13$ $607.80 010

62362 10.88$ $652.80 10.88$ $652.80 010

62365 8.37$ $502.20 8.37$ $502.20 010

62367 1.19$ $71.40 0.72$ $43.20 XXX

62368 1.64$ $98.40 1.00$ $60.00 XXX

62369 3.55$ $213.00 1.02$ $61.20 XXX

62370 3.72$ $223.20 1.33$ $79.80 XXX

63001 33.87$ $2,032.20 33.87$ $2,032.20 090

63003 33.82$ $2,029.20 33.82$ $2,029.20 090

63005 32.43$ $1,945.80 32.43$ $1,945.80 090

63011 30.37$ $1,822.20 30.37$ $1,822.20 090

63012 32.72$ $1,963.20 32.72$ $1,963.20 090

63015 40.47$ $2,428.20 40.47$ $2,428.20 090

63016 41.53$ $2,491.80 41.53$ $2,491.80 090

63017 34.30$ $2,058.00 34.30$ $2,058.00 090

63020 31.96$ $1,917.60 31.96$ $1,917.60 090

63030 26.80$ $1,608.00 26.80$ $1,608.00 090

63035 5.23$ $313.80 5.23$ $313.80 ZZZ

63040 38.27$ $2,296.20 38.27$ $2,296.20 090

63042 35.82$ $2,149.20 35.82$ $2,149.20 090

63043 20.14$ $1,208.40 20.14$ $1,208.40 ZZZ

63044 18.71$ $1,122.60 18.71$ $1,122.60 ZZZ

63045 35.31$ $2,118.60 35.31$ $2,118.60 090

63046 33.66$ $2,019.60 33.66$ $2,019.60 090

63047 30.46$ $1,827.60 30.46$ $1,827.60 090

63048 5.77$ $346.20 5.77$ $346.20 ZZZ

63050 41.06$ $2,463.60 41.06$ $2,463.60 090

63051 47.07$ $2,824.20 47.07$ $2,824.20 090

63055 44.36$ $2,661.60 44.36$ $2,661.60 090

63056 40.75$ $2,445.00 40.75$ $2,445.00 090

63057 8.74$ $524.40 8.74$ $524.40 ZZZ

63064 48.39$ $2,903.40 48.39$ $2,903.40 090



Page | 122

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

63066 5.55$ $333.00 5.55$ $333.00 ZZZ

63075 37.25$ $2,235.00 37.25$ $2,235.00 090

63076 6.71$ $402.60 6.71$ $402.60 ZZZ

63077 41.32$ $2,479.20 41.32$ $2,479.20 090

63078 5.36$ $321.60 5.36$ $321.60 ZZZ

63081 48.25$ $2,895.00 48.25$ $2,895.00 090

63082 7.26$ $435.60 7.26$ $435.60 ZZZ

63085 52.38$ $3,142.80 52.38$ $3,142.80 090

63086 5.19$ $311.40 5.19$ $311.40 ZZZ

63087 66.04$ $3,962.40 66.04$ $3,962.40 090

63088 7.10$ $426.00 7.10$ $426.00 ZZZ

63090 54.26$ $3,255.60 54.26$ $3,255.60 090

63091 4.90$ $294.00 4.90$ $294.00 ZZZ

63101 63.22$ $3,793.20 63.22$ $3,793.20 090

63102 62.52$ $3,751.20 62.52$ $3,751.20 090

63103 8.01$ $480.60 8.01$ $480.60 ZZZ

63170 43.30$ $2,598.00 43.30$ $2,598.00 090

63172 37.86$ $2,271.60 37.86$ $2,271.60 090

63173 46.41$ $2,784.60 46.41$ $2,784.60 090

63180 40.43$ $2,425.80 40.43$ $2,425.80 090

63182 38.27$ $2,296.20 38.27$ $2,296.20 090

63185 31.50$ $1,890.00 31.50$ $1,890.00 090

63190 35.12$ $2,107.20 35.12$ $2,107.20 090

63191 37.09$ $2,225.40 37.09$ $2,225.40 090

63194 43.47$ $2,608.20 43.47$ $2,608.20 090

63195 41.74$ $2,504.40 41.74$ $2,504.40 090

63196 39.96$ $2,397.60 39.96$ $2,397.60 090

63197 46.48$ $2,788.80 46.48$ $2,788.80 090

63198 47.04$ $2,822.40 47.04$ $2,822.40 090

63199 49.36$ $2,961.60 49.36$ $2,961.60 090

63200 41.66$ $2,499.60 41.66$ $2,499.60 090

63250 76.52$ $4,591.20 76.52$ $4,591.20 090

63251 81.89$ $4,913.40 81.89$ $4,913.40 090

63252 81.81$ $4,908.60 81.81$ $4,908.60 090

63265 45.42$ $2,725.20 45.42$ $2,725.20 090

63266 46.71$ $2,802.60 46.71$ $2,802.60 090

63267 37.53$ $2,251.80 37.53$ $2,251.80 090

63268 38.97$ $2,338.20 38.97$ $2,338.20 090

63270 56.21$ $3,372.60 56.21$ $3,372.60 090

63271 55.95$ $3,357.00 55.95$ $3,357.00 090

63272 51.37$ $3,082.20 51.37$ $3,082.20 090

63273 50.45$ $3,027.00 50.45$ $3,027.00 090



Page | 123

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

63275 48.84$ $2,930.40 48.84$ $2,930.40 090

63276 48.51$ $2,910.60 48.51$ $2,910.60 090

63277 42.42$ $2,545.20 42.42$ $2,545.20 090

63278 43.20$ $2,592.00 43.20$ $2,592.00 090

63280 57.21$ $3,432.60 57.21$ $3,432.60 090

63281 56.58$ $3,394.80 56.58$ $3,394.80 090

63282 53.36$ $3,201.60 53.36$ $3,201.60 090

63283 51.25$ $3,075.00 51.25$ $3,075.00 090

63285 70.71$ $4,242.60 70.71$ $4,242.60 090

63286 69.79$ $4,187.40 69.79$ $4,187.40 090

63287 74.28$ $4,456.80 74.28$ $4,456.80 090

63290 74.74$ $4,484.40 74.74$ $4,484.40 090

63295 8.92$ $535.20 8.92$ $535.20 ZZZ

63300 50.03$ $3,001.80 50.03$ $3,001.80 090

63301 59.55$ $3,573.00 59.55$ $3,573.00 090

63302 58.74$ $3,524.40 58.74$ $3,524.40 090

63303 62.29$ $3,737.40 62.29$ $3,737.40 090

63304 63.23$ $3,793.80 63.23$ $3,793.80 090

63305 65.94$ $3,956.40 65.94$ $3,956.40 090

63306 63.85$ $3,831.00 63.85$ $3,831.00 090

63307 63.41$ $3,804.60 63.41$ $3,804.60 090

63308 8.76$ $525.60 8.76$ $525.60 ZZZ

63600 26.10$ $1,566.00 26.10$ $1,566.00 090

63610 12.22$ $733.20 12.22$ $733.20 000

63615 27.61$ $1,656.60 27.61$ $1,656.60 090

63620 30.36$ $1,821.60 30.36$ $1,821.60 090

63621 6.80$ $408.00 6.80$ $408.00 ZZZ

63650 39.30$ $2,358.00 11.87$ $712.20 010

63655 22.82$ $1,369.20 22.82$ $1,369.20 090

63661 16.85$ $1,011.00 9.14$ $548.40 010

63662 23.02$ $1,381.20 23.02$ $1,381.20 090

63663 23.00$ $1,380.00 12.90$ $774.00 010

63664 23.72$ $1,423.20 23.72$ $1,423.20 090

63685 10.34$ $620.40 10.34$ $620.40 010

63688 10.42$ $625.20 10.42$ $625.20 010

63700 32.76$ $1,965.60 32.76$ $1,965.60 090

63702 35.85$ $2,151.00 35.85$ $2,151.00 090

63704 44.95$ $2,697.00 44.95$ $2,697.00 090

63706 47.16$ $2,829.60 47.16$ $2,829.60 090

63707 25.40$ $1,524.00 25.40$ $1,524.00 090

63709 30.37$ $1,822.20 30.37$ $1,822.20 090

63710 29.95$ $1,797.00 29.95$ $1,797.00 090



Page | 124

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

63740 25.85$ $1,551.00 25.85$ $1,551.00 090

63741 18.63$ $1,117.80 18.63$ $1,117.80 090

63744 18.46$ $1,107.60 18.46$ $1,107.60 090

63746 16.53$ $991.80 16.53$ $991.80 090

64400 3.66$ $219.60 1.98$ $118.80 000

64402 3.71$ $222.60 2.18$ $130.80 000

64405 2.89$ $173.40 1.77$ $106.20 000

64408 2.94$ $176.40 2.12$ $127.20 000

64410 3.54$ $212.40 1.98$ $118.80 000

64413 3.64$ $218.40 2.28$ $136.80 000

64415 3.41$ $204.60 1.83$ $109.80 000

64416 2.22$ $133.20 2.22$ $133.20 000

64417 3.74$ $224.40 2.01$ $120.60 000

64418 4.23$ $253.80 2.17$ $130.20 000

64420 3.26$ $195.60 1.95$ $117.00 000

64421 4.37$ $262.20 2.63$ $157.80 000

64425 3.78$ $226.80 2.64$ $158.40 000

64430 4.01$ $240.60 2.34$ $140.40 000

64435 3.92$ $235.20 2.36$ $141.60 000

64445 3.93$ $235.80 2.03$ $121.80 000

64446 2.23$ $133.80 2.23$ $133.80 000

64447 3.46$ $207.60 1.87$ $112.20 000

64448 2.00$ $120.00 2.00$ $120.00 000

64449 2.36$ $141.60 2.36$ $141.60 000

64450 2.32$ $139.20 1.31$ $78.60 000

64455 1.37$ $82.20 0.99$ $59.40 000

64461 4.28$ $256.80 2.45$ $147.00 XXX

64462 2.41$ $144.60 1.55$ $93.00 XXX

64463 4.68$ $280.80 2.38$ $142.80 XXX

64479 6.88$ $412.80 3.80$ $228.00 000

64480 3.28$ $196.80 1.80$ $108.00 ZZZ

64483 6.43$ $385.80 3.25$ $195.00 000

64484 2.55$ $153.00 1.49$ $89.40 ZZZ

64486 3.61$ $216.60 1.79$ $107.40 XXX

64487 4.45$ $267.00 2.09$ $125.40 XXX

64488 4.45$ $267.00 2.26$ $135.60 XXX

64489 6.23$ $373.80 2.55$ $153.00 XXX

64490 5.56$ $333.60 3.06$ $183.60 000

64491 2.72$ $163.20 1.72$ $103.20 ZZZ

64492 2.73$ $163.80 1.75$ $105.00 ZZZ

64493 5.06$ $303.60 2.62$ $157.20 000

64494 2.51$ $150.60 1.48$ $88.80 ZZZ



Page | 125

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

64495 2.52$ $151.20 1.51$ $90.60 ZZZ

64505 3.00$ $180.00 2.49$ $149.40 000

64508 1.75$ $105.00 2.09$ $125.40 000

64510 3.71$ $222.60 2.12$ $127.20 000

64517 5.28$ $316.80 3.51$ $210.60 000

64520 5.47$ $328.20 2.33$ $139.80 000

64530 5.59$ $335.40 2.65$ $159.00 000

64550 0.46$ $27.60 0.25$ $15.00 000

64553 6.05$ $363.00 4.50$ $270.00 010

64555 6.10$ $366.00 4.40$ $264.00 010

64561 23.92$ $1,435.20 8.56$ $513.60 010

64565 5.48$ $328.80 3.77$ $226.20 010

64566 3.74$ $224.40 0.86$ $51.60 000

64568 18.10$ $1,086.00 18.10$ $1,086.00 090

64569 21.52$ $1,291.20 21.52$ $1,291.20 090

64570 17.95$ $1,077.00 17.95$ $1,077.00 090

64575 9.00$ $540.00 9.00$ $540.00 090

64580 8.44$ $506.40 8.44$ $506.40 090

64581 18.71$ $1,122.60 18.71$ $1,122.60 090

64585 7.10$ $426.00 4.09$ $245.40 010

64590 7.66$ $459.60 4.57$ $274.20 010

64595 7.16$ $429.60 3.62$ $217.20 010

64600 11.24$ $674.40 6.15$ $369.00 010

64605 21.14$ $1,268.40 11.09$ $665.40 010

64610 20.81$ $1,248.60 13.29$ $797.40 010

64611 3.27$ $196.20 2.83$ $169.80 010

64612 3.74$ $224.40 3.31$ $198.60 010

64615 3.93$ $235.80 3.36$ $201.60 010

64616 3.46$ $207.60 2.96$ $177.60 XXX

64617 5.50$ $330.00 3.36$ $201.60 XXX

64620 5.87$ $352.20 4.93$ $295.80 010

64630 6.60$ $396.00 5.45$ $327.00 010

64632 2.46$ $147.60 1.98$ $118.80 010

64633 12.38$ $742.80 6.55$ $393.00 010

64634 5.60$ $336.00 1.96$ $117.60 ZZZ

64635 12.24$ $734.40 6.46$ $387.60 010

64636 5.10$ $306.00 1.72$ $103.20 ZZZ

64640 3.89$ $233.40 2.70$ $162.00 010

64642 3.98$ $238.80 3.01$ $180.60 XXX

64643 2.60$ $156.00 2.01$ $120.60 XXX

64644 4.59$ $275.40 3.30$ $198.00 XXX

64645 3.20$ $192.00 2.29$ $137.40 XXX



Page | 126

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

64646 4.21$ $252.60 3.24$ $194.40 XXX

64647 4.97$ $298.20 3.78$ $226.80 XXX

64650 2.22$ $133.20 1.17$ $70.20 000

64653 2.73$ $163.80 1.47$ $88.20 000

64680 9.04$ $542.40 4.77$ $286.20 010

64681 9.96$ $597.60 5.42$ $325.20 010

64702 14.20$ $852.00 14.20$ $852.00 090

64704 9.12$ $547.20 9.12$ $547.20 090

64708 14.07$ $844.20 14.07$ $844.20 090

64712 16.17$ $970.20 16.17$ $970.20 090

64713 20.30$ $1,218.00 20.30$ $1,218.00 090

64714 18.12$ $1,087.20 18.12$ $1,087.20 090

64716 15.32$ $919.20 15.32$ $919.20 090

64718 16.75$ $1,005.00 16.75$ $1,005.00 090

64719 11.33$ $679.80 11.33$ $679.80 090

64721 12.18$ $730.80 12.10$ $726.00 090

64722 10.44$ $626.40 10.44$ $626.40 090

64726 7.89$ $473.40 7.89$ $473.40 090

64727 5.11$ $306.60 5.11$ $306.60 ZZZ

64732 10.63$ $637.80 10.63$ $637.80 090

64734 11.81$ $708.60 11.81$ $708.60 090

64736 11.33$ $679.80 11.33$ $679.80 090

64738 12.04$ $722.40 12.04$ $722.40 090

64740 13.10$ $786.00 13.10$ $786.00 090

64742 14.05$ $843.00 14.05$ $843.00 090

64744 13.48$ $808.80 13.48$ $808.80 090

64746 12.42$ $745.20 12.42$ $745.20 090

64755 25.35$ $1,521.00 25.35$ $1,521.00 090

64760 14.08$ $844.80 14.08$ $844.80 090

64763 14.13$ $847.80 14.13$ $847.80 090

64766 17.04$ $1,022.40 17.04$ $1,022.40 090

64771 16.96$ $1,017.60 16.96$ $1,017.60 090

64772 15.74$ $944.40 15.74$ $944.40 090

64774 11.76$ $705.60 11.76$ $705.60 090

64776 11.14$ $668.40 11.14$ $668.40 090

64778 4.07$ $244.20 4.07$ $244.20 ZZZ

64782 12.88$ $772.80 12.88$ $772.80 090

64783 6.22$ $373.20 6.22$ $373.20 ZZZ

64784 20.59$ $1,235.40 20.59$ $1,235.40 090

64786 30.00$ $1,800.00 30.00$ $1,800.00 090

64787 6.82$ $409.20 6.82$ $409.20 ZZZ

64788 11.23$ $673.80 11.23$ $673.80 090



Page | 127

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

64790 23.25$ $1,395.00 23.25$ $1,395.00 090

64792 32.40$ $1,944.00 32.40$ $1,944.00 090

64795 5.30$ $318.00 5.30$ $318.00 000

64802 19.05$ $1,143.00 19.05$ $1,143.00 090

64804 27.07$ $1,624.20 27.07$ $1,624.20 090

64809 27.61$ $1,656.60 27.61$ $1,656.60 090

64818 17.23$ $1,033.80 17.23$ $1,033.80 090

64820 20.50$ $1,230.00 20.50$ $1,230.00 090

64821 19.57$ $1,174.20 19.57$ $1,174.20 090

64822 19.57$ $1,174.20 19.57$ $1,174.20 090

64823 22.22$ $1,333.20 22.22$ $1,333.20 090

64831 19.41$ $1,164.60 19.41$ $1,164.60 090

64832 9.46$ $567.60 9.46$ $567.60 ZZZ

64834 20.89$ $1,253.40 20.89$ $1,253.40 090

64835 22.66$ $1,359.60 22.66$ $1,359.60 090

64836 22.73$ $1,363.80 22.73$ $1,363.80 090

64837 10.48$ $628.80 10.48$ $628.80 ZZZ

64840 27.95$ $1,677.00 27.95$ $1,677.00 090

64856 28.43$ $1,705.80 28.43$ $1,705.80 090

64857 29.65$ $1,779.00 29.65$ $1,779.00 090

64858 31.85$ $1,911.00 31.85$ $1,911.00 090

64859 7.13$ $427.80 7.13$ $427.80 ZZZ

64861 36.90$ $2,214.00 36.90$ $2,214.00 090

64862 41.36$ $2,481.60 41.36$ $2,481.60 090

64864 24.99$ $1,499.40 24.99$ $1,499.40 090

64865 32.16$ $1,929.60 32.16$ $1,929.60 090

64866 32.94$ $1,976.40 32.94$ $1,976.40 090

64868 28.96$ $1,737.60 28.96$ $1,737.60 090

64872 3.41$ $204.60 3.41$ $204.60 ZZZ

64874 4.80$ $288.00 4.80$ $288.00 ZZZ

64876 4.98$ $298.80 4.98$ $298.80 ZZZ

64885 32.57$ $1,954.20 32.57$ $1,954.20 090

64886 36.99$ $2,219.40 36.99$ $2,219.40 090

64890 30.88$ $1,852.80 30.88$ $1,852.80 090

64891 32.95$ $1,977.00 32.95$ $1,977.00 090

64892 29.54$ $1,772.40 29.54$ $1,772.40 090

64893 32.10$ $1,926.00 32.10$ $1,926.00 090

64895 37.45$ $2,247.00 37.45$ $2,247.00 090

64896 40.67$ $2,440.20 40.67$ $2,440.20 090

64897 35.30$ $2,118.00 35.30$ $2,118.00 090

64898 38.13$ $2,287.80 38.13$ $2,287.80 090

64901 15.78$ $946.80 15.78$ $946.80 ZZZ



Page | 128

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

64902 18.55$ $1,113.00 18.55$ $1,113.00 ZZZ

64905 29.02$ $1,741.20 29.02$ $1,741.20 090

64907 37.50$ $2,250.00 37.50$ $2,250.00 090

64910 23.33$ $1,399.80 23.33$ $1,399.80 090

64911 28.71$ $1,722.60 28.71$ $1,722.60 090


65091 18.31$ $1,098.60 18.31$ $1,098.60 090

65093 18.11$ $1,086.60 18.11$ $1,086.60 090

65101 21.28$ $1,276.80 21.28$ $1,276.80 090

65103 22.21$ $1,332.60 22.21$ $1,332.60 090

65105 24.46$ $1,467.60 24.46$ $1,467.60 090

65110 35.08$ $2,104.80 35.08$ $2,104.80 090

65112 40.69$ $2,441.40 40.69$ $2,441.40 090

65114 42.72$ $2,563.20 42.72$ $2,563.20 090

65125 13.33$ $799.80 8.44$ $506.40 090

65130 21.09$ $1,265.40 21.09$ $1,265.40 090

65135 21.40$ $1,284.00 21.40$ $1,284.00 090

65140 23.26$ $1,395.60 23.26$ $1,395.60 090

65150 16.53$ $991.80 16.53$ $991.80 090

65155 24.35$ $1,461.00 24.35$ $1,461.00 090

65175 18.96$ $1,137.60 18.96$ $1,137.60 090

65205 1.61$ $96.60 1.26$ $75.60 000

65210 1.98$ $118.80 1.53$ $91.80 000

65220 1.65$ $99.00 1.19$ $71.40 000

65222 1.92$ $115.20 1.49$ $89.40 000

65235 20.47$ $1,228.20 20.47$ $1,228.20 090

65260 27.60$ $1,656.00 27.60$ $1,656.00 090

65265 31.08$ $1,864.80 31.08$ $1,864.80 090

65270 7.78$ $466.80 4.02$ $241.20 010

65272 14.58$ $874.80 10.09$ $605.40 090

65273 10.94$ $656.40 10.94$ $656.40 090

65275 16.70$ $1,002.00 13.27$ $796.20 090

65280 19.28$ $1,156.80 19.28$ $1,156.80 090

65285 31.80$ $1,908.00 31.80$ $1,908.00 090

65286 20.42$ $1,225.20 14.25$ $855.00 090

65290 14.04$ $842.40 14.04$ $842.40 090

65400 19.63$ $1,177.80 17.38$ $1,042.80 090

65410 4.13$ $247.80 2.99$ $179.40 000

65420 15.01$ $900.60 10.91$ $654.60 090

65426 18.92$ $1,135.20 13.78$ $826.80 090

65430 3.28$ $196.80 2.97$ $178.20 000

65435 2.30$ $138.00 2.00$ $120.00 000



Page | 129

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

65436 11.16$ $669.60 10.70$ $642.00 090

65450 9.39$ $563.40 9.31$ $558.60 090

65600 11.41$ $684.60 9.93$ $595.80 090

65710 31.80$ $1,908.00 31.80$ $1,908.00 090

65730 35.24$ $2,114.40 35.24$ $2,114.40 090

65750 35.40$ $2,124.00 35.40$ $2,124.00 090

65755 35.21$ $2,112.60 35.21$ $2,112.60 090

65756 33.95$ $2,037.00 33.95$ $2,037.00 090

65757 By Report By Report ZZZ




65770 40.26$ $2,415.60 40.26$ $2,415.60 090


65772 13.02$ $781.20 11.71$ $702.60 090

65775 15.88$ $952.80 15.88$ $952.80 090

65778 42.76$ $2,565.60 1.67$ $100.20 000

65779 35.69$ $2,141.40 4.34$ $260.40 000

65780 20.81$ $1,248.60 20.81$ $1,248.60 090

65781 38.27$ $2,296.20 38.27$ $2,296.20 090

65782 33.03$ $1,981.80 33.03$ $1,981.80 090

65785 62.59$ $3,755.40 10.97$ $658.20 XXX

65800 3.42$ $205.20 2.61$ $156.60 000

65810 13.40$ $804.00 13.40$ $804.00 090

65815 18.50$ $1,110.00 13.75$ $825.00 090

65820 21.60$ $1,296.00 21.60$ $1,296.00 090

65850 24.10$ $1,446.00 24.10$ $1,446.00 090

65855 7.93$ $475.80 6.96$ $417.60 010

65860 8.90$ $534.00 7.26$ $435.60 090

65865 13.63$ $817.80 13.63$ $817.80 090

65870 17.01$ $1,020.60 17.01$ $1,020.60 090

65875 18.15$ $1,089.00 18.15$ $1,089.00 090

65880 19.02$ $1,141.20 19.02$ $1,141.20 090

65900 27.60$ $1,656.00 27.60$ $1,656.00 090

65920 22.69$ $1,361.40 22.69$ $1,361.40 090

65930 18.32$ $1,099.20 18.32$ $1,099.20 090

66020 5.42$ $325.20 3.79$ $227.40 010

66030 4.83$ $289.80 3.20$ $192.00 010

66130 20.06$ $1,203.60 16.31$ $978.60 090

66150 25.26$ $1,515.60 25.26$ $1,515.60 090

66155 25.24$ $1,514.40 25.24$ $1,514.40 090

66160 28.43$ $1,705.80 28.43$ $1,705.80 090



Page | 130

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

66170 28.02$ $1,681.20 28.02$ $1,681.20 090

66172 35.49$ $2,129.40 35.49$ $2,129.40 090

66174 27.19$ $1,631.40 27.19$ $1,631.40 090

66175 28.48$ $1,708.80 28.48$ $1,708.80 090

66179 30.98$ $1,858.80 30.98$ $1,858.80 XXX

66180 32.68$ $1,960.80 32.68$ $1,960.80 090

66183 29.63$ $1,777.80 29.63$ $1,777.80 XXX

66184 22.61$ $1,356.60 22.61$ $1,356.60 XXX

66185 24.33$ $1,459.80 24.33$ $1,459.80 090

66220 21.50$ $1,290.00 21.50$ $1,290.00 090

66225 26.71$ $1,602.60 26.71$ $1,602.60 090

66250 21.72$ $1,303.20 16.04$ $962.40 090

66500 10.23$ $613.80 10.23$ $613.80 090

66505 11.22$ $673.20 11.22$ $673.20 090

66600 23.95$ $1,437.00 23.95$ $1,437.00 090

66605 30.33$ $1,819.80 30.33$ $1,819.80 090

66625 12.37$ $742.20 12.37$ $742.20 090

66630 16.38$ $982.80 16.38$ $982.80 090

66635 16.54$ $992.40 16.54$ $992.40 090

66680 14.91$ $894.60 14.91$ $894.60 090

66682 18.40$ $1,104.00 18.40$ $1,104.00 090

66700 12.99$ $779.40 11.31$ $678.60 090

66710 12.68$ $760.80 11.30$ $678.00 090

66711 18.50$ $1,110.00 18.50$ $1,110.00 090

66720 13.71$ $822.60 12.22$ $733.20 090

66740 12.61$ $756.60 11.31$ $678.60 090

66761 8.58$ $514.80 6.80$ $408.00 010

66762 13.71$ $822.60 12.28$ $736.80 090

66770 15.21$ $912.60 13.92$ $835.20 090

66820 11.39$ $683.40 11.39$ $683.40 090

66821 9.55$ $573.00 9.00$ $540.00 090

66825 21.91$ $1,314.60 21.91$ $1,314.60 090

66830 20.45$ $1,227.00 20.45$ $1,227.00 090

66840 20.02$ $1,201.20 20.02$ $1,201.20 090

66850 22.77$ $1,366.20 22.77$ $1,366.20 090

66852 24.25$ $1,455.00 24.25$ $1,455.00 090

66920 21.65$ $1,299.00 21.65$ $1,299.00 090

66930 24.59$ $1,475.40 24.59$ $1,475.40 090

66940 22.48$ $1,348.80 22.48$ $1,348.80 090

66982 22.80$ $1,368.00 22.80$ $1,368.00 090

66983 21.25$ $1,275.00 21.25$ $1,275.00 090

66984 18.37$ $1,102.20 18.37$ $1,102.20 090



Page | 131

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

66985 22.15$ $1,329.00 22.15$ $1,329.00 090

66986 26.08$ $1,564.80 26.08$ $1,564.80 090

66990 2.58$ $154.80 2.58$ $154.80 ZZZ


67005 13.62$ $817.20 13.62$ $817.20 090

67010 15.60$ $936.00 15.60$ $936.00 090

67015 16.71$ $1,002.60 16.71$ $1,002.60 090

67025 20.96$ $1,257.60 18.20$ $1,092.00 090

67027 24.47$ $1,468.20 24.47$ $1,468.20 090

67028 2.92$ $175.20 2.87$ $172.20 000

67030 15.36$ $921.60 15.36$ $921.60 090

67031 11.21$ $672.60 10.28$ $616.80 090

67036 25.89$ $1,553.40 25.89$ $1,553.40 090

67039 27.71$ $1,662.60 27.71$ $1,662.60 090

67040 29.92$ $1,795.20 29.92$ $1,795.20 090

67041 33.04$ $1,982.40 33.04$ $1,982.40 090

67042 33.05$ $1,983.00 33.05$ $1,983.00 090

67043 34.87$ $2,092.20 34.87$ $2,092.20 090

67101 22.62$ $1,357.20 19.38$ $1,162.80 090

67105 20.72$ $1,243.20 18.50$ $1,110.00 090

67107 29.18$ $1,750.80 29.18$ $1,750.80 090

67108 37.46$ $2,247.60 37.46$ $2,247.60 090

67110 21.98$ $1,318.80 20.10$ $1,206.00 090

67113 40.50$ $2,430.00 40.50$ $2,430.00 090

67115 14.40$ $864.00 14.40$ $864.00 090

67120 18.98$ $1,138.80 16.06$ $963.60 090

67121 26.08$ $1,564.80 26.08$ $1,564.80 090

67141 15.10$ $906.00 14.05$ $843.00 090

67145 15.19$ $911.40 14.34$ $860.40 090

67208 17.23$ $1,033.80 16.63$ $997.80 090

67210 14.92$ $895.20 14.40$ $864.00 090

67218 39.59$ $2,375.40 39.59$ $2,375.40 090

67220 15.39$ $923.40 14.40$ $864.00 090

67221 8.26$ $495.60 6.09$ $365.40 000

67225 0.85$ $51.00 0.79$ $47.40 ZZZ

67227 8.34$ $500.40 7.38$ $442.80 010

67228 9.79$ $587.40 8.81$ $528.60 010

67229 31.76$ $1,905.60 31.76$ $1,905.60 090

67250 22.49$ $1,349.40 22.49$ $1,349.40 090

67255 19.68$ $1,180.80 19.68$ $1,180.80 090


67311 17.20$ $1,032.00 17.20$ $1,032.00 090



Page | 132

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

67312 20.44$ $1,226.40 20.44$ $1,226.40 090

67314 19.36$ $1,161.60 19.36$ $1,161.60 090

67316 23.00$ $1,380.00 23.00$ $1,380.00 090

67318 20.25$ $1,215.00 20.25$ $1,215.00 090

67320 9.20$ $552.00 9.20$ $552.00 ZZZ

67331 8.73$ $523.80 8.73$ $523.80 ZZZ

67332 9.47$ $568.20 9.47$ $568.20 ZZZ

67334 8.61$ $516.60 8.61$ $516.60 ZZZ

67335 4.23$ $253.80 4.23$ $253.80 ZZZ

67340 10.23$ $613.80 10.23$ $613.80 ZZZ

67343 18.80$ $1,128.00 18.80$ $1,128.00 090

67345 6.89$ $413.40 6.17$ $370.20 010

67346 5.53$ $331.80 5.53$ $331.80 000


67400 26.77$ $1,606.20 26.77$ $1,606.20 090

67405 22.87$ $1,372.20 22.87$ $1,372.20 090

67412 24.49$ $1,469.40 24.49$ $1,469.40 090

67413 24.61$ $1,476.60 24.61$ $1,476.60 090

67414 37.98$ $2,278.80 37.98$ $2,278.80 090

67415 2.98$ $178.80 2.98$ $178.80 000

67420 46.29$ $2,777.40 46.29$ $2,777.40 090

67430 35.64$ $2,138.40 35.64$ $2,138.40 090

67440 34.55$ $2,073.00 34.55$ $2,073.00 090

67445 40.14$ $2,408.40 40.14$ $2,408.40 090

67450 36.02$ $2,161.20 36.02$ $2,161.20 090

67500 2.21$ $132.60 2.03$ $121.80 000

67505 2.55$ $153.00 2.33$ $139.80 000

67515 2.77$ $166.20 2.55$ $153.00 000

67550 27.74$ $1,664.40 27.74$ $1,664.40 090

67560 28.41$ $1,704.60 28.41$ $1,704.60 090

67570 33.06$ $1,983.60 33.06$ $1,983.60 090


67700 7.86$ $471.60 3.36$ $201.60 010

67710 6.56$ $393.60 2.82$ $169.20 010

67715 6.97$ $418.20 3.12$ $187.20 010

67800 3.67$ $220.20 2.97$ $178.20 010

67801 4.67$ $280.20 3.83$ $229.80 010

67805 5.82$ $349.20 4.73$ $283.80 010

67808 10.62$ $637.20 10.62$ $637.20 090

67810 4.99$ $299.40 2.02$ $121.20 000

67820 1.43$ $85.80 1.54$ $92.40 000

67825 3.71$ $222.60 3.51$ $210.60 010



Page | 133

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

67830 7.77$ $466.20 3.98$ $238.80 010

67835 12.60$ $756.00 12.60$ $756.00 090

67840 8.01$ $480.60 4.55$ $273.00 010

67850 6.21$ $372.60 3.90$ $234.00 010

67875 4.99$ $299.40 2.79$ $167.40 000

67880 13.26$ $795.60 10.61$ $636.60 090

67882 16.27$ $976.20 13.59$ $815.40 090

67900 18.44$ $1,106.40 14.59$ $875.40 090

67901 21.86$ $1,311.60 16.56$ $993.60 090

67902 20.72$ $1,243.20 20.72$ $1,243.20 090

67903 17.10$ $1,026.00 13.87$ $832.20 090

67904 21.11$ $1,266.60 17.14$ $1,028.40 090

67906 14.54$ $872.40 14.54$ $872.40 090

67908 14.25$ $855.00 12.23$ $733.80 090

67909 15.46$ $927.60 12.61$ $756.60 090

67911 16.15$ $969.00 16.15$ $969.00 090

67912 25.66$ $1,539.60 14.05$ $843.00 090

67914 13.64$ $818.40 9.46$ $567.60 090

67915 8.53$ $511.80 5.74$ $344.40 090

67916 17.14$ $1,028.40 12.39$ $743.40 090

67917 17.42$ $1,045.20 13.17$ $790.20 090

67921 13.40$ $804.00 8.98$ $538.80 090

67922 8.46$ $507.60 5.73$ $343.80 090

67923 17.14$ $1,028.40 12.40$ $744.00 090

67924 18.25$ $1,095.00 13.18$ $790.80 090

67930 10.52$ $631.20 6.86$ $411.60 010

67935 17.10$ $1,026.00 12.64$ $758.40 090

67938 7.09$ $425.40 3.35$ $201.00 010

67950 16.51$ $990.60 13.31$ $798.60 090

67961 16.60$ $996.00 13.08$ $784.80 090

67966 22.11$ $1,326.60 18.85$ $1,131.00 090

67971 20.75$ $1,245.00 20.75$ $1,245.00 090

67973 26.66$ $1,599.60 26.66$ $1,599.60 090

67974 26.61$ $1,596.60 26.61$ $1,596.60 090

67975 19.63$ $1,177.80 19.63$ $1,177.80 090


68020 3.45$ $207.00 3.18$ $190.80 010

68040 1.80$ $108.00 1.45$ $87.00 000

68100 4.94$ $296.40 2.79$ $167.40 000

68110 6.56$ $393.60 4.29$ $257.40 010

68115 9.07$ $544.20 5.30$ $318.00 010

68130 15.60$ $936.00 11.88$ $712.80 090



Page | 134

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

68135 4.51$ $270.60 4.35$ $261.00 010

68200 1.19$ $71.40 1.00$ $60.00 000

68320 21.00$ $1,260.00 15.54$ $932.40 090

68325 18.92$ $1,135.20 18.92$ $1,135.20 090

68326 18.57$ $1,114.20 18.57$ $1,114.20 090

68328 20.33$ $1,219.80 20.33$ $1,219.80 090

68330 17.50$ $1,050.00 13.28$ $796.80 090

68335 18.62$ $1,117.20 18.62$ $1,117.20 090

68340 15.80$ $948.00 11.51$ $690.60 090

68360 15.39$ $923.40 11.87$ $712.20 090

68362 18.88$ $1,132.80 18.88$ $1,132.80 090

68371 11.90$ $714.00 11.90$ $714.00 010


68400 8.30$ $498.00 3.79$ $227.40 010

68420 9.36$ $561.60 4.83$ $289.80 010

68440 2.97$ $178.20 2.88$ $172.80 010

68500 28.03$ $1,681.80 28.03$ $1,681.80 090

68505 27.85$ $1,671.00 27.85$ $1,671.00 090

68510 12.87$ $772.20 8.35$ $501.00 000

68520 19.76$ $1,185.60 19.76$ $1,185.60 090

68525 7.50$ $450.00 7.50$ $450.00 000

68530 12.42$ $745.20 7.38$ $442.80 010

68540 26.73$ $1,603.80 26.73$ $1,603.80 090

68550 31.43$ $1,885.80 31.43$ $1,885.80 090

68700 17.36$ $1,041.60 17.36$ $1,041.60 090

68705 6.85$ $411.00 4.79$ $287.40 010

68720 21.73$ $1,303.80 21.73$ $1,303.80 090

68745 21.85$ $1,311.00 21.85$ $1,311.00 090

68750 22.61$ $1,356.60 22.61$ $1,356.60 090

68760 5.84$ $350.40 4.21$ $252.60 010

68761 4.29$ $257.40 3.44$ $206.40 010

68770 18.07$ $1,084.20 18.07$ $1,084.20 090

68801 2.93$ $175.80 2.53$ $151.80 010

68810 5.69$ $341.40 4.41$ $264.60 010

68811 4.83$ $289.80 4.83$ $289.80 010

68815 11.60$ $696.00 6.40$ $384.00 010

68816 19.03$ $1,141.80 5.86$ $351.60 010

68840 3.70$ $222.00 3.38$ $202.80 010

68850 1.75$ $105.00 1.60$ $96.00 000


69000 5.47$ $328.20 3.43$ $205.80 010

69005 6.23$ $373.80 4.50$ $270.00 010



Page | 135

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

69020 6.85$ $411.00 4.13$ $247.80 010


69100 2.91$ $174.60 1.39$ $83.40 000

69105 4.14$ $248.40 1.83$ $109.80 000

69110 13.36$ $801.60 9.37$ $562.20 090

69120 11.81$ $708.60 11.81$ $708.60 090

69140 25.67$ $1,540.20 25.67$ $1,540.20 090

69145 11.69$ $701.40 7.26$ $435.60 090

69150 30.08$ $1,804.80 30.08$ $1,804.80 090

69155 47.82$ $2,869.20 47.82$ $2,869.20 090

69200 2.90$ $174.00 1.34$ $80.40 000

69205 2.94$ $176.40 2.94$ $176.40 010

69209 0.37$ $22.20 0.37$ $22.20 XXX

69210 1.41$ $84.60 0.92$ $55.20 000

69220 3.24$ $194.40 1.48$ $88.80 000

69222 6.47$ $388.20 3.98$ $238.80 010

69300 21.46$ $1,287.60 13.71$ $822.60 YYY

69310 31.83$ $1,909.80 31.83$ $1,909.80 090

69320 44.80$ $2,688.00 44.80$ $2,688.00 090


69420 5.63$ $337.80 3.50$ $210.00 010

69421 4.31$ $258.60 4.31$ $258.60 010

69424 3.76$ $225.60 1.79$ $107.40 000

69433 5.93$ $355.80 3.84$ $230.40 010

69436 4.63$ $277.80 4.63$ $277.80 010

69440 20.03$ $1,201.80 20.03$ $1,201.80 090

69450 15.88$ $952.80 15.88$ $952.80 090

69501 21.18$ $1,270.80 21.18$ $1,270.80 090

69502 28.02$ $1,681.20 28.02$ $1,681.20 090

69505 34.99$ $2,099.40 34.99$ $2,099.40 090

69511 35.72$ $2,143.20 35.72$ $2,143.20 090

69530 47.87$ $2,872.20 47.87$ $2,872.20 090

69535 76.79$ $4,607.40 76.79$ $4,607.40 090

69540 6.18$ $370.80 3.71$ $222.60 010

69550 30.34$ $1,820.40 30.34$ $1,820.40 090

69552 45.15$ $2,709.00 45.15$ $2,709.00 090

69554 69.69$ $4,181.40 69.69$ $4,181.40 090

69601 30.19$ $1,811.40 30.19$ $1,811.40 090

69602 31.42$ $1,885.20 31.42$ $1,885.20 090

69603 36.93$ $2,215.80 36.93$ $2,215.80 090

69604 32.11$ $1,926.60 32.11$ $1,926.60 090

69605 45.21$ $2,712.60 45.21$ $2,712.60 090



Page | 136

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

69610 11.09$ $665.40 8.30$ $498.00 010

69620 20.32$ $1,219.20 14.14$ $848.40 090

69631 25.67$ $1,540.20 25.67$ $1,540.20 090

69632 31.17$ $1,870.20 31.17$ $1,870.20 090

69633 30.27$ $1,816.20 30.27$ $1,816.20 090

69635 35.91$ $2,154.60 35.91$ $2,154.60 090

69636 40.19$ $2,411.40 40.19$ $2,411.40 090

69637 39.97$ $2,398.20 39.97$ $2,398.20 090

69641 30.11$ $1,806.60 30.11$ $1,806.60 090

69642 38.55$ $2,313.00 38.55$ $2,313.00 090

69643 35.33$ $2,119.80 35.33$ $2,119.80 090

69644 42.88$ $2,572.80 42.88$ $2,572.80 090

69645 42.19$ $2,531.40 42.19$ $2,531.40 090

69646 44.75$ $2,685.00 44.75$ $2,685.00 090

69650 23.33$ $1,399.80 23.33$ $1,399.80 090

69660 26.74$ $1,604.40 26.74$ $1,604.40 090

69661 34.82$ $2,089.20 34.82$ $2,089.20 090

69662 33.33$ $1,999.80 33.33$ $1,999.80 090

69666 23.39$ $1,403.40 23.39$ $1,403.40 090

69667 23.40$ $1,404.00 23.40$ $1,404.00 090

69670 27.37$ $1,642.20 27.37$ $1,642.20 090

69676 24.10$ $1,446.00 24.10$ $1,446.00 090

69700 19.83$ $1,189.80 19.83$ $1,189.80 090


69711 25.01$ $1,500.60 25.01$ $1,500.60 090

69714 31.01$ $1,860.60 31.01$ $1,860.60 090

69715 38.12$ $2,287.20 38.12$ $2,287.20 090

69717 32.55$ $1,953.00 32.55$ $1,953.00 090

69718 38.51$ $2,310.60 38.51$ $2,310.60 090

69720 34.99$ $2,099.40 34.99$ $2,099.40 090

69725 53.85$ $3,231.00 53.85$ $3,231.00 090

69740 33.53$ $2,011.80 33.53$ $2,011.80 090

69745 39.13$ $2,347.80 39.13$ $2,347.80 090


69801 5.68$ $340.80 3.57$ $214.20 000

69805 30.29$ $1,817.40 30.29$ $1,817.40 090

69806 27.23$ $1,633.80 27.23$ $1,633.80 090

69820 24.79$ $1,487.40 24.79$ $1,487.40 090

69840 26.31$ $1,578.60 26.31$ $1,578.60 090

69905 26.54$ $1,592.40 26.54$ $1,592.40 090

69910 29.26$ $1,755.60 29.26$ $1,755.60 090

69915 44.05$ $2,643.00 44.05$ $2,643.00 090



Page | 137

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

69930 35.10$ $2,106.00 35.10$ $2,106.00 090


69950 50.88$ $3,052.80 50.88$ $3,052.80 090

69955 57.08$ $3,424.80 57.08$ $3,424.80 090

69960 54.90$ $3,294.00 54.90$ $3,294.00 090

69970 61.23$ $3,673.80 61.23$ $3,673.80 090


69990 5.86$ $351.60 5.86$ $351.60 ZZZ

70010 1.73$ $103.80 1.73$ $103.80 XXX

70015 4.43$ $265.80 4.43$ $265.80 XXX

70015 26 1.74$ $104.40 1.74$ $104.40 XXX

70015 TC 2.69$ $161.40 2.69$ $161.40 XXX

70030 0.80$ $48.00 0.80$ $48.00 XXX

70030 26 0.24$ $14.40 0.24$ $14.40 XXX

70030 TC 0.57$ $34.20 0.57$ $34.20 XXX

70100 0.95$ $57.00 0.95$ $57.00 XXX

70100 26 0.26$ $15.60 0.26$ $15.60 XXX

70100 TC 0.69$ $41.40 0.69$ $41.40 XXX

70110 1.10$ $66.00 1.10$ $66.00 XXX

70110 26 0.36$ $21.60 0.36$ $21.60 XXX

70110 TC 0.73$ $43.80 0.73$ $43.80 XXX

70120 0.98$ $58.80 0.98$ $58.80 XXX

70120 26 0.26$ $15.60 0.26$ $15.60 XXX

70120 TC 0.72$ $43.20 0.72$ $43.20 XXX

70130 1.58$ $94.80 1.58$ $94.80 XXX

70130 26 0.49$ $29.40 0.49$ $29.40 XXX

70130 TC 1.09$ $65.40 1.09$ $65.40 XXX

70134 1.49$ $89.40 1.49$ $89.40 XXX

70134 26 0.51$ $30.60 0.51$ $30.60 XXX

70134 TC 0.99$ $59.40 0.99$ $59.40 XXX

70140 0.86$ $51.60 0.86$ $51.60 XXX

70140 26 0.30$ $18.00 0.30$ $18.00 XXX

70140 TC 0.55$ $33.00 0.55$ $33.00 XXX

70150 1.20$ $72.00 1.20$ $72.00 XXX

70150 26 0.38$ $22.80 0.38$ $22.80 XXX

70150 TC 0.82$ $49.20 0.82$ $49.20 XXX

70160 0.94$ $56.40 0.94$ $56.40 XXX

70160 26 0.25$ $15.00 0.25$ $15.00 XXX

70160 TC 0.69$ $41.40 0.69$ $41.40 XXX


70170 TC By Report By Report XXX

70170 26 0.43$ $25.80 0.43$ $25.80 XXX



Page | 138

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

70190 1.04$ $62.40 1.04$ $62.40 XXX

70190 26 0.32$ $19.20 0.32$ $19.20 XXX

70190 TC 0.71$ $42.60 0.71$ $42.60 XXX

70200 1.22$ $73.20 1.22$ $73.20 XXX

70200 26 0.40$ $24.00 0.40$ $24.00 XXX

70200 TC 0.82$ $49.20 0.82$ $49.20 XXX

70210 0.86$ $51.60 0.86$ $51.60 XXX

70210 26 0.25$ $15.00 0.25$ $15.00 XXX

70210 TC 0.61$ $36.60 0.61$ $36.60 XXX

70220 1.09$ $65.40 1.09$ $65.40 XXX

70220 26 0.36$ $21.60 0.36$ $21.60 XXX

70220 TC 0.72$ $43.20 0.72$ $43.20 XXX

70240 0.87$ $52.20 0.87$ $52.20 XXX

70240 26 0.28$ $16.80 0.28$ $16.80 XXX

70240 TC 0.59$ $35.40 0.59$ $35.40 XXX

70250 1.04$ $62.40 1.04$ $62.40 XXX

70250 26 0.36$ $21.60 0.36$ $21.60 XXX

70250 TC 0.68$ $40.80 0.68$ $40.80 XXX

70260 1.32$ $79.20 1.32$ $79.20 XXX

70260 26 0.50$ $30.00 0.50$ $30.00 XXX

70260 TC 0.82$ $49.20 0.82$ $49.20 XXX

70300 0.43$ $25.80 0.43$ $25.80 XXX

70300 26 0.17$ $10.20 0.17$ $10.20 XXX

70300 TC 0.26$ $15.60 0.26$ $15.60 XXX

70310 1.07$ $64.20 1.07$ $64.20 XXX

70310 26 0.23$ $13.80 0.23$ $13.80 XXX

70310 TC 0.84$ $50.40 0.84$ $50.40 XXX

70320 1.53$ $91.80 1.53$ $91.80 XXX

70320 26 0.34$ $20.40 0.34$ $20.40 XXX

70320 TC 1.19$ $71.40 1.19$ $71.40 XXX

70328 0.89$ $53.40 0.89$ $53.40 XXX

70328 26 0.26$ $15.60 0.26$ $15.60 XXX

70328 TC 0.63$ $37.80 0.63$ $37.80 XXX

70330 1.37$ $82.20 1.37$ $82.20 XXX

70330 26 0.36$ $21.60 0.36$ $21.60 XXX

70330 TC 1.01$ $60.60 1.01$ $60.60 XXX

70332 2.35$ $141.00 2.35$ $141.00 XXX

70332 26 0.89$ $53.40 0.89$ $53.40 XXX

70332 TC 1.46$ $87.60 1.46$ $87.60 XXX

70336 9.40$ $564.00 9.40$ $564.00 XXX

70336 26 2.10$ $126.00 2.10$ $126.00 XXX

70336 TC 7.30$ $438.00 7.30$ $438.00 XXX



Page | 139

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

70350 0.57$ $34.20 0.57$ $34.20 XXX

70350 26 0.29$ $17.40 0.29$ $17.40 XXX

70350 TC 0.28$ $16.80 0.28$ $16.80 XXX

70355 0.59$ $35.40 0.59$ $35.40 XXX

70355 26 0.32$ $19.20 0.32$ $19.20 XXX

70355 TC 0.27$ $16.20 0.27$ $16.20 XXX

70360 0.82$ $49.20 0.82$ $49.20 XXX

70360 26 0.24$ $14.40 0.24$ $14.40 XXX

70360 TC 0.58$ $34.80 0.58$ $34.80 XXX

70370 2.30$ $138.00 2.30$ $138.00 XXX

70370 26 0.46$ $27.60 0.46$ $27.60 XXX

70370 TC 1.84$ $110.40 1.84$ $110.40 XXX

70371 2.64$ $158.40 2.64$ $158.40 XXX

70371 26 1.22$ $73.20 1.22$ $73.20 XXX

70371 TC 1.42$ $85.20 1.42$ $85.20 XXX

70380 1.05$ $63.00 1.05$ $63.00 XXX

70380 26 0.26$ $15.60 0.26$ $15.60 XXX

70380 TC 0.79$ $47.40 0.79$ $47.40 XXX

70390 2.75$ $165.00 2.75$ $165.00 XXX

70390 26 0.54$ $32.40 0.54$ $32.40 XXX

70390 TC 2.21$ $132.60 2.21$ $132.60 XXX

70450 3.38$ $202.80 3.38$ $202.80 XXX

70450 26 1.22$ $73.20 1.22$ $73.20 XXX

70450 TC 2.16$ $129.60 2.16$ $129.60 XXX

70460 4.71$ $282.60 4.71$ $282.60 XXX

70460 26 1.61$ $96.60 1.61$ $96.60 XXX

70460 TC 3.10$ $186.00 3.10$ $186.00 XXX

70470 5.60$ $336.00 5.60$ $336.00 XXX

70470 26 1.82$ $109.20 1.82$ $109.20 XXX

70470 TC 3.78$ $226.80 3.78$ $226.80 XXX

70480 6.84$ $410.40 6.84$ $410.40 XXX

70480 26 1.83$ $109.80 1.83$ $109.80 XXX

70480 TC 5.00$ $300.00 5.00$ $300.00 XXX

70481 8.09$ $485.40 8.09$ $485.40 XXX

70481 26 1.97$ $118.20 1.97$ $118.20 XXX

70481 TC 6.12$ $367.20 6.12$ $367.20 XXX

70482 8.83$ $529.80 8.83$ $529.80 XXX

70482 26 2.06$ $123.60 2.06$ $123.60 XXX

70482 TC 6.77$ $406.20 6.77$ $406.20 XXX

70486 4.09$ $245.40 4.09$ $245.40 XXX

70486 26 1.22$ $73.20 1.22$ $73.20 XXX

70486 TC 2.87$ $172.20 2.87$ $172.20 XXX



Page | 140

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

70487 4.91$ $294.60 4.91$ $294.60 XXX

70487 26 1.61$ $96.60 1.61$ $96.60 XXX

70487 TC 3.30$ $198.00 3.30$ $198.00 XXX

70488 5.99$ $359.40 5.99$ $359.40 XXX

70488 26 1.81$ $108.60 1.81$ $108.60 XXX

70488 TC 4.18$ $250.80 4.18$ $250.80 XXX

70490 5.63$ $337.80 5.63$ $337.80 XXX

70490 26 1.83$ $109.80 1.83$ $109.80 XXX

70490 TC 3.80$ $228.00 3.80$ $228.00 XXX

70491 6.89$ $413.40 6.89$ $413.40 XXX

70491 26 1.98$ $118.80 1.98$ $118.80 XXX

70491 TC 4.91$ $294.60 4.91$ $294.60 XXX

70492 8.14$ $488.40 8.14$ $488.40 XXX

70492 26 2.07$ $124.20 2.07$ $124.20 XXX

70492 TC 6.07$ $364.20 6.07$ $364.20 XXX

70496 8.60$ $516.00 8.60$ $516.00 XXX

70496 26 2.49$ $149.40 2.49$ $149.40 XXX

70496 TC 6.11$ $366.60 6.11$ $366.60 XXX

70498 8.57$ $514.20 8.57$ $514.20 XXX

70498 26 2.49$ $149.40 2.49$ $149.40 XXX

70498 TC 6.08$ $364.80 6.08$ $364.80 XXX

70540 10.55$ $633.00 10.55$ $633.00 XXX

70540 26 1.92$ $115.20 1.92$ $115.20 XXX

70540 TC 8.63$ $517.80 8.63$ $517.80 XXX

70542 11.80$ $708.00 11.80$ $708.00 XXX

70542 26 2.31$ $138.60 2.31$ $138.60 XXX

70542 TC 9.49$ $569.40 9.49$ $569.40 XXX

70543 14.43$ $865.80 14.43$ $865.80 XXX

70543 26 3.06$ $183.60 3.06$ $183.60 XXX

70543 TC 11.37$ $682.20 11.37$ $682.20 XXX

70544 11.54$ $692.40 11.54$ $692.40 XXX

70544 26 1.72$ $103.20 1.72$ $103.20 XXX

70544 TC 9.82$ $589.20 9.82$ $589.20 XXX

70545 11.39$ $683.40 11.39$ $683.40 XXX

70545 26 1.71$ $102.60 1.71$ $102.60 XXX

70545 TC 9.68$ $580.80 9.68$ $580.80 XXX

70546 17.63$ $1,057.80 17.63$ $1,057.80 XXX

70546 26 2.57$ $154.20 2.57$ $154.20 XXX

70546 TC 15.06$ $903.60 15.06$ $903.60 XXX

70547 11.58$ $694.80 11.58$ $694.80 XXX

70547 26 1.72$ $103.20 1.72$ $103.20 XXX

70547 TC 9.86$ $591.60 9.86$ $591.60 XXX



Page | 141

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

70548 12.16$ $729.60 12.16$ $729.60 XXX

70548 26 1.72$ $103.20 1.72$ $103.20 XXX

70548 TC 10.44$ $626.40 10.44$ $626.40 XXX

70549 17.74$ $1,064.40 17.74$ $1,064.40 XXX

70549 26 2.57$ $154.20 2.57$ $154.20 XXX

70549 TC 15.17$ $910.20 15.17$ $910.20 XXX

70551 6.72$ $403.20 6.72$ $403.20 XXX

70551 26 2.11$ $126.60 2.11$ $126.60 XXX

70551 TC 4.61$ $276.60 4.61$ $276.60 XXX

70552 9.35$ $561.00 9.35$ $561.00 XXX

70552 26 2.54$ $152.40 2.54$ $152.40 XXX

70552 TC 6.81$ $408.60 6.81$ $408.60 XXX

70553 11.03$ $661.80 11.03$ $661.80 XXX

70553 26 3.27$ $196.20 3.27$ $196.20 XXX

70553 TC 7.76$ $465.60 7.76$ $465.60 XXX

70554 13.21$ $792.60 13.21$ $792.60 XXX

70554 26 3.02$ $181.20 3.02$ $181.20 XXX

70554 TC 10.18$ $610.80 10.18$ $610.80 XXX



70555 26 3.60$ $216.00 3.60$ $216.00 XXX



70557 26 4.16$ $249.60 4.16$ $249.60 XXX



70558 26 4.58$ $274.80 4.58$ $274.80 XXX



70559 26 4.61$ $276.60 4.61$ $276.60 XXX

71010 0.65$ $39.00 0.65$ $39.00 XXX

71010 26 0.26$ $15.60 0.26$ $15.60 XXX

71010 TC 0.39$ $23.40 0.39$ $23.40 XXX

71015 0.80$ $48.00 0.80$ $48.00 XXX

71015 26 0.31$ $18.60 0.31$ $18.60 XXX

71015 TC 0.49$ $29.40 0.49$ $29.40 XXX

71020 0.80$ $48.00 0.80$ $48.00 XXX

71020 26 0.31$ $18.60 0.31$ $18.60 XXX

71020 TC 0.49$ $29.40 0.49$ $29.40 XXX

71021 0.98$ $58.80 0.98$ $58.80 XXX

71021 26 0.39$ $23.40 0.39$ $23.40 XXX

71021 TC 0.59$ $35.40 0.59$ $35.40 XXX



Page | 142

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

71022 1.21$ $72.60 1.21$ $72.60 XXX

71022 26 0.48$ $28.80 0.48$ $28.80 XXX

71022 TC 0.73$ $43.80 0.73$ $43.80 XXX

71023 1.85$ $111.00 1.85$ $111.00 XXX

71023 26 0.54$ $32.40 0.54$ $32.40 XXX

71023 TC 1.30$ $78.00 1.30$ $78.00 XXX

71030 1.20$ $72.00 1.20$ $72.00 XXX

71030 26 0.45$ $27.00 0.45$ $27.00 XXX

71030 TC 0.76$ $45.60 0.76$ $45.60 XXX

71034 2.42$ $145.20 2.42$ $145.20 XXX

71034 26 0.66$ $39.60 0.66$ $39.60 XXX

71034 TC 1.76$ $105.60 1.76$ $105.60 XXX

71035 0.95$ $57.00 0.95$ $57.00 XXX

71035 26 0.26$ $15.60 0.26$ $15.60 XXX

71035 TC 0.69$ $41.40 0.69$ $41.40 XXX

71100 0.95$ $57.00 0.95$ $57.00 XXX

71100 26 0.32$ $19.20 0.32$ $19.20 XXX

71100 TC 0.63$ $37.80 0.63$ $37.80 XXX

71101 1.05$ $63.00 1.05$ $63.00 XXX

71101 26 0.39$ $23.40 0.39$ $23.40 XXX

71101 TC 0.66$ $39.60 0.66$ $39.60 XXX

71110 1.09$ $65.40 1.09$ $65.40 XXX

71110 26 0.39$ $23.40 0.39$ $23.40 XXX

71110 TC 0.69$ $41.40 0.69$ $41.40 XXX

71111 1.38$ $82.80 1.38$ $82.80 XXX

71111 26 0.47$ $28.20 0.47$ $28.20 XXX

71111 TC 0.91$ $54.60 0.91$ $54.60 XXX

71120 0.86$ $51.60 0.86$ $51.60 XXX

71120 26 0.29$ $17.40 0.29$ $17.40 XXX

71120 TC 0.57$ $34.20 0.57$ $34.20 XXX

71130 1.05$ $63.00 1.05$ $63.00 XXX

71130 26 0.32$ $19.20 0.32$ $19.20 XXX

71130 TC 0.72$ $43.20 0.72$ $43.20 XXX

71250 5.28$ $316.80 5.28$ $316.80 XXX

71250 26 1.46$ $87.60 1.46$ $87.60 XXX

71250 TC 3.82$ $229.20 3.82$ $229.20 XXX

71260 6.71$ $402.60 6.71$ $402.60 XXX

71260 26 1.78$ $106.80 1.78$ $106.80 XXX

71260 TC 4.93$ $295.80 4.93$ $295.80 XXX

71270 8.06$ $483.60 8.06$ $483.60 XXX

71270 26 1.97$ $118.20 1.97$ $118.20 XXX

71270 TC 6.09$ $365.40 6.09$ $365.40 XXX



Page | 143

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

71275 8.75$ $525.00 8.75$ $525.00 XXX

71275 26 2.59$ $155.40 2.59$ $155.40 XXX

71275 TC 6.16$ $369.60 6.16$ $369.60 XXX

71550 12.17$ $730.20 12.17$ $730.20 XXX

71550 26 2.08$ $124.80 2.08$ $124.80 XXX

71550 TC 10.09$ $605.40 10.09$ $605.40 XXX

71551 13.46$ $807.60 13.46$ $807.60 XXX

71551 26 2.46$ $147.60 2.46$ $147.60 XXX

71551 TC 11.00$ $660.00 11.00$ $660.00 XXX

71552 17.03$ $1,021.80 17.03$ $1,021.80 XXX

71552 26 3.23$ $193.80 3.23$ $193.80 XXX

71552 TC 13.80$ $828.00 13.80$ $828.00 XXX

71555 11.65$ $699.00 11.65$ $699.00 XXX

71555 26 2.55$ $153.00 2.55$ $153.00 XXX

71555 TC 9.10$ $546.00 9.10$ $546.00 XXX

72020 0.64$ $38.40 0.64$ $38.40 XXX

72020 26 0.22$ $13.20 0.22$ $13.20 XXX

72020 TC 0.42$ $25.20 0.42$ $25.20 XXX

72040 0.96$ $57.60 0.96$ $57.60 XXX

72040 26 0.32$ $19.20 0.32$ $19.20 XXX

72040 TC 0.64$ $38.40 0.64$ $38.40 XXX

72050 1.30$ $78.00 1.30$ $78.00 XXX

72050 26 0.45$ $27.00 0.45$ $27.00 XXX

72050 TC 0.85$ $51.00 0.85$ $51.00 XXX

72052 1.64$ $98.40 1.64$ $98.40 XXX

72052 26 0.52$ $31.20 0.52$ $31.20 XXX

72052 TC 1.11$ $66.60 1.11$ $66.60 XXX

72070 0.98$ $58.80 0.98$ $58.80 XXX

72070 26 0.32$ $19.20 0.32$ $19.20 XXX

72070 TC 0.66$ $39.60 0.66$ $39.60 XXX

72072 1.00$ $60.00 1.00$ $60.00 XXX

72072 26 0.31$ $18.60 0.31$ $18.60 XXX

72072 TC 0.69$ $41.40 0.69$ $41.40 XXX

72074 1.14$ $68.40 1.14$ $68.40 XXX

72074 26 0.31$ $18.60 0.31$ $18.60 XXX

72074 TC 0.83$ $49.80 0.83$ $49.80 XXX

72080 0.89$ $53.40 0.89$ $53.40 XXX

72080 26 0.31$ $18.60 0.31$ $18.60 XXX

72080 TC 0.58$ $34.80 0.58$ $34.80 XXX

72081 1.12$ $67.20 1.12$ $67.20 XXX

72081 26 0.38$ $22.80 0.38$ $22.80 XXX

72081 TC 0.74$ $44.40 0.74$ $44.40 XXX



Page | 144

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

72082 1.82$ $109.20 1.82$ $109.20 XXX

72082 26 0.46$ $27.60 0.46$ $27.60 XXX

72082 TC 1.36$ $81.60 1.36$ $81.60 XXX

72083 1.97$ $118.20 1.97$ $118.20 XXX

72083 26 0.50$ $30.00 0.50$ $30.00 XXX

72083 TC 1.47$ $88.20 1.47$ $88.20 XXX

72084 2.36$ $141.60 2.36$ $141.60 XXX

72084 26 0.58$ $34.80 0.58$ $34.80 XXX

72084 TC 1.78$ $106.80 1.78$ $106.80 XXX

72100 1.01$ $60.60 1.01$ $60.60 XXX

72100 26 0.32$ $19.20 0.32$ $19.20 XXX

72100 TC 0.69$ $41.40 0.69$ $41.40 XXX

72110 1.42$ $85.20 1.42$ $85.20 XXX

72110 26 0.45$ $27.00 0.45$ $27.00 XXX

72110 TC 0.97$ $58.20 0.97$ $58.20 XXX

72114 1.82$ $109.20 1.82$ $109.20 XXX

72114 26 0.47$ $28.20 0.47$ $28.20 XXX

72114 TC 1.35$ $81.00 1.35$ $81.00 XXX

72120 1.17$ $70.20 1.17$ $70.20 XXX

72120 26 0.32$ $19.20 0.32$ $19.20 XXX

72120 TC 0.85$ $51.00 0.85$ $51.00 XXX

72125 5.39$ $323.40 5.39$ $323.40 XXX

72125 26 1.53$ $91.80 1.53$ $91.80 XXX

72125 TC 3.86$ $231.60 3.86$ $231.60 XXX

72126 6.70$ $402.00 6.70$ $402.00 XXX

72126 26 1.74$ $104.40 1.74$ $104.40 XXX

72126 TC 4.96$ $297.60 4.96$ $297.60 XXX

72127 7.95$ $477.00 7.95$ $477.00 XXX

72127 26 1.81$ $108.60 1.81$ $108.60 XXX

72127 TC 6.14$ $368.40 6.14$ $368.40 XXX

72128 5.27$ $316.20 5.27$ $316.20 XXX

72128 26 1.43$ $85.80 1.43$ $85.80 XXX

72128 TC 3.84$ $230.40 3.84$ $230.40 XXX

72129 6.71$ $402.60 6.71$ $402.60 XXX

72129 26 1.74$ $104.40 1.74$ $104.40 XXX

72129 TC 4.97$ $298.20 4.97$ $298.20 XXX

72130 8.00$ $480.00 8.00$ $480.00 XXX

72130 26 1.81$ $108.60 1.81$ $108.60 XXX

72130 TC 6.19$ $371.40 6.19$ $371.40 XXX

72131 5.25$ $315.00 5.25$ $315.00 XXX

72131 26 1.43$ $85.80 1.43$ $85.80 XXX

72131 TC 3.82$ $229.20 3.82$ $229.20 XXX



Page | 145

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

72132 6.69$ $401.40 6.69$ $401.40 XXX

72132 26 1.74$ $104.40 1.74$ $104.40 XXX

72132 TC 4.95$ $297.00 4.95$ $297.00 XXX

72133 7.93$ $475.80 7.93$ $475.80 XXX

72133 26 1.80$ $108.00 1.80$ $108.00 XXX

72133 TC 6.12$ $367.20 6.12$ $367.20 XXX

72141 6.53$ $391.80 6.53$ $391.80 XXX

72141 26 2.12$ $127.20 2.12$ $127.20 XXX

72141 TC 4.41$ $264.60 4.41$ $264.60 XXX

72142 9.50$ $570.00 9.50$ $570.00 XXX

72142 26 2.56$ $153.60 2.56$ $153.60 XXX

72142 TC 6.94$ $416.40 6.94$ $416.40 XXX

72146 6.53$ $391.80 6.53$ $391.80 XXX

72146 26 2.12$ $127.20 2.12$ $127.20 XXX

72146 TC 4.41$ $264.60 4.41$ $264.60 XXX

72147 9.40$ $564.00 9.40$ $564.00 XXX

72147 26 2.54$ $152.40 2.54$ $152.40 XXX

72147 TC 6.86$ $411.60 6.86$ $411.60 XXX

72148 6.50$ $390.00 6.50$ $390.00 XXX

72148 26 2.12$ $127.20 2.12$ $127.20 XXX

72148 TC 4.38$ $262.80 4.38$ $262.80 XXX

72149 9.38$ $562.80 9.38$ $562.80 XXX

72149 26 2.56$ $153.60 2.56$ $153.60 XXX

72149 TC 6.83$ $409.80 6.83$ $409.80 XXX

72156 11.08$ $664.80 11.08$ $664.80 XXX

72156 26 3.27$ $196.20 3.27$ $196.20 XXX

72156 TC 7.81$ $468.60 7.81$ $468.60 XXX

72157 11.10$ $666.00 11.10$ $666.00 XXX

72157 26 3.27$ $196.20 3.27$ $196.20 XXX

72157 TC 7.83$ $469.80 7.83$ $469.80 XXX

72158 11.06$ $663.60 11.06$ $663.60 XXX

72158 26 3.27$ $196.20 3.27$ $196.20 XXX

72158 TC 7.79$ $467.40 7.79$ $467.40 XXX

72159 12.23$ $733.80 12.23$ $733.80 XXX

72159 26 2.58$ $154.80 2.58$ $154.80 XXX

72159 TC 9.65$ $579.00 9.65$ $579.00 XXX

72170 0.92$ $55.20 0.92$ $55.20 XXX

72170 26 0.25$ $15.00 0.25$ $15.00 XXX

72170 TC 0.67$ $40.20 0.67$ $40.20 XXX

72190 1.11$ $66.60 1.11$ $66.60 XXX

72190 26 0.31$ $18.60 0.31$ $18.60 XXX

72190 TC 0.80$ $48.00 0.80$ $48.00 XXX



Page | 146

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

72191 8.92$ $535.20 8.92$ $535.20 XXX

72191 26 2.58$ $154.80 2.58$ $154.80 XXX

72191 TC 6.34$ $380.40 6.34$ $380.40 XXX

72192 4.25$ $255.00 4.25$ $255.00 XXX

72192 26 1.56$ $93.60 1.56$ $93.60 XXX

72192 TC 2.69$ $161.40 2.69$ $161.40 XXX

72193 6.62$ $397.20 6.62$ $397.20 XXX

72193 26 1.66$ $99.60 1.66$ $99.60 XXX

72193 TC 4.96$ $297.60 4.96$ $297.60 XXX

72194 7.64$ $458.40 7.64$ $458.40 XXX

72194 26 1.74$ $104.40 1.74$ $104.40 XXX

72194 TC 5.90$ $354.00 5.90$ $354.00 XXX

72195 11.01$ $660.60 11.01$ $660.60 XXX

72195 26 2.09$ $125.40 2.09$ $125.40 XXX

72195 TC 8.92$ $535.20 8.92$ $535.20 XXX

72196 12.08$ $724.80 12.08$ $724.80 XXX

72196 26 2.48$ $148.80 2.48$ $148.80 XXX

72196 TC 9.60$ $576.00 9.60$ $576.00 XXX

72197 14.83$ $889.80 14.83$ $889.80 XXX

72197 26 3.23$ $193.80 3.23$ $193.80 XXX

72197 TC 11.60$ $696.00 11.60$ $696.00 XXX

72198 11.76$ $705.60 11.76$ $705.60 XXX

72198 26 2.55$ $153.00 2.55$ $153.00 XXX

72198 TC 9.21$ $552.60 9.21$ $552.60 XXX

72200 0.83$ $49.80 0.83$ $49.80 XXX

72200 26 0.25$ $15.00 0.25$ $15.00 XXX

72200 TC 0.58$ $34.80 0.58$ $34.80 XXX

72202 0.95$ $57.00 0.95$ $57.00 XXX

72202 26 0.27$ $16.20 0.27$ $16.20 XXX

72202 TC 0.68$ $40.80 0.68$ $40.80 XXX

72220 0.82$ $49.20 0.82$ $49.20 XXX

72220 26 0.25$ $15.00 0.25$ $15.00 XXX

72220 TC 0.57$ $34.20 0.57$ $34.20 XXX

72240 2.83$ $169.80 2.83$ $169.80 XXX

72240 26 1.30$ $78.00 1.30$ $78.00 XXX

72240 TC 1.53$ $91.80 1.53$ $91.80 XXX

72255 2.81$ $168.60 2.81$ $168.60 XXX

72255 26 1.32$ $79.20 1.32$ $79.20 XXX

72255 TC 1.50$ $90.00 1.50$ $90.00 XXX

72265 2.66$ $159.60 2.66$ $159.60 XXX

72265 26 1.19$ $71.40 1.19$ $71.40 XXX

72265 TC 1.47$ $88.20 1.47$ $88.20 XXX



Page | 147

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

72270 3.67$ $220.20 3.67$ $220.20 XXX

72270 26 1.91$ $114.60 1.91$ $114.60 XXX

72270 TC 1.76$ $105.60 1.76$ $105.60 XXX

72275 3.37$ $202.20 3.37$ $202.20 XXX

72275 26 1.12$ $67.20 1.12$ $67.20 XXX

72275 TC 2.25$ $135.00 2.25$ $135.00 XXX

72285 3.29$ $197.40 3.29$ $197.40 XXX

72285 26 1.73$ $103.80 1.73$ $103.80 XXX

72285 TC 1.56$ $93.60 1.56$ $93.60 XXX

72295 2.86$ $171.60 2.86$ $171.60 XXX

72295 26 1.24$ $74.40 1.24$ $74.40 XXX

72295 TC 1.62$ $97.20 1.62$ $97.20 XXX

73000 0.79$ $47.40 0.79$ $47.40 XXX

73000 26 0.24$ $14.40 0.24$ $14.40 XXX

73000 TC 0.55$ $33.00 0.55$ $33.00 XXX

73010 0.87$ $52.20 0.87$ $52.20 XXX

73010 26 0.26$ $15.60 0.26$ $15.60 XXX

73010 TC 0.61$ $36.60 0.61$ $36.60 XXX

73020 0.66$ $39.60 0.66$ $39.60 XXX

73020 26 0.22$ $13.20 0.22$ $13.20 XXX

73020 TC 0.44$ $26.40 0.44$ $26.40 XXX

73030 0.84$ $50.40 0.84$ $50.40 XXX

73030 26 0.27$ $16.20 0.27$ $16.20 XXX

73030 TC 0.57$ $34.20 0.57$ $34.20 XXX

73040 2.92$ $175.20 2.92$ $175.20 XXX

73040 26 0.78$ $46.80 0.78$ $46.80 XXX

73040 TC 2.14$ $128.40 2.14$ $128.40 XXX

73050 1.03$ $61.80 1.03$ $61.80 XXX

73050 26 0.30$ $18.00 0.30$ $18.00 XXX

73050 TC 0.72$ $43.20 0.72$ $43.20 XXX

73060 0.84$ $50.40 0.84$ $50.40 XXX

73060 26 0.24$ $14.40 0.24$ $14.40 XXX

73060 TC 0.60$ $36.00 0.60$ $36.00 XXX

73070 0.78$ $46.80 0.78$ $46.80 XXX

73070 26 0.23$ $13.80 0.23$ $13.80 XXX

73070 TC 0.55$ $33.00 0.55$ $33.00 XXX

73080 0.90$ $54.00 0.90$ $54.00 XXX

73080 26 0.25$ $15.00 0.25$ $15.00 XXX

73080 TC 0.65$ $39.00 0.65$ $39.00 XXX

73085 2.83$ $169.80 2.83$ $169.80 XXX

73085 26 0.82$ $49.20 0.82$ $49.20 XXX

73085 TC 2.01$ $120.60 2.01$ $120.60 XXX



Page | 148

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

73090 0.74$ $44.40 0.74$ $44.40 XXX

73090 26 0.24$ $14.40 0.24$ $14.40 XXX

73090 TC 0.50$ $30.00 0.50$ $30.00 XXX

73092 0.78$ $46.80 0.78$ $46.80 XXX

73092 26 0.23$ $13.80 0.23$ $13.80 XXX

73092 TC 0.55$ $33.00 0.55$ $33.00 XXX

73100 0.84$ $50.40 0.84$ $50.40 XXX

73100 26 0.24$ $14.40 0.24$ $14.40 XXX

73100 TC 0.60$ $36.00 0.60$ $36.00 XXX

73110 1.03$ $61.80 1.03$ $61.80 XXX

73110 26 0.25$ $15.00 0.25$ $15.00 XXX

73110 TC 0.78$ $46.80 0.78$ $46.80 XXX

73115 3.12$ $187.20 3.12$ $187.20 XXX

73115 26 0.81$ $48.60 0.81$ $48.60 XXX

73115 TC 2.31$ $138.60 2.31$ $138.60 XXX

73120 0.75$ $45.00 0.75$ $45.00 XXX

73120 26 0.24$ $14.40 0.24$ $14.40 XXX

73120 TC 0.51$ $30.60 0.51$ $30.60 XXX

73130 0.89$ $53.40 0.89$ $53.40 XXX

73130 26 0.25$ $15.00 0.25$ $15.00 XXX

73130 TC 0.64$ $38.40 0.64$ $38.40 XXX

73140 0.91$ $54.60 0.91$ $54.60 XXX

73140 26 0.20$ $12.00 0.20$ $12.00 XXX

73140 TC 0.71$ $42.60 0.71$ $42.60 XXX

73200 5.24$ $314.40 5.24$ $314.40 XXX

73200 26 1.43$ $85.80 1.43$ $85.80 XXX

73200 TC 3.81$ $228.60 3.81$ $228.60 XXX

73201 6.52$ $391.20 6.52$ $391.20 XXX

73201 26 1.66$ $99.60 1.66$ $99.60 XXX

73201 TC 4.87$ $292.20 4.87$ $292.20 XXX

73202 8.15$ $489.00 8.15$ $489.00 XXX

73202 26 1.74$ $104.40 1.74$ $104.40 XXX

73202 TC 6.41$ $384.60 6.41$ $384.60 XXX

73206 9.58$ $574.80 9.58$ $574.80 XXX

73206 26 2.56$ $153.60 2.56$ $153.60 XXX

73206 TC 7.02$ $421.20 7.02$ $421.20 XXX

73218 10.71$ $642.60 10.71$ $642.60 XXX

73218 26 1.93$ $115.80 1.93$ $115.80 XXX

73218 TC 8.78$ $526.80 8.78$ $526.80 XXX

73219 11.88$ $712.80 11.88$ $712.80 XXX

73219 26 2.32$ $139.20 2.32$ $139.20 XXX

73219 TC 9.55$ $573.00 9.55$ $573.00 XXX



Page | 149

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

73220 14.66$ $879.60 14.66$ $879.60 XXX

73220 26 3.07$ $184.20 3.07$ $184.20 XXX

73220 TC 11.59$ $695.40 11.59$ $695.40 XXX

73221 6.89$ $413.40 6.89$ $413.40 XXX

73221 26 1.94$ $116.40 1.94$ $116.40 XXX

73221 TC 4.96$ $297.60 4.96$ $297.60 XXX

73222 11.09$ $665.40 11.09$ $665.40 XXX

73222 26 2.32$ $139.20 2.32$ $139.20 XXX

73222 TC 8.77$ $526.20 8.77$ $526.20 XXX

73223 13.75$ $825.00 13.75$ $825.00 XXX

73223 26 3.07$ $184.20 3.07$ $184.20 XXX

73223 TC 10.67$ $640.20 10.67$ $640.20 XXX

73225 11.89$ $713.40 11.89$ $713.40 XXX

73225 26 2.44$ $146.40 2.44$ $146.40 XXX

73225 TC 9.45$ $567.00 9.45$ $567.00 XXX

73501 0.86$ $51.60 0.86$ $51.60 XXX

73501 26 0.27$ $16.20 0.27$ $16.20 XXX

73501 TC 0.59$ $35.40 0.59$ $35.40 XXX

73502 1.20$ $72.00 1.20$ $72.00 XXX

73502 26 0.32$ $19.20 0.32$ $19.20 XXX

73502 TC 0.88$ $52.80 0.88$ $52.80 XXX

73503 1.50$ $90.00 1.50$ $90.00 XXX

73503 26 0.41$ $24.60 0.41$ $24.60 XXX

73503 TC 1.09$ $65.40 1.09$ $65.40 XXX

73521 1.15$ $69.00 1.15$ $69.00 XXX

73521 26 0.33$ $19.80 0.33$ $19.80 XXX

73521 TC 0.82$ $49.20 0.82$ $49.20 XXX

73522 1.42$ $85.20 1.42$ $85.20 XXX

73522 26 0.43$ $25.80 0.43$ $25.80 XXX

73522 TC 0.99$ $59.40 0.99$ $59.40 XXX

73523 1.65$ $99.00 1.65$ $99.00 XXX

73523 26 0.46$ $27.60 0.46$ $27.60 XXX

73523 TC 1.19$ $71.40 1.19$ $71.40 XXX

73525 2.96$ $177.60 2.96$ $177.60 XXX

73525 26 0.82$ $49.20 0.82$ $49.20 XXX

73525 TC 2.14$ $128.40 2.14$ $128.40 XXX

73551 0.81$ $48.60 0.81$ $48.60 XXX

73551 26 0.24$ $14.40 0.24$ $14.40 XXX

73551 TC 0.57$ $34.20 0.57$ $34.20 XXX

73552 0.94$ $56.40 0.94$ $56.40 XXX

73552 26 0.27$ $16.20 0.27$ $16.20 XXX

73552 TC 0.67$ $40.20 0.67$ $40.20 XXX



Page | 150

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

73560 0.90$ $54.00 0.90$ $54.00 XXX

73560 26 0.24$ $14.40 0.24$ $14.40 XXX

73560 TC 0.66$ $39.60 0.66$ $39.60 XXX

73562 1.04$ $62.40 1.04$ $62.40 XXX

73562 26 0.27$ $16.20 0.27$ $16.20 XXX

73562 TC 0.77$ $46.20 0.77$ $46.20 XXX

73564 1.14$ $68.40 1.14$ $68.40 XXX

73564 26 0.32$ $19.20 0.32$ $19.20 XXX

73564 TC 0.82$ $49.20 0.82$ $49.20 XXX

73565 1.04$ $62.40 1.04$ $62.40 XXX

73565 26 0.25$ $15.00 0.25$ $15.00 XXX

73565 TC 0.79$ $47.40 0.79$ $47.40 XXX

73580 3.37$ $202.20 3.37$ $202.20 XXX

73580 26 0.81$ $48.60 0.81$ $48.60 XXX

73580 TC 2.56$ $153.60 2.56$ $153.60 XXX

73590 0.83$ $49.80 0.83$ $49.80 XXX

73590 26 0.24$ $14.40 0.24$ $14.40 XXX

73590 TC 0.59$ $35.40 0.59$ $35.40 XXX

73592 0.81$ $48.60 0.81$ $48.60 XXX

73592 26 0.23$ $13.80 0.23$ $13.80 XXX

73592 TC 0.58$ $34.80 0.58$ $34.80 XXX

73600 0.87$ $52.20 0.87$ $52.20 XXX

73600 26 0.24$ $14.40 0.24$ $14.40 XXX

73600 TC 0.63$ $37.80 0.63$ $37.80 XXX

73610 0.90$ $54.00 0.90$ $54.00 XXX

73610 26 0.25$ $15.00 0.25$ $15.00 XXX

73610 TC 0.65$ $39.00 0.65$ $39.00 XXX

73615 3.06$ $183.60 3.06$ $183.60 XXX

73615 26 0.82$ $49.20 0.82$ $49.20 XXX

73615 TC 2.24$ $134.40 2.24$ $134.40 XXX

73620 0.75$ $45.00 0.75$ $45.00 XXX

73620 26 0.22$ $13.20 0.22$ $13.20 XXX

73620 TC 0.53$ $31.80 0.53$ $31.80 XXX

73630 0.84$ $50.40 0.84$ $50.40 XXX

73630 26 0.24$ $14.40 0.24$ $14.40 XXX

73630 TC 0.60$ $36.00 0.60$ $36.00 XXX

73650 0.78$ $46.80 0.78$ $46.80 XXX

73650 26 0.23$ $13.80 0.23$ $13.80 XXX

73650 TC 0.55$ $33.00 0.55$ $33.00 XXX

73660 0.82$ $49.20 0.82$ $49.20 XXX

73660 26 0.19$ $11.40 0.19$ $11.40 XXX

73660 TC 0.63$ $37.80 0.63$ $37.80 XXX



Page | 151

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

73700 5.24$ $314.40 5.24$ $314.40 XXX

73700 26 1.43$ $85.80 1.43$ $85.80 XXX

73700 TC 3.81$ $228.60 3.81$ $228.60 XXX

73701 6.62$ $397.20 6.62$ $397.20 XXX

73701 26 1.66$ $99.60 1.66$ $99.60 XXX

73701 TC 4.96$ $297.60 4.96$ $297.60 XXX

73702 8.05$ $483.00 8.05$ $483.00 XXX

73702 26 1.73$ $103.80 1.73$ $103.80 XXX

73702 TC 6.33$ $379.80 6.33$ $379.80 XXX

73706 10.30$ $618.00 10.30$ $618.00 XXX

73706 26 2.70$ $162.00 2.70$ $162.00 XXX

73706 TC 7.60$ $456.00 7.60$ $456.00 XXX

73718 10.71$ $642.60 10.71$ $642.60 XXX

73718 26 1.93$ $115.80 1.93$ $115.80 XXX

73718 TC 8.78$ $526.80 8.78$ $526.80 XXX

73719 11.86$ $711.60 11.86$ $711.60 XXX

73719 26 2.31$ $138.60 2.31$ $138.60 XXX

73719 TC 9.55$ $573.00 9.55$ $573.00 XXX

73720 14.75$ $885.00 14.75$ $885.00 XXX

73720 26 3.07$ $184.20 3.07$ $184.20 XXX

73720 TC 11.68$ $700.80 11.68$ $700.80 XXX

73721 6.91$ $414.60 6.91$ $414.60 XXX

73721 26 1.94$ $116.40 1.94$ $116.40 XXX

73721 TC 4.97$ $298.20 4.97$ $298.20 XXX

73722 11.20$ $672.00 11.20$ $672.00 XXX

73722 26 2.32$ $139.20 2.32$ $139.20 XXX

73722 TC 8.88$ $532.80 8.88$ $532.80 XXX

73723 13.80$ $828.00 13.80$ $828.00 XXX

73723 26 3.07$ $184.20 3.07$ $184.20 XXX

73723 TC 10.73$ $643.80 10.73$ $643.80 XXX

73725 11.78$ $706.80 11.78$ $706.80 XXX

73725 26 2.57$ $154.20 2.57$ $154.20 XXX

73725 TC 9.21$ $552.60 9.21$ $552.60 XXX

74000 0.68$ $40.80 0.68$ $40.80 XXX

74000 26 0.26$ $15.60 0.26$ $15.60 XXX

74000 TC 0.42$ $25.20 0.42$ $25.20 XXX

74010 1.02$ $61.20 1.02$ $61.20 XXX

74010 26 0.33$ $19.80 0.33$ $19.80 XXX

74010 TC 0.69$ $41.40 0.69$ $41.40 XXX

74020 1.08$ $64.80 1.08$ $64.80 XXX

74020 26 0.39$ $23.40 0.39$ $23.40 XXX

74020 TC 0.69$ $41.40 0.69$ $41.40 XXX



Page | 152

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

74022 1.29$ $77.40 1.29$ $77.40 XXX

74022 26 0.46$ $27.60 0.46$ $27.60 XXX

74022 TC 0.83$ $49.80 0.83$ $49.80 XXX

74150 4.35$ $261.00 4.35$ $261.00 XXX

74150 26 1.70$ $102.00 1.70$ $102.00 XXX

74150 TC 2.65$ $159.00 2.65$ $159.00 XXX

74160 6.75$ $405.00 6.75$ $405.00 XXX

74160 26 1.82$ $109.20 1.82$ $109.20 XXX

74160 TC 4.93$ $295.80 4.93$ $295.80 XXX

74170 7.68$ $460.80 7.68$ $460.80 XXX

74170 26 2.00$ $120.00 2.00$ $120.00 XXX

74170 TC 5.68$ $340.80 5.68$ $340.80 XXX

74174 11.36$ $681.60 11.36$ $681.60 XXX

74174 26 3.12$ $187.20 3.12$ $187.20 XXX

74174 TC 8.24$ $494.40 8.24$ $494.40 XXX

74175 8.96$ $537.60 8.96$ $537.60 XXX

74175 26 2.58$ $154.80 2.58$ $154.80 XXX

74175 TC 6.38$ $382.80 6.38$ $382.80 XXX

74176 5.81$ $348.60 5.81$ $348.60 XXX

74176 26 2.49$ $149.40 2.49$ $149.40 XXX

74176 TC 3.32$ $199.20 3.32$ $199.20 XXX

74177 9.10$ $546.00 9.10$ $546.00 XXX

74177 26 2.60$ $156.00 2.60$ $156.00 XXX

74177 TC 6.49$ $389.40 6.49$ $389.40 XXX

74178 10.32$ $619.20 10.32$ $619.20 XXX

74178 26 2.87$ $172.20 2.87$ $172.20 XXX

74178 TC 7.45$ $447.00 7.45$ $447.00 XXX

74181 9.77$ $586.20 9.77$ $586.20 XXX

74181 26 2.08$ $124.80 2.08$ $124.80 XXX

74181 TC 7.69$ $461.40 7.69$ $461.40 XXX

74182 13.33$ $799.80 13.33$ $799.80 XXX

74182 26 2.47$ $148.20 2.47$ $148.20 XXX

74182 TC 10.87$ $652.20 10.87$ $652.20 XXX

74183 14.85$ $891.00 14.85$ $891.00 XXX

74183 26 3.23$ $193.80 3.23$ $193.80 XXX

74183 TC 11.63$ $697.80 11.63$ $697.80 XXX

74185 11.82$ $709.20 11.82$ $709.20 XXX

74185 26 2.55$ $153.00 2.55$ $153.00 XXX

74185 TC 9.27$ $556.20 9.27$ $556.20 XXX



74190 26 0.67$ $40.20 0.67$ $40.20 XXX



Page | 153

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

74210 2.27$ $136.20 2.27$ $136.20 XXX

74210 26 0.51$ $30.60 0.51$ $30.60 XXX

74210 TC 1.76$ $105.60 1.76$ $105.60 XXX

74220 2.59$ $155.40 2.59$ $155.40 XXX

74220 26 0.66$ $39.60 0.66$ $39.60 XXX

74220 TC 1.93$ $115.80 1.93$ $115.80 XXX

74230 3.76$ $225.60 3.76$ $225.60 XXX

74230 26 0.76$ $45.60 0.76$ $45.60 XXX

74230 TC 3.00$ $180.00 3.00$ $180.00 XXX



74235 26 1.67$ $100.20 1.67$ $100.20 XXX

74240 3.30$ $198.00 3.30$ $198.00 XXX

74240 26 0.99$ $59.40 0.99$ $59.40 XXX

74240 TC 2.31$ $138.60 2.31$ $138.60 XXX

74241 3.44$ $206.40 3.44$ $206.40 XXX

74241 26 0.99$ $59.40 0.99$ $59.40 XXX

74241 TC 2.45$ $147.00 2.45$ $147.00 XXX

74245 5.02$ $301.20 5.02$ $301.20 XXX

74245 26 1.30$ $78.00 1.30$ $78.00 XXX

74245 TC 3.71$ $222.60 3.71$ $222.60 XXX

74246 3.72$ $223.20 3.72$ $223.20 XXX

74246 26 0.99$ $59.40 0.99$ $59.40 XXX

74246 TC 2.73$ $163.80 2.73$ $163.80 XXX

74247 4.12$ $247.20 4.12$ $247.20 XXX

74247 26 0.99$ $59.40 0.99$ $59.40 XXX

74247 TC 3.13$ $187.80 3.13$ $187.80 XXX

74249 5.39$ $323.40 5.39$ $323.40 XXX

74249 26 1.30$ $78.00 1.30$ $78.00 XXX

74249 TC 4.08$ $244.80 4.08$ $244.80 XXX

74250 3.04$ $182.40 3.04$ $182.40 XXX

74250 26 0.67$ $40.20 0.67$ $40.20 XXX

74250 TC 2.37$ $142.20 2.37$ $142.20 XXX

74251 12.37$ $742.20 12.37$ $742.20 XXX

74251 26 0.99$ $59.40 0.99$ $59.40 XXX

74251 TC 11.38$ $682.80 11.38$ $682.80 XXX

74260 10.44$ $626.40 10.44$ $626.40 XXX

74260 26 0.72$ $43.20 0.72$ $43.20 XXX

74260 TC 9.72$ $583.20 9.72$ $583.20 XXX

74261 14.23$ $853.80 14.23$ $853.80 XXX

74261 26 3.44$ $206.40 3.44$ $206.40 XXX

74261 TC 10.79$ $647.40 10.79$ $647.40 XXX



Page | 154

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

74262 15.84$ $950.40 15.84$ $950.40 XXX

74262 26 3.57$ $214.20 3.57$ $214.20 XXX

74262 TC 12.27$ $736.20 12.27$ $736.20 XXX

74263 22.24$ $1,334.40 22.24$ $1,334.40 XXX

74263 26 3.25$ $195.00 3.25$ $195.00 XXX

74263 TC 18.99$ $1,139.40 18.99$ $1,139.40 XXX

74270 4.41$ $264.60 4.41$ $264.60 XXX

74270 26 0.99$ $59.40 0.99$ $59.40 XXX

74270 TC 3.42$ $205.20 3.42$ $205.20 XXX

74280 6.23$ $373.80 6.23$ $373.80 XXX

74280 26 1.42$ $85.20 1.42$ $85.20 XXX

74280 TC 4.81$ $288.60 4.81$ $288.60 XXX

74283 5.94$ $356.40 5.94$ $356.40 XXX

74283 26 2.91$ $174.60 2.91$ $174.60 XXX

74283 TC 3.03$ $181.80 3.03$ $181.80 XXX

74290 2.05$ $123.00 2.05$ $123.00 XXX

74290 26 0.46$ $27.60 0.46$ $27.60 XXX

74290 TC 1.59$ $95.40 1.59$ $95.40 XXX



74300 26 0.51$ $30.60 0.51$ $30.60 XXX


74301 TC By Report By Report ZZZ

74301 26 0.30$ $18.00 0.30$ $18.00 ZZZ



74328 26 1.01$ $60.60 1.01$ $60.60 XXX



74329 26 1.02$ $61.20 1.02$ $61.20 XXX



74330 26 1.30$ $78.00 1.30$ $78.00 XXX



74340 26 0.77$ $46.20 0.77$ $46.20 XXX



74355 26 1.09$ $65.40 1.09$ $65.40 XXX



74360 26 0.79$ $47.40 0.79$ $47.40 XXX



Page | 155

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



74363 26 1.22$ $73.20 1.22$ $73.20 XXX

74400 3.22$ $193.20 3.22$ $193.20 XXX

74400 26 0.70$ $42.00 0.70$ $42.00 XXX

74400 TC 2.52$ $151.20 2.52$ $151.20 XXX

74410 3.17$ $190.20 3.17$ $190.20 XXX

74410 26 0.69$ $41.40 0.69$ $41.40 XXX

74410 TC 2.48$ $148.80 2.48$ $148.80 XXX

74415 4.01$ $240.60 4.01$ $240.60 XXX

74415 26 0.70$ $42.00 0.70$ $42.00 XXX

74415 TC 3.31$ $198.60 3.31$ $198.60 XXX



74420 26 0.51$ $30.60 0.51$ $30.60 XXX



74425 26 0.50$ $30.00 0.50$ $30.00 XXX

74430 1.09$ $65.40 1.09$ $65.40 XXX

74430 26 0.46$ $27.60 0.46$ $27.60 XXX

74430 TC 0.63$ $37.80 0.63$ $37.80 XXX

74440 2.38$ $142.80 2.38$ $142.80 XXX

74440 26 0.53$ $31.80 0.53$ $31.80 XXX

74440 TC 1.85$ $111.00 1.85$ $111.00 XXX



74445 26 1.55$ $93.00 1.55$ $93.00 XXX



74450 26 0.47$ $28.20 0.47$ $28.20 XXX

74455 2.39$ $143.40 2.39$ $143.40 XXX

74455 26 0.47$ $28.20 0.47$ $28.20 XXX

74455 TC 1.92$ $115.20 1.92$ $115.20 XXX



74470 26 0.75$ $45.00 0.75$ $45.00 XXX

74485 2.69$ $161.40 2.69$ $161.40 XXX

74485 26 0.74$ $44.40 0.74$ $44.40 XXX

74485 TC 1.95$ $117.00 1.95$ $117.00 XXX

74710 1.05$ $63.00 1.05$ $63.00 XXX

74710 26 0.49$ $29.40 0.49$ $29.40 XXX

74710 TC 0.57$ $34.20 0.57$ $34.20 XXX



Page | 156

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

74712 14.07$ $844.20 14.07$ $844.20 XXX

74712 26 4.29$ $257.40 4.29$ $257.40 XXX

74712 TC 9.78$ $586.80 9.78$ $586.80 XXX

74713 6.74$ $404.40 6.74$ $404.40 XXX

74713 26 2.55$ $153.00 2.55$ $153.00 XXX

74713 TC 4.19$ $251.40 4.19$ $251.40 XXX

74740 2.18$ $130.80 2.18$ $130.80 XXX

74740 26 0.54$ $32.40 0.54$ $32.40 XXX

74740 TC 1.64$ $98.40 1.64$ $98.40 XXX



74742 26 0.83$ $49.80 0.83$ $49.80 XXX



74775 26 0.89$ $53.40 0.89$ $53.40 XXX

75557 9.28$ $556.80 9.28$ $556.80 XXX

75557 26 3.30$ $198.00 3.30$ $198.00 XXX

75557 TC 5.98$ $358.80 5.98$ $358.80 XXX

75559 12.75$ $765.00 12.75$ $765.00 XXX

75559 26 4.09$ $245.40 4.09$ $245.40 XXX

75559 TC 8.65$ $519.00 8.65$ $519.00 XXX

75561 12.37$ $742.20 12.37$ $742.20 XXX

75561 26 3.65$ $219.00 3.65$ $219.00 XXX

75561 TC 8.72$ $523.20 8.72$ $523.20 XXX

75563 14.69$ $881.40 14.69$ $881.40 XXX

75563 26 4.19$ $251.40 4.19$ $251.40 XXX

75563 TC 10.50$ $630.00 10.50$ $630.00 XXX

75565 1.61$ $96.60 1.61$ $96.60 ZZZ

75565 26 0.35$ $21.00 0.35$ $21.00 ZZZ

75565 TC 1.26$ $75.60 1.26$ $75.60 ZZZ

75571 2.93$ $175.80 2.93$ $175.80 XXX

75571 26 0.82$ $49.20 0.82$ $49.20 XXX

75571 TC 2.11$ $126.60 2.11$ $126.60 XXX

75572 8.30$ $498.00 8.30$ $498.00 XXX

75572 26 2.47$ $148.20 2.47$ $148.20 XXX

75572 TC 5.82$ $349.20 5.82$ $349.20 XXX

75573 11.42$ $685.20 11.42$ $685.20 XXX

75573 26 3.59$ $215.40 3.59$ $215.40 XXX

75573 TC 7.82$ $469.20 7.82$ $469.20 XXX

75574 12.25$ $735.00 12.25$ $735.00 XXX

75574 26 3.38$ $202.80 3.38$ $202.80 XXX

75574 TC 8.87$ $532.20 8.87$ $532.20 XXX



Page | 157

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

75600 5.83$ $349.80 5.83$ $349.80 XXX

75600 26 0.68$ $40.80 0.68$ $40.80 XXX

75600 TC 5.15$ $309.00 5.15$ $309.00 XXX

75605 4.02$ $241.20 4.02$ $241.20 XXX

75605 26 1.57$ $94.20 1.57$ $94.20 XXX

75605 TC 2.46$ $147.60 2.46$ $147.60 XXX

75625 4.00$ $240.00 4.00$ $240.00 XXX

75625 26 1.55$ $93.00 1.55$ $93.00 XXX

75625 TC 2.45$ $147.00 2.45$ $147.00 XXX

75630 4.91$ $294.60 4.91$ $294.60 XXX

75630 26 2.46$ $147.60 2.46$ $147.60 XXX

75630 TC 2.45$ $147.00 2.45$ $147.00 XXX

75635 11.10$ $666.00 11.10$ $666.00 XXX

75635 26 3.40$ $204.00 3.40$ $204.00 XXX

75635 TC 7.71$ $462.60 7.71$ $462.60 XXX

75658 4.84$ $290.40 4.84$ $290.40 XXX

75658 26 1.77$ $106.20 1.77$ $106.20 XXX

75658 TC 3.06$ $183.60 3.06$ $183.60 XXX

75705 7.01$ $420.60 7.01$ $420.60 XXX

75705 26 3.17$ $190.20 3.17$ $190.20 XXX

75705 TC 3.84$ $230.40 3.84$ $230.40 XXX

75710 4.75$ $285.00 4.75$ $285.00 XXX

75710 26 1.57$ $94.20 1.57$ $94.20 XXX

75710 TC 3.18$ $190.80 3.18$ $190.80 XXX

75716 5.45$ $327.00 5.45$ $327.00 XXX

75716 26 1.80$ $108.00 1.80$ $108.00 XXX

75716 TC 3.65$ $219.00 3.65$ $219.00 XXX

75726 4.36$ $261.60 4.36$ $261.60 XXX

75726 26 1.57$ $94.20 1.57$ $94.20 XXX

75726 TC 2.80$ $168.00 2.80$ $168.00 XXX

75731 5.05$ $303.00 5.05$ $303.00 XXX

75731 26 1.63$ $97.80 1.63$ $97.80 XXX

75731 TC 3.41$ $204.60 3.41$ $204.60 XXX

75733 5.39$ $323.40 5.39$ $323.40 XXX

75733 26 1.82$ $109.20 1.82$ $109.20 XXX

75733 TC 3.57$ $214.20 3.57$ $214.20 XXX

75736 4.68$ $280.80 4.68$ $280.80 XXX

75736 26 1.56$ $93.60 1.56$ $93.60 XXX

75736 TC 3.13$ $187.80 3.13$ $187.80 XXX

75741 4.41$ $264.60 4.41$ $264.60 XXX

75741 26 1.80$ $108.00 1.80$ $108.00 XXX

75741 TC 2.61$ $156.60 2.61$ $156.60 XXX



Page | 158

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

75743 4.92$ $295.20 4.92$ $295.20 XXX

75743 26 2.29$ $137.40 2.29$ $137.40 XXX

75743 TC 2.64$ $158.40 2.64$ $158.40 XXX

75746 4.44$ $266.40 4.44$ $266.40 XXX

75746 26 1.60$ $96.00 1.60$ $96.00 XXX

75746 TC 2.84$ $170.40 2.84$ $170.40 XXX

75756 4.85$ $291.00 4.85$ $291.00 XXX

75756 26 1.55$ $93.00 1.55$ $93.00 XXX

75756 TC 3.30$ $198.00 3.30$ $198.00 XXX

75774 2.58$ $154.80 2.58$ $154.80 ZZZ

75774 26 0.49$ $29.40 0.49$ $29.40 ZZZ

75774 TC 2.09$ $125.40 2.09$ $125.40 ZZZ

75791 9.48$ $568.80 9.48$ $568.80 XXX

75791 26 2.38$ $142.80 2.38$ $142.80 XXX

75791 TC 7.10$ $426.00 7.10$ $426.00 XXX



75801 26 1.20$ $72.00 1.20$ $72.00 XXX



75803 26 1.67$ $100.20 1.67$ $100.20 XXX



75805 26 1.16$ $69.60 1.16$ $69.60 XXX



75807 26 1.68$ $100.80 1.68$ $100.80 XXX

75809 2.91$ $174.60 2.91$ $174.60 XXX

75809 26 0.68$ $40.80 0.68$ $40.80 XXX

75809 TC 2.24$ $134.40 2.24$ $134.40 XXX



75810 26 1.64$ $98.40 1.64$ $98.40 XXX

75820 3.37$ $202.20 3.37$ $202.20 XXX

75820 26 0.98$ $58.80 0.98$ $58.80 XXX

75820 TC 2.39$ $143.40 2.39$ $143.40 XXX

75822 4.00$ $240.00 4.00$ $240.00 XXX

75822 26 1.47$ $88.20 1.47$ $88.20 XXX

75822 TC 2.53$ $151.80 2.53$ $151.80 XXX

75825 3.94$ $236.40 3.94$ $236.40 XXX

75825 26 1.57$ $94.20 1.57$ $94.20 XXX

75825 TC 2.37$ $142.20 2.37$ $142.20 XXX



Page | 159

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

75827 4.01$ $240.60 4.01$ $240.60 XXX

75827 26 1.57$ $94.20 1.57$ $94.20 XXX

75827 TC 2.45$ $147.00 2.45$ $147.00 XXX

75831 4.10$ $246.00 4.10$ $246.00 XXX

75831 26 1.56$ $93.60 1.56$ $93.60 XXX

75831 TC 2.54$ $152.40 2.54$ $152.40 XXX

75833 4.74$ $284.40 4.74$ $284.40 XXX

75833 26 2.00$ $120.00 2.00$ $120.00 XXX

75833 TC 2.74$ $164.40 2.74$ $164.40 XXX

75840 4.34$ $260.40 4.34$ $260.40 XXX

75840 26 1.63$ $97.80 1.63$ $97.80 XXX

75840 TC 2.71$ $162.60 2.71$ $162.60 XXX

75842 5.26$ $315.60 5.26$ $315.60 XXX

75842 26 2.12$ $127.20 2.12$ $127.20 XXX

75842 TC 3.14$ $188.40 3.14$ $188.40 XXX

75860 4.17$ $250.20 4.17$ $250.20 XXX

75860 26 1.57$ $94.20 1.57$ $94.20 XXX

75860 TC 2.59$ $155.40 2.59$ $155.40 XXX

75870 4.32$ $259.20 4.32$ $259.20 XXX

75870 26 1.63$ $97.80 1.63$ $97.80 XXX

75870 TC 2.69$ $161.40 2.69$ $161.40 XXX

75872 4.09$ $245.40 4.09$ $245.40 XXX

75872 26 1.50$ $90.00 1.50$ $90.00 XXX

75872 TC 2.58$ $154.80 2.58$ $154.80 XXX

75880 4.20$ $252.00 4.20$ $252.00 XXX

75880 26 1.03$ $61.80 1.03$ $61.80 XXX

75880 TC 3.17$ $190.20 3.17$ $190.20 XXX

75885 4.61$ $276.60 4.61$ $276.60 XXX

75885 26 1.97$ $118.20 1.97$ $118.20 XXX

75885 TC 2.64$ $158.40 2.64$ $158.40 XXX

75887 4.64$ $278.40 4.64$ $278.40 XXX

75887 26 1.99$ $119.40 1.99$ $119.40 XXX

75887 TC 2.66$ $159.60 2.66$ $159.60 XXX

75889 4.21$ $252.60 4.21$ $252.60 XXX

75889 26 1.56$ $93.60 1.56$ $93.60 XXX

75889 TC 2.65$ $159.00 2.65$ $159.00 XXX

75891 4.24$ $254.40 4.24$ $254.40 XXX

75891 26 1.58$ $94.80 1.58$ $94.80 XXX

75891 TC 2.66$ $159.60 2.66$ $159.60 XXX

75893 3.49$ $209.40 3.49$ $209.40 XXX

75893 26 0.77$ $46.20 0.77$ $46.20 XXX

75893 TC 2.72$ $163.20 2.72$ $163.20 XXX



Page | 160

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



75894 26 1.85$ $111.00 1.85$ $111.00 XXX



75898 26 2.35$ $141.00 2.35$ $141.00 XXX

75901 5.24$ $314.40 5.24$ $314.40 XXX

75901 26 0.68$ $40.80 0.68$ $40.80 XXX

75901 TC 4.56$ $273.60 4.56$ $273.60 XXX

75902 2.10$ $126.00 2.10$ $126.00 XXX

75902 26 0.53$ $31.80 0.53$ $31.80 XXX

75902 TC 1.57$ $94.20 1.57$ $94.20 XXX



75952 26 6.10$ $366.00 6.10$ $366.00 XXX



75953 26 1.85$ $111.00 1.85$ $111.00 XXX



75954 26 3.07$ $184.20 3.07$ $184.20 XXX



75956 26 9.50$ $570.00 9.50$ $570.00 XXX



75957 26 8.15$ $489.00 8.15$ $489.00 XXX



75958 26 5.41$ $324.60 5.41$ $324.60 XXX



75959 26 4.72$ $283.20 4.72$ $283.20 XXX

75962 4.12$ $247.20 4.12$ $247.20 XXX

75962 26 0.74$ $44.40 0.74$ $44.40 XXX

75962 TC 3.38$ $202.80 3.38$ $202.80 XXX

75964 2.59$ $155.40 2.59$ $155.40 ZZZ

75964 26 0.49$ $29.40 0.49$ $29.40 ZZZ

75964 TC 2.10$ $126.00 2.10$ $126.00 ZZZ

75966 4.97$ $298.20 4.97$ $298.20 XXX

75966 26 1.80$ $108.00 1.80$ $108.00 XXX

75966 TC 3.17$ $190.20 3.17$ $190.20 XXX



Page | 161

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

75968 2.57$ $154.20 2.57$ $154.20 ZZZ

75968 26 0.50$ $30.00 0.50$ $30.00 ZZZ

75968 TC 2.07$ $124.20 2.07$ $124.20 ZZZ



75970 26 1.15$ $69.00 1.15$ $69.00 XXX

75978 4.07$ $244.20 4.07$ $244.20 XXX

75978 26 0.74$ $44.40 0.74$ $44.40 XXX

75978 TC 3.33$ $199.80 3.33$ $199.80 XXX

75984 3.11$ $186.60 3.11$ $186.60 XXX

75984 26 1.00$ $60.00 1.00$ $60.00 XXX

75984 TC 2.11$ $126.60 2.11$ $126.60 XXX

75989 3.50$ $210.00 3.50$ $210.00 XXX

75989 26 1.67$ $100.20 1.67$ $100.20 XXX

75989 TC 1.83$ $109.80 1.83$ $109.80 XXX

76000 1.38$ $82.80 1.38$ $82.80 XXX

76000 26 0.24$ $14.40 0.24$ $14.40 XXX

76000 TC 1.14$ $68.40 1.14$ $68.40 XXX



76001 26 1.00$ $60.00 1.00$ $60.00 XXX

76010 0.75$ $45.00 0.75$ $45.00 XXX

76010 26 0.26$ $15.60 0.26$ $15.60 XXX

76010 TC 0.49$ $29.40 0.49$ $29.40 XXX

76080 1.60$ $96.00 1.60$ $96.00 XXX

76080 26 0.75$ $45.00 0.75$ $45.00 XXX

76080 TC 0.85$ $51.00 0.85$ $51.00 XXX

76098 0.48$ $28.80 0.48$ $28.80 XXX

76098 26 0.23$ $13.80 0.23$ $13.80 XXX

76098 TC 0.25$ $15.00 0.25$ $15.00 XXX

76100 2.69$ $161.40 2.69$ $161.40 XXX

76100 26 0.89$ $53.40 0.89$ $53.40 XXX

76100 TC 1.79$ $107.40 1.79$ $107.40 XXX

76101 3.86$ $231.60 3.86$ $231.60 XXX

76101 26 0.97$ $58.20 0.97$ $58.20 XXX

76101 TC 2.89$ $173.40 2.89$ $173.40 XXX

76102 5.12$ $307.20 5.12$ $307.20 XXX

76102 26 0.97$ $58.20 0.97$ $58.20 XXX

76102 TC 4.14$ $248.40 4.14$ $248.40 XXX

76120 2.45$ $147.00 2.45$ $147.00 XXX

76120 26 0.55$ $33.00 0.55$ $33.00 XXX

76120 TC 1.90$ $114.00 1.90$ $114.00 XXX



Page | 162

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



76125 26 0.40$ $24.00 0.40$ $24.00 ZZZ


76376 0.67$ $40.20 0.67$ $40.20 XXX

76376 26 0.28$ $16.80 0.28$ $16.80 XXX

76376 TC 0.39$ $23.40 0.39$ $23.40 XXX

76377 2.05$ $123.00 2.05$ $123.00 XXX

76377 26 1.13$ $67.80 1.13$ $67.80 XXX

76377 TC 0.92$ $55.20 0.92$ $55.20 XXX

76380 4.27$ $256.20 4.27$ $256.20 XXX

76380 26 1.40$ $84.00 1.40$ $84.00 XXX

76380 TC 2.87$ $172.20 2.87$ $172.20 XXX

76390 13.10$ $786.00 13.10$ $786.00 XXX

76390 26 2.00$ $120.00 2.00$ $120.00 XXX

76390 TC 11.10$ $666.00 11.10$ $666.00 XXX


76496 26 By Report By Report XXX











76506 3.49$ $209.40 3.49$ $209.40 XXX

76506 26 0.91$ $54.60 0.91$ $54.60 XXX

76506 TC 2.57$ $154.20 2.57$ $154.20 XXX

76510 4.99$ $299.40 4.99$ $299.40 XXX

76510 26 2.58$ $154.80 2.58$ $154.80 XXX

76510 TC 2.41$ $144.60 2.41$ $144.60 XXX

76511 2.97$ $178.20 2.97$ $178.20 XXX

76511 26 1.53$ $91.80 1.53$ $91.80 XXX

76511 TC 1.43$ $85.80 1.43$ $85.80 XXX

76512 2.71$ $162.60 2.71$ $162.60 XXX

76512 26 1.53$ $91.80 1.53$ $91.80 XXX

76512 TC 1.18$ $70.80 1.18$ $70.80 XXX

76513 2.80$ $168.00 2.80$ $168.00 XXX

76513 26 1.03$ $61.80 1.03$ $61.80 XXX



Page | 163

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

76513 TC 1.77$ $106.20 1.77$ $106.20 XXX

76514 0.43$ $25.80 0.43$ $25.80 XXX

76514 26 0.28$ $16.80 0.28$ $16.80 XXX

76514 TC 0.15$ $9.00 0.15$ $9.00 XXX

76516 2.31$ $138.60 2.31$ $138.60 XXX

76516 26 0.90$ $54.00 0.90$ $54.00 XXX

76516 TC 1.41$ $84.60 1.41$ $84.60 XXX

76519 2.47$ $148.20 2.47$ $148.20 XXX

76519 26 0.90$ $54.00 0.90$ $54.00 XXX

76519 TC 1.57$ $94.20 1.57$ $94.20 XXX

76529 2.33$ $139.80 2.33$ $139.80 XXX

76529 26 0.94$ $56.40 0.94$ $56.40 XXX

76529 TC 1.39$ $83.40 1.39$ $83.40 XXX

76536 3.43$ $205.80 3.43$ $205.80 XXX

76536 26 0.80$ $48.00 0.80$ $48.00 XXX

76536 TC 2.63$ $157.80 2.63$ $157.80 XXX

76604 2.58$ $154.80 2.58$ $154.80 XXX

76604 26 0.77$ $46.20 0.77$ $46.20 XXX

76604 TC 1.81$ $108.60 1.81$ $108.60 XXX

76641 3.15$ $189.00 3.15$ $189.00 XXX

76641 26 1.04$ $62.40 1.04$ $62.40 XXX

76641 TC 2.11$ $126.60 2.11$ $126.60 XXX

76642 2.58$ $154.80 2.58$ $154.80 XXX

76642 26 0.97$ $58.20 0.97$ $58.20 XXX

76642 TC 1.61$ $96.60 1.61$ $96.60 XXX

76700 3.60$ $216.00 3.60$ $216.00 XXX

76700 26 1.15$ $69.00 1.15$ $69.00 XXX

76700 TC 2.45$ $147.00 2.45$ $147.00 XXX

76705 2.69$ $161.40 2.69$ $161.40 XXX

76705 26 0.84$ $50.40 0.84$ $50.40 XXX

76705 TC 1.84$ $110.40 1.84$ $110.40 XXX

76770 3.33$ $199.80 3.33$ $199.80 XXX

76770 26 1.05$ $63.00 1.05$ $63.00 XXX

76770 TC 2.28$ $136.80 2.28$ $136.80 XXX

76775 1.68$ $100.80 1.68$ $100.80 XXX

76775 26 0.82$ $49.20 0.82$ $49.20 XXX

76775 TC 0.86$ $51.60 0.86$ $51.60 XXX

76776 4.63$ $277.80 4.63$ $277.80 XXX

76776 26 1.08$ $64.80 1.08$ $64.80 XXX

76776 TC 3.55$ $213.00 3.55$ $213.00 XXX

76800 4.07$ $244.20 4.07$ $244.20 XXX

76800 26 1.67$ $100.20 1.67$ $100.20 XXX



Page | 164

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

76800 TC 2.40$ $144.00 2.40$ $144.00 XXX

76801 3.60$ $216.00 3.60$ $216.00 XXX

76801 26 1.43$ $85.80 1.43$ $85.80 XXX

76801 TC 2.17$ $130.20 2.17$ $130.20 XXX

76802 1.87$ $112.20 1.87$ $112.20 ZZZ

76802 26 1.20$ $72.00 1.20$ $72.00 ZZZ

76802 TC 0.67$ $40.20 0.67$ $40.20 ZZZ

76805 4.17$ $250.20 4.17$ $250.20 XXX

76805 26 1.43$ $85.80 1.43$ $85.80 XXX

76805 TC 2.73$ $163.80 2.73$ $163.80 XXX

76810 2.71$ $162.60 2.71$ $162.60 ZZZ

76810 26 1.42$ $85.20 1.42$ $85.20 ZZZ

76810 TC 1.29$ $77.40 1.29$ $77.40 ZZZ

76811 5.27$ $316.20 5.27$ $316.20 XXX

76811 26 2.77$ $166.20 2.77$ $166.20 XXX

76811 TC 2.49$ $149.40 2.49$ $149.40 XXX

76812 6.03$ $361.80 6.03$ $361.80 ZZZ

76812 26 2.61$ $156.60 2.61$ $156.60 ZZZ

76812 TC 3.42$ $205.20 3.42$ $205.20 ZZZ

76813 3.51$ $210.60 3.51$ $210.60 XXX

76813 26 1.72$ $103.20 1.72$ $103.20 XXX

76813 TC 1.79$ $107.40 1.79$ $107.40 XXX

76814 2.34$ $140.40 2.34$ $140.40 XXX

76814 26 1.45$ $87.00 1.45$ $87.00 XXX

76814 TC 0.88$ $52.80 0.88$ $52.80 XXX

76815 2.47$ $148.20 2.47$ $148.20 XXX

76815 26 0.93$ $55.80 0.93$ $55.80 XXX

76815 TC 1.54$ $92.40 1.54$ $92.40 XXX

76816 3.37$ $202.20 3.37$ $202.20 XXX

76816 26 1.24$ $74.40 1.24$ $74.40 XXX

76816 TC 2.13$ $127.80 2.13$ $127.80 XXX

76817 2.85$ $171.00 2.85$ $171.00 XXX

76817 26 1.09$ $65.40 1.09$ $65.40 XXX

76817 TC 1.76$ $105.60 1.76$ $105.60 XXX

76818 3.54$ $212.40 3.54$ $212.40 XXX

76818 26 1.54$ $92.40 1.54$ $92.40 XXX

76818 TC 2.01$ $120.60 2.01$ $120.60 XXX

76819 2.59$ $155.40 2.59$ $155.40 XXX

76819 26 1.12$ $67.20 1.12$ $67.20 XXX

76819 TC 1.46$ $87.60 1.46$ $87.60 XXX

76820 1.36$ $81.60 1.36$ $81.60 XXX

76820 26 0.72$ $43.20 0.72$ $43.20 XXX



Page | 165

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

76820 TC 0.64$ $38.40 0.64$ $38.40 XXX

76821 2.72$ $163.20 2.72$ $163.20 XXX

76821 26 1.02$ $61.20 1.02$ $61.20 XXX

76821 TC 1.70$ $102.00 1.70$ $102.00 XXX

76825 8.14$ $488.40 8.14$ $488.40 XXX

76825 26 2.39$ $143.40 2.39$ $143.40 XXX

76825 TC 5.75$ $345.00 5.75$ $345.00 XXX

76826 4.82$ $289.20 4.82$ $289.20 XXX

76826 26 1.18$ $70.80 1.18$ $70.80 XXX

76826 TC 3.64$ $218.40 3.64$ $218.40 XXX

76827 2.22$ $133.20 2.22$ $133.20 XXX

76827 26 0.82$ $49.20 0.82$ $49.20 XXX

76827 TC 1.40$ $84.00 1.40$ $84.00 XXX

76828 1.55$ $93.00 1.55$ $93.00 XXX

76828 26 0.81$ $48.60 0.81$ $48.60 XXX

76828 TC 0.74$ $44.40 0.74$ $44.40 XXX

76830 3.59$ $215.40 3.59$ $215.40 XXX

76830 26 0.99$ $59.40 0.99$ $59.40 XXX

76830 TC 2.61$ $156.60 2.61$ $156.60 XXX

76831 3.48$ $208.80 3.48$ $208.80 XXX

76831 26 1.05$ $63.00 1.05$ $63.00 XXX

76831 TC 2.44$ $146.40 2.44$ $146.40 XXX

76856 3.22$ $193.20 3.22$ $193.20 XXX

76856 26 0.98$ $58.80 0.98$ $58.80 XXX

76856 TC 2.25$ $135.00 2.25$ $135.00 XXX

76857 1.38$ $82.80 1.38$ $82.80 XXX

76857 26 0.71$ $42.60 0.71$ $42.60 XXX

76857 TC 0.67$ $40.20 0.67$ $40.20 XXX

76870 1.96$ $117.60 1.96$ $117.60 XXX

76870 26 0.91$ $54.60 0.91$ $54.60 XXX

76870 TC 1.05$ $63.00 1.05$ $63.00 XXX

76872 2.76$ $165.60 2.76$ $165.60 XXX

76872 26 0.96$ $57.60 0.96$ $57.60 XXX

76872 TC 1.80$ $108.00 1.80$ $108.00 XXX

76873 4.90$ $294.00 4.90$ $294.00 XXX

76873 26 2.23$ $133.80 2.23$ $133.80 XXX

76873 TC 2.68$ $160.80 2.68$ $160.80 XXX

76881 3.37$ $202.20 3.37$ $202.20 XXX

76881 26 0.89$ $53.40 0.89$ $53.40 XXX

76881 TC 2.48$ $148.80 2.48$ $148.80 XXX

76882 1.03$ $61.80 1.03$ $61.80 XXX

76882 26 0.70$ $42.00 0.70$ $42.00 XXX



Page | 166

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

76882 TC 0.33$ $19.80 0.33$ $19.80 XXX

76885 4.30$ $258.00 4.30$ $258.00 XXX

76885 26 1.06$ $63.60 1.06$ $63.60 XXX

76885 TC 3.24$ $194.40 3.24$ $194.40 XXX

76886 3.12$ $187.20 3.12$ $187.20 XXX

76886 26 0.87$ $52.20 0.87$ $52.20 XXX

76886 TC 2.25$ $135.00 2.25$ $135.00 XXX



76930 26 0.93$ $55.80 0.93$ $55.80 XXX


76932 TC By Report By Report YYY

76932 26 0.93$ $55.80 0.93$ $55.80 XXX

76936 7.89$ $473.40 7.89$ $473.40 XXX

76936 26 2.72$ $163.20 2.72$ $163.20 XXX

76936 TC 5.17$ $310.20 5.17$ $310.20 XXX

76937 0.91$ $54.60 0.91$ $54.60 ZZZ

76937 26 0.41$ $24.60 0.41$ $24.60 ZZZ

76937 TC 0.51$ $30.60 0.51$ $30.60 ZZZ


76940 TC By Report By Report YYY

76940 26 2.87$ $172.20 2.87$ $172.20 XXX



76941 26 1.92$ $115.20 1.92$ $115.20 XXX

76942 1.76$ $105.60 1.76$ $105.60 XXX

76942 26 0.95$ $57.00 0.95$ $57.00 XXX

76942 TC 0.81$ $48.60 0.81$ $48.60 XXX



76945 26 0.98$ $58.80 0.98$ $58.80 XXX

76946 0.94$ $56.40 0.94$ $56.40 XXX

76946 26 0.56$ $33.60 0.56$ $33.60 XXX

76946 TC 0.39$ $23.40 0.39$ $23.40 XXX

76948 1.72$ $103.20 1.72$ $103.20 XXX

76948 26 0.56$ $33.60 0.56$ $33.60 XXX

76948 TC 1.17$ $70.20 1.17$ $70.20 XXX

76965 2.60$ $156.00 2.60$ $156.00 XXX

76965 26 1.90$ $114.00 1.90$ $114.00 XXX

76965 TC 0.70$ $42.00 0.70$ $42.00 XXX

76970 2.74$ $164.40 2.74$ $164.40 XXX

76970 26 0.55$ $33.00 0.55$ $33.00 XXX



Page | 167

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

76970 TC 2.19$ $131.40 2.19$ $131.40 XXX



76975 26 1.20$ $72.00 1.20$ $72.00 XXX

76977 0.20$ $12.00 0.20$ $12.00 XXX

76977 26 0.08$ $4.80 0.08$ $4.80 XXX

76977 TC 0.12$ $7.20 0.12$ $7.20 XXX



76998 26 1.73$ $103.80 1.73$ $103.80 XXX




77001 2.06$ $123.60 2.06$ $123.60 ZZZ

77001 26 0.53$ $31.80 0.53$ $31.80 ZZZ

77001 TC 1.52$ $91.20 1.52$ $91.20 ZZZ

77002 2.71$ $162.60 2.71$ $162.60 XXX

77002 26 0.80$ $48.00 0.80$ $48.00 XXX

77002 TC 1.92$ $115.20 1.92$ $115.20 XXX

77003 2.49$ $149.40 2.49$ $149.40 XXX

77003 26 0.86$ $51.60 0.86$ $51.60 XXX

77003 TC 1.63$ $97.80 1.63$ $97.80 XXX

77011 6.53$ $391.80 6.53$ $391.80 XXX

77011 26 1.78$ $106.80 1.78$ $106.80 XXX

77011 TC 4.75$ $285.00 4.75$ $285.00 XXX

77012 3.62$ $217.20 3.62$ $217.20 XXX

77012 26 1.64$ $98.40 1.64$ $98.40 XXX

77012 TC 1.98$ $118.80 1.98$ $118.80 XXX



77013 26 5.55$ $333.00 5.55$ $333.00 XXX

77014 3.44$ $206.40 3.44$ $206.40 XXX

77014 26 1.25$ $75.00 1.25$ $75.00 XXX

77014 TC 2.19$ $131.40 2.19$ $131.40 XXX

77021 11.87$ $712.20 11.87$ $712.20 XXX

77021 26 2.14$ $128.40 2.14$ $128.40 XXX

77021 TC 9.73$ $583.80 9.73$ $583.80 XXX



77022 26 6.03$ $361.80 6.03$ $361.80 XXX

77051 0.24$ $14.40 0.24$ $14.40 ZZZ

77051 26 0.08$ $4.80 0.08$ $4.80 ZZZ



Page | 168

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

77051 TC 0.16$ $9.60 0.16$ $9.60 ZZZ

77052 0.24$ $14.40 0.24$ $14.40 ZZZ

77052 26 0.08$ $4.80 0.08$ $4.80 ZZZ

77052 TC 0.16$ $9.60 0.16$ $9.60 ZZZ

77053 1.70$ $102.00 1.70$ $102.00 XXX

77053 26 0.51$ $30.60 0.51$ $30.60 XXX

77053 TC 1.19$ $71.40 1.19$ $71.40 XXX

77054 2.24$ $134.40 2.24$ $134.40 XXX

77054 26 0.65$ $39.00 0.65$ $39.00 XXX

77054 TC 1.59$ $95.40 1.59$ $95.40 XXX

77055 2.60$ $156.00 2.60$ $156.00 XXX

77055 26 1.00$ $60.00 1.00$ $60.00 XXX

77055 TC 1.60$ $96.00 1.60$ $96.00 XXX

77056 3.35$ $201.00 3.35$ $201.00 XXX

77056 26 1.24$ $74.40 1.24$ $74.40 XXX

77056 TC 2.11$ $126.60 2.11$ $126.60 XXX

77057 2.38$ $142.80 2.38$ $142.80 XXX

77057 26 1.00$ $60.00 1.00$ $60.00 XXX

77057 TC 1.38$ $82.80 1.38$ $82.80 XXX

77058 15.85$ $951.00 15.85$ $951.00 XXX

77058 26 2.32$ $139.20 2.32$ $139.20 XXX

77058 TC 13.53$ $811.80 13.53$ $811.80 XXX

77059 15.77$ $946.20 15.77$ $946.20 XXX

77059 26 2.32$ $139.20 2.32$ $139.20 XXX

77059 TC 13.45$ $807.00 13.45$ $807.00 XXX







77063 1.60$ $96.00 1.60$ $96.00 XXX

77063 26 0.85$ $51.00 0.85$ $51.00 XXX

77063 TC 0.75$ $45.00 0.75$ $45.00 XXX

77071 1.38$ $82.80 1.38$ $82.80 XXX

77072 0.67$ $40.20 0.67$ $40.20 XXX

77072 26 0.27$ $16.20 0.27$ $16.20 XXX

77072 TC 0.40$ $24.00 0.40$ $24.00 XXX

77073 1.04$ $62.40 1.04$ $62.40 XXX

77073 26 0.41$ $24.60 0.41$ $24.60 XXX

77073 TC 0.63$ $37.80 0.63$ $37.80 XXX

77074 1.87$ $112.20 1.87$ $112.20 XXX



Page | 169

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

77074 26 0.65$ $39.00 0.65$ $39.00 XXX

77074 TC 1.22$ $73.20 1.22$ $73.20 XXX

77075 2.55$ $153.00 2.55$ $153.00 XXX

77075 26 0.77$ $46.20 0.77$ $46.20 XXX

77075 TC 1.78$ $106.80 1.78$ $106.80 XXX

77076 2.79$ $167.40 2.79$ $167.40 XXX

77076 26 1.00$ $60.00 1.00$ $60.00 XXX

77076 TC 1.79$ $107.40 1.79$ $107.40 XXX

77077 1.08$ $64.80 1.08$ $64.80 XXX

77077 26 0.46$ $27.60 0.46$ $27.60 XXX

77077 TC 0.62$ $37.20 0.62$ $37.20 XXX

77078 3.36$ $201.60 3.36$ $201.60 XXX

77078 26 0.35$ $21.00 0.35$ $21.00 XXX

77078 TC 3.01$ $180.60 3.01$ $180.60 XXX

77080 1.20$ $72.00 1.20$ $72.00 XXX

77080 26 0.29$ $17.40 0.29$ $17.40 XXX

77080 TC 0.91$ $54.60 0.91$ $54.60 XXX

77081 0.81$ $48.60 0.81$ $48.60 XXX

77081 26 0.31$ $18.60 0.31$ $18.60 XXX

77081 TC 0.50$ $30.00 0.50$ $30.00 XXX

77084 11.46$ $687.60 11.46$ $687.60 XXX

77084 26 2.29$ $137.40 2.29$ $137.40 XXX

77084 TC 9.17$ $550.20 9.17$ $550.20 XXX

77085 1.65$ $99.00 1.65$ $99.00 XXX

77085 26 0.44$ $26.40 0.44$ $26.40 XXX

77085 TC 1.21$ $72.60 1.21$ $72.60 XXX

77086 1.04$ $62.40 1.04$ $62.40 XXX

77086 26 0.25$ $15.00 0.25$ $15.00 XXX

77086 TC 0.79$ $47.40 0.79$ $47.40 XXX

77261 2.14$ $128.40 2.14$ $128.40 XXX

77262 3.19$ $191.40 3.19$ $191.40 XXX

77263 4.66$ $279.60 4.66$ $279.60 XXX

77280 8.09$ $485.40 8.09$ $485.40 XXX

77280 26 1.03$ $61.80 1.03$ $61.80 XXX

77280 TC 7.07$ $424.20 7.07$ $424.20 XXX

77285 12.77$ $766.20 12.77$ $766.20 XXX

77285 26 1.55$ $93.00 1.55$ $93.00 XXX

77285 TC 11.22$ $673.20 11.22$ $673.20 XXX

77290 15.25$ $915.00 15.25$ $915.00 XXX

77290 26 2.30$ $138.00 2.30$ $138.00 XXX

77290 TC 12.94$ $776.40 12.94$ $776.40 XXX

77293 13.75$ $825.00 13.75$ $825.00 XXX



Page | 170

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

77293 26 2.95$ $177.00 2.95$ $177.00 XXX

77293 TC 10.80$ $648.00 10.80$ $648.00 XXX

77295 14.30$ $858.00 14.30$ $858.00 XXX

77295 26 6.30$ $378.00 6.30$ $378.00 XXX

77295 TC 7.99$ $479.40 7.99$ $479.40 XXX




77300 1.93$ $115.80 1.93$ $115.80 XXX

77300 26 0.91$ $54.60 0.91$ $54.60 XXX

77300 TC 1.02$ $61.20 1.02$ $61.20 XXX

77301 57.57$ $3,454.20 57.57$ $3,454.20 XXX

77301 26 11.75$ $705.00 11.75$ $705.00 XXX

77301 TC 45.82$ $2,749.20 45.82$ $2,749.20 XXX

77306 4.35$ $261.00 4.35$ $261.00 XXX

77306 26 2.06$ $123.60 2.06$ $123.60 XXX

77306 TC 2.28$ $136.80 2.28$ $136.80 XXX

77307 8.39$ $503.40 8.39$ $503.40 XXX

77307 26 4.26$ $255.60 4.26$ $255.60 XXX

77307 TC 4.13$ $247.80 4.13$ $247.80 XXX

77316 5.51$ $330.60 5.51$ $330.60 XXX

77316 26 2.06$ $123.60 2.06$ $123.60 XXX

77316 TC 3.45$ $207.00 3.45$ $207.00 XXX

77317 7.18$ $430.80 7.18$ $430.80 XXX

77317 26 2.70$ $162.00 2.70$ $162.00 XXX

77317 TC 4.48$ $268.80 4.48$ $268.80 XXX

77318 10.33$ $619.80 10.33$ $619.80 XXX

77318 26 4.26$ $255.60 4.26$ $255.60 XXX

77318 TC 6.07$ $364.20 6.07$ $364.20 XXX

77321 2.69$ $161.40 2.69$ $161.40 XXX

77321 26 1.40$ $84.00 1.40$ $84.00 XXX

77321 TC 1.29$ $77.40 1.29$ $77.40 XXX

77331 1.83$ $109.80 1.83$ $109.80 XXX

77331 26 1.28$ $76.80 1.28$ $76.80 XXX

77331 TC 0.55$ $33.00 0.55$ $33.00 XXX

77332 2.43$ $145.80 2.43$ $145.80 XXX

77332 26 0.81$ $48.60 0.81$ $48.60 XXX

77332 TC 1.62$ $97.20 1.62$ $97.20 XXX

77333 1.52$ $91.20 1.52$ $91.20 XXX

77333 26 1.24$ $74.40 1.24$ $74.40 XXX

77333 TC 0.28$ $16.80 0.28$ $16.80 XXX

77334 4.46$ $267.60 4.46$ $267.60 XXX



Page | 171

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

77334 26 1.82$ $109.20 1.82$ $109.20 XXX

77334 TC 2.64$ $158.40 2.64$ $158.40 XXX

77336 2.33$ $139.80 2.33$ $139.80 XXX

77338 14.81$ $888.60 14.81$ $888.60 XXX

77338 26 6.30$ $378.00 6.30$ $378.00 XXX

77338 TC 8.51$ $510.60 8.51$ $510.60 XXX

77370 3.57$ $214.20 3.57$ $214.20 XXX


77372 31.90$ $1,914.00 31.90$ $1,914.00 XXX

77373 40.56$ $2,433.60 40.56$ $2,433.60 XXX







77401 0.71$ $42.60 0.71$ $42.60 XXX

77402 -$ $0.00 -$ $0.00 XXX

77407 -$ $0.00 -$ $0.00 XXX

77412 -$ $0.00 -$ $0.00 XXX

77417 0.32$ $19.20 0.32$ $19.20 XXX





77427 5.24$ $314.40 5.24$ $314.40 XXX

77431 2.88$ $172.80 2.88$ $172.80 XXX

77432 11.76$ $705.60 11.76$ $705.60 XXX

77435 17.75$ $1,065.00 17.75$ $1,065.00 XXX

77469 9.12$ $547.20 9.12$ $547.20 XXX

77470 4.50$ $270.00 4.50$ $270.00 XXX

77470 26 3.07$ $184.20 3.07$ $184.20 XXX

77470 TC 1.43$ $85.80 1.43$ $85.80 XXX








77600 12.41$ $744.60 12.41$ $744.60 XXX

77600 26 2.33$ $139.80 2.33$ $139.80 XXX



Page | 172

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

77600 TC 10.08$ $604.80 10.08$ $604.80 XXX

77605 23.50$ $1,410.00 23.50$ $1,410.00 XXX

77605 26 3.16$ $189.60 3.16$ $189.60 XXX

77605 TC 20.33$ $1,219.80 20.33$ $1,219.80 XXX

77610 29.35$ $1,761.00 29.35$ $1,761.00 XXX

77610 26 2.32$ $139.20 2.32$ $139.20 XXX

77610 TC 27.03$ $1,621.80 27.03$ $1,621.80 XXX

77615 31.50$ $1,890.00 31.50$ $1,890.00 XXX

77615 26 3.06$ $183.60 3.06$ $183.60 XXX

77615 TC 28.44$ $1,706.40 28.44$ $1,706.40 XXX

77620 11.32$ $679.20 11.32$ $679.20 XXX

77620 26 2.29$ $137.40 2.29$ $137.40 XXX

77620 TC 9.02$ $541.20 9.02$ $541.20 XXX

77750 10.70$ $642.00 10.70$ $642.00 090

77750 26 7.34$ $440.40 7.34$ $440.40 090

77750 TC 3.36$ $201.60 3.36$ $201.60 090

77761 11.30$ $678.00 11.30$ $678.00 090

77761 26 5.58$ $334.80 5.58$ $334.80 090

77761 TC 5.72$ $343.20 5.72$ $343.20 090

77762 15.01$ $900.60 15.01$ $900.60 090

77762 26 8.45$ $507.00 8.45$ $507.00 090

77762 TC 6.56$ $393.60 6.56$ $393.60 090

77763 21.22$ $1,273.20 21.22$ $1,273.20 090

77763 26 12.73$ $763.80 12.73$ $763.80 090

77763 TC 8.49$ $509.40 8.49$ $509.40 090

77767 6.61$ $396.60 6.61$ $396.60 XXX

77767 26 1.55$ $93.00 1.55$ $93.00 XXX

77767 TC 5.07$ $304.20 5.07$ $304.20 XXX

77768 10.39$ $623.40 10.39$ $623.40 XXX

77768 26 2.05$ $123.00 2.05$ $123.00 XXX

77768 TC 8.33$ $499.80 8.33$ $499.80 XXX

77770 9.41$ $564.60 9.41$ $564.60 XXX

77770 26 2.87$ $172.20 2.87$ $172.20 XXX

77770 TC 6.54$ $392.40 6.54$ $392.40 XXX

77771 17.50$ $1,050.00 17.50$ $1,050.00 XXX

77771 26 5.59$ $335.40 5.59$ $335.40 XXX

77771 TC 11.91$ $714.60 11.91$ $714.60 XXX

77772 26.76$ $1,605.60 26.76$ $1,605.60 XXX

77772 26 7.93$ $475.80 7.93$ $475.80 XXX

77772 TC 18.83$ $1,129.80 18.83$ $1,129.80 XXX

77778 22.64$ $1,358.40 22.64$ $1,358.40 000

77778 26 11.73$ $703.80 11.73$ $703.80 000



Page | 173

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

77778 TC 10.91$ $654.60 10.91$ $654.60 000

77789 3.48$ $208.80 3.48$ $208.80 000

77789 26 1.69$ $101.40 1.69$ $101.40 000

77789 TC 1.79$ $107.40 1.79$ $107.40 000

77790 0.44$ $26.40 0.44$ $26.40 XXX




78012 2.40$ $144.00 2.40$ $144.00 XXX

78012 26 0.27$ $16.20 0.27$ $16.20 XXX

78012 TC 2.13$ $127.80 2.13$ $127.80 XXX

78013 5.83$ $349.80 5.83$ $349.80 XXX

78013 26 0.52$ $31.20 0.52$ $31.20 XXX

78013 TC 5.31$ $318.60 5.31$ $318.60 XXX

78014 7.38$ $442.80 7.38$ $442.80 XXX

78014 26 0.70$ $42.00 0.70$ $42.00 XXX

78014 TC 6.68$ $400.80 6.68$ $400.80 XXX

78015 6.71$ $402.60 6.71$ $402.60 XXX

78015 26 0.93$ $55.80 0.93$ $55.80 XXX

78015 TC 5.78$ $346.80 5.78$ $346.80 XXX

78016 8.52$ $511.20 8.52$ $511.20 XXX

78016 26 0.98$ $58.80 0.98$ $58.80 XXX

78016 TC 7.55$ $453.00 7.55$ $453.00 XXX

78018 9.54$ $572.40 9.54$ $572.40 XXX

78018 26 1.18$ $70.80 1.18$ $70.80 XXX

78018 TC 8.36$ $501.60 8.36$ $501.60 XXX

78020 2.52$ $151.20 2.52$ $151.20 ZZZ

78020 26 0.79$ $47.40 0.79$ $47.40 ZZZ

78020 TC 1.72$ $103.20 1.72$ $103.20 ZZZ

78070 9.15$ $549.00 9.15$ $549.00 XXX

78070 26 1.11$ $66.60 1.11$ $66.60 XXX

78070 TC 8.04$ $482.40 8.04$ $482.40 XXX

78071 10.91$ $654.60 10.91$ $654.60 XXX

78071 26 1.67$ $100.20 1.67$ $100.20 XXX

78071 TC 9.24$ $554.40 9.24$ $554.40 XXX

78072 12.58$ $754.80 12.58$ $754.80 XXX

78072 26 2.19$ $131.40 2.19$ $131.40 XXX

78072 TC 10.40$ $624.00 10.40$ $624.00 XXX

78075 13.09$ $785.40 13.09$ $785.40 XXX

78075 26 1.00$ $60.00 1.00$ $60.00 XXX

78075 TC 12.08$ $724.80 12.08$ $724.80 XXX




Page | 174

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



78102 5.16$ $309.60 5.16$ $309.60 XXX

78102 26 0.76$ $45.60 0.76$ $45.60 XXX

78102 TC 4.40$ $264.00 4.40$ $264.00 XXX

78103 6.77$ $406.20 6.77$ $406.20 XXX

78103 26 1.03$ $61.80 1.03$ $61.80 XXX

78103 TC 5.74$ $344.40 5.74$ $344.40 XXX

78104 7.47$ $448.20 7.47$ $448.20 XXX

78104 26 1.09$ $65.40 1.09$ $65.40 XXX

78104 TC 6.38$ $382.80 6.38$ $382.80 XXX

78110 2.85$ $171.00 2.85$ $171.00 XXX

78110 26 0.27$ $16.20 0.27$ $16.20 XXX

78110 TC 2.58$ $154.80 2.58$ $154.80 XXX

78111 2.93$ $175.80 2.93$ $175.80 XXX

78111 26 0.31$ $18.60 0.31$ $18.60 XXX

78111 TC 2.61$ $156.60 2.61$ $156.60 XXX

78120 2.85$ $171.00 2.85$ $171.00 XXX

78120 26 0.33$ $19.80 0.33$ $19.80 XXX

78120 TC 2.52$ $151.20 2.52$ $151.20 XXX

78121 3.09$ $185.40 3.09$ $185.40 XXX

78121 26 0.46$ $27.60 0.46$ $27.60 XXX

78121 TC 2.64$ $158.40 2.64$ $158.40 XXX

78122 2.95$ $177.00 2.95$ $177.00 XXX

78122 26 0.61$ $36.60 0.61$ $36.60 XXX

78122 TC 2.34$ $140.40 2.34$ $140.40 XXX

78130 5.10$ $306.00 5.10$ $306.00 XXX

78130 26 0.87$ $52.20 0.87$ $52.20 XXX

78130 TC 4.24$ $254.40 4.24$ $254.40 XXX

78135 10.77$ $646.20 10.77$ $646.20 XXX

78135 26 0.91$ $54.60 0.91$ $54.60 XXX

78135 TC 9.86$ $591.60 9.86$ $591.60 XXX

78140 4.13$ $247.80 4.13$ $247.80 XXX

78140 26 0.87$ $52.20 0.87$ $52.20 XXX

78140 TC 3.26$ $195.60 3.26$ $195.60 XXX

78185 6.47$ $388.20 6.47$ $388.20 XXX

78185 26 0.57$ $34.20 0.57$ $34.20 XXX

78185 TC 5.90$ $354.00 5.90$ $354.00 XXX

78190 11.99$ $719.40 11.99$ $719.40 XXX

78190 26 1.56$ $93.60 1.56$ $93.60 XXX

78190 TC 10.43$ $625.80 10.43$ $625.80 XXX

78191 5.10$ $306.00 5.10$ $306.00 XXX



Page | 175

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

78191 26 0.87$ $52.20 0.87$ $52.20 XXX

78191 TC 4.24$ $254.40 4.24$ $254.40 XXX

78195 10.84$ $650.40 10.84$ $650.40 XXX

78195 26 1.68$ $100.80 1.68$ $100.80 XXX

78195 TC 9.16$ $549.60 9.16$ $549.60 XXX




78201 5.73$ $343.80 5.73$ $343.80 XXX

78201 26 0.60$ $36.00 0.60$ $36.00 XXX

78201 TC 5.13$ $307.80 5.13$ $307.80 XXX

78202 6.16$ $369.60 6.16$ $369.60 XXX

78202 26 0.68$ $40.80 0.68$ $40.80 XXX

78202 TC 5.48$ $328.80 5.48$ $328.80 XXX

78205 6.44$ $386.40 6.44$ $386.40 XXX

78205 26 0.96$ $57.60 0.96$ $57.60 XXX

78205 TC 5.48$ $328.80 5.48$ $328.80 XXX

78206 10.45$ $627.00 10.45$ $627.00 XXX

78206 26 1.33$ $79.80 1.33$ $79.80 XXX

78206 TC 9.12$ $547.20 9.12$ $547.20 XXX

78215 5.93$ $355.80 5.93$ $355.80 XXX

78215 26 0.69$ $41.40 0.69$ $41.40 XXX

78215 TC 5.25$ $315.00 5.25$ $315.00 XXX

78216 3.81$ $228.60 3.81$ $228.60 XXX

78216 26 0.78$ $46.80 0.78$ $46.80 XXX

78216 TC 3.03$ $181.80 3.03$ $181.80 XXX

78226 10.14$ $608.40 10.14$ $608.40 XXX

78226 26 1.04$ $62.40 1.04$ $62.40 XXX

78226 TC 9.10$ $546.00 9.10$ $546.00 XXX

78227 13.77$ $826.20 13.77$ $826.20 XXX

78227 26 1.27$ $76.20 1.27$ $76.20 XXX

78227 TC 12.50$ $750.00 12.50$ $750.00 XXX

78230 4.30$ $258.00 4.30$ $258.00 XXX

78230 26 0.54$ $32.40 0.54$ $32.40 XXX

78230 TC 3.76$ $225.60 3.76$ $225.60 XXX

78231 3.95$ $237.00 3.95$ $237.00 XXX

78231 26 0.75$ $45.00 0.75$ $45.00 XXX

78231 TC 3.20$ $192.00 3.20$ $192.00 XXX

78232 2.99$ $179.40 2.99$ $179.40 XXX

78232 26 0.56$ $33.60 0.56$ $33.60 XXX

78232 TC 2.42$ $145.20 2.42$ $145.20 XXX

78258 6.75$ $405.00 6.75$ $405.00 XXX



Page | 176

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

78258 26 1.04$ $62.40 1.04$ $62.40 XXX

78258 TC 5.71$ $342.60 5.71$ $342.60 XXX

78261 7.58$ $454.80 7.58$ $454.80 XXX

78261 26 0.97$ $58.20 0.97$ $58.20 XXX

78261 TC 6.61$ $396.60 6.61$ $396.60 XXX

78262 7.46$ $447.60 7.46$ $447.60 XXX

78262 26 0.94$ $56.40 0.94$ $56.40 XXX

78262 TC 6.51$ $390.60 6.51$ $390.60 XXX

78264 10.22$ $613.20 10.22$ $613.20 XXX

78264 26 1.04$ $62.40 1.04$ $62.40 XXX

78264 TC 9.18$ $550.80 9.18$ $550.80 XXX

78265 12.19$ $731.40 12.19$ $731.40 XXX

78265 26 1.37$ $82.20 1.37$ $82.20 XXX

78265 TC 10.82$ $649.20 10.82$ $649.20 XXX

78266 14.47$ $868.20 14.47$ $868.20 XXX

78266 26 1.52$ $91.20 1.52$ $91.20 XXX

78266 TC 12.95$ $777.00 12.95$ $777.00 XXX

78267 $10.71 per unit $10.71 per unit XXX


78270 3.07$ $184.20 3.07$ $184.20 XXX

78270 26 0.30$ $18.00 0.30$ $18.00 XXX

78270 TC 2.77$ $166.20 2.77$ $166.20 XXX

78271 2.74$ $164.40 2.74$ $164.40 XXX

78271 26 0.29$ $17.40 0.29$ $17.40 XXX

78271 TC 2.45$ $147.00 2.45$ $147.00 XXX

78272 2.93$ $175.80 2.93$ $175.80 XXX

78272 26 0.38$ $22.80 0.38$ $22.80 XXX

78272 TC 2.55$ $153.00 2.55$ $153.00 XXX

78278 10.65$ $639.00 10.65$ $639.00 XXX

78278 26 1.39$ $83.40 1.39$ $83.40 XXX

78278 TC 9.26$ $555.60 9.26$ $555.60 XXX



78282 26 0.54$ $32.40 0.54$ $32.40 XXX

78290 10.21$ $612.60 10.21$ $612.60 XXX

78290 26 0.96$ $57.60 0.96$ $57.60 XXX

78290 TC 9.25$ $555.00 9.25$ $555.00 XXX

78291 7.67$ $460.20 7.67$ $460.20 XXX

78291 26 1.20$ $72.00 1.20$ $72.00 XXX

78291 TC 6.47$ $388.20 6.47$ $388.20 XXX





Page | 177

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


78300 5.50$ $330.00 5.50$ $330.00 XXX

78300 26 0.89$ $53.40 0.89$ $53.40 XXX

78300 TC 4.61$ $276.60 4.61$ $276.60 XXX

78305 7.03$ $421.80 7.03$ $421.80 XXX

78305 26 1.17$ $70.20 1.17$ $70.20 XXX

78305 TC 5.86$ $351.60 5.86$ $351.60 XXX

78306 7.68$ $460.80 7.68$ $460.80 XXX

78306 26 1.21$ $72.60 1.21$ $72.60 XXX

78306 TC 6.47$ $388.20 6.47$ $388.20 XXX

78315 10.58$ $634.80 10.58$ $634.80 XXX

78315 26 1.43$ $85.80 1.43$ $85.80 XXX

78315 TC 9.15$ $549.00 9.15$ $549.00 XXX

78320 6.92$ $415.20 6.92$ $415.20 XXX

78320 26 1.43$ $85.80 1.43$ $85.80 XXX

78320 TC 5.49$ $329.40 5.49$ $329.40 XXX

78350 0.96$ $57.60 0.96$ $57.60 XXX

78350 26 0.31$ $18.60 0.31$ $18.60 XXX

78350 TC 0.65$ $39.00 0.65$ $39.00 XXX

78351 0.43$ $25.80 0.43$ $25.80 XXX






78414 26 0.63$ $37.80 0.63$ $37.80 XXX

78428 5.48$ $328.80 5.48$ $328.80 XXX

78428 26 1.08$ $64.80 1.08$ $64.80 XXX

78428 TC 4.40$ $264.00 4.40$ $264.00 XXX

78445 5.34$ $320.40 5.34$ $320.40 XXX

78445 26 0.66$ $39.60 0.66$ $39.60 XXX

78445 TC 4.68$ $280.80 4.68$ $280.80 XXX

78451 10.38$ $622.80 10.38$ $622.80 XXX

78451 26 1.92$ $115.20 1.92$ $115.20 XXX

78451 TC 8.46$ $507.60 8.46$ $507.60 XXX

78452 14.40$ $864.00 14.40$ $864.00 XXX

78452 26 2.25$ $135.00 2.25$ $135.00 XXX

78452 TC 12.15$ $729.00 12.15$ $729.00 XXX

78453 9.26$ $555.60 9.26$ $555.60 XXX

78453 26 1.40$ $84.00 1.40$ $84.00 XXX

78453 TC 7.86$ $471.60 7.86$ $471.60 XXX

78454 13.33$ $799.80 13.33$ $799.80 XXX



Page | 178

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

78454 26 1.90$ $114.00 1.90$ $114.00 XXX

78454 TC 11.43$ $685.80 11.43$ $685.80 XXX

78456 9.63$ $577.80 9.63$ $577.80 XXX

78456 26 1.39$ $83.40 1.39$ $83.40 XXX

78456 TC 8.24$ $494.40 8.24$ $494.40 XXX

78457 5.70$ $342.00 5.70$ $342.00 XXX

78457 26 1.07$ $64.20 1.07$ $64.20 XXX

78457 TC 4.62$ $277.20 4.62$ $277.20 XXX

78458 5.07$ $304.20 5.07$ $304.20 XXX

78458 26 1.09$ $65.40 1.09$ $65.40 XXX

78458 TC 3.99$ $239.40 3.99$ $239.40 XXX



78459 26 2.02$ $121.20 2.02$ $121.20 XXX

78466 5.80$ $348.00 5.80$ $348.00 XXX

78466 26 1.00$ $60.00 1.00$ $60.00 XXX

78466 TC 4.80$ $288.00 4.80$ $288.00 XXX

78468 6.01$ $360.60 6.01$ $360.60 XXX

78468 26 1.12$ $67.20 1.12$ $67.20 XXX

78468 TC 4.90$ $294.00 4.90$ $294.00 XXX

78469 6.88$ $412.80 6.88$ $412.80 XXX

78469 26 1.30$ $78.00 1.30$ $78.00 XXX

78469 TC 5.58$ $334.80 5.58$ $334.80 XXX

78472 6.97$ $418.20 6.97$ $418.20 XXX

78472 26 1.36$ $81.60 1.36$ $81.60 XXX

78472 TC 5.61$ $336.60 5.61$ $336.60 XXX

78473 8.76$ $525.60 8.76$ $525.60 XXX

78473 26 2.03$ $121.80 2.03$ $121.80 XXX

78473 TC 6.73$ $403.80 6.73$ $403.80 XXX

78481 5.28$ $316.80 5.28$ $316.80 XXX

78481 26 1.36$ $81.60 1.36$ $81.60 XXX

78481 TC 3.92$ $235.20 3.92$ $235.20 XXX

78483 7.30$ $438.00 7.30$ $438.00 XXX

78483 26 2.03$ $121.80 2.03$ $121.80 XXX

78483 TC 5.27$ $316.20 5.27$ $316.20 XXX



78491 26 2.04$ $122.40 2.04$ $122.40 XXX



78492 26 2.55$ $153.00 2.55$ $153.00 XXX

78494 6.81$ $408.60 6.81$ $408.60 XXX



Page | 179

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

78494 26 1.66$ $99.60 1.66$ $99.60 XXX

78494 TC 5.15$ $309.00 5.15$ $309.00 XXX

78496 1.31$ $78.60 1.31$ $78.60 ZZZ

78496 26 0.69$ $41.40 0.69$ $41.40 ZZZ

78496 TC 0.62$ $37.20 0.62$ $37.20 ZZZ




78579 5.70$ $342.00 5.70$ $342.00 XXX

78579 26 0.67$ $40.20 0.67$ $40.20 XXX

78579 TC 5.02$ $301.20 5.02$ $301.20 XXX

78580 7.30$ $438.00 7.30$ $438.00 XXX

78580 26 1.04$ $62.40 1.04$ $62.40 XXX

78580 TC 6.26$ $375.60 6.26$ $375.60 XXX

78582 10.22$ $613.20 10.22$ $613.20 XXX

78582 26 1.50$ $90.00 1.50$ $90.00 XXX

78582 TC 8.72$ $523.20 8.72$ $523.20 XXX

78597 6.15$ $369.00 6.15$ $369.00 XXX

78597 26 1.01$ $60.60 1.01$ $60.60 XXX

78597 TC 5.14$ $308.40 5.14$ $308.40 XXX

78598 9.37$ $562.20 9.37$ $562.20 XXX

78598 26 1.18$ $70.80 1.18$ $70.80 XXX

78598 TC 8.19$ $491.40 8.19$ $491.40 XXX




78600 5.65$ $339.00 5.65$ $339.00 XXX

78600 26 0.64$ $38.40 0.64$ $38.40 XXX

78600 TC 5.01$ $300.60 5.01$ $300.60 XXX

78601 6.53$ $391.80 6.53$ $391.80 XXX

78601 26 0.71$ $42.60 0.71$ $42.60 XXX

78601 TC 5.82$ $349.20 5.82$ $349.20 XXX

78605 6.07$ $364.20 6.07$ $364.20 XXX

78605 26 0.76$ $45.60 0.76$ $45.60 XXX

78605 TC 5.31$ $318.60 5.31$ $318.60 XXX

78606 10.13$ $607.80 10.13$ $607.80 XXX

78606 26 0.89$ $53.40 0.89$ $53.40 XXX

78606 TC 9.24$ $554.40 9.24$ $554.40 XXX

78607 10.68$ $640.80 10.68$ $640.80 XXX

78607 26 1.68$ $100.80 1.68$ $100.80 XXX

78607 TC 9.00$ $540.00 9.00$ $540.00 XXX




Page | 180

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


78608 26 2.04$ $122.40 2.04$ $122.40 XXX


78609 2.13$ $127.80 2.13$ $127.80 XXX

78609 26 2.13$ $127.80 2.13$ $127.80 XXX

78610 5.35$ $321.00 5.35$ $321.00 XXX

78610 26 0.43$ $25.80 0.43$ $25.80 XXX

78610 TC 4.92$ $295.20 4.92$ $295.20 XXX

78630 10.35$ $621.00 10.35$ $621.00 XXX

78630 26 0.96$ $57.60 0.96$ $57.60 XXX

78630 TC 9.39$ $563.40 9.39$ $563.40 XXX

78635 10.37$ $622.20 10.37$ $622.20 XXX

78635 26 0.87$ $52.20 0.87$ $52.20 XXX

78635 TC 9.50$ $570.00 9.50$ $570.00 XXX

78645 9.88$ $592.80 9.88$ $592.80 XXX

78645 26 0.79$ $47.40 0.79$ $47.40 XXX

78645 TC 9.09$ $545.40 9.09$ $545.40 XXX

78647 10.69$ $641.40 10.69$ $641.40 XXX

78647 26 1.28$ $76.80 1.28$ $76.80 XXX

78647 TC 9.41$ $564.60 9.41$ $564.60 XXX

78650 10.08$ $604.80 10.08$ $604.80 XXX

78650 26 0.85$ $51.00 0.85$ $51.00 XXX

78650 TC 9.23$ $553.80 9.23$ $553.80 XXX

78660 5.49$ $329.40 5.49$ $329.40 XXX

78660 26 0.76$ $45.60 0.76$ $45.60 XXX

78660 TC 4.73$ $283.80 4.73$ $283.80 XXX




78700 5.24$ $314.40 5.24$ $314.40 XXX

78700 26 0.63$ $37.80 0.63$ $37.80 XXX

78700 TC 4.61$ $276.60 4.61$ $276.60 XXX

78701 6.44$ $386.40 6.44$ $386.40 XXX

78701 26 0.67$ $40.20 0.67$ $40.20 XXX

78701 TC 5.76$ $345.60 5.76$ $345.60 XXX

78707 7.06$ $423.60 7.06$ $423.60 XXX

78707 26 1.33$ $79.80 1.33$ $79.80 XXX

78707 TC 5.73$ $343.80 5.73$ $343.80 XXX

78708 5.23$ $313.80 5.23$ $313.80 XXX

78708 26 1.68$ $100.80 1.68$ $100.80 XXX

78708 TC 3.55$ $213.00 3.55$ $213.00 XXX

78709 11.06$ $663.60 11.06$ $663.60 XXX



Page | 181

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

78709 26 1.95$ $117.00 1.95$ $117.00 XXX

78709 TC 9.11$ $546.60 9.11$ $546.60 XXX

78710 6.10$ $366.00 6.10$ $366.00 XXX

78710 26 0.87$ $52.20 0.87$ $52.20 XXX

78710 TC 5.23$ $313.80 5.23$ $313.80 XXX

78725 3.29$ $197.40 3.29$ $197.40 XXX

78725 26 0.52$ $31.20 0.52$ $31.20 XXX

78725 TC 2.77$ $166.20 2.77$ $166.20 XXX

78730 2.33$ $139.80 2.33$ $139.80 ZZZ

78730 26 0.22$ $13.20 0.22$ $13.20 ZZZ

78730 TC 2.11$ $126.60 2.11$ $126.60 ZZZ

78740 6.66$ $399.60 6.66$ $399.60 XXX

78740 26 0.79$ $47.40 0.79$ $47.40 XXX

78740 TC 5.87$ $352.20 5.87$ $352.20 XXX

78761 6.35$ $381.00 6.35$ $381.00 XXX

78761 26 1.02$ $61.20 1.02$ $61.20 XXX

78761 TC 5.33$ $319.80 5.33$ $319.80 XXX




78800 5.80$ $348.00 5.80$ $348.00 XXX

78800 26 0.95$ $57.00 0.95$ $57.00 XXX

78800 TC 4.86$ $291.60 4.86$ $291.60 XXX

78801 7.94$ $476.40 7.94$ $476.40 XXX

78801 26 1.13$ $67.80 1.13$ $67.80 XXX

78801 TC 6.81$ $408.60 6.81$ $408.60 XXX

78802 9.92$ $595.20 9.92$ $595.20 XXX

78802 26 1.19$ $71.40 1.19$ $71.40 XXX

78802 TC 8.73$ $523.80 8.73$ $523.80 XXX

78803 10.37$ $622.20 10.37$ $622.20 XXX

78803 26 1.48$ $88.80 1.48$ $88.80 XXX

78803 TC 8.89$ $533.40 8.89$ $533.40 XXX

78804 17.35$ $1,041.00 17.35$ $1,041.00 XXX

78804 26 1.48$ $88.80 1.48$ $88.80 XXX

78804 TC 15.87$ $952.20 15.87$ $952.20 XXX

78805 5.54$ $332.40 5.54$ $332.40 XXX

78805 26 1.02$ $61.20 1.02$ $61.20 XXX

78805 TC 4.52$ $271.20 4.52$ $271.20 XXX

78806 10.18$ $610.80 10.18$ $610.80 XXX

78806 26 1.19$ $71.40 1.19$ $71.40 XXX

78806 TC 8.98$ $538.80 8.98$ $538.80 XXX

78807 10.37$ $622.20 10.37$ $622.20 XXX



Page | 182

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

78807 26 1.47$ $88.20 1.47$ $88.20 XXX

78807 TC 8.90$ $534.00 8.90$ $534.00 XXX

78808 1.36$ $81.60 1.36$ $81.60 XXX



78811 26 2.20$ $132.00 2.20$ $132.00 XXX



78812 26 2.68$ $160.80 2.68$ $160.80 XXX



78813 26 2.79$ $167.40 2.79$ $167.40 XXX



78814 26 3.08$ $184.80 3.08$ $184.80 XXX



78815 26 3.41$ $204.60 3.41$ $204.60 XXX



78816 26 3.43$ $205.80 3.43$ $205.80 XXX




79005 3.97$ $238.20 3.97$ $238.20 XXX

79005 26 2.51$ $150.60 2.51$ $150.60 XXX

79005 TC 1.46$ $87.60 1.46$ $87.60 XXX

79101 4.14$ $248.40 4.14$ $248.40 XXX

79101 26 2.72$ $163.20 2.72$ $163.20 XXX

79101 TC 1.42$ $85.20 1.42$ $85.20 XXX

79200 4.64$ $278.40 4.64$ $278.40 XXX

79200 26 2.91$ $174.60 2.91$ $174.60 XXX

79200 TC 1.73$ $103.80 1.73$ $103.80 XXX



79300 26 2.28$ $136.80 2.28$ $136.80 XXX

79403 5.61$ $336.60 5.61$ $336.60 XXX

79403 26 3.16$ $189.60 3.16$ $189.60 XXX

79403 TC 2.45$ $147.00 2.45$ $147.00 XXX

79440 4.21$ $252.60 4.21$ $252.60 XXX

79440 26 2.72$ $163.20 2.72$ $163.20 XXX

79440 TC 1.50$ $90.00 1.50$ $90.00 XXX



Page | 183

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



79445 26 3.28$ $196.80 3.28$ $196.80 XXX









80055 XXX





80081 XXX


























See Drugs and Biologicals Fee Schedule




Page | 184

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 185

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 186

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL















80500 0.63$ $37.80 0.55$ $33.00 XXX

80502 2.04$ $122.40 1.96$ $117.60 XXX













81162 XXX

81170 XXX

81200 XXX

81201 XXX

81202 XXX

81203 XXX

81205 XXX

81206 XXX

81207 XXX

81208 XXX

81209 XXX

81210 XXX

81211 XXX

81212 XXX



Code Accepted for Tracking Purpose only














Page | 187

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

81213 XXX

81214 XXX

81215 XXX

81216 XXX

81217 XXX

81218 XXX

81219 XXX

81220 XXX

81221 XXX

81222 XXX

81223 XXX

81224 XXX

81225 XXX

81226 XXX

81227 XXX

81228 XXX

81229 XXX

81235 XXX

81240 XXX

81241 XXX

81242 XXX

81243 XXX

81244 XXX

81245 XXX


81250 XXX

81251 XXX

81252 XXX

81253 XXX

81254 XXX

81255 XXX

81256 XXX

81257 XXX

81260 XXX

81261 XXX

81262 XXX

81263 XXX

81264 XXX

81265 XXX

81266 XXX

81267 XXX

81268 XXX












































Page | 188

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

81270 XXX

81272 XXX

81273 XXX

81275 XXX

81276 XXX

81280 XXX

81281 XXX

81282 XXX



81290 XXX

81291 XXX

81292 XXX

81293 XXX

81294 XXX

81295 XXX

81296 XXX

81297 XXX

81298 XXX

81299 XXX

81300 XXX

81301 XXX

81302 XXX

81303 XXX

81304 XXX

81310 XXX

81311 XXX


81314 XXX

81315 XXX

81316 XXX

81317 XXX

81318 XXX

81319 XXX

81321 XXX

81322 XXX

81323 XXX

81324 XXX

81325 XXX

81326 XXX

81330 XXX

81331 XXX










































Page | 189

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

81332 XXX

81340 XXX

81341 XXX

81342 XXX

81350 XXX

81355 XXX

81370 XXX

81371 XXX

81372 XXX

81373 XXX

81374 XXX

81375 XXX

81376 XXX

81377 XXX

81378 XXX

81379 XXX

81380 XXX

81381 XXX

81382 XXX

81383 XXX

81400 XXX

81401 XXX

81402 XXX

81403 XXX

81404 XXX

81405 XXX

81406 XXX

81407 XXX

81408 XXX



81412 XXX










81432 XXXSee Drugs and Biologicals Fee Schedule

































Page | 190

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

81433 XXX

81434 XXX



81437 XXX

81438 XXX


81442 XXX









81490 XXX

81493 XXX











81519 XXX

81525 XXX

81528 XXX

81535 XXX

81536 XXX

81538 XXX

81540 XXX

81545 XXX

81595 XXX
























Page | 191

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 192

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 193

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 194

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 195

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL











83020 26 0.53$ $31.80 0.53$ $31.80 XXX


































Page | 196

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 197

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 198

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

















84165 26 0.53$ $31.80 0.53$ $31.80 XXX


84166 26 0.53$ $31.80 0.53$ $31.80 XXX


84181 26 0.53$ $31.80 0.53$ $31.80 XXX


84182 26 0.53$ $31.80 0.53$ $31.80 XXX






















Page | 199

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 200

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL










































85060 0.72$ $43.20 0.72$ $43.20 XXX



Page | 201

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

85097 2.61$ $156.60 1.43$ $85.80 XXX












































Page | 202

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

85390 26 0.53$ $31.80 0.53$ $31.80 XXX

85396 0.59$ $35.40 0.59$ $35.40 XXX






















85576 26 0.53$ $31.80 0.53$ $31.80 XXX





















Page | 203

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL











86077 1.62$ $97.20 1.49$ $89.40 XXX

86078 1.61$ $96.60 1.49$ $89.40 XXX

86079 1.58$ $94.80 1.47$ $88.20 XXX







86153 26 0.98$ $58.80 0.98$ $58.80 XXX
















86255 26 0.53$ $31.80 0.53$ $31.80 XXX


86256 26 0.53$ $31.80 0.53$ $31.80 XXX







Page | 204

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL











86320 26 0.53$ $31.80 0.53$ $31.80 XXX


86325 26 0.53$ $31.80 0.53$ $31.80 XXX


86327 26 0.60$ $36.00 0.60$ $36.00 XXX





86334 26 0.53$ $31.80 0.53$ $31.80 XXX


86335 26 0.53$ $31.80 0.53$ $31.80 XXX























Page | 205

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL








86486 0.14$ $8.40 0.14$ $8.40 XXX

86490 2.08$ $124.80 2.08$ $124.80 XXX

86510 0.17$ $10.20 0.17$ $10.20 XXX

86580 0.23$ $13.80 0.23$ $13.80 XXX


































Page | 206

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 207

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL









































86850 XXX





Page | 208

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 209

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL





























87164 26 0.53$ $31.80 0.53$ $31.80 XXX
















Page | 210

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL





87207 26 0.53$ $31.80 0.53$ $31.80 XXX








































Page | 211

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 212

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 213

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 214

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL






















88104 2.22$ $133.20 2.22$ $133.20 XXX

88104 26 0.85$ $51.00 0.85$ $51.00 XXX

88104 TC 1.37$ $82.20 1.37$ $82.20 XXX

88106 2.20$ $132.00 2.20$ $132.00 XXX

88106 26 0.58$ $34.80 0.58$ $34.80 XXX

88106 TC 1.62$ $97.20 1.62$ $97.20 XXX

88108 2.12$ $127.20 2.12$ $127.20 XXX

88108 26 0.67$ $40.20 0.67$ $40.20 XXX

88108 TC 1.45$ $87.00 1.45$ $87.00 XXX

88112 2.10$ $126.00 2.10$ $126.00 XXX

88112 26 0.82$ $49.20 0.82$ $49.20 XXX

88112 TC 1.27$ $76.20 1.27$ $76.20 XXX

88120 18.80$ $1,128.00 18.80$ $1,128.00 XXX

88120 26 1.70$ $102.00 1.70$ $102.00 XXX

88120 TC 17.10$ $1,026.00 17.10$ $1,026.00 XXX

88121 16.42$ $985.20 16.42$ $985.20 XXX

88121 26 1.47$ $88.20 1.47$ $88.20 XXX

88121 TC 14.95$ $897.00 14.95$ $897.00 XXX

88125 0.67$ $40.20 0.67$ $40.20 XXX

88125 26 0.39$ $23.40 0.39$ $23.40 XXX

88125 TC 0.28$ $16.80 0.28$ $16.80 XXX



Page | 215

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



88141 0.94$ $56.40 0.94$ $56.40 XXX










88160 2.12$ $127.20 2.12$ $127.20 XXX

88160 26 0.77$ $46.20 0.77$ $46.20 XXX

88160 TC 1.35$ $81.00 1.35$ $81.00 XXX

88161 1.90$ $114.00 1.90$ $114.00 XXX

88161 26 0.74$ $44.40 0.74$ $44.40 XXX

88161 TC 1.16$ $69.60 1.16$ $69.60 XXX

88162 3.06$ $183.60 3.06$ $183.60 XXX

88162 26 1.17$ $70.20 1.17$ $70.20 XXX

88162 TC 1.89$ $113.40 1.89$ $113.40 XXX





88172 1.66$ $99.60 1.66$ $99.60 XXX

88172 26 1.08$ $64.80 1.08$ $64.80 XXX

88172 TC 0.59$ $35.40 0.59$ $35.40 XXX

88173 4.49$ $269.40 4.49$ $269.40 XXX

88173 26 2.10$ $126.00 2.10$ $126.00 XXX

88173 TC 2.39$ $143.40 2.39$ $143.40 XXX



88177 0.88$ $52.80 0.88$ $52.80 ZZZ

88177 26 0.66$ $39.60 0.66$ $39.60 ZZZ

88177 TC 0.22$ $13.20 0.22$ $13.20 ZZZ

88182 3.28$ $196.80 3.28$ $196.80 XXX

88182 26 1.07$ $64.20 1.07$ $64.20 XXX

88182 TC 2.21$ $132.60 2.21$ $132.60 XXX

88184 2.25$ $135.00 2.25$ $135.00 XXX

88185 1.37$ $82.20 1.37$ $82.20 ZZZ

88187 2.05$ $123.00 2.05$ $123.00 XXX



Page | 216

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

88188 2.61$ $156.60 2.61$ $156.60 XXX

88189 3.20$ $192.00 3.20$ $192.00 XXX





























88291 0.91$ $54.60 0.91$ $54.60 XXX


88300 0.44$ $26.40 0.44$ $26.40 XXX

88300 26 0.13$ $7.80 0.13$ $7.80 XXX

88300 TC 0.31$ $18.60 0.31$ $18.60 XXX

88302 0.95$ $57.00 0.95$ $57.00 XXX

88302 26 0.21$ $12.60 0.21$ $12.60 XXX

88302 TC 0.74$ $44.40 0.74$ $44.40 XXX

88304 1.34$ $80.40 1.34$ $80.40 XXX

88304 26 0.33$ $19.80 0.33$ $19.80 XXX

88304 TC 1.01$ $60.60 1.01$ $60.60 XXX

88305 2.13$ $127.80 2.13$ $127.80 XXX



Page | 217

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

88305 26 1.12$ $67.20 1.12$ $67.20 XXX

88305 TC 1.01$ $60.60 1.01$ $60.60 XXX

88307 9.10$ $546.00 9.10$ $546.00 XXX

88307 26 2.48$ $148.80 2.48$ $148.80 XXX

88307 TC 6.63$ $397.80 6.63$ $397.80 XXX

88309 13.80$ $828.00 13.80$ $828.00 XXX

88309 26 4.39$ $263.40 4.39$ $263.40 XXX

88309 TC 9.41$ $564.60 9.41$ $564.60 XXX

88311 0.62$ $37.20 0.62$ $37.20 XXX

88311 26 0.37$ $22.20 0.37$ $22.20 XXX

88311 TC 0.25$ $15.00 0.25$ $15.00 XXX

88312 2.88$ $172.80 2.88$ $172.80 XXX

88312 26 0.80$ $48.00 0.80$ $48.00 XXX

88312 TC 2.08$ $124.80 2.08$ $124.80 XXX

88313 2.02$ $121.20 2.02$ $121.20 XXX

88313 26 0.35$ $21.00 0.35$ $21.00 XXX

88313 TC 1.66$ $99.60 1.66$ $99.60 XXX

88314 2.26$ $135.60 2.26$ $135.60 XXX

88314 26 0.66$ $39.60 0.66$ $39.60 XXX

88314 TC 1.60$ $96.00 1.60$ $96.00 XXX

88319 2.62$ $157.20 2.62$ $157.20 XXX

88319 26 0.80$ $48.00 0.80$ $48.00 XXX

88319 TC 1.81$ $108.60 1.81$ $108.60 XXX

88321 2.93$ $175.80 2.46$ $147.60 XXX

88323 4.04$ $242.40 4.04$ $242.40 XXX

88323 26 2.55$ $153.00 2.55$ $153.00 XXX

88323 TC 1.50$ $90.00 1.50$ $90.00 XXX

88325 4.97$ $298.20 3.89$ $233.40 XXX

88329 1.46$ $87.60 1.06$ $63.60 XXX

88331 2.78$ $166.80 2.78$ $166.80 XXX

88331 26 1.86$ $111.60 1.86$ $111.60 XXX

88331 TC 0.92$ $55.20 0.92$ $55.20 XXX

88332 1.47$ $88.20 1.47$ $88.20 XXX

88332 26 0.92$ $55.20 0.92$ $55.20 XXX

88332 TC 0.55$ $33.00 0.55$ $33.00 XXX

88333 2.92$ $175.20 2.92$ $175.20 XXX

88333 26 1.87$ $112.20 1.87$ $112.20 XXX

88333 TC 1.05$ $63.00 1.05$ $63.00 XXX

88334 1.80$ $108.00 1.80$ $108.00 XXX

88334 26 1.15$ $69.00 1.15$ $69.00 XXX

88334 TC 0.65$ $39.00 0.65$ $39.00 XXX

88341 2.63$ $157.80 2.63$ $157.80 XXX



Page | 218

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RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

88341 26 0.79$ $47.40 0.79$ $47.40 XXX

88341 TC 1.84$ $110.40 1.84$ $110.40 XXX

88342 3.12$ $187.20 3.12$ $187.20 XXX

88342 26 1.05$ $63.00 1.05$ $63.00 XXX

88342 TC 2.07$ $124.20 2.07$ $124.20 XXX

88344 5.08$ $304.80 5.08$ $304.80 XXX

88344 26 1.16$ $69.60 1.16$ $69.60 XXX

88344 TC 3.93$ $235.80 3.93$ $235.80 XXX

88346 2.72$ $163.20 2.72$ $163.20 XXX

88346 26 1.08$ $64.80 1.08$ $64.80 XXX

88346 TC 1.63$ $97.80 1.63$ $97.80 XXX

88348 10.18$ $610.80 10.18$ $610.80 XXX

88348 26 2.24$ $134.40 2.24$ $134.40 XXX

88348 TC 7.93$ $475.80 7.93$ $475.80 XXX

88350 2.10$ $126.00 2.10$ $126.00 XXX

88350 26 0.81$ $48.60 0.81$ $48.60 XXX

88350 TC 1.29$ $77.40 1.29$ $77.40 XXX

88355 4.57$ $274.20 4.57$ $274.20 XXX

88355 26 2.39$ $143.40 2.39$ $143.40 XXX

88355 TC 2.18$ $130.80 2.18$ $130.80 XXX

88356 5.93$ $355.80 5.93$ $355.80 XXX

88356 26 3.49$ $209.40 3.49$ $209.40 XXX

88356 TC 2.45$ $147.00 2.45$ $147.00 XXX

88358 2.47$ $148.20 2.47$ $148.20 XXX

88358 26 1.31$ $78.60 1.31$ $78.60 XXX

88358 TC 1.17$ $70.20 1.17$ $70.20 XXX

88360 3.52$ $211.20 3.52$ $211.20 XXX

88360 26 1.60$ $96.00 1.60$ $96.00 XXX

88360 TC 1.92$ $115.20 1.92$ $115.20 XXX

88361 4.34$ $260.40 4.34$ $260.40 XXX

88361 26 1.72$ $103.20 1.72$ $103.20 XXX

88361 TC 2.62$ $157.20 2.62$ $157.20 XXX

88362 7.56$ $453.60 7.56$ $453.60 XXX

88362 26 3.19$ $191.40 3.19$ $191.40 XXX

88362 TC 4.38$ $262.80 4.38$ $262.80 XXX

88363 0.66$ $39.60 0.56$ $33.60 XXX

88364 3.95$ $237.00 3.95$ $237.00 XXX

88364 26 0.99$ $59.40 0.99$ $59.40 XXX

88364 TC 2.95$ $177.00 2.95$ $177.00 XXX

88365 5.20$ $312.00 5.20$ $312.00 XXX

88365 26 1.30$ $78.00 1.30$ $78.00 XXX

88365 TC 3.91$ $234.60 3.91$ $234.60 XXX



Page | 219

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

88366 7.69$ $461.40 7.69$ $461.40 XXX

88366 26 1.84$ $110.40 1.84$ $110.40 XXX

88366 TC 5.85$ $351.00 5.85$ $351.00 XXX

88367 3.11$ $186.60 3.11$ $186.60 XXX

88367 26 1.02$ $61.20 1.02$ $61.20 XXX

88367 TC 2.10$ $126.00 2.10$ $126.00 XXX

88368 3.33$ $199.80 3.33$ $199.80 XXX

88368 26 1.17$ $70.20 1.17$ $70.20 XXX

88368 TC 2.16$ $129.60 2.16$ $129.60 XXX

88369 3.16$ $189.60 3.16$ $189.60 XXX

88369 26 0.90$ $54.00 0.90$ $54.00 XXX

88369 TC 2.26$ $135.60 2.26$ $135.60 XXX


88371 26 0.53$ $31.80 0.53$ $31.80 XXX


88372 26 0.53$ $31.80 0.53$ $31.80 XXX

88373 2.19$ $131.40 2.19$ $131.40 XXX

88373 26 0.61$ $36.60 0.61$ $36.60 XXX

88373 TC 1.59$ $95.40 1.59$ $95.40 XXX

88374 10.15$ $609.00 10.15$ $609.00 XXX

88374 26 1.31$ $78.60 1.31$ $78.60 XXX

88374 TC 8.84$ $530.40 8.84$ $530.40 XXX

88375 1.41$ $84.60 1.41$ $84.60 XXX

88377 12.07$ $724.20 12.07$ $724.20 XXX

88377 26 1.89$ $113.40 1.89$ $113.40 XXX

88377 TC 10.19$ $611.40 10.19$ $611.40 XXX

88380 4.22$ $253.20 4.22$ $253.20 XXX

88380 26 1.66$ $99.60 1.66$ $99.60 XXX

88380 TC 2.56$ $153.60 2.56$ $153.60 XXX

88381 3.44$ $206.40 3.44$ $206.40 XXX

88381 26 0.73$ $43.80 0.73$ $43.80 XXX

88381 TC 2.72$ $163.20 2.72$ $163.20 XXX

88387 1.21$ $72.60 1.21$ $72.60 XXX

88387 26 0.94$ $56.40 0.94$ $56.40 XXX

88387 TC 0.27$ $16.20 0.27$ $16.20 XXX

88388 1.00$ $60.00 1.00$ $60.00 XXX

88388 26 0.71$ $42.60 0.71$ $42.60 XXX

88388 TC 0.29$ $17.40 0.29$ $17.40 XXX







Page | 220

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL





89049 7.66$ $459.60 1.83$ $109.80 XXX





89060 26 0.53$ $31.80 0.53$ $31.80 XXX




89220 0.48$ $28.80 0.48$ $28.80 XXX

89230 0.15$ $9.00 0.15$ $9.00 XXX






























Page | 221

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL















90287 XXX

90288 XXX

90291 XXX

90296 XXX

90371 XXX

90375 XXX

90376 XXX

90378 XXX

90384 XXX

90386 XXX


90393 XXX

90396 XXX

90399 XXX

90460 0.74$ $44.40 0.74$ $44.40 XXX

90461 0.36$ $21.60 0.36$ $21.60 ZZZ

90471 0.74$ $44.40 0.74$ $44.40 XXX

90472 0.36$ $21.60 0.36$ $21.60 ZZZ

90473 0.74$ $44.40 0.74$ $44.40 XXX

90474 0.36$ $21.60 0.36$ $21.60 ZZZ

90476 XXX

90477 XXX

90581 XXX

90585 XXX

90586 XXX

90620 XXX

90621 XXX
























Page | 222

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


90632 XXX

90633 XXX

90634 XXX

90636 XXX


90647 XXX

90648 XXX

90649 XXX

90650 XXX



90656 XXX

90657 XXX

90661 XXX

90662 XXX





90670 XXX

90672 XXX

90675 XXX

90676 XXX

90680 XXX

90681 XXX

90685 XXX

90686 XXX

90687 XXX

90688 XXX

90690 XXX

90691 XXX

90696 XXX

90697 XXX

90698 XXX






90714 XXX

90715 XXX
































Page | 223

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


90717 XXX

90723 XXX

90732 XXX

90734 XXX

90736 XXX



90740 XXX

90743 XXX

90744 XXX

90746 XXX

90747 XXX



90785 0.39$ $23.40 0.39$ $23.40 ZZZ

90791 3.70$ $222.00 3.57$ $214.20 XXX

90792 4.08$ $244.80 3.96$ $237.60 XXX

90832 1.79$ $107.40 1.78$ $106.80 XXX

90833 1.85$ $111.00 1.83$ $109.80 ZZZ

90834 2.38$ $142.80 2.37$ $142.20 XXX

90836 2.34$ $140.40 2.32$ $139.20 ZZZ

90837 3.57$ $214.20 3.54$ $212.40 XXX

90838 3.09$ $185.40 3.07$ $184.20 ZZZ

90839 3.73$ $223.80 3.70$ $222.00 XXX

90840 1.78$ $106.80 1.77$ $106.20 ZZZ

90845 2.57$ $154.20 2.56$ $153.60 XXX

90846 2.89$ $173.40 2.86$ $171.60 XXX

90847 2.99$ $179.40 2.96$ $177.60 XXX

90849 0.97$ $58.20 0.86$ $51.60 XXX

90853 0.72$ $43.20 0.71$ $42.60 XXX

90863 1.76$ $105.60 1.31$ $78.60 XXX

90865 4.75$ $285.00 3.63$ $217.80 XXX




90870 5.10$ $306.00 3.12$ $187.20 000

90875 1.73$ $103.80 1.73$ $103.80 XXX

90876 3.06$ $183.60 2.74$ $164.40 XXX

90880 2.86$ $171.60 2.64$ $158.40 XXX















Page | 224

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL




90901 1.10$ $66.00 0.56$ $33.60 000

90911 2.43$ $145.80 1.25$ $75.00 000

90935 2.05$ $123.00 2.05$ $123.00 000

90937 2.94$ $176.40 2.94$ $176.40 000


90945 2.44$ $146.40 2.44$ $146.40 000

90947 3.50$ $210.00 3.50$ $210.00 000

90951 26.48$ $1,588.80 26.48$ $1,588.80 XXX



90954 22.98$ $1,378.80 22.98$ $1,378.80 XXX

90955 12.92$ $775.20 12.92$ $775.20 XXX

90956 9.02$ $541.20 9.02$ $541.20 XXX

90957 18.21$ $1,092.60 18.21$ $1,092.60 XXX

90958 12.33$ $739.80 12.33$ $739.80 XXX

90959 8.39$ $503.40 8.39$ $503.40 XXX

90960 8.05$ $483.00 8.05$ $483.00 XXX

90961 6.77$ $406.20 6.77$ $406.20 XXX

90962 5.24$ $314.40 5.24$ $314.40 XXX

90963 15.37$ $922.20 15.37$ $922.20 XXX

90964 13.44$ $806.40 13.44$ $806.40 XXX

90965 12.79$ $767.40 12.79$ $767.40 XXX

90966 6.76$ $405.60 6.76$ $405.60 XXX

90967 0.51$ $30.60 0.51$ $30.60 XXX

90968 0.44$ $26.40 0.44$ $26.40 XXX

90969 0.43$ $25.80 0.43$ $25.80 XXX

90970 0.22$ $13.20 0.22$ $13.20 XXX



90997 2.64$ $158.40 2.64$ $158.40 000


91010 5.14$ $308.40 5.14$ $308.40 000

91010 26 1.91$ $114.60 1.91$ $114.60 000

91010 TC 3.23$ $193.80 3.23$ $193.80 000

91013 0.67$ $40.20 0.67$ $40.20 ZZZ

91013 26 0.27$ $16.20 0.27$ $16.20 ZZZ

91013 TC 0.40$ $24.00 0.40$ $24.00 ZZZ

91020 6.85$ $411.00 6.85$ $411.00 000

91020 26 2.15$ $129.00 2.15$ $129.00 000



Page | 225

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

91020 TC 4.70$ $282.00 4.70$ $282.00 000

91022 4.88$ $292.80 4.88$ $292.80 000

91022 26 2.15$ $129.00 2.15$ $129.00 000

91022 TC 2.73$ $163.80 2.73$ $163.80 000

91030 3.99$ $239.40 3.99$ $239.40 000

91030 26 1.35$ $81.00 1.35$ $81.00 000

91030 TC 2.64$ $158.40 2.64$ $158.40 000

91034 5.56$ $333.60 5.56$ $333.60 000

91034 26 1.46$ $87.60 1.46$ $87.60 000

91034 TC 4.11$ $246.60 4.11$ $246.60 000

91035 14.16$ $849.60 14.16$ $849.60 000

91035 26 2.38$ $142.80 2.38$ $142.80 000

91035 TC 11.78$ $706.80 11.78$ $706.80 000

91037 4.70$ $282.00 4.70$ $282.00 000

91037 26 1.45$ $87.00 1.45$ $87.00 000

91037 TC 3.25$ $195.00 3.25$ $195.00 000

91038 13.29$ $797.40 13.29$ $797.40 000

91038 26 1.63$ $97.80 1.63$ $97.80 000

91038 TC 11.65$ $699.00 11.65$ $699.00 000

91040 12.88$ $772.80 12.88$ $772.80 000

91040 26 1.44$ $86.40 1.44$ $86.40 000

91040 TC 11.44$ $686.40 11.44$ $686.40 000

91065 2.30$ $138.00 2.30$ $138.00 000

91065 26 0.29$ $17.40 0.29$ $17.40 000

91065 TC 2.01$ $120.60 2.01$ $120.60 000

91110 26.01$ $1,560.60 26.01$ $1,560.60 XXX

91110 26 5.44$ $326.40 5.44$ $326.40 XXX

91110 TC 20.57$ $1,234.20 20.57$ $1,234.20 XXX

91111 21.49$ $1,289.40 21.49$ $1,289.40 XXX

91111 26 1.50$ $90.00 1.50$ $90.00 XXX

91111 TC 19.99$ $1,199.40 19.99$ $1,199.40 XXX

91112 32.01$ $1,920.60 32.01$ $1,920.60 XXX

91112 26 3.13$ $187.80 3.13$ $187.80 XXX

91112 TC 28.88$ $1,732.80 28.88$ $1,732.80 XXX

91117 3.94$ $236.40 3.94$ $236.40 000

91120 12.57$ $754.20 12.57$ $754.20 XXX

91120 26 1.42$ $85.20 1.42$ $85.20 XXX

91120 TC 11.15$ $669.00 11.15$ $669.00 XXX

91122 6.60$ $396.00 6.60$ $396.00 000

91122 26 2.55$ $153.00 2.55$ $153.00 000

91122 TC 4.05$ $243.00 4.05$ $243.00 000

91132 4.54$ $272.40 4.54$ $272.40 XXX



Page | 226

CODE MOD

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

91132 26 0.78$ $46.80 0.78$ $46.80 XXX

91132 TC 3.76$ $225.60 3.76$ $225.60 XXX

91133 5.07$ $304.20 5.07$ $304.20 XXX

91133 26 0.99$ $59.40 0.99$ $59.40 XXX

91133 TC 4.08$ $244.80 4.08$ $244.80 XXX

91200 0.92$ $55.20 0.92$ $55.20 XXX

91200 26 0.37$ $22.20 0.37$ $22.20 XXX

91200 TC 0.54$ $32.40 0.54$ $32.40 XXX




92002 2.35$ $141.00 1.37$ $82.20 XXX

92004 4.29$ $257.40 2.85$ $171.00 XXX

92012 2.47$ $148.20 1.51$ $90.60 XXX

92014 3.57$ $214.20 2.28$ $136.80 XXX

92015 0.56$ $33.60 0.55$ $33.00 XXX

92018 4.16$ $249.60 4.16$ $249.60 XXX

92019 2.05$ $123.00 2.05$ $123.00 XXX

92020 0.77$ $46.20 0.60$ $36.00 XXX

92025 1.10$ $66.00 1.10$ $66.00 XXX

92025 26 0.58$ $34.80 0.58$ $34.80 XXX

92025 TC 0.52$ $31.20 0.52$ $31.20 XXX

92060 1.89$ $113.40 1.89$ $113.40 XXX

92060 26 1.10$ $66.00 1.10$ $66.00 XXX

92060 TC 0.79$ $47.40 0.79$ $47.40 XXX

92065 1.56$ $93.60 1.56$ $93.60 XXX

92065 26 0.52$ $31.20 0.52$ $31.20 XXX

92065 TC 1.04$ $62.40 1.04$ $62.40 XXX

92071 1.09$ $65.40 0.96$ $57.60 XXX

92072 3.89$ $233.40 2.95$ $177.00 XXX

92081 0.98$ $58.80 0.98$ $58.80 XXX

92081 26 0.47$ $28.20 0.47$ $28.20 XXX

92081 TC 0.51$ $30.60 0.51$ $30.60 XXX

92082 1.40$ $84.00 1.40$ $84.00 XXX

92082 26 0.62$ $37.20 0.62$ $37.20 XXX

92082 TC 0.78$ $46.80 0.78$ $46.80 XXX

92083 1.88$ $112.80 1.88$ $112.80 XXX

92083 26 0.80$ $48.00 0.80$ $48.00 XXX

92083 TC 1.07$ $64.20 1.07$ $64.20 XXX

92100 2.34$ $140.40 0.97$ $58.20 XXX

92132 1.01$ $60.60 1.01$ $60.60 XXX

92132 26 0.55$ $33.00 0.55$ $33.00 XXX



Page | 227

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

92132 TC 0.46$ $27.60 0.46$ $27.60 XXX

92133 1.27$ $76.20 1.27$ $76.20 XXX

92133 26 0.80$ $48.00 0.80$ $48.00 XXX

92133 TC 0.47$ $28.20 0.47$ $28.20 XXX

92134 1.31$ $78.60 1.31$ $78.60 XXX

92134 26 0.83$ $49.80 0.83$ $49.80 XXX

92134 TC 0.48$ $28.80 0.48$ $28.80 XXX

92136 2.65$ $159.00 2.65$ $159.00 XXX

92136 26 0.90$ $54.00 0.90$ $54.00 XXX

92136 TC 1.75$ $105.00 1.75$ $105.00 XXX

92140 1.84$ $110.40 0.76$ $45.60 XXX

92145 0.43$ $25.80 0.43$ $25.80 XXX

92145 26 0.24$ $14.40 0.24$ $14.40 XXX

92145 TC 0.20$ $12.00 0.20$ $12.00 XXX

92225 0.78$ $46.80 0.61$ $36.60 XXX

92226 0.72$ $43.20 0.55$ $33.00 XXX

92227 0.43$ $25.80 0.43$ $25.80 XXX

92228 1.00$ $60.00 1.00$ $60.00 XXX

92228 26 0.60$ $36.00 0.60$ $36.00 XXX

92228 TC 0.40$ $24.00 0.40$ $24.00 XXX

92230 1.69$ $101.40 0.96$ $57.60 XXX

92235 3.21$ $192.60 3.21$ $192.60 XXX

92235 26 1.36$ $81.60 1.36$ $81.60 XXX

92235 TC 1.85$ $111.00 1.85$ $111.00 XXX

92240 7.53$ $451.80 7.53$ $451.80 XXX

92240 26 1.85$ $111.00 1.85$ $111.00 XXX

92240 TC 5.68$ $340.80 5.68$ $340.80 XXX

92250 2.31$ $138.60 2.31$ $138.60 XXX

92250 26 0.69$ $41.40 0.69$ $41.40 XXX

92250 TC 1.62$ $97.20 1.62$ $97.20 XXX

92260 0.53$ $31.80 0.31$ $18.60 XXX

92265 2.29$ $137.40 2.29$ $137.40 XXX

92265 26 1.23$ $73.80 1.23$ $73.80 XXX

92265 TC 1.06$ $63.60 1.06$ $63.60 XXX

92270 2.66$ $159.60 2.66$ $159.60 XXX

92270 26 1.18$ $70.80 1.18$ $70.80 XXX

92270 TC 1.48$ $88.80 1.48$ $88.80 XXX

92275 4.35$ $261.00 4.35$ $261.00 XXX

92275 26 1.56$ $93.60 1.56$ $93.60 XXX

92275 TC 2.79$ $167.40 2.79$ $167.40 XXX

92283 1.63$ $97.80 1.63$ $97.80 XXX

92283 26 0.26$ $15.60 0.26$ $15.60 XXX



Page | 228

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

92283 TC 1.37$ $82.20 1.37$ $82.20 XXX

92284 1.81$ $108.60 1.81$ $108.60 XXX

92284 26 0.35$ $21.00 0.35$ $21.00 XXX

92284 TC 1.45$ $87.00 1.45$ $87.00 XXX

92285 0.60$ $36.00 0.60$ $36.00 XXX

92285 26 0.09$ $5.40 0.09$ $5.40 XXX

92285 TC 0.51$ $30.60 0.51$ $30.60 XXX

92286 1.11$ $66.60 1.11$ $66.60 XXX

92286 26 0.64$ $38.40 0.64$ $38.40 XXX

92286 TC 0.47$ $28.20 0.47$ $28.20 XXX

92287 4.04$ $242.40 4.04$ $242.40 XXX

92287 26 1.35$ $81.00 1.35$ $81.00 XXX

92287 TC 2.69$ $161.40 2.69$ $161.40 XXX

92310 2.76$ $165.60 1.69$ $101.40 XXX

92311 2.94$ $176.40 1.59$ $95.40 XXX

92312 3.38$ $202.80 1.82$ $109.20 XXX

92313 2.82$ $169.20 1.35$ $81.00 XXX

92314 2.31$ $138.60 0.99$ $59.40 XXX

92315 2.13$ $127.80 0.62$ $37.20 XXX

92316 2.68$ $160.80 0.94$ $56.40 XXX

92317 2.23$ $133.80 0.63$ $37.80 XXX

92325 1.24$ $74.40 1.24$ $74.40 XXX

92326 1.04$ $62.40 1.04$ $62.40 XXX

92340 1.03$ $61.80 0.53$ $31.80 XXX

92341 1.16$ $69.60 0.68$ $40.80 XXX

92342 1.26$ $75.60 0.76$ $45.60 XXX






92370 0.89$ $53.40 0.46$ $27.60 XXX





92502 2.79$ $167.40 2.79$ $167.40 000

92504 0.88$ $52.80 0.27$ $16.20 XXX

92507 2.26$ $135.60 2.26$ $135.60 XXX

92508 0.68$ $40.80 0.68$ $40.80 XXX

92511 3.31$ $198.60 1.13$ $67.80 000

92512 1.77$ $106.20 0.82$ $49.20 XXX



Page | 229

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

92516 2.07$ $124.20 0.66$ $39.60 XXX

92520 2.19$ $131.40 1.18$ $70.80 XXX

92521 3.18$ $190.80 3.18$ $190.80 XXX

92522 2.64$ $158.40 2.64$ $158.40 XXX

92523 5.56$ $333.60 5.56$ $333.60 XXX

92524 2.56$ $153.60 2.56$ $153.60 XXX

92526 2.47$ $148.20 2.47$ $148.20 XXX





92537 1.16$ $69.60 1.16$ $69.60 XXX

92537 26 0.91$ $54.60 0.91$ $54.60 XXX

92537 TC 0.25$ $15.00 0.25$ $15.00 XXX

92538 0.59$ $35.40 0.59$ $35.40 XXX

92538 26 0.46$ $27.60 0.46$ $27.60 XXX

92538 TC 0.13$ $7.80 0.13$ $7.80 XXX

92540 2.93$ $175.80 2.93$ $175.80 XXX

92540 26 2.28$ $136.80 2.28$ $136.80 XXX

92540 TC 0.65$ $39.00 0.65$ $39.00 XXX

92541 0.69$ $41.40 0.69$ $41.40 XXX

92541 26 0.60$ $36.00 0.60$ $36.00 XXX

92541 TC 0.09$ $5.40 0.09$ $5.40 XXX

92542 0.79$ $47.40 0.79$ $47.40 XXX

92542 26 0.72$ $43.20 0.72$ $43.20 XXX

92542 TC 0.08$ $4.80 0.08$ $4.80 XXX

92544 0.47$ $28.20 0.47$ $28.20 XXX

92544 26 0.40$ $24.00 0.40$ $24.00 XXX

92544 TC 0.07$ $4.20 0.07$ $4.20 XXX

92545 0.43$ $25.80 0.43$ $25.80 XXX

92545 26 0.37$ $22.20 0.37$ $22.20 XXX

92545 TC 0.06$ $3.60 0.06$ $3.60 XXX

92546 3.04$ $182.40 3.04$ $182.40 XXX

92546 26 0.42$ $25.20 0.42$ $25.20 XXX

92546 TC 2.62$ $157.20 2.62$ $157.20 XXX

92547 0.18$ $10.80 0.18$ $10.80 ZZZ

92548 3.01$ $180.60 3.01$ $180.60 XXX

92548 26 0.75$ $45.00 0.75$ $45.00 XXX

92548 TC 2.27$ $136.20 2.27$ $136.20 XXX

92550 0.61$ $36.60 0.61$ $36.60 XXX

92551 0.35$ $21.00 0.35$ $21.00 XXX

92552 0.92$ $55.20 0.92$ $55.20 XXX



Page | 230

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

92553 1.10$ $66.00 1.10$ $66.00 XXX

92555 0.69$ $41.40 0.69$ $41.40 XXX

92556 1.10$ $66.00 1.10$ $66.00 XXX

92557 1.07$ $64.20 0.94$ $56.40 XXX




92561 1.12$ $67.20 1.12$ $67.20 XXX

92562 1.38$ $82.80 1.38$ $82.80 XXX

92563 0.91$ $54.60 0.91$ $54.60 XXX

92564 0.83$ $49.80 0.83$ $49.80 XXX

92565 0.47$ $28.20 0.47$ $28.20 XXX

92567 0.42$ $25.20 0.31$ $18.60 XXX

92568 0.45$ $27.00 0.44$ $26.40 XXX

92570 0.92$ $55.20 0.85$ $51.00 XXX

92571 0.81$ $48.60 0.81$ $48.60 XXX

92572 1.06$ $63.60 1.06$ $63.60 XXX

92575 2.14$ $128.40 2.14$ $128.40 XXX

92576 1.06$ $63.60 1.06$ $63.60 XXX

92577 0.49$ $29.40 0.49$ $29.40 XXX

92579 1.19$ $71.40 1.06$ $63.60 XXX

92582 2.01$ $120.60 2.01$ $120.60 XXX

92583 1.56$ $93.60 1.56$ $93.60 XXX

92584 2.18$ $130.80 2.18$ $130.80 XXX

92585 4.00$ $240.00 4.00$ $240.00 XXX

92585 26 0.77$ $46.20 0.77$ $46.20 XXX

92585 TC 3.23$ $193.80 3.23$ $193.80 XXX

92586 2.54$ $152.40 2.54$ $152.40 XXX

92587 0.62$ $37.20 0.62$ $37.20 XXX

92587 26 0.53$ $31.80 0.53$ $31.80 XXX

92587 TC 0.09$ $5.40 0.09$ $5.40 XXX

92588 0.94$ $56.40 0.94$ $56.40 XXX

92588 26 0.83$ $49.80 0.83$ $49.80 XXX

92588 TC 0.11$ $6.60 0.11$ $6.60 XXX







92596 1.25$ $75.00 1.25$ $75.00 XXX

92597 2.05$ $123.00 2.05$ $123.00 XXX



Page | 231

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

92601 4.03$ $241.80 3.40$ $204.00 XXX

92602 2.57$ $154.20 1.97$ $118.20 XXX

92603 4.36$ $261.60 3.50$ $210.00 XXX

92604 2.58$ $154.80 1.94$ $116.40 XXX



92607 3.64$ $218.40 3.64$ $218.40 XXX

92608 1.52$ $91.20 1.52$ $91.20 ZZZ

92609 3.20$ $192.00 3.20$ $192.00 XXX

92610 2.45$ $147.00 2.08$ $124.80 XXX

92611 2.48$ $148.80 2.48$ $148.80 XXX

92612 5.46$ $327.60 1.94$ $116.40 XXX

92613 1.08$ $64.80 1.08$ $64.80 XXX

92614 4.26$ $255.60 1.93$ $115.80 XXX

92615 0.96$ $57.60 0.95$ $57.00 XXX

92616 6.08$ $364.80 2.88$ $172.80 XXX

92617 1.19$ $71.40 1.19$ $71.40 XXX

92618 Bundled Bundled ZZZ

92620 2.70$ $162.00 2.37$ $142.20 XXX

92621 0.64$ $38.40 0.55$ $33.00 ZZZ

92625 2.01$ $120.60 1.79$ $107.40 XXX

92626 2.58$ $154.80 2.19$ $131.40 XXX

92627 0.64$ $38.40 0.52$ $31.20 ZZZ



92640 3.26$ $195.60 2.75$ $165.00 XXX


92920 14.94$ $896.40 14.94$ $896.40 000


92924 17.75$ $1,065.00 17.75$ $1,065.00 000


92928 16.58$ $994.80 16.58$ $994.80 000


92933 18.55$ $1,113.00 18.55$ $1,113.00 000


92937 16.57$ $994.20 16.57$ $994.20 000


92941 18.58$ $1,114.80 18.58$ $1,114.80 000

92943 18.58$ $1,114.80 18.58$ $1,114.80 000


92950 8.70$ $522.00 5.23$ $313.80 000

92953 0.32$ $19.20 0.32$ $19.20 000



Page | 232

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

92960 5.97$ $358.20 3.48$ $208.80 000

92961 7.18$ $430.80 7.18$ $430.80 000

92970 5.21$ $312.60 5.21$ $312.60 000

92971 2.77$ $166.20 2.77$ $166.20 000

92973 4.85$ $291.00 4.85$ $291.00 ZZZ

92974 4.43$ $265.80 4.43$ $265.80 ZZZ

92975 10.69$ $641.40 10.69$ $641.40 000

92977 1.77$ $106.20 1.77$ $106.20 XXX



92978 26 2.64$ $158.40 2.64$ $158.40 ZZZ



92979 26 2.11$ $126.60 2.11$ $126.60 ZZZ

92986 36.77$ $2,206.20 36.77$ $2,206.20 090

92987 37.96$ $2,277.60 37.96$ $2,277.60 090

92990 29.96$ $1,797.60 29.96$ $1,797.60 090



92997 17.94$ $1,076.40 17.94$ $1,076.40 000

92998 8.85$ $531.00 8.85$ $531.00 ZZZ

93000 0.49$ $29.40 0.49$ $29.40 XXX

93005 0.25$ $15.00 0.25$ $15.00 XXX

93010 0.24$ $14.40 0.24$ $14.40 XXX

93015 2.21$ $132.60 2.21$ $132.60 XXX

93016 0.63$ $37.80 0.63$ $37.80 XXX

93017 1.17$ $70.20 1.17$ $70.20 XXX

93018 0.41$ $24.60 0.41$ $24.60 XXX

93024 3.25$ $195.00 3.25$ $195.00 XXX

93024 26 1.63$ $97.80 1.63$ $97.80 XXX

93024 TC 1.62$ $97.20 1.62$ $97.20 XXX

93025 4.70$ $282.00 4.70$ $282.00 XXX

93025 26 1.05$ $63.00 1.05$ $63.00 XXX

93025 TC 3.65$ $219.00 3.65$ $219.00 XXX

93040 0.36$ $21.60 0.36$ $21.60 XXX

93041 0.16$ $9.60 0.16$ $9.60 XXX

93042 0.20$ $12.00 0.20$ $12.00 XXX

93050 0.50$ $30.00 0.50$ $30.00 XXX

93050 26 0.24$ $14.40 0.24$ $14.40 XXX

93050 TC 0.26$ $15.60 0.26$ $15.60 XXX

93224 2.67$ $160.20 2.67$ $160.20 XXX

93225 0.79$ $47.40 0.79$ $47.40 XXX



Page | 233

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

93226 1.13$ $67.80 1.13$ $67.80 XXX

93227 0.76$ $45.60 0.76$ $45.60 XXX

93228 0.74$ $44.40 0.74$ $44.40 XXX

93229 21.63$ $1,297.80 21.63$ $1,297.80 XXX

93260 1.93$ $115.80 1.93$ $115.80 XXX

93260 26 1.28$ $76.80 1.28$ $76.80 XXX

93260 TC 0.65$ $39.00 0.65$ $39.00 XXX

93261 1.75$ $105.00 1.75$ $105.00 XXX

93261 26 1.10$ $66.00 1.10$ $66.00 XXX

93261 TC 0.65$ $39.00 0.65$ $39.00 XXX

93268 6.07$ $364.20 6.07$ $364.20 XXX

93270 0.27$ $16.20 0.27$ $16.20 XXX

93271 5.08$ $304.80 5.08$ $304.80 XXX

93272 0.72$ $43.20 0.72$ $43.20 XXX

93278 0.87$ $52.20 0.87$ $52.20 XXX

93278 26 0.35$ $21.00 0.35$ $21.00 XXX

93278 TC 0.52$ $31.20 0.52$ $31.20 XXX

93279 1.43$ $85.80 1.43$ $85.80 XXX

93279 26 0.92$ $55.20 0.92$ $55.20 XXX

93279 TC 0.51$ $30.60 0.51$ $30.60 XXX

93280 1.67$ $100.20 1.67$ $100.20 XXX

93280 26 1.10$ $66.00 1.10$ $66.00 XXX

93280 TC 0.58$ $34.80 0.58$ $34.80 XXX

93281 1.96$ $117.60 1.96$ $117.60 XXX

93281 26 1.28$ $76.80 1.28$ $76.80 XXX

93281 TC 0.68$ $40.80 0.68$ $40.80 XXX

93282 1.81$ $108.60 1.81$ $108.60 XXX

93282 26 1.21$ $72.60 1.21$ $72.60 XXX

93282 TC 0.60$ $36.00 0.60$ $36.00 XXX

93283 2.35$ $141.00 2.35$ $141.00 XXX

93283 26 1.64$ $98.40 1.64$ $98.40 XXX

93283 TC 0.70$ $42.00 0.70$ $42.00 XXX

93284 2.59$ $155.40 2.59$ $155.40 XXX

93284 26 1.79$ $107.40 1.79$ $107.40 XXX

93284 TC 0.80$ $48.00 0.80$ $48.00 XXX

93285 1.22$ $73.20 1.22$ $73.20 XXX

93285 26 0.75$ $45.00 0.75$ $45.00 XXX

93285 TC 0.47$ $28.20 0.47$ $28.20 XXX

93286 0.79$ $47.40 0.79$ $47.40 XXX

93286 26 0.43$ $25.80 0.43$ $25.80 XXX

93286 TC 0.35$ $21.00 0.35$ $21.00 XXX

93287 1.04$ $62.40 1.04$ $62.40 XXX



Page | 234

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

93287 26 0.65$ $39.00 0.65$ $39.00 XXX

93287 TC 0.39$ $23.40 0.39$ $23.40 XXX

93288 1.06$ $63.60 1.06$ $63.60 XXX

93288 26 0.60$ $36.00 0.60$ $36.00 XXX

93288 TC 0.46$ $27.60 0.46$ $27.60 XXX

93289 1.88$ $112.80 1.88$ $112.80 XXX

93289 26 1.30$ $78.00 1.30$ $78.00 XXX

93289 TC 0.58$ $34.80 0.58$ $34.80 XXX

93290 0.89$ $53.40 0.89$ $53.40 XXX

93290 26 0.61$ $36.60 0.61$ $36.60 XXX

93290 TC 0.28$ $16.80 0.28$ $16.80 XXX

93291 1.04$ $62.40 1.04$ $62.40 XXX

93291 26 0.61$ $36.60 0.61$ $36.60 XXX

93291 TC 0.43$ $25.80 0.43$ $25.80 XXX

93292 0.93$ $55.80 0.93$ $55.80 XXX

93292 26 0.61$ $36.60 0.61$ $36.60 XXX

93292 TC 0.32$ $19.20 0.32$ $19.20 XXX

93293 1.56$ $93.60 1.56$ $93.60 XXX

93293 26 0.44$ $26.40 0.44$ $26.40 XXX

93293 TC 1.11$ $66.60 1.11$ $66.60 XXX

93294 0.96$ $57.60 0.96$ $57.60 XXX

93295 1.90$ $114.00 1.90$ $114.00 XXX

93296 0.77$ $46.20 0.77$ $46.20 XXX

93297 0.75$ $45.00 0.75$ $45.00 XXX

93298 0.75$ $45.00 0.75$ $45.00 XXX


93303 7.01$ $420.60 7.01$ $420.60 XXX

93303 26 1.82$ $109.20 1.82$ $109.20 XXX

93303 TC 5.19$ $311.40 5.19$ $311.40 XXX

93304 4.59$ $275.40 4.59$ $275.40 XXX

93304 26 1.05$ $63.00 1.05$ $63.00 XXX

93304 TC 3.55$ $213.00 3.55$ $213.00 XXX

93306 6.69$ $401.40 6.69$ $401.40 XXX

93306 26 1.81$ $108.60 1.81$ $108.60 XXX

93306 TC 4.88$ $292.80 4.88$ $292.80 XXX

93307 3.82$ $229.20 3.82$ $229.20 XXX

93307 26 1.29$ $77.40 1.29$ $77.40 XXX

93307 TC 2.53$ $151.80 2.53$ $151.80 XXX

93308 3.68$ $220.80 3.68$ $220.80 XXX

93308 26 0.73$ $43.80 0.73$ $43.80 XXX

93308 TC 2.94$ $176.40 2.94$ $176.40 XXX

93312 8.93$ $535.80 8.93$ $535.80 XXX



Page | 235

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

93312 26 3.45$ $207.00 3.45$ $207.00 XXX

93312 TC 5.48$ $328.80 5.48$ $328.80 XXX

93313 0.63$ $37.80 0.63$ $37.80 XXX

93314 8.73$ $523.80 8.73$ $523.80 XXX

93314 26 2.91$ $174.60 2.91$ $174.60 XXX

93314 TC 5.82$ $349.20 5.82$ $349.20 XXX



93315 26 4.03$ $241.80 4.03$ $241.80 XXX

93316 1.07$ $64.20 1.07$ $64.20 XXX



93317 26 2.95$ $177.00 2.95$ $177.00 XXX



93318 26 3.28$ $196.80 3.28$ $196.80 XXX

93320 1.59$ $95.40 1.59$ $95.40 ZZZ

93320 26 0.53$ $31.80 0.53$ $31.80 ZZZ

93320 TC 1.07$ $64.20 1.07$ $64.20 ZZZ

93321 0.80$ $48.00 0.80$ $48.00 ZZZ

93321 26 0.21$ $12.60 0.21$ $12.60 ZZZ

93321 TC 0.59$ $35.40 0.59$ $35.40 ZZZ

93325 0.76$ $45.60 0.76$ $45.60 ZZZ

93325 26 0.09$ $5.40 0.09$ $5.40 ZZZ

93325 TC 0.67$ $40.20 0.67$ $40.20 ZZZ

93350 7.08$ $424.80 7.08$ $424.80 XXX

93350 26 2.03$ $121.80 2.03$ $121.80 XXX

93350 TC 5.04$ $302.40 5.04$ $302.40 XXX

93351 7.95$ $477.00 7.95$ $477.00 XXX

93351 26 2.43$ $145.80 2.43$ $145.80 XXX

93351 TC 5.52$ $331.20 5.52$ $331.20 XXX

93352 0.99$ $59.40 0.99$ $59.40 ZZZ

93355 6.38$ $382.80 6.38$ $382.80 XXX

93451 23.03$ $1,381.80 23.03$ $1,381.80 000

93451 26 3.97$ $238.20 3.97$ $238.20 000

93451 TC 19.05$ $1,143.00 19.05$ $1,143.00 000

93452 25.68$ $1,540.80 25.68$ $1,540.80 000

93452 26 6.95$ $417.00 6.95$ $417.00 000

93452 TC 18.73$ $1,123.80 18.73$ $1,123.80 000

93453 33.09$ $1,985.40 33.09$ $1,985.40 000

93453 26 9.16$ $549.60 9.16$ $549.60 000

93453 TC 23.92$ $1,435.20 23.92$ $1,435.20 000



Page | 236

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

93454 26.05$ $1,563.00 26.05$ $1,563.00 000

93454 26 7.02$ $421.20 7.02$ $421.20 000

93454 TC 19.02$ $1,141.20 19.02$ $1,141.20 000

93455 30.33$ $1,819.80 30.33$ $1,819.80 000

93455 26 8.12$ $487.20 8.12$ $487.20 000

93455 TC 22.21$ $1,332.60 22.21$ $1,332.60 000

93456 32.62$ $1,957.20 32.62$ $1,957.20 000

93456 26 9.01$ $540.60 9.01$ $540.60 000

93456 TC 23.61$ $1,416.60 23.61$ $1,416.60 000

93457 36.87$ $2,212.20 36.87$ $2,212.20 000

93457 26 10.10$ $606.00 10.10$ $606.00 000

93457 TC 26.78$ $1,606.80 26.78$ $1,606.80 000

93458 31.23$ $1,873.80 31.23$ $1,873.80 000

93458 26 8.58$ $514.80 8.58$ $514.80 000

93458 TC 22.65$ $1,359.00 22.65$ $1,359.00 000

93459 34.49$ $2,069.40 34.49$ $2,069.40 000

93459 26 9.67$ $580.20 9.67$ $580.20 000

93459 TC 24.82$ $1,489.20 24.82$ $1,489.20 000

93460 36.96$ $2,217.60 36.96$ $2,217.60 000

93460 26 10.77$ $646.20 10.77$ $646.20 000

93460 TC 26.18$ $1,570.80 26.18$ $1,570.80 000

93461 42.31$ $2,538.60 42.31$ $2,538.60 000

93461 26 11.88$ $712.80 11.88$ $712.80 000

93461 TC 30.43$ $1,825.80 30.43$ $1,825.80 000

93462 5.74$ $344.40 5.74$ $344.40 ZZZ

93463 2.80$ $168.00 2.80$ $168.00 ZZZ

93464 8.06$ $483.60 8.06$ $483.60 ZZZ

93464 26 2.49$ $149.40 2.49$ $149.40 ZZZ

93464 TC 5.57$ $334.20 5.57$ $334.20 ZZZ

93503 3.62$ $217.20 3.62$ $217.20 000

93505 22.15$ $1,329.00 22.15$ $1,329.00 000

93505 26 6.40$ $384.00 6.40$ $384.00 000

93505 TC 15.75$ $945.00 15.75$ $945.00 000


93530 TC By Report By Report 000

93530 26 6.12$ $367.20 6.12$ $367.20 000



93531 26 12.02$ $721.20 12.02$ $721.20 000



93532 26 14.64$ $878.40 14.64$ $878.40 000



Page | 237

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



93533 26 9.78$ $586.80 9.78$ $586.80 000



93561 26 0.72$ $43.20 0.72$ $43.20 000



93562 26 0.23$ $13.80 0.23$ $13.80 000

93563 1.62$ $97.20 1.62$ $97.20 ZZZ

93564 1.68$ $100.80 1.68$ $100.80 ZZZ

93565 1.27$ $76.20 1.27$ $76.20 ZZZ

93566 4.99$ $299.40 1.26$ $75.60 ZZZ

93567 4.06$ $243.60 1.43$ $85.80 ZZZ

93568 4.46$ $267.60 1.30$ $78.00 ZZZ



93571 26 2.63$ $157.80 2.63$ $157.80 ZZZ



93572 26 2.11$ $126.60 2.11$ $126.60 ZZZ

93580 26.86$ $1,611.60 26.86$ $1,611.60 000

93581 36.43$ $2,185.80 36.43$ $2,185.80 000

93582 18.33$ $1,099.80 18.33$ $1,099.80 XXX

93583 20.73$ $1,243.80 20.73$ $1,243.80 XXX



93600 26 3.26$ $195.60 3.26$ $195.60 000



93602 26 3.20$ $192.00 3.20$ $192.00 000



93603 26 3.20$ $192.00 3.20$ $192.00 000



93609 26 7.64$ $458.40 7.64$ $458.40 ZZZ



93610 26 4.54$ $272.40 4.54$ $272.40 000





Page | 238

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

93612 26 4.50$ $270.00 4.50$ $270.00 000

93613 10.91$ $654.60 10.91$ $654.60 ZZZ



93615 26 1.50$ $90.00 1.50$ $90.00 000



93616 26 1.82$ $109.20 1.82$ $109.20 000



93618 26 6.53$ $391.80 6.53$ $391.80 000



93619 26 11.14$ $668.40 11.14$ $668.40 000



93620 26 17.67$ $1,060.20 17.67$ $1,060.20 000



93621 26 3.22$ $193.20 3.22$ $193.20 ZZZ



93622 26 4.71$ $282.60 4.71$ $282.60 ZZZ



93623 26 4.38$ $262.80 4.38$ $262.80 ZZZ



93624 26 7.22$ $433.20 7.22$ $433.20 000



93631 26 10.91$ $654.60 10.91$ $654.60 000



93640 26 5.29$ $317.40 5.29$ $317.40 000



93641 26 9.01$ $540.60 9.01$ $540.60 000

93642 11.99$ $719.40 11.99$ $719.40 000

93642 26 7.47$ $448.20 7.47$ $448.20 000

93642 TC 4.52$ $271.20 4.52$ $271.20 000

93644 8.10$ $486.00 8.10$ $486.00 XXX



Page | 239

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

93644 26 4.97$ $298.20 4.97$ $298.20 XXX

93644 TC 3.13$ $187.80 3.13$ $187.80 XXX

93650 16.58$ $994.80 16.58$ $994.80 000

93653 23.28$ $1,396.80 23.28$ $1,396.80 000

93654 31.01$ $1,860.60 31.01$ $1,860.60 000

93655 11.64$ $698.40 11.64$ $698.40 ZZZ

93656 31.03$ $1,861.80 31.03$ $1,861.80 000

93657 11.64$ $698.40 11.64$ $698.40 ZZZ

93660 4.57$ $274.20 4.57$ $274.20 000

93660 26 2.69$ $161.40 2.69$ $161.40 000

93660 TC 1.88$ $112.80 1.88$ $112.80 000



93662 26 4.09$ $245.40 4.09$ $245.40 ZZZ

93668 0.57$ $34.20 0.57$ $34.20 XXX

93701 0.71$ $42.60 0.71$ $42.60 XXX

93702 3.22$ $193.20 3.22$ $193.20 XXX

93724 7.75$ $465.00 7.75$ $465.00 000

93724 26 6.92$ $415.20 6.92$ $415.20 000

93724 TC 0.83$ $49.80 0.83$ $49.80 000





93750 1.57$ $94.20 1.29$ $77.40 XXX


93784 1.57$ $94.20 1.57$ $94.20 XXX

93786 0.88$ $52.80 0.88$ $52.80 XXX

93788 0.15$ $9.00 0.15$ $9.00 XXX

93790 0.54$ $32.40 0.54$ $32.40 XXX

93797 0.47$ $28.20 0.25$ $15.00 000

93798 0.73$ $43.80 0.40$ $24.00 000




93880 6.00$ $360.00 6.00$ $360.00 XXX

93880 26 1.13$ $67.80 1.13$ $67.80 XXX

93880 TC 4.87$ $292.20 4.87$ $292.20 XXX

93882 3.82$ $229.20 3.82$ $229.20 XXX

93882 26 0.70$ $42.00 0.70$ $42.00 XXX

93882 TC 3.12$ $187.20 3.12$ $187.20 XXX

93886 8.36$ $501.60 8.36$ $501.60 XXX



Page | 240

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

93886 26 1.34$ $80.40 1.34$ $80.40 XXX

93886 TC 7.02$ $421.20 7.02$ $421.20 XXX

93888 4.39$ $263.40 4.39$ $263.40 XXX

93888 26 0.72$ $43.20 0.72$ $43.20 XXX

93888 TC 3.66$ $219.60 3.66$ $219.60 XXX

93890 8.58$ $514.80 8.58$ $514.80 XXX

93890 26 1.47$ $88.20 1.47$ $88.20 XXX

93890 TC 7.11$ $426.60 7.11$ $426.60 XXX

93892 9.93$ $595.80 9.93$ $595.80 XXX

93892 26 1.72$ $103.20 1.72$ $103.20 XXX

93892 TC 8.21$ $492.60 8.21$ $492.60 XXX

93893 10.39$ $623.40 10.39$ $623.40 XXX

93893 26 1.69$ $101.40 1.69$ $101.40 XXX

93893 TC 8.70$ $522.00 8.70$ $522.00 XXX




93922 2.64$ $158.40 2.64$ $158.40 XXX

93922 26 0.35$ $21.00 0.35$ $21.00 XXX

93922 TC 2.29$ $137.40 2.29$ $137.40 XXX

93923 4.10$ $246.00 4.10$ $246.00 XXX

93923 26 0.63$ $37.80 0.63$ $37.80 XXX

93923 TC 3.48$ $208.80 3.48$ $208.80 XXX

93924 5.16$ $309.60 5.16$ $309.60 XXX

93924 26 0.70$ $42.00 0.70$ $42.00 XXX

93924 TC 4.46$ $267.60 4.46$ $267.60 XXX

93925 7.74$ $464.40 7.74$ $464.40 XXX

93925 26 1.11$ $66.60 1.11$ $66.60 XXX

93925 TC 6.63$ $397.80 6.63$ $397.80 XXX

93926 4.54$ $272.40 4.54$ $272.40 XXX

93926 26 0.68$ $40.80 0.68$ $40.80 XXX

93926 TC 3.87$ $232.20 3.87$ $232.20 XXX

93930 6.19$ $371.40 6.19$ $371.40 XXX

93930 26 1.12$ $67.20 1.12$ $67.20 XXX

93930 TC 5.07$ $304.20 5.07$ $304.20 XXX

93931 3.83$ $229.80 3.83$ $229.80 XXX

93931 26 0.70$ $42.00 0.70$ $42.00 XXX

93931 TC 3.13$ $187.80 3.13$ $187.80 XXX

93965 3.56$ $213.60 3.56$ $213.60 XXX

93965 26 0.49$ $29.40 0.49$ $29.40 XXX

93965 TC 3.07$ $184.20 3.07$ $184.20 XXX

93970 5.85$ $351.00 5.85$ $351.00 XXX



Page | 241

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

93970 26 0.98$ $58.80 0.98$ $58.80 XXX

93970 TC 4.87$ $292.20 4.87$ $292.20 XXX

93971 3.57$ $214.20 3.57$ $214.20 XXX

93971 26 0.63$ $37.80 0.63$ $37.80 XXX

93971 TC 2.94$ $176.40 2.94$ $176.40 XXX

93975 8.37$ $502.20 8.37$ $502.20 XXX

93975 26 1.63$ $97.80 1.63$ $97.80 XXX

93975 TC 6.74$ $404.40 6.74$ $404.40 XXX

93976 4.83$ $289.80 4.83$ $289.80 XXX

93976 26 1.14$ $68.40 1.14$ $68.40 XXX

93976 TC 3.69$ $221.40 3.69$ $221.40 XXX

93978 5.67$ $340.20 5.67$ $340.20 XXX

93978 26 1.11$ $66.60 1.11$ $66.60 XXX

93978 TC 4.55$ $273.00 4.55$ $273.00 XXX

93979 3.55$ $213.00 3.55$ $213.00 XXX

93979 26 0.69$ $41.40 0.69$ $41.40 XXX

93979 TC 2.86$ $171.60 2.86$ $171.60 XXX

93980 3.52$ $211.20 3.52$ $211.20 XXX

93980 26 1.75$ $105.00 1.75$ $105.00 XXX

93980 TC 1.77$ $106.20 1.77$ $106.20 XXX

93981 2.14$ $128.40 2.14$ $128.40 XXX

93981 26 0.62$ $37.20 0.62$ $37.20 XXX

93981 TC 1.53$ $91.80 1.53$ $91.80 XXX

93982 1.25$ $75.00 1.25$ $75.00 XXX

93990 4.79$ $287.40 4.79$ $287.40 XXX

93990 26 0.68$ $40.80 0.68$ $40.80 XXX

93990 TC 4.11$ $246.60 4.11$ $246.60 XXX


94002 2.60$ $156.00 2.60$ $156.00 XXX

94003 1.88$ $112.80 1.88$ $112.80 XXX

94004 1.38$ $82.80 1.38$ $82.80 XXX


94010 1.06$ $63.60 1.06$ $63.60 XXX

94010 26 0.24$ $14.40 0.24$ $14.40 XXX

94010 TC 0.82$ $49.20 0.82$ $49.20 XXX

94011 2.90$ $174.00 2.90$ $174.00 XXX

94012 4.46$ $267.60 4.46$ $267.60 XXX

94013 0.94$ $56.40 0.94$ $56.40 XXX

94014 1.64$ $98.40 1.64$ $98.40 XXX

94015 0.91$ $54.60 0.91$ $54.60 XXX

94016 0.72$ $43.20 0.72$ $43.20 XXX

94060 1.79$ $107.40 1.79$ $107.40 XXX



Page | 242

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

94060 26 0.37$ $22.20 0.37$ $22.20 XXX

94060 TC 1.42$ $85.20 1.42$ $85.20 XXX

94070 1.73$ $103.80 1.73$ $103.80 XXX

94070 26 0.82$ $49.20 0.82$ $49.20 XXX

94070 TC 0.91$ $54.60 0.91$ $54.60 XXX


94150 26 Bundled Bundled XXX

94150 TC Bundled Bundled XXX

94200 0.73$ $43.80 0.73$ $43.80 XXX

94200 26 0.16$ $9.60 0.16$ $9.60 XXX

94200 TC 0.58$ $34.80 0.58$ $34.80 XXX

94250 0.77$ $46.20 0.77$ $46.20 XXX

94250 26 0.15$ $9.00 0.15$ $9.00 XXX

94250 TC 0.62$ $37.20 0.62$ $37.20 XXX

94375 1.15$ $69.00 1.15$ $69.00 XXX

94375 26 0.42$ $25.20 0.42$ $25.20 XXX

94375 TC 0.72$ $43.20 0.72$ $43.20 XXX

94400 1.63$ $97.80 1.63$ $97.80 XXX

94400 26 0.56$ $33.60 0.56$ $33.60 XXX

94400 TC 1.07$ $64.20 1.07$ $64.20 XXX

94450 2.00$ $120.00 2.00$ $120.00 XXX

94450 26 0.57$ $34.20 0.57$ $34.20 XXX

94450 TC 1.43$ $85.80 1.43$ $85.80 XXX

94452 1.70$ $102.00 1.70$ $102.00 XXX

94452 26 0.41$ $24.60 0.41$ $24.60 XXX

94452 TC 1.28$ $76.80 1.28$ $76.80 XXX

94453 2.35$ $141.00 2.35$ $141.00 XXX

94453 26 0.54$ $32.40 0.54$ $32.40 XXX

94453 TC 1.81$ $108.60 1.81$ $108.60 XXX

94610 1.69$ $101.40 1.69$ $101.40 XXX

94620 1.63$ $97.80 1.63$ $97.80 XXX

94620 26 0.87$ $52.20 0.87$ $52.20 XXX

94620 TC 0.76$ $45.60 0.76$ $45.60 XXX

94621 4.77$ $286.20 4.77$ $286.20 XXX

94621 26 1.97$ $118.20 1.97$ $118.20 XXX

94621 TC 2.80$ $168.00 2.80$ $168.00 XXX

94640 0.54$ $32.40 0.54$ $32.40 XXX


94644 1.30$ $78.00 1.30$ $78.00 XXX

94645 0.42$ $25.20 0.42$ $25.20 XXX

94660 1.82$ $109.20 1.07$ $64.20 XXX

94662 1.04$ $62.40 1.04$ $62.40 XXX



Page | 243

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

94664 0.51$ $30.60 0.51$ $30.60 XXX

94667 0.77$ $46.20 0.77$ $46.20 XXX

94668 0.86$ $51.60 0.86$ $51.60 XXX

94669 0.97$ $58.20 0.97$ $58.20 XXX

94680 1.69$ $101.40 1.69$ $101.40 XXX

94680 26 0.36$ $21.60 0.36$ $21.60 XXX

94680 TC 1.33$ $79.80 1.33$ $79.80 XXX

94681 1.55$ $93.00 1.55$ $93.00 XXX

94681 26 0.28$ $16.80 0.28$ $16.80 XXX

94681 TC 1.27$ $76.20 1.27$ $76.20 XXX

94690 1.48$ $88.80 1.48$ $88.80 XXX

94690 26 0.11$ $6.60 0.11$ $6.60 XXX

94690 TC 1.37$ $82.20 1.37$ $82.20 XXX

94726 1.55$ $93.00 1.55$ $93.00 XXX

94726 26 0.35$ $21.00 0.35$ $21.00 XXX

94726 TC 1.20$ $72.00 1.20$ $72.00 XXX

94727 1.23$ $73.80 1.23$ $73.80 XXX

94727 26 0.35$ $21.00 0.35$ $21.00 XXX

94727 TC 0.88$ $52.80 0.88$ $52.80 XXX

94728 1.18$ $70.80 1.18$ $70.80 XXX

94728 26 0.36$ $21.60 0.36$ $21.60 XXX

94728 TC 0.82$ $49.20 0.82$ $49.20 XXX

94729 1.61$ $96.60 1.61$ $96.60 ZZZ

94729 26 0.26$ $15.60 0.26$ $15.60 ZZZ

94729 TC 1.35$ $81.00 1.35$ $81.00 ZZZ

94750 2.39$ $143.40 2.39$ $143.40 XXX

94750 26 0.32$ $19.20 0.32$ $19.20 XXX

94750 TC 2.07$ $124.20 2.07$ $124.20 XXX

94760 0.09$ $5.40 0.09$ $5.40 XXX

94761 0.14$ $8.40 0.14$ $8.40 XXX

94762 0.72$ $43.20 0.72$ $43.20 XXX

94770 0.21$ $12.60 0.21$ $12.60 XXX








94780 1.63$ $97.80 0.64$ $38.40 XXX

94781 0.67$ $40.20 0.24$ $14.40 ZZZ




Page | 244

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



95004 0.19$ $11.40 0.19$ $11.40 XXX

95012 0.57$ $34.20 0.57$ $34.20 XXX

95017 0.22$ $13.20 0.10$ $6.00 XXX

95018 0.60$ $36.00 0.20$ $12.00 XXX

95024 0.23$ $13.80 0.03$ $1.80 XXX

95027 0.13$ $7.80 0.13$ $7.80 XXX

95028 0.40$ $24.00 0.40$ $24.00 XXX

95044 0.16$ $9.60 0.16$ $9.60 XXX

95052 0.20$ $12.00 0.20$ $12.00 XXX

95056 1.31$ $78.60 1.31$ $78.60 XXX

95060 1.04$ $62.40 1.04$ $62.40 XXX

95065 0.76$ $45.60 0.76$ $45.60 XXX

95070 0.90$ $54.00 0.90$ $54.00 XXX

95071 1.03$ $61.80 1.03$ $61.80 XXX

95076 3.37$ $202.20 2.09$ $125.40 XXX

95079 2.38$ $142.80 1.91$ $114.60 ZZZ

95115 0.26$ $15.60 0.26$ $15.60 XXX

95117 0.30$ $18.00 0.30$ $18.00 XXX








95144 0.36$ $21.60 0.09$ $5.40 XXX

95145 0.64$ $38.40 0.09$ $5.40 XXX

95146 1.15$ $69.00 0.09$ $5.40 XXX

95147 1.04$ $62.40 0.09$ $5.40 XXX

95148 1.55$ $93.00 0.09$ $5.40 XXX

95149 2.08$ $124.80 0.09$ $5.40 XXX

95165 0.37$ $22.20 0.09$ $5.40 XXX

95170 0.28$ $16.80 0.09$ $5.40 XXX

95180 3.85$ $231.00 2.89$ $173.40 XXX


95250 4.69$ $281.40 4.69$ $281.40 XXX

95251 1.23$ $73.80 1.23$ $73.80 XXX

95782 30.40$ $1,824.00 30.40$ $1,824.00 XXX

95782 26 3.61$ $216.60 3.61$ $216.60 XXX

95782 TC 26.79$ $1,607.40 26.79$ $1,607.40 XXX



Page | 245

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

95783 31.88$ $1,912.80 31.88$ $1,912.80 XXX

95783 26 4.01$ $240.60 4.01$ $240.60 XXX

95783 TC 27.88$ $1,672.80 27.88$ $1,672.80 XXX

95800 5.25$ $315.00 5.25$ $315.00 XXX

95800 26 1.48$ $88.80 1.48$ $88.80 XXX

95800 TC 3.77$ $226.20 3.77$ $226.20 XXX

95801 2.62$ $157.20 2.62$ $157.20 XXX

95801 26 1.40$ $84.00 1.40$ $84.00 XXX

95801 TC 1.22$ $73.20 1.22$ $73.20 XXX

95803 4.16$ $249.60 4.16$ $249.60 XXX

95803 26 1.24$ $74.40 1.24$ $74.40 XXX

95803 TC 2.91$ $174.60 2.91$ $174.60 XXX

95805 12.65$ $759.00 12.65$ $759.00 XXX

95805 26 1.69$ $101.40 1.69$ $101.40 XXX

95805 TC 10.96$ $657.60 10.96$ $657.60 XXX

95806 4.94$ $296.40 4.94$ $296.40 XXX

95806 26 1.74$ $104.40 1.74$ $104.40 XXX

95806 TC 3.20$ $192.00 3.20$ $192.00 XXX

95807 14.16$ $849.60 14.16$ $849.60 XXX

95807 26 1.77$ $106.20 1.77$ $106.20 XXX

95807 TC 12.39$ $743.40 12.39$ $743.40 XXX

95808 18.68$ $1,120.80 18.68$ $1,120.80 XXX

95808 26 2.51$ $150.60 2.51$ $150.60 XXX

95808 TC 16.17$ $970.20 16.17$ $970.20 XXX

95810 18.40$ $1,104.00 18.40$ $1,104.00 XXX

95810 26 3.47$ $208.20 3.47$ $208.20 XXX

95810 TC 14.93$ $895.80 14.93$ $895.80 XXX

95811 19.33$ $1,159.80 19.33$ $1,159.80 XXX

95811 26 3.61$ $216.60 3.61$ $216.60 XXX

95811 TC 15.72$ $943.20 15.72$ $943.20 XXX

95812 10.32$ $619.20 10.32$ $619.20 XXX

95812 26 1.65$ $99.00 1.65$ $99.00 XXX

95812 TC 8.67$ $520.20 8.67$ $520.20 XXX

95813 12.48$ $748.80 12.48$ $748.80 XXX

95813 26 2.63$ $157.80 2.63$ $157.80 XXX

95813 TC 9.84$ $590.40 9.84$ $590.40 XXX

95816 10.72$ $643.20 10.72$ $643.20 XXX

95816 26 1.65$ $99.00 1.65$ $99.00 XXX

95816 TC 9.07$ $544.20 9.07$ $544.20 XXX

95819 12.27$ $736.20 12.27$ $736.20 XXX

95819 26 1.65$ $99.00 1.65$ $99.00 XXX

95819 TC 10.62$ $637.20 10.62$ $637.20 XXX



Page | 246

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

95822 11.05$ $663.00 11.05$ $663.00 XXX

95822 26 1.65$ $99.00 1.65$ $99.00 XXX

95822 TC 9.40$ $564.00 9.40$ $564.00 XXX



95824 26 1.12$ $67.20 1.12$ $67.20 XXX

95827 20.70$ $1,242.00 20.70$ $1,242.00 XXX

95827 26 1.64$ $98.40 1.64$ $98.40 XXX

95827 TC 19.07$ $1,144.20 19.07$ $1,144.20 XXX

95829 55.65$ $3,339.00 55.65$ $3,339.00 XXX

95829 26 9.53$ $571.80 9.53$ $571.80 XXX

95829 TC 46.11$ $2,766.60 46.11$ $2,766.60 XXX

95830 7.18$ $430.80 2.61$ $156.60 XXX

95831 0.88$ $52.80 0.42$ $25.20 XXX

95832 0.84$ $50.40 0.44$ $26.40 XXX

95833 1.08$ $64.80 0.61$ $36.60 XXX

95834 1.48$ $88.80 0.89$ $53.40 XXX

95851 0.54$ $32.40 0.22$ $13.20 XXX

95852 0.48$ $28.80 0.17$ $10.20 XXX

95857 1.57$ $94.20 0.84$ $50.40 XXX

95860 3.57$ $214.20 3.57$ $214.20 XXX

95860 26 1.48$ $88.80 1.48$ $88.80 XXX

95860 TC 2.09$ $125.40 2.09$ $125.40 XXX

95861 4.99$ $299.40 4.99$ $299.40 XXX

95861 26 2.37$ $142.20 2.37$ $142.20 XXX

95861 TC 2.63$ $157.80 2.63$ $157.80 XXX

95863 6.21$ $372.60 6.21$ $372.60 XXX

95863 26 2.86$ $171.60 2.86$ $171.60 XXX

95863 TC 3.36$ $201.60 3.36$ $201.60 XXX

95864 7.00$ $420.00 7.00$ $420.00 XXX

95864 26 3.08$ $184.80 3.08$ $184.80 XXX

95864 TC 3.93$ $235.80 3.93$ $235.80 XXX

95865 4.17$ $250.20 4.17$ $250.20 XXX

95865 26 2.41$ $144.60 2.41$ $144.60 XXX

95865 TC 1.76$ $105.60 1.76$ $105.60 XXX

95866 3.90$ $234.00 3.90$ $234.00 XXX

95866 26 1.93$ $115.80 1.93$ $115.80 XXX

95866 TC 1.97$ $118.20 1.97$ $118.20 XXX

95867 2.75$ $165.00 2.75$ $165.00 XXX

95867 26 1.20$ $72.00 1.20$ $72.00 XXX

95867 TC 1.56$ $93.60 1.56$ $93.60 XXX

95868 3.86$ $231.60 3.86$ $231.60 XXX



Page | 247

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

95868 26 1.80$ $108.00 1.80$ $108.00 XXX

95868 TC 2.06$ $123.60 2.06$ $123.60 XXX

95869 2.74$ $164.40 2.74$ $164.40 XXX

95869 26 0.57$ $34.20 0.57$ $34.20 XXX

95869 TC 2.17$ $130.20 2.17$ $130.20 XXX

95870 2.74$ $164.40 2.74$ $164.40 XXX

95870 26 0.56$ $33.60 0.56$ $33.60 XXX

95870 TC 2.18$ $130.80 2.18$ $130.80 XXX

95872 5.63$ $337.80 5.63$ $337.80 XXX

95872 26 4.39$ $263.40 4.39$ $263.40 XXX

95872 TC 1.24$ $74.40 1.24$ $74.40 XXX

95873 2.17$ $130.20 2.17$ $130.20 ZZZ

95873 26 0.58$ $34.80 0.58$ $34.80 ZZZ

95873 TC 1.60$ $96.00 1.60$ $96.00 ZZZ

95874 2.16$ $129.60 2.16$ $129.60 ZZZ

95874 26 0.57$ $34.20 0.57$ $34.20 ZZZ

95874 TC 1.59$ $95.40 1.59$ $95.40 ZZZ

95875 3.63$ $217.80 3.63$ $217.80 XXX

95875 26 1.68$ $100.80 1.68$ $100.80 XXX

95875 TC 1.95$ $117.00 1.95$ $117.00 XXX

95885 1.73$ $103.80 1.73$ $103.80 ZZZ

95885 26 0.54$ $32.40 0.54$ $32.40 ZZZ

95885 TC 1.18$ $70.80 1.18$ $70.80 ZZZ

95886 2.66$ $159.60 2.66$ $159.60 ZZZ

95886 26 1.33$ $79.80 1.33$ $79.80 ZZZ

95886 TC 1.33$ $79.80 1.33$ $79.80 ZZZ

95887 2.36$ $141.60 2.36$ $141.60 ZZZ

95887 26 1.08$ $64.80 1.08$ $64.80 ZZZ

95887 TC 1.28$ $76.80 1.28$ $76.80 ZZZ

95905 2.08$ $124.80 2.08$ $124.80 XXX

95905 26 0.08$ $4.80 0.08$ $4.80 XXX

95905 TC 2.00$ $120.00 2.00$ $120.00 XXX

95907 2.77$ $166.20 2.77$ $166.20 XXX

95907 26 1.53$ $91.80 1.53$ $91.80 XXX

95907 TC 1.24$ $74.40 1.24$ $74.40 XXX

95908 3.44$ $206.40 3.44$ $206.40 XXX

95908 26 1.91$ $114.60 1.91$ $114.60 XXX

95908 TC 1.53$ $91.80 1.53$ $91.80 XXX

95909 4.19$ $251.40 4.19$ $251.40 XXX

95909 26 2.30$ $138.00 2.30$ $138.00 XXX

95909 TC 1.90$ $114.00 1.90$ $114.00 XXX

95910 5.59$ $335.40 5.59$ $335.40 XXX



Page | 248

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

95910 26 3.07$ $184.20 3.07$ $184.20 XXX

95910 TC 2.52$ $151.20 2.52$ $151.20 XXX

95911 6.75$ $405.00 6.75$ $405.00 XXX

95911 26 3.84$ $230.40 3.84$ $230.40 XXX

95911 TC 2.91$ $174.60 2.91$ $174.60 XXX

95912 7.53$ $451.80 7.53$ $451.80 XXX

95912 26 4.54$ $272.40 4.54$ $272.40 XXX

95912 TC 2.99$ $179.40 2.99$ $179.40 XXX

95913 8.61$ $516.60 8.61$ $516.60 XXX

95913 26 5.38$ $322.80 5.38$ $322.80 XXX

95913 TC 3.23$ $193.80 3.23$ $193.80 XXX

95921 2.51$ $150.60 2.51$ $150.60 XXX

95921 26 1.30$ $78.00 1.30$ $78.00 XXX

95921 TC 1.21$ $72.60 1.21$ $72.60 XXX

95922 2.94$ $176.40 2.94$ $176.40 XXX

95922 26 1.39$ $83.40 1.39$ $83.40 XXX

95922 TC 1.55$ $93.00 1.55$ $93.00 XXX

95923 4.82$ $289.20 4.82$ $289.20 XXX

95923 26 1.32$ $79.20 1.32$ $79.20 XXX

95923 TC 3.50$ $210.00 3.50$ $210.00 XXX

95924 4.30$ $258.00 4.30$ $258.00 XXX

95924 26 2.54$ $152.40 2.54$ $152.40 XXX

95924 TC 1.76$ $105.60 1.76$ $105.60 XXX

95925 4.60$ $276.00 4.60$ $276.00 XXX

95925 26 0.80$ $48.00 0.80$ $48.00 XXX

95925 TC 3.79$ $227.40 3.79$ $227.40 XXX

95926 4.06$ $243.60 4.06$ $243.60 XXX

95926 26 0.78$ $46.80 0.78$ $46.80 XXX

95926 TC 3.28$ $196.80 3.28$ $196.80 XXX

95927 4.19$ $251.40 4.19$ $251.40 XXX

95927 26 0.78$ $46.80 0.78$ $46.80 XXX

95927 TC 3.41$ $204.60 3.41$ $204.60 XXX

95928 6.59$ $395.40 6.59$ $395.40 XXX

95928 26 2.29$ $137.40 2.29$ $137.40 XXX

95928 TC 4.30$ $258.00 4.30$ $258.00 XXX

95929 6.63$ $397.80 6.63$ $397.80 XXX

95929 26 2.30$ $138.00 2.30$ $138.00 XXX

95929 TC 4.33$ $259.80 4.33$ $259.80 XXX

95930 3.83$ $229.80 3.83$ $229.80 XXX

95930 26 0.54$ $32.40 0.54$ $32.40 XXX

95930 TC 3.30$ $198.00 3.30$ $198.00 XXX

95933 2.19$ $131.40 2.19$ $131.40 XXX



Page | 249

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

95933 26 0.89$ $53.40 0.89$ $53.40 XXX

95933 TC 1.29$ $77.40 1.29$ $77.40 XXX

95937 2.38$ $142.80 2.38$ $142.80 XXX

95937 26 0.99$ $59.40 0.99$ $59.40 XXX

95937 TC 1.39$ $83.40 1.39$ $83.40 XXX

95938 10.12$ $607.20 10.12$ $607.20 XXX

95938 26 1.31$ $78.60 1.31$ $78.60 XXX

95938 TC 8.81$ $528.60 8.81$ $528.60 XXX

95939 14.76$ $885.60 14.76$ $885.60 XXX

95939 26 3.42$ $205.20 3.42$ $205.20 XXX

95939 TC 11.34$ $680.40 11.34$ $680.40 XXX

95940 0.92$ $55.20 0.92$ $55.20 XXX





95950 9.76$ $585.60 9.76$ $585.60 XXX

95950 26 2.29$ $137.40 2.29$ $137.40 XXX

95950 TC 7.47$ $448.20 7.47$ $448.20 XXX



95951 26 9.14$ $548.40 9.14$ $548.40 XXX

95953 12.35$ $741.00 12.35$ $741.00 XXX

95953 26 4.68$ $280.80 4.68$ $280.80 XXX

95953 TC 7.67$ $460.20 7.67$ $460.20 XXX

95954 13.25$ $795.00 13.25$ $795.00 XXX

95954 26 3.56$ $213.60 3.56$ $213.60 XXX

95954 TC 9.70$ $582.00 9.70$ $582.00 XXX

95955 6.38$ $382.80 6.38$ $382.80 XXX

95955 26 1.54$ $92.40 1.54$ $92.40 XXX

95955 TC 4.84$ $290.40 4.84$ $290.40 XXX

95956 48.70$ $2,922.00 48.70$ $2,922.00 XXX

95956 26 5.47$ $328.20 5.47$ $328.20 XXX

95956 TC 43.23$ $2,593.80 43.23$ $2,593.80 XXX

95957 9.25$ $555.00 9.25$ $555.00 XXX

95957 26 3.00$ $180.00 3.00$ $180.00 XXX

95957 TC 6.25$ $375.00 6.25$ $375.00 XXX

95958 16.71$ $1,002.60 16.71$ $1,002.60 XXX

95958 26 6.43$ $385.80 6.43$ $385.80 XXX

95958 TC 10.28$ $616.80 10.28$ $616.80 XXX

95961 8.49$ $509.40 8.49$ $509.40 XXX

95961 26 4.57$ $274.20 4.57$ $274.20 XXX



Page | 250

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

95961 TC 3.92$ $235.20 3.92$ $235.20 XXX

95962 7.55$ $453.00 7.55$ $453.00 ZZZ

95962 26 4.93$ $295.80 4.93$ $295.80 ZZZ

95962 TC 2.62$ $157.20 2.62$ $157.20 ZZZ



95965 26 12.01$ $720.60 12.01$ $720.60 XXX



95966 26 6.08$ $364.80 6.08$ $364.80 XXX



95967 26 5.30$ $318.00 5.30$ $318.00 ZZZ

95970 1.98$ $118.80 0.67$ $40.20 XXX

95971 1.42$ $85.20 1.15$ $69.00 XXX

95972 1.66$ $99.60 1.17$ $70.20 XXX

95974 5.91$ $354.60 4.61$ $276.60 XXX

95975 3.18$ $190.80 2.62$ $157.20 ZZZ

95978 7.09$ $425.40 5.42$ $325.20 XXX

95979 3.08$ $184.80 2.53$ $151.80 ZZZ

95980 1.26$ $75.60 1.26$ $75.60 XXX

95981 0.91$ $54.60 0.50$ $30.00 XXX

95982 1.49$ $89.40 1.02$ $61.20 XXX

95990 2.72$ $163.20 2.72$ $163.20 XXX

95991 3.55$ $213.00 1.12$ $67.20 XXX

95992 1.23$ $73.80 1.06$ $63.60 XXX


96000 2.70$ $162.00 2.70$ $162.00 XXX

96001 2.98$ $178.80 2.98$ $178.80 XXX

96002 0.62$ $37.20 0.62$ $37.20 XXX

96003 0.49$ $29.40 0.49$ $29.40 XXX

96004 3.31$ $198.60 3.31$ $198.60 XXX



96020 26 4.65$ $279.00 4.65$ $279.00 XXX


96101 2.25$ $135.00 2.24$ $134.40 XXX

96102 1.85$ $111.00 0.66$ $39.60 XXX

96103 0.78$ $46.80 0.76$ $45.60 XXX

96105 3.07$ $184.20 3.07$ $184.20 XXX


96111 3.66$ $219.60 3.47$ $208.20 XXX



Page | 251

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

96116 2.62$ $157.20 2.45$ $147.00 XXX

96118 2.79$ $167.40 2.22$ $133.20 XXX

96119 2.35$ $141.00 0.67$ $40.20 XXX

96120 1.39$ $83.40 0.73$ $43.80 XXX

96125 3.38$ $202.80 3.38$ $202.80 XXX

96127 0.15$ $9.00 0.15$ $9.00 XXX

96150 0.61$ $36.60 0.60$ $36.00 XXX

96151 0.58$ $34.80 0.57$ $34.20 XXX

96152 0.56$ $33.60 0.55$ $33.00 XXX

96153 0.13$ $7.80 0.13$ $7.80 XXX

96154 0.55$ $33.00 0.54$ $32.40 XXX

96155 0.64$ $38.40 0.64$ $38.40 XXX

96360 1.68$ $100.80 1.68$ $100.80 XXX

96361 0.44$ $26.40 0.44$ $26.40 ZZZ

96365 2.03$ $121.80 2.03$ $121.80 XXX

96366 0.55$ $33.00 0.55$ $33.00 ZZZ

96367 0.89$ $53.40 0.89$ $53.40 ZZZ

96368 0.60$ $36.00 0.60$ $36.00 ZZZ

96369 5.70$ $342.00 5.70$ $342.00 XXX

96370 0.43$ $25.80 0.43$ $25.80 ZZZ

96371 2.17$ $130.20 2.17$ $130.20 ZZZ

96372 0.74$ $44.40 0.74$ $44.40 XXX

96373 0.57$ $34.20 0.57$ $34.20 XXX

96374 1.66$ $99.60 1.66$ $99.60 XXX

96375 0.66$ $39.60 0.66$ $39.60 ZZZ



96401 2.18$ $130.80 2.18$ $130.80 XXX

96402 0.94$ $56.40 0.94$ $56.40 XXX

96405 2.40$ $144.00 0.86$ $51.60 000

96406 3.41$ $204.60 1.33$ $79.80 000

96409 3.25$ $195.00 3.25$ $195.00 XXX

96411 1.82$ $109.20 1.82$ $109.20 ZZZ

96413 3.97$ $238.20 3.97$ $238.20 XXX

96415 0.82$ $49.20 0.82$ $49.20 ZZZ

96416 4.13$ $247.80 4.13$ $247.80 XXX

96417 1.83$ $109.80 1.83$ $109.80 ZZZ

96420 3.09$ $185.40 3.09$ $185.40 XXX

96422 4.99$ $299.40 4.99$ $299.40 XXX

96423 2.30$ $138.00 2.30$ $138.00 ZZZ

96425 5.32$ $319.20 5.32$ $319.20 XXX

96440 24.80$ $1,488.00 3.80$ $228.00 000



Page | 252

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

96446 5.81$ $348.60 0.69$ $41.40 XXX

96450 5.29$ $317.40 2.29$ $137.40 000

96521 4.06$ $243.60 4.06$ $243.60 XXX

96522 3.32$ $199.20 3.32$ $199.20 XXX

96523 0.73$ $43.80 0.73$ $43.80 XXX

96542 3.54$ $212.40 1.20$ $72.00 XXX


96567 4.02$ $241.20 4.02$ $241.20 XXX

96570 1.57$ $94.20 1.57$ $94.20 ZZZ

96571 0.76$ $45.60 0.76$ $45.60 ZZZ

96900 0.61$ $36.60 0.61$ $36.60 XXX


96904 1.86$ $111.60 1.86$ $111.60 XXX

96910 2.12$ $127.20 2.12$ $127.20 XXX

96912 2.71$ $162.60 2.71$ $162.60 XXX

96913 3.88$ $232.80 3.88$ $232.80 XXX

96920 4.55$ $273.00 1.92$ $115.20 000

96921 5.01$ $300.60 2.17$ $130.20 000

96922 6.92$ $415.20 3.50$ $210.00 000








97001 2.15$ $129.00 2.15$ $129.00 XXX

97002 1.21$ $72.60 1.21$ $72.60 XXX

97003 2.44$ $146.40 2.44$ $146.40 XXX

97004 1.52$ $91.20 1.52$ $91.20 XXX




97012 0.46$ $27.60 0.46$ $27.60 XXX

97014 0.46$ $27.60 0.46$ $27.60 XXX

97016 0.56$ $33.60 0.56$ $33.60 XXX

97018 0.32$ $19.20 0.32$ $19.20 XXX

97022 0.68$ $40.80 0.68$ $40.80 XXX

97024 0.18$ $10.80 0.18$ $10.80 XXX

97026 0.17$ $10.20 0.17$ $10.20 XXX

97028 0.21$ $12.60 0.21$ $12.60 XXX

97032 0.55$ $33.00 0.55$ $33.00 XXX



Page | 253

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

97033 0.76$ $45.60 0.76$ $45.60 XXX

97034 0.52$ $31.20 0.52$ $31.20 XXX

97035 0.36$ $21.60 0.36$ $21.60 XXX

97036 0.96$ $57.60 0.96$ $57.60 XXX

97039 0.31$ $18.60 0.31$ $18.60 XXX

97110 0.93$ $55.80 0.93$ $55.80 XXX

97112 0.97$ $58.20 0.97$ $58.20 XXX

97113 1.25$ $75.00 1.25$ $75.00 XXX

97116 0.82$ $49.20 0.82$ $49.20 XXX

97124 0.76$ $45.60 0.76$ $45.60 XXX

97139 0.42$ $25.20 0.42$ $25.20 XXX

97140 0.86$ $51.60 0.86$ $51.60 XXX

97150 0.50$ $30.00 0.50$ $30.00 XXX

97530 1.01$ $60.60 1.01$ $60.60 XXX

97532 0.77$ $46.20 0.77$ $46.20 XXX

97533 0.84$ $50.40 0.84$ $50.40 XXX

97535 1.01$ $60.60 1.01$ $60.60 XXX

97537 0.86$ $51.60 0.86$ $51.60 XXX

97542 0.89$ $53.40 0.89$ $53.40 XXX

97545 2.41$ $144.60 2.41$ $144.60 XXX

97546 1.13$ $67.80 1.13$ $67.80 ZZZ

97597 2.20$ $132.00 0.66$ $39.60 000

97598 0.71$ $42.60 0.31$ $18.60 ZZZ


97605 1.19$ $71.40 0.71$ $42.60 XXX

97606 1.41$ $84.60 0.77$ $46.20 XXX



97610 3.54$ $212.40 0.45$ $27.00 XXX

97750 0.95$ $57.00 0.95$ $57.00 XXX

97755 1.03$ $61.80 1.03$ $61.80 XXX

97760 1.10$ $66.00 1.10$ $66.00 XXX

97761 0.95$ $57.00 0.95$ $57.00 XXX

97762 1.40$ $84.00 1.40$ $84.00 XXX


97802 1.00$ $60.00 0.93$ $55.80 XXX

97803 0.86$ $51.60 0.79$ $47.40 XXX

97804 0.46$ $27.60 0.44$ $26.40 XXX

97810 1.04$ $62.40 0.87$ $52.20 XXX

97811 0.77$ $46.20 0.72$ $43.20 ZZZ

97813 1.11$ $66.60 0.94$ $56.40 XXX

97814 0.88$ $52.80 0.79$ $47.40 ZZZ



Page | 254

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

98925 0.90$ $54.00 0.67$ $40.20 000

98926 1.31$ $78.60 1.02$ $61.20 000

98927 1.69$ $101.40 1.34$ $80.40 000

98928 2.07$ $124.20 1.69$ $101.40 000

98929 2.48$ $148.80 2.03$ $121.80 000

98940 0.81$ $48.60 0.64$ $38.40 000

98941 1.17$ $70.20 0.99$ $59.40 000

98942 1.52$ $91.20 1.33$ $79.80 000

98943 0.77$ $46.20 0.67$ $40.20 XXX




98966 0.39$ $23.40 0.36$ $21.60 XXX

98967 0.76$ $45.60 0.72$ $43.20 XXX

98968 1.11$ $66.60 1.08$ $64.80 XXX

98969 0.78$ $46.80 0.74$ $44.40 XXX





























Page | 255

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL





99170 5.03$ $301.80 2.53$ $151.80 000


99173 0.09$ $5.40 0.09$ $5.40 XXX

99174 -$ $0.00 -$ $0.00 XXX

99175 0.50$ $30.00 0.50$ $30.00 XXX


99183 3.06$ $183.60 3.06$ $183.60 XXX

99184 6.48$ $388.80 6.48$ $388.80 XXX





99195 2.95$ $177.00 2.95$ $177.00 XXX


99201 1.25$ $75.00 0.74$ $44.40 XXX

99202 2.13$ $127.80 1.41$ $84.60 XXX

99203 3.06$ $183.60 2.14$ $128.40 XXX

99204 4.66$ $279.60 3.63$ $217.80 XXX

99205 5.83$ $349.80 4.72$ $283.20 XXX

99211 0.58$ $34.80 0.26$ $15.60 XXX

99212 1.24$ $74.40 0.70$ $42.00 XXX

99213 2.08$ $124.80 1.43$ $85.80 XXX

99214 3.06$ $183.60 2.20$ $132.00 XXX

99215 4.11$ $246.60 3.12$ $187.20 XXX

99217 2.05$ $123.00 2.05$ $123.00 XXX

99218 2.79$ $167.40 2.79$ $167.40 XXX

99219 3.81$ $228.60 3.81$ $228.60 XXX

99220 5.20$ $312.00 5.20$ $312.00 XXX

99221 2.82$ $169.20 2.82$ $169.20 XXX

99222 3.83$ $229.80 3.83$ $229.80 XXX

99223 5.68$ $340.80 5.68$ $340.80 XXX

99224 1.11$ $66.60 1.11$ $66.60 XXX

99225 2.05$ $123.00 2.05$ $123.00 XXX

99226 2.96$ $177.60 2.96$ $177.60 XXX

99231 1.10$ $66.00 1.10$ $66.00 XXX

99232 2.03$ $121.80 2.03$ $121.80 XXX

99233 2.92$ $175.20 2.92$ $175.20 XXX

99234 3.74$ $224.40 3.74$ $224.40 XXX



Page | 256

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

99235 4.74$ $284.40 4.74$ $284.40 XXX

99236 6.11$ $366.60 6.11$ $366.60 XXX

99238 2.05$ $123.00 2.05$ $123.00 XXX

99239 3.03$ $181.80 3.03$ $181.80 XXX

99241 1.36$ $81.60 0.92$ $55.20 XXX

99242 2.55$ $153.00 1.93$ $115.80 XXX

99243 3.49$ $209.40 2.70$ $162.00 XXX

99244 5.20$ $312.00 4.34$ $260.40 XXX

99245 6.34$ $380.40 5.36$ $321.60 XXX

99251 1.38$ $82.80 1.38$ $82.80 XXX

99252 2.10$ $126.00 2.10$ $126.00 XXX

99253 3.24$ $194.40 3.24$ $194.40 XXX

99254 4.71$ $282.60 4.71$ $282.60 XXX

99255 5.67$ $340.20 5.67$ $340.20 XXX

99281 0.59$ $35.40 0.59$ $35.40 XXX

99282 1.15$ $69.00 1.15$ $69.00 XXX

99283 1.71$ $102.60 1.71$ $102.60 XXX

99284 3.25$ $195.00 3.25$ $195.00 XXX

99285 4.79$ $287.40 4.79$ $287.40 XXX


99291 7.75$ $465.00 6.22$ $373.20 XXX

99292 3.44$ $206.40 3.12$ $187.20 ZZZ

99304 2.58$ $154.80 2.58$ $154.80 XXX

99305 3.68$ $220.80 3.68$ $220.80 XXX

99306 4.69$ $281.40 4.69$ $281.40 XXX

99307 1.27$ $76.20 1.27$ $76.20 XXX

99308 1.96$ $117.60 1.96$ $117.60 XXX

99309 2.58$ $154.80 2.58$ $154.80 XXX

99310 3.83$ $229.80 3.83$ $229.80 XXX

99315 2.07$ $124.20 2.07$ $124.20 XXX

99316 2.98$ $178.80 2.98$ $178.80 XXX

99318 2.71$ $162.60 2.71$ $162.60 XXX

99324 1.56$ $93.60 1.56$ $93.60 XXX

99325 2.27$ $136.20 2.27$ $136.20 XXX

99326 3.92$ $235.20 3.92$ $235.20 XXX

99327 5.23$ $313.80 5.23$ $313.80 XXX

99328 6.11$ $366.60 6.11$ $366.60 XXX

99334 1.70$ $102.00 1.70$ $102.00 XXX

99335 2.69$ $161.40 2.69$ $161.40 XXX

99336 3.79$ $227.40 3.79$ $227.40 XXX

99337 5.43$ $325.80 5.43$ $325.80 XXX




Page | 257

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


99341 1.55$ $93.00 1.55$ $93.00 XXX

99342 2.23$ $133.80 2.23$ $133.80 XXX

99343 3.65$ $219.00 3.65$ $219.00 XXX

99344 5.12$ $307.20 5.12$ $307.20 XXX

99345 6.21$ $372.60 6.21$ $372.60 XXX

99347 1.56$ $93.60 1.56$ $93.60 XXX

99348 2.37$ $142.20 2.37$ $142.20 XXX

99349 3.61$ $216.60 3.61$ $216.60 XXX

99350 5.00$ $300.00 5.00$ $300.00 XXX

99354 2.82$ $169.20 2.61$ $156.60 ZZZ

99355 2.74$ $164.40 2.53$ $151.80 ZZZ

99356 2.59$ $155.40 2.59$ $155.40 ZZZ

99357 2.57$ $154.20 2.57$ $154.20 ZZZ



99360 1.73$ $103.80 1.73$ $103.80 XXX







99375 2.98$ $178.80 2.49$ $149.40 XXX


99378 2.98$ $178.80 2.49$ $149.40 XXX



99381 3.15$ $189.00 2.16$ $129.60 XXX

99382 3.29$ $197.40 2.30$ $138.00 XXX

99383 3.43$ $205.80 2.45$ $147.00 XXX

99384 3.87$ $232.20 2.88$ $172.80 XXX

99385 3.74$ $224.40 2.76$ $165.60 XXX

99386 4.34$ $260.40 3.36$ $201.60 XXX

99387 4.71$ $282.60 3.61$ $216.60 XXX

99391 2.84$ $170.40 1.97$ $118.20 XXX

99392 3.02$ $181.20 2.16$ $129.60 XXX

99393 3.01$ $180.60 2.16$ $129.60 XXX

99394 3.30$ $198.00 2.45$ $147.00 XXX

99395 3.38$ $202.80 2.52$ $151.20 XXX

99396 3.60$ $216.00 2.74$ $164.40 XXX

99397 3.87$ $232.20 2.88$ $172.80 XXX



Page | 258

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

99401 1.04$ $62.40 0.69$ $41.40 XXX

99402 1.76$ $105.60 1.41$ $84.60 XXX

99403 2.45$ $147.00 2.11$ $126.60 XXX

99404 3.15$ $189.00 2.82$ $169.20 XXX

99406 0.40$ $24.00 0.35$ $21.00 XXX

99407 0.78$ $46.80 0.72$ $43.20 XXX

99408 0.99$ $59.40 0.94$ $56.40 XXX

99409 1.93$ $115.80 1.88$ $112.80 XXX

99411 0.47$ $28.20 0.22$ $13.20 XXX

99412 0.62$ $37.20 0.36$ $21.60 XXX

99415 0.26$ $15.60 0.26$ $15.60 XXX

99416 0.14$ $8.40 0.14$ $8.40 XXX

99420 0.32$ $19.20 0.32$ $19.20 XXX


99441 0.39$ $23.40 0.36$ $21.60 XXX

99442 0.76$ $45.60 0.72$ $43.20 XXX

99443 1.11$ $66.60 1.08$ $64.80 XXX

99444 0.78$ $46.80 0.74$ $44.40 XXX








99460 2.71$ $162.60 2.71$ $162.60 XXX

99461 2.62$ $157.20 1.77$ $106.20 XXX

99462 1.18$ $70.80 1.18$ $70.80 XXX

99463 3.37$ $202.20 3.37$ $202.20 XXX

99464 2.00$ $120.00 2.00$ $120.00 XXX

99465 4.30$ $258.00 4.30$ $258.00 XXX

99466 6.44$ $386.40 6.44$ $386.40 XXX

99467 3.29$ $197.40 3.29$ $197.40 ZZZ

99468 26.59$ $1,595.40 26.59$ $1,595.40 XXX

99469 11.20$ $672.00 11.20$ $672.00 XXX

99471 24.42$ $1,465.20 24.42$ $1,465.20 XXX

99472 11.48$ $688.80 11.48$ $688.80 XXX

99475 16.15$ $969.00 16.15$ $969.00 XXX

99476 9.71$ $582.60 9.71$ $582.60 XXX

99477 10.09$ $605.40 10.09$ $605.40 XXX

99478 3.84$ $230.40 3.84$ $230.40 XXX

99479 3.51$ $210.60 3.51$ $210.60 XXX



Page | 259

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

99480 3.36$ $201.60 3.36$ $201.60 XXX





99490 1.15$ $69.00 0.88$ $52.80 XXX

99495 4.71$ $282.60 3.11$ $186.60 XXX

99496 6.62$ $397.20 4.50$ $270.00 XXX

99497 2.41$ $144.60 2.22$ $133.20 XXX

99498 2.08$ $124.80 2.07$ $124.20 XXX




















0001F XXX

0001M By Report By Report XXX




0005F XXX

0006M XXX

0007M XXX

0008M XXX

0009M XXX

0010M XXX

0012F XXX

0014F XXX












Page | 260

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

0015F XXX

0019T By Report By Report XXX











0075T 26 By Report By Report XXX

0075T TC By Report By Report XXX


0076T 26 By Report By Report XXX

0076T TC By Report By Report XXX














0159T 0.34$ $20.40 0.34$ $20.40 ZZZ

0159T 26 0.09$ $5.40 0.09$ $5.40 ZZZ

0159T TC 0.25$ $15.00 0.25$ $15.00 ZZZ

0163T By Report By Report YYY












Page | 261

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL














0205T By Report By Report ZZZ































Page | 262

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL




0255T 26 By Report By Report YYY

0255T TC By Report By Report YYY








































Page | 263

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 264

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 265

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



































0500F XXX

0501F XXX

0502F XXX

0503F XXX

0505F XXX

0507F XXX

0509F XXX

0513F XXX











Page | 266

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

0514F XXX

0516F XXX

0517F XXX

0518F XXX

0519F XXX

0520F XXX

0521F XXX

0525F XXX

0526F XXX

0528F XXX

0529F XXX

0535F XXX

0540F XXX

0545F XXX

0550F XXX

0551F XXX

0555F XXX

0556F XXX

0557F XXX

0575F XXX

0580F XXX

0581F XXX

0582F XXX

0583F XXX

0584F XXX

1000F XXX

1002F XXX

1003F XXX

1004F XXX

1005F XXX

1006F XXX

1007F XXX

1008F XXX

1010F XXX

1011F XXX

1012F XXX

1015F XXX

1018F XXX

1019F XXX

1022F XXX

1026F XXX

1030F XXX













































Page | 267

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

1031F XXX

1032F XXX

1033F XXX

1034F XXX

1035F XXX

1036F XXX

1038F XXX

1039F XXX

1040F XXX

1050F XXX

1052F XXX

1055F XXX

1060F XXX

1061F XXX

1065F XXX

1066F XXX

1070F XXX

1071F XXX

1090F XXX

1091F XXX

1100F XXX

1101F XXX

1110F XXX

1111F XXX

1116F XXX

1118F XXX

1119F XXX

1121F XXX

1123F XXX

1124F XXX

1125F XXX

1126F XXX

1127F XXX

1128F XXX

1130F XXX

1134F XXX

1135F XXX

1136F XXX

1137F XXX

1150F XXX

1151F XXX

1152F XXX













































Page | 268

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

1153F XXX

1157F XXX

1158F XXX

1159F XXX

1160F XXX

1170F XXX

1175F XXX

1180F XXX

1181F XXX

1182F XXX

1183F XXX

1200F XXX

1205F XXX

1220F XXX

1400F XXX

1450F XXX

1451F XXX

1460F XXX

1461F XXX

1490F XXX

1491F XXX

1493F XXX

1494F XXX

1500F XXX

1501F XXX

1502F XXX

1503F XXX

1504F XXX

1505F XXX

2000F XXX

2001F XXX

2002F XXX

2004F XXX

2010F XXX

2014F XXX

2015F XXX

2016F XXX

2018F XXX

2019F XXX

2020F XXX

2021F XXX

2022F XXX













































Page | 269

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

2024F XXX

2026F XXX

2027F XXX

2028F XXX

2029F XXX

2030F XXX

2031F XXX

2035F XXX

2040F XXX

2044F XXX

2050F XXX

2060F XXX

3006F XXX

3008F XXX

3011F XXX

3014F XXX

3015F XXX

3016F XXX

3017F XXX

3018F XXX

3019F XXX

3020F XXX

3021F XXX

3022F XXX

3023F XXX

3025F XXX

3027F XXX

3028F XXX

3035F XXX

3037F XXX

3038F XXX

3040F XXX

3042F XXX

3044F XXX

3045F XXX

3046F XXX

3048F XXX

3049F XXX

3050F XXX

3055F XXX

3056F XXX

3060F XXX













































Page | 270

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

3061F XXX

3062F XXX

3066F XXX

3072F XXX

3073F XXX

3074F XXX

3075F XXX

3077F XXX

3078F XXX

3079F XXX

3080F XXX

3082F XXX

3083F XXX

3084F XXX

3085F XXX

3088F XXX

3089F XXX

3090F XXX

3091F XXX

3092F XXX

3093F XXX

3095F XXX

3096F XXX

3100F XXX

3110F XXX

3111F XXX

3112F XXX

3115F XXX

3117F XXX

3118F XXX

3119F XXX

3120F XXX

3126F XXX

3130F XXX

3132F XXX

3140F XXX

3141F XXX

3142F XXX

3150F XXX

3155F XXX

3160F XXX

3170F XXX













































Page | 271

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

3200F XXX

3210F XXX

3215F XXX

3216F XXX

3218F XXX

3220F XXX

3230F XXX

3250F XXX

3260F XXX

3265F XXX

3266F XXX

3267F XXX

3268F XXX

3269F XXX

3270F XXX

3271F XXX

3272F XXX

3273F XXX

3274F XXX

3278F XXX

3279F XXX

3280F XXX

3281F XXX

3284F XXX

3285F XXX

3288F XXX

3290F XXX

3291F XXX

3292F XXX

3293F XXX

3294F XXX

3300F XXX

3301F XXX

3315F XXX

3316F XXX

3317F XXX

3318F XXX

3319F XXX

3320F XXX

3321F XXX

3322F XXX

3323F XXX













































Page | 272

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

3324F XXX

3325F XXX

3328F XXX

3330F XXX

3331F XXX

3340F XXX

3341F XXX

3342F XXX

3343F XXX

3344F XXX

3345F XXX

3350F XXX

3351F XXX

3352F XXX

3353F XXX

3354F XXX

3370F XXX

3372F XXX

3374F XXX

3376F XXX

3378F XXX

3380F XXX

3382F XXX

3384F XXX

3386F XXX

3388F XXX

3390F XXX

3394F XXX

3395F XXX

3450F XXX

3451F XXX

3452F XXX

3455F XXX

3470F XXX

3471F XXX

3472F XXX

3475F XXX

3476F XXX

3490F XXX

3491F XXX

3492F XXX

3493F XXX













































Page | 273

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

3494F XXX

3495F XXX

3496F XXX

3497F XXX

3498F XXX

3500F XXX

3502F XXX

3503F XXX

3510F XXX

3511F XXX

3512F XXX

3513F XXX

3514F XXX

3515F XXX

3517F XXX

3520F XXX

3550F XXX

3551F XXX

3552F XXX

3555F XXX

3570F XXX

3572F XXX

3573F XXX

3650F XXX

3700F XXX

3720F XXX

3725F XXX

3750F XXX

3751F XXX

3752F XXX

3753F XXX

3754F XXX

3755F XXX

3756F XXX

3757F XXX

3758F XXX

3759F XXX

3760F XXX

3761F XXX

3762F XXX

3763F XXX

3775F XXX













































Page | 274

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

3776F XXX

4000F XXX

4001F XXX

4003F XXX

4004F XXX

4005F XXX

4008F XXX

4010F XXX

4011F XXX

4012F XXX

4013F XXX

4014F XXX

4015F XXX

4016F XXX

4017F XXX

4018F XXX

4019F XXX

4025F XXX

4030F XXX

4033F XXX

4035F XXX

4037F XXX

4040F XXX

4041F XXX

4042F XXX

4043F XXX

4044F XXX

4045F XXX

4046F XXX

4047F XXX

4048F XXX

4049F XXX

4050F XXX

4051F XXX

4052F XXX

4053F XXX

4054F XXX

4055F XXX

4056F XXX

4058F XXX

4060F XXX

4062F XXX













































Page | 275

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

4063F XXX

4064F XXX

4065F XXX

4066F XXX

4067F XXX

4069F XXX

4070F XXX

4073F XXX

4075F XXX

4077F XXX

4079F XXX

4084F XXX

4086F XXX

4090F XXX

4095F XXX

4100F XXX

4110F XXX

4115F XXX

4120F XXX

4124F XXX

4130F XXX

4131F XXX

4132F XXX

4133F XXX

4134F XXX

4135F XXX

4136F XXX

4140F XXX

4142F XXX

4144F XXX

4145F XXX

4148F XXX

4149F XXX

4150F XXX

4151F XXX

4153F XXX

4155F XXX

4157F XXX

4158F XXX

4159F XXX

4163F XXX

4164F XXX













































Page | 276

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

4165F XXX

4167F XXX

4168F XXX

4169F XXX

4171F XXX

4172F XXX

4174F XXX

4175F XXX

4176F XXX

4177F XXX

4178F XXX

4179F XXX

4180F XXX

4181F XXX

4182F XXX

4185F XXX

4186F XXX

4187F XXX

4188F XXX

4189F XXX

4190F XXX

4191F XXX

4192F XXX

4193F XXX

4194F XXX

4195F XXX

4196F XXX

4200F XXX

4201F XXX

4210F XXX

4220F XXX

4221F XXX

4230F XXX

4240F XXX

4242F XXX

4245F XXX

4248F XXX

4250F XXX

4255F XXX

4256F XXX

4260F XXX

4261F XXX













































Page | 277

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

4265F XXX

4266F XXX

4267F XXX

4268F XXX

4269F XXX

4270F XXX

4271F XXX

4274F XXX

4276F XXX

4279F XXX

4280F XXX

4290F XXX

4293F XXX

4300F XXX

4301F XXX

4305F XXX

4306F XXX

4320F XXX

4322F XXX

4324F XXX

4325F XXX

4326F XXX

4328F XXX

4330F XXX

4340F XXX

4350F XXX

4400F XXX

4450F XXX

4470F XXX

4480F XXX

4481F XXX

4500F XXX

4510F XXX

4525F XXX

4526F XXX

4540F XXX

4541F XXX

4550F XXX

4551F XXX

4552F XXX

4553F XXX

4554F XXX













































Page | 278

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

4555F XXX

4556F XXX

4557F XXX

4558F XXX

4559F XXX

4560F XXX

4561F XXX

4562F XXX

4563F XXX

5005F XXX

5010F XXX

5015F XXX

5020F XXX

5050F XXX

5060F XXX

5062F XXX

5100F XXX

5200F XXX

5250F XXX

6005F XXX

6010F XXX

6015F XXX

6020F XXX

6030F XXX

6040F XXX

6045F XXX

6070F XXX

6080F XXX

6090F XXX

6100F XXX

6101F XXX

6102F XXX

6110F XXX

6150F XXX

7010F XXX

7020F XXX

7025F XXX

9001F By Report By Report XXX


9003F XXX

9004F XXX











































Page | 279

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

9006F XXX

9007F XXX

A0021 By Report By Report XXX












































Page | 280

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


A4206 Bundled Bundled XXX











A4217 AU



A4221 XXX

A4222 XXX





A4233 NU


A4234 NU


A4235 NU


A4236 NU










A4253 NU

A4255 XXX


A4256 KL

A4257 XXX

See Prosthetics & Orthotics Fee Schedule













Page | 281

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


A4258 KL


A4259 KL











A4280 XXX

































Page | 282

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 283

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 284

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL




A4435 XXX


A4450 AU

A4450 AV

A4450 AW


A4452 AU

A4452 AV

A4452 AW

























A4561 XXX

A4562 XXX

A4565 $7.84 per unit $7.84 per unit XXX















Page | 285

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



A4595 XXX




A4604 NU


A4605 NU



A4608 XXX




A4614 XXX

A4615 XXX

A4616 XXX

A4617 XXX

A4618 NU

A4618 RR

A4618 UE


A4619 NU


A4620 XXX


A4624 NU





A4628 NU



A4630 NU


A4633 NU



A4635 NU

A4635 RR






















Page | 286

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

A4635 UE


A4636 NU

A4636 RR

A4636 UE


A4637 NU

A4637 RR

A4637 UE


A4638 NU

A4638 RR

A4638 UE


A4639 NU

A4639 RR XXX


A4640 NU

A4640 RR

A4640 UE


A4641 XXX

A4642 XXX







































Page | 287

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 288

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


A5056 XXX

A5057 XXX

















A5120 AU

A5120 AV






A5500 XXX

A5501 XXX

A5503 XXX

A5504 XXX

A5505 XXX

A5506 XXX

A5507 XXX

A5508 XXX

A5510 XXX

A5512 XXX

A5513 XXX























Page | 289

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 290

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 291

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL





















A6531 AW


A6532 AW













A6545 AW


A6550 XXX

A7000 NU


A7001 NU










Page | 292

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

A7002 NU


A7003 NU


A7004 NU


A7005 NU


A7006 NU


A7007 NU


A7008 NU


A7009 NU


A7010 NU


A7012 NU


A7013 NU


A7014 NU


A7015 NU


A7016 NU


A7017 NU

A7017 RR

A7017 UE


A7018 XXX

A7020 NU


A7025 NU

A7025 RR XXX


A7026 NU


A7027 NU



























Page | 293

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

A7028 NU


A7029 NU


A7030 NU


A7031 NU


A7032 NU


A7033 NU


A7034 NU


A7035 NU


A7036 NU


A7037 NU


A7038 NU


A7039 NU


A7040 XXX

A7041 XXX

A7044 NU


A7045 NU

A7045 RR

A7045 UE


A7046 NU


A7047 NU XXX






























Page | 294

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













A8000 NU

A8000 RR

A8000 UE


A8001 NU

A8001 RR

A8001 UE


A8002 NU

A8002 RR

A8002 UE


A8003 NU

A8003 RR

A8003 UE


A8004 NU

A8004 RR

A8004 UE








A9272 XXX






















Page | 295

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL











A9500 XXX


A9502 XXX

A9503 XXX

A9504 XXX

A9505 XXX

A9507 XXX

A9508 XXX


A9510 XXX

A9512 XXX

A9516 XXX



A9521 XXX

A9524 XXX








A9536 XXX

A9537 XXX

A9538 XXX

A9539 XXX

A9540 XXX

A9541 XXX

A9542 XXX

A9543 XXX

A9544 XXX
























Page | 296

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

A9545 XXX


A9547 XXX

A9548 XXX


A9551 XXX


A9553 XXX

A9554 XXX

A9555 XXX

A9556 XXX

A9557 XXX

A9558 XXX

A9559 XXX

A9560 XXX

A9561 XXX

A9562 XXX

A9563 XXX

A9564 XXX



A9568 XXX





A9575 XXX

A9576 XXX

A9577 XXX

A9578 XXX

A9579 XXX


A9581 XXX

A9582 XXX

A9583 XXX


A9585 XXX

A9586 YYY


A9600 XXX

































Page | 297

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

A9698 XXX






ATP02 $7.1 per unit $7.1 per unit XXX


















B4034

B4035

B4036

B4081

B4082

B4083

B4087

B4088

B4100 By Report By Report




B4149

B4150

B4152

B4153

B4154

B4155


















Page | 298

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL







B4164

B4168


B4176

B4178

B4180

B4185

B4189

B4193

B4197

B4199

B4216

B4220

B4222

B4224

B5000

B5100


B9000 MS XXX

B9000 NU

B9000 RR

B9000 UE


B9002 MS XXX

B9002 NU

B9002 RR

B9002 UE


B9004 MS XXX

B9004 NU

B9004 RR

B9004 UE


B9006 MS XXX

B9006 NU

B9006 RR


































Page | 299

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

B9006 UE




C1822 By Report By Report XXX




























D0171 By Report By Report XXX













Page | 300

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

























E0100 NU

E0100 RR

E0100 UE

E0100 By Report By Report

E0105 NU

E0105 RR

E0105 UE


E0110 NU

E0110 RR

E0110 UE


E0111 NU

E0111 RR

E0111 UE


E0112 NU

E0112 RR

















Page | 301

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E0112 UE


E0113 NU

E0113 RR

E0113 UE


E0114 NU

E0114 RR

E0114 UE


E0116 NU

E0116 RR

E0116 UE


E0117 NU

E0117 RR

E0117 UE



E0130 NU

E0130 RR

E0130 UE


E0135 NU

E0135 RR

E0135 UE


E0140 NU

E0140 RR

E0140 UE


E0141 NU

E0141 RR

E0141 UE


E0143 NU

E0143 RR

E0143 UE


E0144 NU

E0144 RR

E0144 UE


































Page | 302

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E0147 NU

E0147 RR

E0147 UE


E0148 NU

E0148 RR

E0148 UE


E0149 NU

E0149 RR

E0149 UE


E0153 NU

E0153 RR

E0153 UE


E0154 NU

E0154 RR

E0154 UE


E0155 NU

E0155 RR

E0155 UE


E0156 NU

E0156 RR

E0156 UE


E0157 NU

E0157 RR

E0157 UE


E0158 NU

E0158 RR

E0158 UE


E0159 NU

E0159 RR

E0159 UE


E0160 NU


































Page | 303

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E0160 RR

E0160 UE


E0161 NU

E0161 RR

E0161 UE


E0162 NU

E0162 RR

E0162 UE


E0163 NU

E0163 RR

E0163 UE


E0165 RR


E0167 NU

E0167 RR

E0167 UE


E0168 NU

E0168 RR

E0168 UE


E0170 RR


E0171 RR



E0175 NU

E0175 RR

E0175 UE


E0181 RR


E0182 RR


E0184 NU

E0184 RR

E0184 UE
































Page | 304

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E0185 NU

E0185 RR

E0185 UE


E0186 RR


E0187 RR


E0188 NU

E0188 RR

E0188 UE


E0189 NU

E0189 RR

E0189 UE



E0191 NU

E0191 RR

E0191 UE


E0193 RR


E0194 RR


E0196 RR


E0197 NU

E0197 RR

E0197 UE


E0198 NU

E0198 RR

E0198 UE


E0199 NU

E0199 RR

E0199 UE


E0200 NU

E0200 RR

E0200 UE
































Page | 305

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E0202 RR



E0205 NU

E0205 RR

E0205 UE


E0210 NU

E0210 RR

E0210 UE


E0215 NU

E0215 RR

E0215 UE


E0217 NU

E0217 RR

E0217 UE




E0225 NU

E0225 RR

E0225 UE




E0235 RR


E0236 RR


E0239 NU

E0239 RR

E0239 UE































Page | 306

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL




E0249 NU

E0249 RR

E0249 UE


E0250 RR


E0251 RR


E0255 RR


E0256 RR


E0260 RR


E0261 RR


E0265 RR


E0266 RR



E0271 NU

E0271 RR

E0271 UE


E0272 NU

E0272 RR

E0272 UE




E0275 NU

E0275 RR

E0275 UE


E0276 NU

E0276 RR

E0276 UE



























Page | 307

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E0277 RR


E0280 NU

E0280 RR

E0280 UE


E0290 RR


E0291 RR


E0292 RR


E0293 RR


E0294 RR


E0295 RR


E0296 RR


E0297 RR


E0300 NU

E0300 RR

E0300 UE


E0301 RR


E0302 RR


E0303 RR


E0304 RR


E0305 RR


E0310 NU

E0310 RR

E0310 UE



E0316 RR



























Page | 308

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E0325 NU

E0325 RR

E0325 UE


E0326 NU

E0326 RR

E0326 UE







E0371 RR


E0372 RR


E0373 RR


E0424 RR




E0431 RR


E0433 RR


E0434 RR



E0439 RR



E0441

E0442

E0443

E0444


E0446
























Page | 309

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E0462 RR


E0465 RR XXX

E0465 By Report By Report XXX

E0466 RR XXX


E0470 RR


E0471 RR


E0472 RR


E0480 RR



E0482 RR


E0483 RR


E0484 NU

E0484 RR

E0484 UE


E0485 NU

E0485 RR

E0485 UE


E0486 NU

E0486 RR

E0486 UE



E0500 RR


E0550 RR



E0560 NU

E0560 RR

E0560 UE



























Page | 310

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E0561 NU

E0561 RR

E0561 UE


E0562 NU

E0562 RR

E0562 UE


E0565 RR


E0570 RR


E0572 RR


E0574 RR


E0575 RR


E0580 NU

E0580 RR

E0580 UE


E0585 RR


E0600 RR


E0601 RR


E0602 NU

E0602 RR

E0602 UE




E0605 NU

E0605 RR

E0605 UE


E0606 RR


E0607 NU

E0607 RR





























Page | 311

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E0607 UE


E0610 NU

E0610 RR

E0610 UE


E0615 NU

E0615 RR

E0615 UE



E0617 RR


E0618 RR


E0619 RR


E0620 NU

E0620 RR

E0620 UE


E0621 NU

E0621 RR

E0621 UE



E0627 NU

E0627 RR

E0627 UE


E0628 NU

E0628 RR

E0628 UE


E0629 NU

E0629 RR

E0629 UE


E0630 RR


E0635 RR































Page | 312

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E0636 RR




E0639 RR XXX


E0640 RR XXX




E0650 NU

E0650 RR

E0650 UE


E0651 NU

E0651 RR

E0651 UE


E0652 NU

E0652 RR

E0652 UE


E0655 NU

E0655 RR

E0655 UE


E0656 NU

E0656 RR

E0656 UE


E0657 NU

E0657 RR

E0657 UE


E0660 NU

E0660 RR

E0660 UE


E0665 NU

E0665 RR

E0665 UE































Page | 313

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E0666 NU

E0666 RR

E0666 UE


E0667 NU

E0667 RR

E0667 UE


E0668 NU

E0668 RR

E0668 UE


E0669 NU

E0669 RR

E0669 UE


E0670

E0670 NU

E0670 RR

E0670 UE

E0671 NU

E0671 RR

E0671 UE


E0672 NU

E0672 RR

E0672 UE


E0673 NU

E0673 RR

E0673 UE


E0675 RR



E0691 NU

E0691 RR

E0691 UE


E0692 NU

E0692 RR

E0692 UE



































Page | 314

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E0693 NU

E0693 RR

E0693 UE


E0694 NU

E0694 RR

E0694 UE



E0705 NU

E0705 RR

E0705 UE



E0720 NU


E0730 NU


E0731 NU


E0740 NU

E0740 RR

E0740 UE


E0744 RR


E0745 RR



E0747 NU

E0747 RR

E0747 UE


E0748 NU

E0748 RR

E0748 UE


E0749 RR



E0760 NU




























Page | 315

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E0760 RR

E0760 UE



E0762 NU

E0762 RR

E0762 UE


E0764 NU

E0764 RR

E0764 UE


E0765 NU

E0765 RR

E0765 UE


E0766 RR XXX



E0776 NU

E0776 RR

E0776 UE


E0779 RR


E0780 NU


E0781 RR


E0782 NU

E0782 RR

E0782 UE


E0783 NU

E0783 RR

E0783 UE


E0784 RR


E0785 KF


E0786 NU






























Page | 316

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E0786 RR

E0786 UE


E0791 RR



E0840 NU

E0840 RR

E0840 UE


E0849 NU

E0849 RR

E0849 UE


E0850 NU

E0850 RR

E0850 UE


E0855 NU

E0855 RR

E0855 UE


E0856 NU

E0856 RR

E0856 UE


E0860 NU

E0860 RR

E0860 UE


E0870 NU

E0870 RR

E0870 UE


E0880 NU

E0880 RR

E0880 UE


E0890 NU

E0890 RR

E0890 UE


































Page | 317

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E0900 NU

E0900 RR

E0900 UE


E0910 RR


E0911 RR


E0912 RR


E0920 RR


E0930 RR


E0935 RR



E0940 RR


E0941 RR


E0942 NU

E0942 RR

E0942 UE


E0944 NU

E0944 RR

E0944 UE


E0945 NU

E0945 RR

E0945 UE


E0946 RR


E0947 NU

E0947 RR

E0947 UE


E0948 NU

E0948 RR

E0948 UE






























Page | 318

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E0950 NU

E0950 RR

E0950 UE


E0951 NU

E0951 RR

E0951 UE


E0952 NU

E0952 RR

E0952 UE


E0955 NU

E0955 RR

E0955 UE


E0956 NU

E0956 RR

E0956 UE


E0957 NU

E0957 RR

E0957 UE


E0958 RR


E0959 NU

E0959 RR

E0959 UE


E0960 NU

E0960 RR

E0960 UE


E0961 NU

E0961 RR

E0961 UE


E0966 NU

E0966 RR

E0966 UE


































Page | 319

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E0967 NU

E0967 RR

E0967 UE


E0968 RR


E0969 NU

E0969 RR

E0969 UE



E0971 NU

E0971 RR

E0971 UE


E0973 NU

E0973 RR

E0973 UE


E0974 NU

E0974 RR

E0974 UE


E0978 NU

E0978 RR

E0978 UE


E0980 NU

E0980 RR

E0980 UE


E0981 NU

E0981 RR

E0981 UE


E0982 NU

E0982 RR

E0982 UE


E0983 RR

































Page | 320

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E0984 NU

E0984 RR

E0984 UE


E0985 NU

E0985 RR

E0985 UE


E0986 NU

E0986 RR

E0986 UE


E0988 RR

E0990 NU

E0990 RR

E0990 UE


E0992 NU

E0992 RR

E0992 UE


E0994 NU

E0994 RR

E0994 UE


E0995 NU

E0995 RR

E0995 UE


E1002 NU

E1002 RR

E1002 UE


E1003 NU

E1003 RR

E1003 UE


E1004 NU

E1004 RR

E1004 UE


E1005 NU



































Page | 321

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E1005 RR

E1005 UE


E1006 NU

E1006 RR

E1006 UE


E1007 NU

E1007 RR

E1007 UE


E1008 NU

E1008 RR

E1008 UE


E1009 NU

E1009 RR

E1009 UE


E1010 NU

E1010 RR

E1010 UE


E1011 NU

E1011 RR

E1011 UE


E1012 RR XXX


E1014 NU

E1014 RR

E1014 UE


E1015 NU

E1015 RR

E1015 UE


E1016 NU

E1016 RR

E1016 UE


E1017 NU


































Page | 322

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E1017 RR

E1017 UE


E1018 NU

E1018 RR

E1018 UE


E1020 NU

E1020 RR

E1020 UE


E1028 NU

E1028 RR

E1028 UE


E1029 NU

E1029 RR

E1029 UE


E1030 NU

E1030 RR

E1030 UE


E1031 RR


E1035 RR


E1036 RR


E1037 RR


E1038 RR


E1039 RR


E1050 RR


E1060 RR


E1070 RR


E1083 RR






























Page | 323

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E1084 RR




E1087 RR


E1088 RR




E1092 RR


E1093 RR


E1100 RR


E1110 RR




E1150 RR


E1160 RR


E1161 NU

E1161 RR

E1161 UE


E1170 RR


E1171 RR


E1172 RR


E1180 RR


E1190 RR


E1195 RR


E1200 RR






















Page | 324

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



E1221 RR


E1222 RR


E1223 RR


E1224 RR


E1225 RR


E1226 NU

E1226 RR

E1226 UE


E1227 NU

E1227 RR

E1227 UE


E1228 RR



E1230 NU

E1230 RR

E1230 UE


E1231 NU

E1231 RR

E1231 UE


E1232 NU

E1232 RR

E1232 UE


E1233 NU

E1233 RR

E1233 UE


E1234 NU

E1234 RR

E1234 UE






























Page | 325

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E1235 NU

E1235 RR

E1235 UE


E1236 NU

E1236 RR

E1236 UE


E1237 NU

E1237 RR

E1237 UE


E1238 NU

E1238 RR

E1238 UE



E1240 RR




E1270 RR


E1280 RR




E1295 RR


E1296 NU

E1296 RR

E1296 UE


E1297 NU

E1297 RR

E1297 UE


E1298 NU

E1298 RR

E1298 UE





























Page | 326

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E1310 NU

E1310 RR

E1310 UE



E1353


E1355




E1372 NU

E1372 RR

E1372 UE


E1390 RR


E1391 RR


E1392 RR



E1405 RR


E1406 RR
































Page | 327

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL












E1700 NU

E1700 RR

E1700 UE


E1701

E1702

E1800 RR


E1801 RR


E1802 RR


E1805 RR


E1806 RR


E1810 RR


E1811 RR


E1812 RR


E1815 RR


E1816 RR


E1818 RR


E1820 NU

E1820 RR

E1820 UE






















Page | 328

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E1821 NU

E1821 RR

E1821 UE


E1825 RR


E1830 RR


E1831 RR

E1840 RR


E1841 RR



E2000 RR


E2100 NU

E2100 RR

E2100 UE


E2101 NU

E2101 RR

E2101 UE


E2120 RR


E2201 NU

E2201 RR

E2201 UE


E2202 NU

E2202 RR

E2202 UE


E2203 NU

E2203 RR

E2203 UE


E2204 NU

E2204 RR

E2204 UE































Page | 329

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E2205 NU

E2205 RR

E2205 UE


E2206 NU

E2206 RR

E2206 UE


E2207 NU

E2207 RR

E2207 UE


E2208 NU

E2208 RR

E2208 UE


E2209 NU

E2209 RR

E2209 UE


E2210 NU

E2210 RR

E2210 UE


E2211 NU

E2211 RR

E2211 UE


E2212 NU

E2212 RR

E2212 UE


E2213 NU

E2213 RR

E2213 UE


E2214 NU

E2214 RR

E2214 UE


E2215 NU


































Page | 330

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E2215 RR

E2215 UE


E2216 NU

E2216 RR

E2216 UE


E2217 NU

E2217 RR

E2217 UE


E2218 NU

E2218 RR

E2218 UE


E2219 NU

E2219 RR

E2219 UE


E2220 NU

E2220 RR

E2220 UE


E2221 NU

E2221 RR

E2221 UE


E2222 NU

E2222 RR

E2222 UE


E2224 NU

E2224 RR

E2224 UE


E2225 NU

E2225 RR

E2225 UE


E2226 NU

E2226 RR

E2226 UE



































Page | 331

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


E2227 NU

E2227 RR

E2227 UE


E2228 NU

E2228 RR

E2228 UE



E2231 NU

E2231 RR

E2231 UE









E2310 NU

E2310 RR

E2310 UE


E2311 NU

E2311 RR

E2311 UE


E2312 NU

E2312 RR

E2312 UE


E2313 NU

E2313 RR

E2313 UE


E2321 NU

E2321 RR

E2321 UE


E2322 NU




























Page | 332

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E2322 RR

E2322 UE


E2323 NU

E2323 RR

E2323 UE


E2324 NU

E2324 RR

E2324 UE


E2325 NU

E2325 RR

E2325 UE


E2326 NU

E2326 RR

E2326 UE


E2327 NU

E2327 RR

E2327 UE


E2328 NU

E2328 RR

E2328 UE


E2329 NU

E2329 RR

E2329 UE


E2330 NU

E2330 RR

E2330 UE



E2340 NU

E2340 RR

E2340 UE


E2341 NU

E2341 RR


































Page | 333

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E2341 UE


E2342 NU

E2342 RR

E2342 UE


E2343 NU

E2343 RR

E2343 UE


E2351 NU

E2351 RR

E2351 UE


E2358

E2359 NU

E2359 RR

E2359 UE

E2360 NU

E2360 RR

E2360 UE


E2361 NU

E2361 RR

E2361 UE


E2362 NU

E2362 RR

E2362 UE


E2363 NU

E2363 RR

E2363 UE


E2364 NU

E2364 RR

E2364 UE


E2365 NU

E2365 RR

E2365 UE




































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RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E2366 NU

E2366 RR

E2366 UE


E2367 NU

E2367 RR

E2367 UE


E2368 NU

E2368 RR

E2368 UE


E2369 NU

E2369 RR

E2369 UE


E2370 NU

E2370 RR

E2370 UE


E2371 NU

E2371 RR

E2371 UE


E2372 NU

E2372 RR

E2372 UE


E2373 NU

E2373 RR

E2373 UE


E2374 NU

E2374 RR

E2374 UE


E2375 NU

E2375 RR

E2375 UE


E2376 NU

E2376 RR



































Page | 335

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Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E2376 UE


E2377 NU

E2377 RR

E2377 UE


E2378

E2378 NU

E2378 RR

E2378 UE

E2381 NU

E2381 RR

E2381 UE


E2382 NU

E2382 RR

E2382 UE


E2383 NU

E2383 RR

E2383 UE


E2384 NU

E2384 RR

E2384 UE


E2385 NU

E2385 RR

E2385 UE


E2386 NU

E2386 RR

E2386 UE


E2387 NU

E2387 RR

E2387 UE


E2388 NU

E2388 RR

E2388 UE




































Page | 336

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Nonfac

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Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E2389 NU

E2389 RR

E2389 UE


E2390 NU

E2390 RR

E2390 UE


E2391 NU

E2391 RR

E2391 UE


E2392 NU

E2392 RR

E2392 UE


E2394 NU

E2394 RR

E2394 UE


E2395 NU

E2395 RR

E2395 UE


E2396 NU

E2396 RR

E2396 UE


E2397 NU

E2397 RR

E2397 UE


E2402 RR


E2500 NU

E2500 RR

E2500 UE


E2502 NU

E2502 RR

E2502 UE



































Page | 337

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Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E2504 NU

E2504 RR

E2504 UE


E2506 NU

E2506 RR

E2506 UE


E2508 NU

E2508 RR

E2508 UE


E2510 NU

E2510 RR

E2510 UE


E2511 NU

E2511 RR

E2511 UE


E2512 NU

E2512 RR

E2512 UE



E2601 NU

E2601 RR

E2601 UE


E2602 NU

E2602 RR

E2602 UE


E2603 NU

E2603 RR

E2603 UE


E2604 NU

E2604 RR

E2604 UE


E2605 NU


































Page | 338

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Allowed

Amount

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Facility

RVUs

Facility Allowed

Amount GLOBAL

E2605 RR

E2605 UE


E2606 NU

E2606 RR

E2606 UE


E2607 NU

E2607 RR

E2607 UE


E2608 NU

E2608 RR

E2608 UE




E2611 NU

E2611 RR

E2611 UE


E2612 NU

E2612 RR

E2612 UE


E2613 NU

E2613 RR

E2613 UE


E2614 NU

E2614 RR

E2614 UE


E2615 NU

E2615 RR

E2615 UE


E2616 NU

E2616 RR

E2616 UE


































Page | 339

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Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

E2619 NU

E2619 RR

E2619 UE


E2620 NU

E2620 RR

E2620 UE


E2621 NU

E2621 RR

E2621 UE


E2622 NU

E2622 RR

E2622 UE

E2623 NU

E2623 RR

E2623 UE

E2624 NU

E2624 RR

E2624 UE

E2625 NU

E2625 RR

E2625 UE

E2626 NU

E2626 RR

E2626 UE

E2627 NU

E2627 RR

E2627 UE

E2628 NU

E2628 RR

E2628 UE

E2629 NU

E2629 RR

E2629 UE

E2630 NU

E2630 RR

E2630 UE

E2631 NU

E2631 RR

E2631 UE










































Page | 340

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Amount

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Facility

RVUs

Facility Allowed

Amount GLOBAL

E2632 NU

E2632 RR

E2632 UE

E2633 NU

E2633 RR

E2633 UE




G0008 By Report By Report XXX



G0027 $8.86 per unit $8.86 per unit XXX

G0101 1.09$ $65.40 0.78$ $46.80 XXX

G0102 0.57$ $34.20 0.25$ $15.00 XXX


G0104 4.90$ $294.00 1.61$ $96.60 000

G0105 10.94$ $656.40 5.45$ $327.00 000

G0105 53 5.45$ $327.00 2.74$ $164.40 000

G0106 6.23$ $373.80 6.23$ $373.80 XXX

G0106 26 1.41$ $84.60 1.41$ $84.60 XXX

G0106 TC 4.81$ $288.60 4.81$ $288.60 XXX

G0108 1.50$ $90.00 1.50$ $90.00 XXX

G0109 0.40$ $24.00 0.40$ $24.00 XXX

G0117 1.58$ $94.80 1.58$ $94.80 XXX

G0118 1.31$ $78.60 1.31$ $78.60 XXX

G0120 6.25$ $375.00 6.25$ $375.00 XXX

G0120 26 1.44$ $86.40 1.44$ $86.40 XXX

G0120 TC 4.81$ $288.60 4.81$ $288.60 XXX

G0121 10.94$ $656.40 5.46$ $327.60 000

G0121 53 5.46$ $327.60 2.73$ $163.80 000

G0122 7.90$ $474.00 7.90$ $474.00 XXX

G0122 26 1.41$ $84.60 1.41$ $84.60 XXX

G0122 TC 6.49$ $389.40 6.49$ $389.40 XXX


G0124 0.94$ $56.40 0.94$ $56.40 XXX

G0127 0.67$ $40.20 0.22$ $13.20 000

G0128 0.23$ $13.80 0.23$ $13.80 XXX


G0130 0.99$ $59.40 0.99$ $59.40 XXX

G0130 26 0.32$ $19.20 0.32$ $19.20 XXX

G0130 TC 0.67$ $40.20 0.67$ $40.20 XXX









Page | 341

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RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G0141 0.94$ $56.40 0.94$ $56.40 XXX



















G0166 4.09$ $245.40 4.09$ $245.40 XXX

G0168 3.01$ $180.60 0.79$ $47.40 000




G0179 1.19$ $71.40 1.19$ $71.40 XXX

G0180 1.53$ $91.80 1.53$ $91.80 XXX

G0181 3.06$ $183.60 3.06$ $183.60 XXX

G0182 3.08$ $184.80 3.08$ $184.80 XXX

G0186 By Report By Report YYY

G0202 3.92$ $235.20 3.92$ $235.20 XXX

G0202 26 0.99$ $59.40 0.99$ $59.40 XXX

G0202 TC 2.93$ $175.80 2.93$ $175.80 XXX

G0204 4.80$ $288.00 4.80$ $288.00 XXX

G0204 26 1.24$ $74.40 1.24$ $74.40 XXX

G0204 TC 3.56$ $213.60 3.56$ $213.60 XXX

G0206 3.76$ $225.60 3.76$ $225.60 XXX

G0206 26 0.99$ $59.40 0.99$ $59.40 XXX

G0206 TC 2.77$ $166.20 2.77$ $166.20 XXX


G0219 26 By Report By Report XXX

G0219 TC By Report By Report XXX




Page | 342

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RVUs

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Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL



G0237 0.29$ $17.40 0.29$ $17.40 XXX

G0238 0.31$ $18.60 0.31$ $18.60 XXX

G0239 0.39$ $23.40 0.39$ $23.40 XXX

G0245 1.89$ $113.40 1.21$ $72.60 XXX

G0246 1.10$ $66.00 0.61$ $36.60 XXX

G0247 2.13$ $127.80 0.66$ $39.60 ZZZ

G0248 3.31$ $198.60 3.31$ $198.60 XXX

G0249 3.31$ $198.60 3.31$ $198.60 XXX

G0250 0.26$ $15.60 0.26$ $15.60 XXX



G0252 26 2.13$ $127.80 2.13$ $127.80 XXX







G0268 1.52$ $91.20 0.94$ $56.40 000

G0269 Bundled Bundled XXX

G0270 0.86$ $51.60 0.79$ $47.40 XXX

G0271 0.46$ $27.60 0.44$ $26.40 XXX


G0277 1.33$ $79.80 1.33$ $79.80 XXX

G0278 0.38$ $22.80 0.38$ $22.80 ZZZ

G0279 1.60$ $96.00 1.60$ $96.00 XXX

G0279 26 0.85$ $51.00 0.85$ $51.00 XXX

G0279 TC 0.75$ $45.00 0.75$ $45.00 XXX

G0281 0.40$ $24.00 0.40$ $24.00 XXX


G0283 0.40$ $24.00 0.40$ $24.00 XXX

G0288 1.04$ $62.40 1.04$ $62.40 XXX

G0289 2.42$ $145.20 2.42$ $145.20 ZZZ




G0296 0.80$ $48.00 0.75$ $45.00 XXX

G0297 7.45$ $447.00 7.45$ $447.00 XXX

G0297 26 1.45$ $87.00 1.45$ $87.00 XXX

G0297 TC 6.00$ $360.00 6.00$ $360.00 XXX



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RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL











G0329 0.28$ $16.80 0.28$ $16.80 XXX

G0333 Bundled Bundled XXX

G0337 2.04$ $122.40 2.04$ $122.40 XXX



G0341 68.40$ $4,104.00 10.78$ $646.80 000

G0342 19.80$ $1,188.00 19.80$ $1,188.00 090

G0343 34.09$ $2,045.40 34.09$ $2,045.40 090

G0364 0.36$ $21.60 0.25$ $15.00 ZZZ

G0365 5.95$ $357.00 5.95$ $357.00 XXX

G0365 26 0.34$ $20.40 0.34$ $20.40 XXX

G0365 TC 5.61$ $336.60 5.61$ $336.60 XXX

G0372 0.25$ $15.00 0.25$ $15.00 XXX








G0389 3.40$ $204.00 3.40$ $204.00 XXX

G0389 26 0.83$ $49.80 0.83$ $49.80 XXX

G0389 TC 2.57$ $154.20 2.57$ $154.20 XXX


G0396 1.01$ $60.60 0.95$ $57.00 XXX

G0397 2.01$ $120.60 1.94$ $116.40 XXX









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Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL




G0402 4.74$ $284.40 3.58$ $214.80 XXX

G0403 0.49$ $29.40 0.49$ $29.40 XXX

G0404 0.25$ $15.00 0.25$ $15.00 XXX

G0405 0.24$ $14.40 0.24$ $14.40 XXX

G0406 1.10$ $66.00 1.10$ $66.00 XXX

G0407 2.02$ $121.20 2.02$ $121.20 XXX

G0408 2.90$ $174.00 2.90$ $174.00 XXX

G0409 0.35$ $21.00 0.35$ $21.00 XXX



G0412 20.11$ $1,206.60 20.11$ $1,206.60 090

G0413 29.93$ $1,795.80 29.93$ $1,795.80 090

G0414 27.54$ $1,652.40 27.54$ $1,652.40 090

G0415 38.33$ $2,299.80 38.33$ $2,299.80 090

G0416 15.57$ $934.20 15.57$ $934.20 XXX

G0416 26 4.48$ $268.80 4.48$ $268.80 XXX

G0416 TC 11.09$ $665.40 11.09$ $665.40 XXX

G0420 3.07$ $184.20 3.07$ $184.20 XXX

G0421 0.71$ $42.60 0.71$ $42.60 XXX

G0422 2.93$ $175.80 2.93$ $175.80 XXX

G0423 2.93$ $175.80 2.93$ $175.80 XXX

G0424 0.86$ $51.60 0.39$ $23.40 XXX

G0425 2.79$ $167.40 2.79$ $167.40 XXX

G0426 3.81$ $228.60 3.81$ $228.60 XXX

G0427 5.66$ $339.60 5.66$ $339.60 XXX


G0429 2.80$ $168.00 2.00$ $120.00 000




G0436 0.41$ $24.60 0.35$ $21.00 XXX

G0437 0.78$ $46.80 0.73$ $43.80 XXX

G0438 4.89$ $293.40 4.89$ $293.40 XXX

G0439 3.33$ $199.80 3.33$ $199.80 XXX

G0442 0.52$ $31.20 0.27$ $16.20 XXX

G0443 0.73$ $43.80 0.67$ $40.20 XXX

G0444 0.52$ $31.20 0.26$ $15.60 XXX

G0445 0.76$ $45.60 0.67$ $40.20 XXX

G0446 0.73$ $43.80 0.67$ $40.20 XXX



Page | 345

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RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G0447 0.73$ $43.80 0.67$ $40.20 XXX


G0451 0.26$ $15.60 0.26$ $15.60 XXX

G0452 By Report By Report

G0452 26 0.53$ $31.80 0.53$ $31.80 XXX

G0453 0.92$ $55.20 0.92$ $55.20 XXX

G0454 0.26$ $15.60 0.26$ $15.60 XXX

G0455 3.68$ $220.80 2.06$ $123.60 000


G0459 1.16$ $69.60 1.16$ $69.60 XXX

G0460 By Report By Report YYY








G0472 XXX

G0473 0.35$ $21.00 0.33$ $19.80 XXX










G0913 XXX

G0914 XXX

G0915 XXX

G0916 XXX

G0917 XXX

G0918 XXX


G6001 1.50$ $90.00 1.50$ $90.00 XXX

G6001 26 0.85$ $51.00 0.85$ $51.00 XXX

G6001 TC 0.65$ $39.00 0.65$ $39.00 XXX

G6002 2.20$ $132.00 2.20$ $132.00 XXX

G6002 26 0.57$ $34.20 0.57$ $34.20 XXX

G6002 TC 1.63$ $97.80 1.63$ $97.80 XXX










Page | 346

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RVUs

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Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G6003 5.55$ $333.00 5.55$ $333.00 XXX

G6004 4.30$ $258.00 4.30$ $258.00 XXX

G6005 4.29$ $257.40 4.29$ $257.40 XXX

G6006 4.28$ $256.80 4.28$ $256.80 XXX

G6007 8.94$ $536.40 8.94$ $536.40 XXX

G6008 5.95$ $357.00 5.95$ $357.00 XXX

G6009 5.88$ $352.80 5.88$ $352.80 XXX

G6010 5.87$ $352.20 5.87$ $352.20 XXX

G6011 9.55$ $573.00 9.55$ $573.00 XXX

G6012 7.84$ $470.40 7.84$ $470.40 XXX

G6013 7.85$ $471.00 7.85$ $471.00 XXX

G6014 7.85$ $471.00 7.85$ $471.00 XXX

G6015 10.23$ $613.80 10.23$ $613.80 XXX

G6016 10.22$ $613.20 10.22$ $613.20 XXX


G8395 XXX

G8396 XXX

G8397 XXX

G8398 XXX

G8399 XXX

G8400 XXX

G8401 XXX

G8404 XXX

G8405 XXX

G8410 XXX

G8415 XXX

G8416 XXX

G8417 XXX

G8418 XXX

G8419 XXX

G8420 XXX

G8421 XXX

G8422 XXX

G8427 XXX

G8428 XXX

G8430 XXX

G8431 XXX

G8432 XXX

G8433 XXX

G8442 XXX

G8450 XXX

G8451 XXX






























Page | 347

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Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G8452 XXX

G8458 XXX

G8460 XXX

G8461 XXX

G8465 XXX

G8473 XXX

G8474 XXX

G8475 XXX

G8476 XXX

G8477 XXX

G8478 XXX

G8482 XXX

G8483 XXX

G8484 XXX

G8485 XXX

G8486 XXX

G8487 XXX

G8489 XXX

G8490 XXX

G8491 XXX

G8494 XXX

G8495 XXX

G8496 XXX

G8497 XXX

G8498 XXX

G8499 XXX

G8500 XXX

G8506 XXX

G8509 XXX

G8510 XXX

G8511 XXX

G8535 XXX

G8536 XXX

G8539 XXX

G8540 XXX

G8541 XXX

G8542 XXX

G8543 XXX

G8544 XXX

G8545 XXX

G8548 XXX

G8549 XXX













































Page | 348

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RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G8551 XXX

G8559 XXX

G8560 XXX

G8561 XXX

G8562 XXX

G8563 XXX

G8564 XXX

G8565 XXX

G8566 XXX

G8567 XXX

G8568 XXX

G8569 XXX

G8570 XXX

G8571 XXX

G8572 XXX

G8573 XXX

G8574 XXX

G8575 XXX

G8576 XXX

G8577 XXX

G8578 XXX

G8598 XXX

G8599 XXX

G8600 XXX

G8601 XXX

G8602 XXX

G8627 XXX

G8628 XXX

G8633 XXX

G8634 XXX

G8635 XXX

G8645 XXX

G8646 XXX

G8647 XXX

G8648 XXX

G8649 XXX

G8650 XXX

G8651 XXX

G8652 XXX

G8653 XXX

G8654 XXX

G8655 XXX













































Page | 349

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RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G8656 XXX

G8657 XXX

G8658 XXX

G8659 XXX

G8660 XXX

G8661 XXX

G8662 XXX

G8663 XXX

G8664 XXX

G8665 XXX

G8666 XXX

G8667 XXX

G8668 XXX

G8669 XXX

G8670 XXX

G8671 XXX

G8672 XXX

G8673 XXX

G8674 XXX

G8694 XXX

G8696 XXX

G8697 XXX

G8698 XXX

G8708 XXX

G8709 XXX

G8710 XXX

G8711 XXX

G8712 XXX

G8721 XXX

G8722 XXX

G8723 XXX

G8724 XXX

G8725 XXX

G8726 XXX

G8728 XXX

G8730 XXX

G8731 XXX

G8732 XXX

G8733 XXX

G8734 XXX

G8735 XXX

G8749 XXX













































Page | 350

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RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G8752 XXX

G8753 XXX

G8754 XXX

G8755 XXX

G8756 XXX

G8757 XXX

G8758 XXX

G8759 XXX

G8761 XXX

G8762 XXX

G8765 XXX

G8783 XXX

G8784 XXX

G8785 XXX

G8797 XXX

G8798 XXX

G8806 XXX

G8807 XXX

G8808 XXX

G8809 XXX

G8810 XXX

G8811 XXX

G8815 XXX

G8816 XXX

G8817 XXX

G8818 XXX

G8825 XXX

G8826 XXX

G8833 XXX

G8834 XXX

G8838 XXX

G8839 XXX

G8840 XXX

G8841 XXX

G8842 XXX

G8843 XXX

G8844 XXX

G8845 XXX

G8846 XXX

G8848 XXX

G8849 XXX

G8850 XXX













































Page | 351

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Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G8851 XXX

G8852 XXX

G8853 XXX

G8854 XXX

G8855 XXX

G8856 XXX

G8857 XXX

G8858 XXX

G8861 XXX

G8863 XXX

G8864 XXX

G8865 XXX

G8866 XXX

G8867 XXX

G8868 XXX

G8869 XXX

G8872 XXX

G8873 XXX

G8874 XXX

G8875 XXX

G8876 XXX

G8877 XXX

G8878 XXX

G8879 XXX

G8880 XXX

G8881 XXX

G8882 XXX

G8883 XXX

G8884 XXX

G8885 XXX

G8898 XXX

G8899 XXX

G8900 XXX

G8902 XXX

G8903 XXX

G8906 XXX













































Page | 352

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RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL







G8923 XXX

G8924 XXX

G8925 XXX

G8926 XXX

G8927 XXX

G8928 XXX

G8929 XXX

G8934 XXX

G8935 XXX

G8936 XXX

G8937 XXX

G8938 XXX

G8939 XXX

G8940 XXX

G8941 XXX

G8942 XXX

G8944 XXX

G8946 XXX

G8947 XXX

G8948 XXX

G8950 XXX

G8952 XXX

G8953 XXX

G8955 XXX

G8956 XXX

G8958 XXX

G8959 XXX

G8960 XXX

G8961 XXX

G8962 XXX

G8963 XXX

G8964 XXX

G8965 XXX

G8966 XXX

G8967 XXX

G8968 XXX







































Page | 353

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RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G8969 XXX

G8970 XXX

G8971 XXX

G8972 XXX

G8973 XXX

G8974 XXX

G8975 XXX

G8976 XXX

G8977 XXX

G8978 XXX

G8979 XXX

G8980 XXX

G8981 XXX

G8982 XXX

G8983 XXX

G8984 XXX

G8985 XXX

G8986 XXX

G8987 XXX

G8988 XXX

G8989 XXX

G8990 XXX

G8991 XXX

G8992 XXX

G8993 XXX

G8994 XXX

G8995 XXX

G8996 XXX

G8997 XXX

G8998 XXX

G8999 XXX













































Page | 354

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RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


























G9063 XXX

G9064 XXX

G9065 XXX

G9066 XXX

G9067 XXX

G9068 XXX

G9069 XXX

G9070 XXX

G9071 XXX

G9072 XXX

G9073 XXX

G9074 XXX

G9075 XXX

G9077 XXX

G9078 XXX

G9079 XXX

G9080 XXX




















Page | 355

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DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G9083 XXX

G9084 XXX

G9085 XXX

G9086 XXX

G9087 XXX

G9088 XXX

G9089 XXX

G9090 XXX

G9091 XXX

G9092 XXX

G9093 XXX

G9094 XXX

G9095 XXX

G9096 XXX

G9097 XXX

G9098 XXX

G9099 XXX

G9100 XXX

G9101 XXX

G9102 XXX

G9103 XXX

G9104 XXX

G9105 XXX

G9106 XXX

G9107 XXX

G9108 XXX

G9109 XXX

G9110 XXX

G9111 XXX

G9112 XXX

G9113 XXX

G9114 XXX

G9115 XXX

G9116 XXX

G9117 XXX

G9123 XXX

G9124 XXX

G9125 XXX

G9126 XXX

G9128 XXX

G9129 XXX

G9130 XXX













































Page | 356

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G9131 XXX

G9132 XXX

G9133 XXX

G9134 XXX

G9135 XXX

G9136 XXX

G9137 XXX

G9138 XXX

G9139 XXX




G9148 XXX

G9149 XXX

G9150 XXX

G9151 XXX

G9152 XXX

G9153 XXX


G9157 2.70$ $162.00 2.70$ $162.00 XXX

G9158 XXX

G9159 XXX

G9160 XXX

G9161 XXX

G9162 XXX

G9163 XXX

G9164 XXX

G9165 XXX

G9166 XXX

G9167 XXX

G9168 XXX

G9169 XXX

G9170 XXX

G9171 XXX

G9172 XXX

G9173 XXX

G9174 XXX

G9175 XXX

G9176 XXX

G9186 XXX

G9187 1.31$ $78.60 1.31$ $78.60 XXX

G9188 XXX

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

































Page | 357

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G9189 XXX

G9190 XXX

G9191 XXX

G9192 XXX

G9196 XXX

G9197 XXX

G9198 XXX

G9203 XXX

G9204 XXX

G9205 XXX

G9206 XXX

G9207 XXX

G9208 XXX

G9209 XXX

G9210 XXX

G9211 XXX

G9212 XXX

G9213 XXX

G9217 XXX

G9219 XXX

G9222 XXX

G9223 XXX

G9225 XXX

G9226 XXX

G9227 XXX

G9228 XXX

G9229 XXX

G9230 XXX

G9231 XXX

G9232 XXX

G9233 XXX

G9234 XXX

G9235 XXX

G9236 XXX

G9237 XXX

G9238 XXX

G9239 XXX

G9240 XXX

G9241 XXX

G9242 XXX

G9243 XXX

G9244 XXX













































Page | 358

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G9245 XXX

G9246 XXX

G9247 XXX

G9250 XXX

G9251 XXX

G9254 XXX

G9255 XXX

G9256 XXX

G9257 XXX

G9258 XXX

G9259 XXX

G9260 XXX

G9261 XXX

G9262 XXX

G9263 XXX

G9264 XXX

G9265 XXX

G9266 XXX

G9267 XXX

G9268 XXX

G9269 XXX

G9270 XXX

G9273 XXX

G9274 XXX

G9275 XXX

G9276 XXX

G9277 XXX

G9278 XXX

G9279 XXX

G9280 XXX

G9281 XXX

G9282 XXX

G9283 XXX

G9284 XXX

G9285 XXX

G9286 XXX

G9287 XXX

G9288 XXX

G9289 XXX

G9290 XXX

G9291 XXX

G9292 XXX













































Page | 359

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G9293 XXX

G9294 XXX

G9295 XXX

G9296 XXX

G9297 XXX

G9298 XXX

G9299 XXX

G9300 XXX

G9301 XXX

G9302 XXX

G9303 XXX

G9304 XXX

G9305 XXX

G9306 XXX

G9307 XXX

G9308 XXX

G9309 XXX

G9310 XXX

G9311 XXX

G9312 XXX

G9313 XXX

G9314 XXX

G9315 XXX

G9316 XXX

G9317 XXX

G9318 XXX

G9319 XXX

G9321 XXX

G9322 XXX

G9324 XXX

G9326 XXX

G9327 XXX

G9329 XXX

G9340 XXX

G9341 XXX

G9342 XXX

G9344 XXX

G9345 XXX

G9347 XXX

G9348 XXX

G9349 XXX

G9350 XXX













































Page | 360

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G9351 XXX

G9352 XXX

G9353 XXX

G9354 XXX

G9355 XXX

G9356 XXX

G9357 XXX

G9358 XXX

G9359 XXX

G9360 XXX

G9361 XXX

G9364 XXX

G9365 XXX

G9366 XXX

G9367 XXX

G9368 XXX

G9380 XXX

G9381 XXX

G9382 XXX

G9383 XXX

G9384 XXX

G9385 XXX

G9386 XXX

G9389 XXX

G9390 XXX

G9393 XXX

G9394 XXX

G9395 XXX

G9396 XXX

G9399 XXX

G9400 XXX

G9401 XXX

G9402 XXX

G9403 XXX

G9404 XXX

G9405 XXX

G9406 XXX

G9407 XXX

G9408 XXX

G9409 XXX

G9410 XXX

G9411 XXX













































Page | 361

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G9412 XXX

G9413 XXX

G9414 XXX

G9415 XXX

G9416 XXX

G9417 XXX

G9418 XXX

G9419 XXX

G9420 XXX

G9421 XXX

G9422 XXX

G9423 XXX

G9424 XXX

G9425 XXX

G9426 XXX

G9427 XXX

G9428 XXX

G9429 XXX

G9430 XXX

G9431 XXX

G9432 XXX

G9434 XXX

G9435 XXX

G9436 XXX

G9437 XXX

G9438 XXX

G9439 XXX

G9440 XXX

G9441 XXX

G9442 XXX

G9443 XXX

G9448 XXX

G9449 XXX

G9450 XXX

G9451 XXX

G9452 XXX

G9453 XXX

G9454 XXX

G9455 XXX

G9456 XXX

G9457 XXX

G9458 XXX













































Page | 362

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G9459 XXX

G9460 XXX

G9463 XXX

G9464 XXX

G9465 XXX

G9466 XXX

G9467 XXX

G9468 XXX

G9469 XXX

G9470 XXX

G9471 XXX

G9472 XXX









G9496 XXX

G9497 XXX

G9498 XXX

G9499 XXX

G9500 XXX

G9501 XXX

G9502 XXX

G9503 XXX

G9504 XXX

G9505 XXX

G9506 XXX

G9507 XXX

G9508 XXX

G9509 XXX

G9510 XXX

G9511 XXX

G9512 XXX

G9513 XXX

G9514 XXX

G9515 XXX

G9516 XXX

G9517 XXX





































Page | 363

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G9518 XXX

G9519 XXX

G9520 XXX

G9521 XXX

G9522 XXX

G9523 XXX

G9524 XXX

G9525 XXX

G9526 XXX

G9529 XXX

G9530 XXX

G9531 XXX

G9532 XXX

G9533 XXX

G9534 XXX

G9535 XXX

G9536 XXX

G9537 XXX

G9538 XXX

G9539 XXX

G9540 XXX

G9541 XXX

G9542 XXX

G9543 XXX

G9544 XXX

G9547 XXX

G9548 XXX

G9549 XXX

G9550 XXX

G9551 XXX

G9552 XXX

G9553 XXX

G9554 XXX

G9555 XXX

G9556 XXX

G9557 XXX

G9558 XXX

G9559 XXX

G9560 XXX

G9561 XXX

G9562 XXX

G9563 XXX













































Page | 364

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G9572 XXX

G9573 XXX

G9574 XXX

G9577 XXX

G9578 XXX

G9579 XXX

G9580 XXX

G9581 XXX

G9582 XXX

G9583 XXX

G9584 XXX

G9585 XXX

G9593 XXX

G9594 XXX

G9595 XXX

G9596 XXX

G9597 XXX

G9598 XXX

G9599 XXX

G9600 XXX

G9601 XXX

G9602 XXX

G9603 XXX

G9604 XXX

G9605 XXX

G9606 XXX

G9607 XXX

G9608 XXX

G9609 XXX

G9610 XXX

G9611 XXX

G9612 XXX

G9613 XXX

G9614 XXX

G9615 XXX

G9616 XXX

G9617 XXX

G9618 XXX

G9619 XXX

G9620 XXX

G9621 XXX

G9622 XXX













































Page | 365

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G9623 XXX

G9624 XXX

G9625 XXX

G9626 XXX

G9627 XXX

G9628 XXX

G9629 XXX

G9630 XXX

G9631 XXX

G9632 XXX

G9633 XXX

G9634 XXX

G9635 XXX

G9636 XXX

G9637 XXX

G9638 XXX

G9639 XXX

G9640 XXX

G9641 XXX

G9642 XXX

G9643 XXX

G9644 XXX

G9645 XXX

G9646 XXX

G9647 XXX

G9648 XXX

G9649 XXX

G9650 XXX

G9651 XXX

G9652 XXX

G9653 XXX

G9654 XXX

G9655 XXX

G9656 XXX

G9657 XXX

G9658 XXX

G9659 XXX

G9660 XXX

G9661 XXX

G9662 XXX

G9663 XXX

G9664 XXX













































Page | 366

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

G9665 XXX

G9666 XXX

G9667 XXX


G9669 XXX

G9670 XXX

G9671 XXX

G9672 XXX

G9673 XXX

G9674 XXX

G9675 XXX

G9676 XXX

G9677 XXX

H0001 By Report By Report XXX











































Page | 367

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL













































Page | 368

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


















J0120 XXX

J0129 XXX

J0130 XXX

J0131 XXX

J0132 XXX

J0133 XXX

J0135 XXX

J0153 XXX

J0171 XXX

J0178 XXX

J0180 XXX

J0190 XXX

J0200 XXX

J0202 XXX

J0207 XXX

J0220 XXX

J0221 XXX

J0256 XXX

J0257 XXX

J0270 XXX

J0278 XXX

J0280 XXX

J0285 XXX

J0287 XXX

J0288 XXX




























Page | 369

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J0289 XXX

J0290 XXX

J0295 XXX

J0300 XXX

J0348 XXX

J0350 XXX

J0360 XXX

J0365 XXX

J0380 XXX

J0390 XXX

J0395 XXX

J0400 XXX

J0401 XXX

J0456 XXX

J0461 XXX

J0470 XXX

J0475 XXX

J0476 XXX

J0480 XXX

J0485 XXX

J0490 XXX

J0500 XXX

J0515 XXX

J0520 XXX

J0558 XXX

J0561 XXX

J0571 XXX

J0572 XXX

J0573 XXX

J0574 XXX

J0575 XXX

J0583 XXX

J0585 XXX

J0586 XXX

J0587 XXX

J0588 XXX

J0592 XXX

J0594 XXX

J0595 XXX

J0596 XXX

J0597 XXX

J0598 XXX













































Page | 370

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J0600 XXX

J0610 XXX

J0620 XXX

J0630 XXX

J0636 XXX

J0637 XXX

J0638 XXX

J0640 XXX

J0641 XXX

J0670 XXX

J0690 XXX

J0692 XXX

J0694 XXX

J0695 XXX

J0696 XXX

J0697 XXX

J0698 XXX

J0702 XXX

J0710 XXX

J0712 XXX

J0713 XXX

J0714 XXX

J0715 XXX

J0716 XXX

J0717 XXX

J0720 XXX

J0725 XXX

J0735 XXX

J0740 XXX

J0743 XXX

J0744 XXX

J0770 XXX

J0775 XXX

J0780 XXX

J0795 XXX

J0800 XXX

J0834 XXX

J0840 XXX

J0850 XXX

J0875 XXX

J0878 XXX

J0881 XXX













































Page | 371

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J0882 XXX

J0885 XXX

J0887 XXX

J0888 XXX

J0894 XXX

J0895 XXX

J0897 XXX

J0945 XXX

J1000 XXX

J1020 XXX

J1030 XXX

J1040 XXX

J1050 XXX

J1071 XXX

J1100 XXX

J1110 XXX

J1120 XXX

J1160 XXX

J1162 XXX

J1165 XXX

J1170 XXX

J1180 XXX

J1190 XXX

J1200 XXX

J1205 XXX

J1212 XXX

J1230 XXX

J1240 XXX

J1245 XXX

J1250 XXX

J1260 XXX

J1265 XXX

J1267 XXX

J1270 XXX

J1290 XXX

J1300 XXX

J1320 XXX

J1322 XXX

J1324 XXX

J1325 XXX

J1330 XXX

J1335 XXX













































Page | 372

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J1364 XXX

J1380 XXX

J1410 XXX

J1430 XXX

J1435 XXX

J1436 XXX

J1438 XXX

J1439 XXX

J1442 XXX

J1443 XXX

J1447 XXX

J1450 XXX

J1452 XXX

J1453 XXX

J1455 XXX

J1457 XXX

J1458 XXX

J1459 XXX

J1460 XXX

J1556 XXX

J1557 XXX

J1559 XXX

J1560 XXX

J1561 XXX

J1566 XXX

J1568 XXX

J1569 XXX

J1570 XXX

J1571 XXX

J1572 XXX

J1575 XXX

J1580 XXX

J1590 XXX

J1595 XXX

J1599 XXX

J1602 XXX

J1610 XXX

J1620 XXX

J1626 XXX

J1630 XXX

J1631 XXX

J1640 XXX













































Page | 373

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J1642 XXX

J1644 XXX

J1645 XXX

J1650 XXX

J1652 XXX

J1670 XXX

J1675 XXX

J1700 XXX

J1710 XXX

J1720 XXX

J1725 XXX

J1730 XXX

J1740 XXX

J1741 XXX

J1742 XXX

J1743 XXX

J1744 XXX

J1745 XXX

J1750 XXX

J1756 XXX

J1786 XXX

J1800 XXX

J1810 XXX

J1815 XXX

J1817 XXX

J1826 By Report By Report XXX

J1830 XXX

J1833 XXX

J1885 XXX

J1890 XXX

J1930 XXX

J1931 XXX

J1940 XXX

J1945 XXX

J1950 XXX

J1953 XXX

J1955 XXX

J1956 XXX

J1960 XXX

J1980 XXX

J1990 XXX

J2001 XXX












































Page | 374

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J2010 XXX

J2020 XXX

J2060 XXX

J2150 XXX

J2170 XXX

J2175 XXX

J2180 XXX

J2185 XXX

J2210 XXX

J2212 XXX

J2248 XXX

J2250 XXX

J2265 XXX

J2270 XXX

J2274 XXX

J2278 XXX

J2280 XXX

J2300 XXX

J2310 XXX

J2315 XXX

J2320 XXX

J2323 XXX

J2353 XXX

J2354 XXX

J2355 XXX

J2357 XXX

J2358 XXX

J2360 XXX

J2400 XXX

J2405 XXX

J2407 XXX

J2410 XXX

J2425 XXX

J2426 XXX

J2430 XXX

J2460 XXX

J2469 XXX

J2501 XXX

J2502 XXX

J2503 XXX

J2504 XXX

J2505 XXX













































Page | 375

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J2507 XXX

J2510 XXX

J2513 XXX

J2515 XXX

J2540 XXX

J2543 XXX

J2545 XXX

J2547 XXX

J2550 XXX

J2560 XXX

J2562 XXX

J2597 XXX

J2670 XXX

J2675 XXX

J2680 XXX

J2690 XXX

J2700 XXX

J2704 XXX

J2720 XXX

J2724 XXX

J2725 XXX

J2760 XXX

J2765 XXX

J2770 XXX

J2778 XXX

J2780 XXX

J2783 XXX

J2785 XXX

J2788 XXX

J2790 XXX

J2791 XXX

J2792 XXX

J2793 XXX

J2794 XXX

J2795 XXX

J2796 XXX

J2800 XXX

J2805 XXX

J2810 XXX

J2820 XXX

J2850 XXX

J2860 XXX













































Page | 376

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J2910 XXX

J2916 XXX

J2920 XXX

J2930 XXX

J2940 XXX

J2941 XXX

J2950 XXX

J2995 XXX

J2997 XXX

J3000 XXX

J3010 XXX

J3030 XXX

J3060 XXX

J3070 XXX

J3090 XXX

J3095 XXX

J3101 XXX

J3105 XXX

J3110 XXX

J3121 XXX

J3145 XXX

J3230 XXX

J3240 XXX

J3243 XXX

J3250 XXX

J3260 XXX

J3262 XXX

J3265 XXX

J3280 XXX

J3285 XXX

J3300 XXX

J3301 XXX

J3302 XXX

J3303 XXX

J3305 XXX

J3310 XXX

J3315 XXX

J3320 XXX

J3350 XXX

J3357 XXX

J3360 XXX

J3364 XXX













































Page | 377

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J3370 XXX

J3380 XXX

J3385 XXX

J3396 XXX

J3400 XXX

J3410 XXX

J3411 XXX

J3415 XXX

J3420 XXX

J3430 XXX

J3465 XXX

J3470 XXX

J3473 XXX

J3475 XXX

J3480 XXX

J3485 XXX

J3486 XXX

J3489 XXX

J3490 XXX


J3530 XXX



J3590 XXX

J7030 XXX

J7040 XXX

J7042 XXX

J7050 XXX

J7060 XXX

J7070 XXX

J7120 XXX

J7121 XXX

J7131 XXX

J7178 XXX

J7180 XXX

J7181 XXX

J7182 XXX

J7183 XXX

J7185 XXX

J7186 XXX

J7187 XXX

J7188 XXX










































Page | 378

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J7189 XXX

J7190 XXX

J7191 XXX

J7192 XXX

J7193 XXX

J7194 XXX

J7195 XXX

J7196 XXX

J7197 XXX

J7198 XXX

J7199 XXX

J7200 XXX

J7201 XXX

J7205 XXX



J7300 XXX

J7301 XXX

J7303 XXX




J7308 XXX

J7311 XXX

J7312 XXX

J7313 XXX

J7315 XXX

J7316 XXX

J7321 XXX

J7323 XXX

J7324 XXX

J7325 XXX

J7326 XXX

J7327 XXX

J7328 XXX

J7336 XXX

J7340 XXX

J7500 XXX

J7502 XXX

J7503 XXX

J7504 XXX

J7505 XXX








































Page | 379

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J7507 XXX

J7508 XXX

J7509 XXX

J7510 XXX

J7511 XXX

J7512 XXX

J7513 XXX

J7515 XXX

J7516 XXX

J7517 XXX

J7518 XXX

J7520 XXX

J7525 XXX

J7527 XXX

J7599 XXX

J7604 XXX

J7605 XXX

J7606 XXX

J7607 XXX

J7608 XXX

J7609 XXX

J7610 XXX

J7611 XXX

J7612 XXX

J7613 XXX

J7614 XXX

J7615 XXX

J7620 XXX

J7622 XXX

J7624 XXX

J7626 XXX

J7627 XXX

J7628 XXX

J7629 XXX

J7631 XXX

J7632 XXX

J7633 XXX

J7634 XXX

J7635 XXX

J7636 XXX

J7637 XXX

J7638 XXX













































Page | 380

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J7639 XXX


J7641 XXX

J7642 XXX

J7643 XXX

J7644 XXX

J7645 XXX

J7647 XXX

J7648 XXX

J7649 XXX

J7650 XXX

J7657 XXX

J7658 XXX

J7659 XXX

J7660 XXX

J7667 XXX

J7668 XXX

J7670 XXX

J7674 XXX

J7676 XXX

J7680 XXX

J7681 XXX

J7682 XXX

J7683 XXX

J7684 XXX

J7685 XXX

J7686 XXX

J7699 XXX

J7799 XXX

J7999 XXX

J8498 XXX


J8501 XXX

J8510 XXX

J8520 XXX

J8521 XXX

J8530 XXX

J8540 XXX

J8560 XXX

J8562 XXX


J8597 XXX










































Page | 381

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J8600 XXX

J8610 XXX

J8650 XXX

J8655 XXX

J8700 XXX

J8705 XXX

J8999 XXX

J9000 XXX

J9017 XXX

J9019 XXX

J9025 XXX

J9027 XXX

J9031 XXX

J9032 XXX

J9033 XXX

J9035 XXX

J9039 XXX

J9040 XXX

J9041 XXX

J9042 XXX

J9043 XXX

J9045 XXX

J9047 XXX

J9050 XXX

J9055 XXX

J9060 XXX

J9065 XXX

J9070 XXX

J9098 XXX

J9100 XXX

J9120 XXX

J9130 XXX

J9150 XXX

J9151 XXX

J9155 XXX

J9165 XXX

J9171 XXX

J9178 XXX

J9179 XXX

J9181 XXX

J9185 XXX

J9190 XXX













































Page | 382

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J9200 XXX

J9201 XXX

J9202 XXX

J9206 XXX

J9207 XXX

J9208 XXX

J9209 XXX

J9211 XXX

J9213 XXX

J9214 XXX

J9215 XXX

J9217 XXX

J9218 XXX

J9225 XXX

J9226 XXX

J9228 XXX

J9230 XXX

J9245 XXX

J9250 XXX

J9260 XXX

J9261 XXX

J9262 XXX

J9263 XXX

J9264 XXX

J9266 XXX

J9267 XXX

J9268 XXX

J9270 XXX

J9271 XXX

J9280 XXX

J9293 XXX

J9299 XXX

J9301 XXX

J9302 XXX

J9303 XXX

J9305 XXX

J9306 XXX

J9307 XXX

J9308 XXX

J9310 XXX

J9315 XXX

J9320 XXX













































Page | 383

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

J9328 XXX

J9330 XXX

J9340 XXX

J9351 XXX

J9354 XXX

J9355 XXX

J9357 XXX

J9360 XXX

J9370 XXX

J9371 XXX

J9390 XXX

J9395 XXX

J9400 XXX

J9999 XXX

K0001 RR

K0001 By Report By Report

K0002 RR


K0003 RR


K0004 RR


K0005 NU

K0005 RR

K0005 UE


K0006 RR


K0007 RR


K0008 By Report By Report XXX

K0009 RR


K0010 RR


K0011 RR


K0012 RR




K0015 NU































Page | 384

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

K0015 RR

K0015 UE


K0017 NU

K0017 RR

K0017 UE


K0018 NU

K0018 RR

K0018 UE


K0019 NU

K0019 RR

K0019 UE


K0020 NU

K0020 RR

K0020 UE


K0037 NU

K0037 RR

K0037 UE


K0038 NU

K0038 RR

K0038 UE


K0039 NU

K0039 RR

K0039 UE


K0040 NU

K0040 RR

K0040 UE


K0041 NU

K0041 RR

K0041 UE


K0042 NU

K0042 RR

K0042 UE



































Page | 385

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


K0043 NU

K0043 RR

K0043 UE


K0044 NU

K0044 RR

K0044 UE


K0045 NU

K0045 RR

K0045 UE


K0046 NU

K0046 RR

K0046 UE


K0047 NU

K0047 RR

K0047 UE


K0050 NU

K0050 RR

K0050 UE


K0051 NU

K0051 RR

K0051 UE


K0052 NU

K0052 RR

K0052 UE


K0053 NU

K0053 RR

K0053 UE


K0056 NU

K0056 RR

K0056 UE


K0065 NU


































Page | 386

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

K0065 RR

K0065 UE


K0069 NU

K0069 RR

K0069 UE


K0070 NU

K0070 RR

K0070 UE


K0071 NU

K0071 RR

K0071 UE


K0072 NU

K0072 RR

K0072 UE


K0073 NU

K0073 RR

K0073 UE


K0077 NU

K0077 RR

K0077 UE


K0098 NU

K0098 RR

K0098 UE


K0105 NU

K0105 RR

K0105 UE



K0195 RR


K0455 RR



K0552
































Page | 387

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

K0601 NU


K0602 NU


K0603 NU


K0604 NU


K0605 NU


K0606 RR


K0607 NU

K0607 RR

K0607 UE


K0608 NU

K0608 RR

K0608 UE


K0609

K0609 KF


K0672

K0730 NU

K0730 RR

K0730 UE


K0733 NU

K0733 RR

K0733 UE


K0738 RR




K0743

K0744

K0745

K0746

K0800 NU

K0800 RR































Page | 388

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

K0800 UE


K0801 NU

K0801 RR

K0801 UE


K0802 NU

K0802 RR

K0802 UE


K0806 NU

K0806 RR

K0806 UE


K0807 NU

K0807 RR

K0807 UE


K0808 NU

K0808 RR

K0808 UE



K0813 RR


K0814 RR


K0815 RR


K0816 RR


K0820 RR


K0821 RR


K0822 RR


K0823 RR


K0824 RR


K0825 RR





























Page | 389

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


K0826 RR


K0827 RR


K0828 RR


K0829 RR




K0835 RR


K0836 RR


K0837 RR


K0838 RR


K0839 RR


K0840 RR


K0841 RR


K0842 RR


K0843 RR


K0848 RR


K0849 RR


K0850 RR


K0851 RR


K0852 RR


K0853 RR


K0854 RR























Page | 390

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL


K0855 RR


K0856 RR


K0857 RR


K0858 RR


K0859 RR


K0860 RR


K0861 RR


K0862 RR


K0863 RR


K0864 RR


















K0901 XXX

K0902 XXX

L0112

L0113

L0120


















Page | 391

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L0130

L0140

L0150

L0160

L0170

L0172

L0174

L0180

L0190

L0200

L0220

L0450

L0452

L0454

L0455 XXX

L0456

L0457 XXX

L0458

L0460

L0462

L0464

L0466

L0467 XXX

L0468

L0469 XXX

L0470

L0472

L0480

L0482

L0484

L0486

L0488

L0490

L0491

L0492

L0621

L0622

L0623

L0624

L0625

L0626

L0627













































Page | 392

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L0628

L0629

L0630

L0631

L0632

L0633

L0634

L0635

L0636

L0637

L0638

L0639

L0640

L0641 XXX

L0642 XXX

L0643 XXX

L0648 XXX

L0649 XXX

L0650 XXX

L0651 XXX

L0700

L0710

L0810

L0820

L0830

L0859

L0861

L0970

L0972

L0974

L0976

L0978

L0980

L0982

L0984

L0999

L1000

L1001

L1005

L1010

L1020

L1025













































Page | 393

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L1030

L1040

L1050

L1060

L1070

L1080

L1085

L1090

L1100

L1110

L1120

L1200

L1210

L1220

L1230

L1240

L1250

L1260

L1270

L1280

L1290

L1300

L1310

L1499

L1600

L1610

L1620

L1630

L1640

L1650

L1652

L1660

L1680

L1685

L1686

L1690

L1700

L1710

L1720

L1730

L1755

L1810













































Page | 394

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L1812 XXX

L1820

L1830

L1831

L1832

L1833 XXX

L1834

L1836

L1840

L1843

L1844

L1845

L1846

L1847

L1848 XXX

L1850

L1860

L1900

L1902

L1904

L1906

L1907

L1910

L1920

L1930

L1932

L1940

L1945

L1950

L1951

L1960

L1970

L1971

L1980

L1990

L2000

L2005

L2010

L2020

L2030

L2034

L2035













































Page | 395

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L2036

L2037

L2038

L2040

L2050

L2060

L2070

L2080

L2090

L2106

L2108

L2112

L2114

L2116

L2126

L2128

L2132

L2134

L2136

L2180

L2182

L2184

L2186

L2188

L2190

L2192

L2200

L2210

L2220

L2230

L2232

L2240

L2250

L2260

L2265

L2270

L2275

L2280

L2300

L2310

L2320

L2330













































Page | 396

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L2335

L2340

L2350

L2360

L2370

L2375

L2380

L2385

L2387

L2390

L2395

L2397

L2405

L2415

L2425

L2430

L2492

L2500

L2510

L2520

L2525

L2526

L2530

L2540

L2550

L2570

L2580

L2600

L2610

L2620

L2622

L2624

L2627

L2628

L2630

L2640

L2650

L2660

L2670

L2680

L2750

L2755













































Page | 397

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L2760

L2768

L2780

L2785

L2795

L2800

L2810

L2820

L2830

L2840

L2850

L2861

L2999

L3000

L3001

L3002

L3003

L3010

L3020

L3030

L3031

L3040

L3050

L3060

L3070

L3080

L3090

L3100

L3140

L3150

L3160

L3170

L3201

L3202

L3203

L3204

L3206

L3207

L3208

L3209

L3211

L3212













































Page | 398

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L3213

L3214

L3215

L3216

L3217

L3219

L3221

L3222

L3224

L3225

L3230

L3250

L3251

L3252

L3253

L3254

L3255

L3257

L3260

L3265

L3300

L3310

L3320

L3330

L3332

L3334

L3340

L3350

L3360

L3370

L3380

L3390

L3400

L3410

L3420

L3430

L3440

L3450

L3455

L3460

L3465

L3470













































Page | 399

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L3480

L3485

L3500

L3510

L3520

L3530

L3540

L3550

L3560

L3570

L3580

L3590

L3595

L3600

L3610

L3620

L3630

L3640

L3649

L3650

L3660

L3670

L3671

L3674

L3675

L3677

L3678 By Report By Report XXX

L3702

L3710

L3720

L3730

L3740

L3760

L3762

L3763

L3764

L3765

L3766

L3806

L3807

L3808

L3809 XXX












































Page | 400

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L3891

L3900

L3901

L3904

L3905

L3906

L3908

L3912

L3913

L3915

L3916 XXX

L3917

L3918 XXX

L3919

L3921

L3923

L3924 XXX

L3925

L3927

L3929

L3930 XXX

L3931

L3933

L3935

L3956

L3960

L3961

L3962

L3967

L3971

L3973

L3975

L3976

L3977

L3978

L3980


L3982

L3984

L3995

L3999

L4000












































Page | 401

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L4002

L4010

L4020

L4030

L4040

L4045

L4050

L4055

L4060

L4070

L4080

L4090

L4100

L4110

L4130

L4205

L4210

L4350

L4360

L4361 XXX

L4370

L4386

L4387 XXX

L4392

L4394

L4396

L4397 XXX

L4398

L4631

L5000

L5010

L5020

L5050

L5060

L5100

L5105

L5150

L5160

L5200

L5210

L5220

L5230













































Page | 402

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L5250

L5270

L5280

L5301

L5312

L5321

L5331

L5341

L5400

L5410

L5420

L5430

L5450

L5460

L5500

L5505

L5510

L5520

L5530

L5535

L5540

L5560

L5570

L5580

L5585

L5590

L5595

L5600

L5610

L5611

L5613

L5614

L5616

L5617

L5618

L5620

L5622

L5624

L5626

L5628

L5629

L5630













































Page | 403

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L5631

L5632

L5634

L5636

L5637

L5638

L5639

L5640

L5642

L5643

L5644

L5645

L5646

L5647

L5648

L5649

L5650

L5651

L5652

L5653

L5654

L5655

L5656

L5658

L5661

L5665

L5666

L5668

L5670

L5671

L5672

L5673

L5676

L5677

L5678

L5679

L5680

L5681

L5682

L5683

L5684

L5685













































Page | 404

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L5686

L5688

L5690

L5692

L5694

L5695

L5696

L5697

L5698

L5699

L5700

L5701

L5702

L5703

L5704

L5705

L5706

L5707

L5710

L5711

L5712

L5714

L5716

L5718

L5722

L5724

L5726

L5728

L5780

L5781

L5782

L5785

L5790

L5795

L5810

L5811

L5812

L5814

L5816

L5818

L5822

L5824













































Page | 405

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L5826

L5828

L5830

L5840

L5845

L5848

L5850

L5855

L5856

L5857

L5858

L5859

L5910

L5920

L5925

L5930

L5940

L5950

L5960

L5961

L5962

L5964

L5966

L5968

L5969 XXX

L5970

L5971

L5972

L5973

L5974

L5975

L5976

L5978

L5979

L5980

L5981

L5982

L5984

L5985

L5986

L5987

L5988













































Page | 406

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L5990

L5999

L6000

L6010

L6020


L6050

L6055

L6100

L6110

L6120

L6130

L6200

L6205

L6250

L6300

L6310

L6320

L6350

L6360

L6370

L6380

L6382

L6384

L6386

L6388

L6400

L6450

L6500

L6550

L6570

L6580

L6582

L6584

L6586

L6588

L6590

L6600

L6605

L6610

L6611

L6615












































Page | 407

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L6616

L6620

L6621

L6623

L6624

L6625

L6628

L6629

L6630

L6632

L6635

L6637

L6638

L6640

L6641

L6642

L6645

L6646

L6647

L6648

L6650

L6655

L6660

L6665

L6670

L6672

L6675

L6676

L6677

L6680

L6682

L6684

L6686

L6687

L6688

L6689

L6690

L6691

L6692

L6693

L6694

L6695













































Page | 408

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L6696

L6697

L6698

L6703

L6704

L6706

L6707

L6708

L6709

L6711

L6712

L6713

L6714

L6715

L6721

L6722

L6805

L6810

L6880

L6881

L6882

L6883

L6884

L6885

L6890

L6895

L6900

L6905

L6910

L6915

L6920

L6925

L6930

L6935

L6940

L6945

L6950

L6955

L6960

L6965

L6970

L6975













































Page | 409

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L7007

L7008

L7009

L7040

L7045

L7170

L7180

L7181

L7185

L7186

L7190

L7191


L7360

L7362

L7364

L7366

L7367

L7368

L7400

L7401

L7402

L7403

L7404

L7405

L7499

L7510

L7520

L7600

L8000

L8001

L8002

L8010

L8015

L8020

L8030

L8031

L8032

L8035

L8039

L8040

L8040 KM












































Page | 410

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L8040 KN

L8041

L8041 KM

L8041 KN

L8042

L8042 KM

L8042 KN

L8043

L8043 KM

L8043 KN

L8044

L8044 KM

L8044 KN

L8045

L8045 KM

L8045 KN

L8046

L8046 KM

L8046 KN

L8047

L8047 KM

L8047 KN

L8048

L8049

L8300

L8310

L8320

L8330

L8400

L8410

L8415

L8417

L8420

L8430

L8435

L8440

L8460

L8465

L8470

L8480

L8485

L8499













































Page | 411

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L8500

L8501

L8505

L8507

L8509

L8510

L8511

L8512

L8513

L8514

L8515

L8600

L8603

L8604

L8605

L8606

L8607 XXX

L8609

L8610

L8612

L8613

L8614

L8615

L8616

L8617

L8618

L8619

L8621

L8622

L8623

L8624

L8627

L8628

L8629

L8630

L8631

L8641

L8642

L8658

L8659

L8670

L8679 XXX













































Page | 412

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

L8680

L8681

L8682

L8683

L8684

L8685

L8686

L8687

L8688

L8689

L8690

L8691

L8692

L8693

L8695


L8699

L9900

M0075 By Report By Report XXX





P2028 By Report By Report XXX




P2038 $6.85 per unit $6.85 per unit XXX

P3000 $14.39 per unit $14.39 per unit XXX

P3001 0.94$ $56.40 0.94$ $56.40 XXX
































Page | 413

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL










P9041 XXX


P9045 XXX

P9046 XXX

P9047 XXX

















P9612 $3 per unit $3 per unit XXX

P9615 $3 per unit $3 per unit XXX

Q0035 0.60$ $36.00 0.60$ $36.00 XXX

Q0035 26 0.25$ $15.00 0.25$ $15.00 XXX

Q0035 TC 0.35$ $21.00 0.35$ $21.00 XXX

Q0081 XXX

Q0083 XXX

Q0084 XXX

Q0085 XXX

Q0091 1.30$ $78.00 0.55$ $33.00 XXX

Q0092 0.74$ $44.40 0.74$ $44.40 XXX

Q0111 $5.82 per unit $5.82 per unit XXX











Page | 414

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL





Q0138 XXX

Q0139 XXX

Q0144 By Report By Report XXX

Q0161 XXX

Q0162 XXX

Q0163 XXX

Q0164 XXX

Q0166 XXX

Q0167 XXX

Q0169 XXX

Q0174 XXX

Q0180 XXX

Q0181 XXX

Q0478 XXX

Q0479 XXX

Q0480 XXX

Q0481 XXX

Q0482 XXX

Q0483 XXX

Q0484 XXX

Q0485 XXX

Q0486 XXX

Q0487 XXX

Q0488 XXX

Q0489 XXX

Q0490 XXX

Q0491 XXX

Q0492 XXX

Q0493 XXX

Q0494 XXX

Q0495 XXX

Q0496 XXX

Q0497 XXX

Q0498 XXX

Q0499 XXX

Q0500 XXX

Q0501 XXX

Q0502 XXX








































Page | 415

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL

Q0503 XXX

Q0504 XXX

Q0506 XXX

Q0507 XXX

Q0508 XXX

Q0509 XXX

Q0510 Bundled Bundled XXX







Q2004 XXX

Q2026 XXX

Q2028 XXX

Q2034 XXX

Q2035 XXX

Q2037 XXX

Q2038 XXX


Q2043 XXX

Q2050 XXX

Q2052 XXX



Q3027 XXX

Q3028 XXX



































Page | 416

CODE MOD

DOC

Nonfac

RVUs

Non-Facility

Allowed

Amount

DOC

Facility

RVUs

Facility Allowed

Amount GLOBAL







































Q4074 XXX

Q4081 XXX

Q4082 XXX

Q4100 XXX







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V2797 Bundled Bundled XXX


V5008 Not Covered Not Covered XXX



V5014 XXX




See Hearing Aid Fee Schedule

























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Documents

DOC Conversion Factor: $60.00 DOC Non-Facility DOC Allowed … · 2019. 7. 11. · RBRVS Physician-Related Services Fee Schedule Effective January 1, 2016 ... DOC Professional Provider