Reimbursement by Procedure Code 90000 - 999999 Effective · PDF file · 2015-03-13Reimbursement by Procedure Code 90000 - 999999 Effective Jan. 1, 2015 CPT Code Reimbursement 90281

Reimbursement by Procedure Code 90000 - 999999

Effective Jan. 1, 2015

CPT Code Reimbursement

90281 $13.20

90283 $27.00

90287 $53.00

90371 $89.00

90375 $94.50

90376 $89.00

90378 $1,234.24

90384 $89.00

90385 $24.85

90386 $29.73

90389 $103.00

90396 $89.00

90460 $12.61

90461 $12.00

90471 $12.61

90472 $12.00

90473 $12.61

90474 $9.28

90476 $33.00

90477 $33.00

90585 $27.50

90586 $27.50

90632 $51.55

90633 $37.77

90634 $32.73

90636 $103.43

90645 $29.73

90646 $29.98

90647 $30.05

90648 $28.60

90649 $139.13

90650 $169.78

90654 $18.92

90655 $19.53

90656 $14.04

90657 $6.83

90658 $12.38

90660 $22.29

90661 $14.00

90662 $31.82

90666 $30.00

90668 $15.00

90669 $108.10

90670 $145.11

90672 $27.85

Confidential

These rates are provided for informational purposes only

and are not to be considered a guarantee of payment.

Actual payment will be based on Health Options policies,

procedures, and Customer Benefit Plans.




90673 $36.48

90675 $267.20

90676 $312.86

90680 $93.35

90681 $135.13

90685 $26.30

90686 $21.97

90688 $19.40

90690 $13.20

90691 $48.65

90692 $13.20

90693 $13.20

90696 $62.70

90698 $105.34

90700 $29.29

90702 $11.00

90703 $11.00

90704 $33.00

90705 $33.00

90706 $27.50

90707 $56.14

90708 $11.00

90710 $159.08

90712 $22.00

90714 $19.30

90715 $31.84

90716 $94.14

90717 $114.57

90719 $11.00

90720 $40.52

90721 $62.24

90723 $92.53

90727 $8.25

90732 $69.26

90733 $106.49

90734 $110.70

90735 $55.00

90736 $192.85

90738 $294.09

90740 $82.50

90743 $27.42

90744 $27.42

90746 $59.71

90747 $58.30

90748 $57.50

Confidential








90785 $5.00

90791 $132.93

90792 $143.27

90832 $64.00

90833 $43.00

90834 $85.18

90836 $69.50

90837 $127.47

90838 $109.76

90839 $133.17

90840 $63.89

90845 $84.00

90846 $88.58

90847 $8.00

90849 $31.81

90853 $26.25

90863 $25.00

90865 $152.81

90870 $140.75

90875 $56.00

90876 $88.00

90880 $103.48

90887 $80.00

90901 $41.21

90911 $78.80

90935 $65.00

90937 $96.00

90945 $70.00

90947 $100.00

90951 $936.75

90952 $590.00

90953 $396.00

90954 $795.00

90955 $450.00

90956 $305.00

90957 $637.00

90958 $430.00

90959 $282.00

90960 $275.00

90961 $230.44

90962 $166.35

90963 $546.00

90964 $456.00

90965 $433.00

90966 $227.80

Confidential








90967 $17.85

90968 $15.33

90969 $14.97

90970 $7.75

90989 $400.00

90997 $89.24

91010 $115.79

91013 $14.18

91020 $146.68

91022 $113.09

91030 $81.00

91034 $193.42

91035 $480.95

91037 $154.87

91038 $133.00

91040 $409.21

91065 $60.00

91110 $911.16

91111 $704.00

91112 $1,010.00

91117 $90.39

91120 $239.20

91122 $194.00

91132 $27.56

91133 $35.20

92002 $63.00

92004 $102.00

92012 $49.00

92014 $80.00

92015 $20.26

92018 $90.00

92019 $66.74

92020 $25.36

92025 $29.56

92060 $48.00

92065 $36.00

92071 $36.90

92072 $110.10

92081 $34.85

92082 $43.00

92083 $62.00

92100 $53.00

92132 $36.26

92133 $45.24

92134 $45.35

Confidential








92136 $78.00

92140 $37.00

92225 $22.26

92226 $20.34

92227 $11.90

92228 $30.58

92230 $60.08

92235 $111.64

92240 $122.00

92250 $39.00

92260 $16.90

92265 $48.18

92270 $53.77

92275 $87.53

92283 $30.10

92284 $36.64

92285 $17.23

92286 $38.88

92287 $109.00

92310 $97.00

92313 $77.32

92317 $54.21

92325 $15.00

92326 $35.00

92341 $18.00

92358 $17.50

92370 $29.00

92371 $20.00

92502 $93.64

92504 $24.00

92507 $62.37

92508 $23.70

92511 $85.00

92512 $61.50

92516 $54.00

92520 $49.89

92521 $114.42

92522 $92.85

92523 $192.91

92524 $96.57

92526 $75.00

92531 $25.00

92532 $35.00

92533 $27.50

92534 $15.00

Confidential








92540 $96.84

92541 $30.86

92542 $26.55

92543 $16.20

92544 $24.07

92545 $20.82

92546 $38.00

92547 $5.47

92550 $20.94

92551 $11.97

92552 $18.00

92553 $26.00

92555 $15.00

92556 $23.00

92557 $37.91

92558 $60.00

92559 $22.50

92560 $33.00

92561 $29.00

92562 $19.00

92563 $15.00

92564 $19.44

92565 $15.25

92567 $14.70

92568 $13.70

92570 $31.88

92571 $16.41

92572 $4.00

92575 $13.00

92576 $18.00

92577 $19.62

92579 $29.00

92582 $29.00

92583 $35.13

92584 $71.74

92585 $100.99

92586 $71.91

92587 $22.05

92588 $33.58

92590 $45.00

92591 $47.22

92592 $45.00

92593 $72.00

92594 $45.00

92595 $72.00

Confidential








92596 $25.22

92597 $74.65

92601 $139.00

92602 $82.97

92603 $94.00

92604 $61.86

92607 $116.00

92608 $23.00

92609 $63.00

92610 $85.88

92611 $48.00

92612 $150.97

92613 $38.12

92614 $139.37

92615 $34.24

92616 $193.21

92617 $42.41

92620 $47.00

92621 $12.00

92625 $46.00

92626 $80.00

92627 $20.77

92630 $85.00

92633 $85.00

92640 $82.00

92920 $529.25

92921 $236.00

92924 $629.15

92925 $259.50

92928 $587.62

92929 $331.00

92933 $657.10

92934 $259.50

92937 $586.92

92938 $331.00

92941 $658.37

92943 $658.37

92944 $331.00

92950 $175.00

92953 $11.26

92960 $173.00

92961 $249.00

92970 $172.90

92971 $93.61

92973 $173.50

Confidential








92974 $161.17

92975 $385.74

92977 $78.00

92978 $177.71

92979 $167.00

92986 $1,249.00

92987 $1,374.64

92990 $1,018.00

92992 $898.00

92993 $1,320.00

92997 $616.92

92998 $306.87

93000 $16.86

93005 $8.33

93010 $8.54

93015 $76.40

93016 $22.58

93017 $39.66

93018 $14.61

93024 $112.71

93025 $166.36

93040 $12.87

93041 $5.77

93042 $7.10

93224 $92.64

93225 $27.27

93226 $38.57

93227 $26.80

93228 $25.86

93229 $680.65

93268 $208.16

93270 $9.42

93271 $101.00

93272 $25.34

93278 $30.63

93279 $50.20

93280 $58.84

93281 $68.55

93282 $63.13

93283 $82.11

93284 $90.41

93285 $42.05

93286 $27.31

93287 $35.92

93288 $37.02

Confidential








93289 $65.62

93290 $30.83

93291 $36.30

93292 $31.93

93293 $54.25

93294 $33.80

93295 $67.25

93296 $26.19

93297 $25.86

93298 $26.69

93299 $17.50

93303 $223.00

93304 $125.77

93306 $231.75

93307 $133.76

93308 $110.76

93312 $265.00

93313 $41.94

93314 $216.00

93315 $345.00

93316 $42.84

93317 $381.20

93318 $330.00

93320 $55.29

93321 $31.46

93325 $26.42

93350 $174.12

93351 $269.00

93352 $34.03

93561 $62.00

93562 $22.46

93582 $683.31

93583 $760.48

93600 $220.00

93602 $182.00

93603 $207.00

93609 $346.54

93610 $243.00

93612 $254.00

93613 $374.65

93615 $63.00

93616 $100.00

93618 $444.00

93619 $802.00

93620 $981.50

Confidential








93621 $145.62

93622 $220.00

93623 $161.00

93624 $359.00

93631 $789.00

93640 $541.00

93641 $621.46

93642 $401.46

93650 $573.02

93653 $801.16

93654 $1,069.27

93655 $400.64

93656 $1,069.61

93657 $400.87

93660 $154.00

93662 $318.00

93668 $29.00

93701 $24.36

93724 $272.94

93745 $80.00

93750 $52.66

93770 $8.80

93784 $54.51

93786 $30.19

93788 $5.41

93790 $18.40

93797 $16.54

93798 $24.83

93880 $190.77

93882 $125.74

93886 $209.18

93888 $96.43

93890 $153.33

93892 $159.91

93893 $160.25

93922 $84.00

93923 $135.00

93924 $160.00

93925 $190.27

93926 $122.23

93930 $180.00

93931 $117.89

93965 $82.00

93970 $190.95

93971 $115.91

Confidential








93975 $250.70

93976 $186.00

93978 $134.87

93979 $123.00

93980 $124.13

93981 $75.54

93990 $114.98

94002 $84.78

94003 $61.92

94004 $45.00

94005 $92.00

94010 $33.42

94011 $97.83

94012 $150.40

94013 $31.61

94014 $42.00

94015 $23.51

94016 $24.88

94060 $56.75

94070 $58.27

94150 $13.00

94200 $21.00

94250 $17.00

94375 $36.09

94400 $51.20

94450 $49.54

94452 $52.66

94453 $74.28

94610 $60.13

94620 $56.40

94621 $118.00

94640 $13.03

94642 $26.00

94644 $36.23

94645 $13.81

94660 $54.08

94662 $35.58

94664 $14.09

94667 $22.15

94668 $18.45

94669 $35.00

94680 $53.00

94681 $51.81

94690 $30.00

94726 $53.89

Confidential








94727 $42.00

94728 $40.83

94729 $54.00

94750 $49.00

94760 $2.60

94761 $5.05

94762 $24.97

94770 $8.08

94772 $127.00

94774 $237.50

94780 $49.20

94781 $19.40

95004 $3.60

95012 $18.89

95017 $8.26

95018 $20.23

95024 $4.90

95027 $3.32

95028 $7.29

95044 $4.12

95052 $4.65

95056 $5.67

95060 $11.34

95065 $6.48

95070 $27.80

95071 $34.64

95076 $115.00

95079 $80.00

95115 $9.06

95117 $10.52

95120 $20.00

95125 $21.00

95130 $25.00

95131 $36.00

95132 $41.00

95133 $44.60

95134 $52.85

95144 $9.00

95145 $15.01

95146 $21.19

95147 $20.80

95148 $28.15

95149 $37.43

95165 $8.00

95170 $7.78

Confidential








95180 $91.00

95250 $63.00

95251 $27.95

95782 $794.00

95783 $832.00

95800 $185.03

95801 $97.69

95803 $155.79

95805 $344.00

95806 $177.98

95807 $482.65

95808 $536.00

95810 $573.00

95811 $657.00

95812 $138.00

95813 $167.00

95816 $123.00

95819 $135.00

95822 $144.00

95824 $58.00

95827 $154.00

95829 $1,346.00

95830 $116.00

95831 $26.50

95832 $25.00

95833 $37.00

95834 $48.47

95851 $18.39

95852 $13.38

95857 $42.27

95860 $84.00

95861 $114.84

95863 $138.61

95864 $173.43

95865 $113.01

95866 $80.00

95867 $67.44

95868 $92.68

95869 $34.47

95870 $33.00

95872 $106.00

95873 $29.00

95874 $29.50

95875 $96.13

95885 $57.64

Confidential








95886 $89.82

95887 $80.20

95905 $69.44

95907 $95.68

95908 $117.99

95909 $142.06

95910 $186.62

95911 $226.81

95912 $266.64

95913 $308.59

95921 $63.00

95922 $67.00

95923 $110.32

95924 $103.50

95925 $75.00

95926 $78.00

95927 $76.00

95928 $180.40

95929 $186.00

95930 $52.00

95933 $63.85

95937 $51.85

95938 $281.70

95939 $442.90

95940 $31.88

95941 $104.55

95943 $99.00

95950 $230.69

95951 $590.00

95953 $400.00

95954 $192.00

95955 $136.15

95956 $723.84

95957 $174.00

95958 $321.71

95961 $219.00

95962 $220.00

95965 $1,224.00

95966 $606.00

95967 $184.78

95970 $25.00

95971 $44.00

95972 $81.00

95973 $51.50

95974 $164.50

Confidential








95975 $94.00

95978 $200.62

95979 $91.89

95980 $37.00

95981 $26.00

95982 $39.00

95990 $55.50

95991 $87.00

95992 $41.67

96000 $86.66

96001 $101.11

96002 $20.27

96003 $18.35

96004 $109.76

96020 $357.44

96040 $25.18

96101 $80.26

96102 $45.00

96103 $28.36

96105 $77.73

96110 $8.33

96111 $127.73

96116 $96.23

96118 $98.85

96119 $64.00

96120 $47.50

96125 $87.50

96150 $21.35

96151 $20.64

96152 $19.57

96153 $4.59

96154 $19.21

96155 $25.00

96360 $57.61

96361 $15.17

96365 $69.61

96366 $18.73

96367 $30.38

96368 $20.56

96369 $155.50

96370 $15.44

96371 $75.70

96372 $21.53

96373 $18.38

96374 $56.21

Confidential








96375 $22.90

96401 $53.53

96402 $32.20

96405 $48.00

96406 $74.00

96409 $110.28

96411 $61.97

96413 $60.00

96415 $28.19

96416 $140.81

96417 $62.68

96420 $49.00

96422 $48.00

96423 $21.00

96425 $56.00

96440 $151.00

96446 $183.05

96450 $127.00

96521 $136.91

96522 $112.10

96523 $25.05

96542 $119.71

96567 $71.00

96570 $56.31

96571 $26.61

96900 $18.09

96902 $22.05

96910 $49.26

96912 $55.00

96913 $69.39

96920 $145.50

96921 $149.00

96922 $219.00

97001 $71.30

97002 $37.00

97003 $72.50

97004 $45.00

97005 $68.00

97006 $26.00

97010 $5.00

97012 $13.80

97014 $14.00

97016 $14.20

97018 $6.89

97022 $15.36

Confidential








97024 $4.96

97026 $4.57

97028 $5.72

97032 $15.34

97033 $21.14

97034 $13.80

97035 $11.48

97036 $23.45

97039 $11.27

97110 $26.83

97112 $27.00

97113 $30.00

97116 $23.80

97124 $21.50

97139 $15.30

97140 $25.34

97150 $17.53

97530 $27.00

97532 $23.79

97533 $25.34

97535 $27.00

97537 $26.11

97542 $26.50

97597 $51.00

97598 $25.49

97602 $19.75

97605 $33.37

97606 $36.01

97750 $25.00

97755 $25.00

97760 $30.25

97761 $27.22

97762 $28.43

97802 $18.00

97803 $19.00

97804 $8.00

97810 $23.00

97811 $18.00

97813 $35.00

97814 $30.00

98925 $27.99

98926 $38.70

98927 $49.85

98928 $59.03

98929 $67.00

Confidential








98940 $24.56

98941 $31.00

98942 $31.00

98943 $20.31

98960 $33.95

98961 $17.17

98962 $13.00

98969 $45.00

99000 $2.10

99001 $2.10

99002 $43.50

99024 $40.00

99050 $20.00

99051 $25.00

99053 $25.00

99058 $25.00

99060 $25.00

99078 $10.00

99091 $25.00

99100 $45.60

99116 $228.00

99135 $228.00

99140 $91.20

99170 $128.59

99173 $2.86

99175 $17.07

99183 $187.00

99190 $50.00

99191 $35.00

99192 $25.00

99195 $16.20

99201 $43.43

99202 $74.56

99203 $108.03

99204 $165.63

99205 $206.27

99211 $20.19

99212 $43.80

99213 $73.06

99214 $107.75

99215 $144.20

99217 $72.35

99218 $98.93

99219 $135.20

99220 $184.95

Confidential








99221 $101.15

99222 $137.46

99223 $202.62

99224 $39.78

99225 $72.31

99226 $104.33

99231 $39.11

99232 $71.89

99233 $103.60

99234 $134.59

99235 $168.59

99236 $217.61

99238 $72.41

99239 $106.97

99281 $20.92

99282 $41.07

99283 $61.26

99284 $116.74

99285 $171.64

99288 $80.00

99291 $273.54

99292 $122.34

99304 $92.88

99305 $132.35

99306 $167.61

99307 $44.63

99308 $68.87

99309 $90.70

99310 $134.87

99315 $57.79

99316 $75.80

99318 $95.90

99324 $55.12

99325 $80.38

99326 $115.58

99327 $151.93

99328 $187.90

99334 $42.48

99335 $66.98

99336 $102.94

99337 $151.16

99339 $25.00

99340 $25.00

99341 $55.16

99342 $79.63

Confidential








99343 $130.10

99344 $181.95

99345 $219.33

99347 $55.54

99348 $84.02

99349 $127.23

99350 $177.30

99354 $99.80

99355 $97.62

99356 $91.84

99357 $91.11

99358 $107.00

99359 $51.50

99360 $61.86

99363 $69.58

99364 $29.02

99374 $67.00

99375 $77.22

99377 $25.00

99378 $25.00

99379 $25.00

99380 $25.00

99381 $111.03

99382 $115.74

99383 $120.69

99384 $136.34

99385 $132.40

99386 $152.68

99387 $165.90

99391 $99.91

99392 $106.66

99393 $106.30

99394 $116.32

99395 $118.83

99396 $126.65

99397 $136.34

99401 $30.00

99402 $50.00

99403 $70.00

99404 $100.00

99406 $14.22

99407 $27.99

99408 $35.26

99409 $68.70

99411 $12.00

Confidential








99412 $19.00

99420 $17.50

99444 $45.00

99460 $94.36

99461 $98.61

99462 $41.95

99463 $114.42

99464 $70.76

99465 $147.01

99466 $259.05

99467 $122.79

99468 $928.29

99469 $394.59

99471 $853.14

99472 $400.81

99475 $574.01

99476 $347.06

99477 $346.16

99478 $137.19

99479 $124.42

99480 $119.78

99485 $76.89

99486 $66.88

99487 $1.00

99488 $1.00

99489 $1.00

99495 $155.00

99496 $225.00

9101026 $55.74

9102026 $62.41

9102226 $63.45

9103026 $46.31

9103426 $49.28

9103526 $80.03

9103726 $49.28

9103826 $56.20

9104026 $48.89

9106526 $9.94

9111026 $182.13

9112026 $40.04

9112226 $87.72

9113226 $26.42

9113326 $33.29

9206026 $35.27

9206526 $18.19

Confidential








9208126 $17.05

9208226 $22.63

9208326 $25.71

9213626 $28.02

9223526 $42.58

9224026 $57.52

9225026 $22.63

9226526 $34.91

9227026 $33.02

9227526 $45.22

9228326 $7.13

9228426 $9.62

9228526 $3.18

9228626 $22.54

9254126 $21.04

9254226 $17.25

9254326 $5.68

9254426 $13.41

9254526 $12.12

9254626 $14.94

9258526 $25.60

9258726 $7.25

9258826 $18.40

9297826 $77.19

9297926 $61.82

9302426 $57.74

9302526 $37.41

9327826 $12.47

9328026 $38.85

9330326 $64.18

9330426 $37.04

9330726 $45.64

9330826 $25.70

9331226 $105.46

9331426 $60.22

9331526 $139.07

9331726 $92.61

9331826 $103.40

9332026 $18.54

9332126 $7.46

9332526 $3.53

9335026 $72.00

9356126 $24.11

9356226 $7.63

9360026 $113.36

Confidential








9360226 $113.31

9360326 $113.25

9360926 $266.94

9361026 $160.61

9361226 $160.56

9361526 $47.89

9361626 $65.80

9361826 $227.60

9361926 $399.19

9362026 $627.62

9362126 $112.26

9362226 $165.73

9362326 $151.99

9362426 $264.77

9364026 $187.15

9364126 $315.85

9364226 $248.95

9366026 $85.50

9366226 $146.15

9372426 $244.57

9388026 $29.77

9388226 $20.16

9388626 $48.12

9388826 $31.64

9389026 $51.20

9389226 $58.12

9389326 $58.12

9392226 $12.10

9392326 $22.32

9392426 $24.82

9392526 $29.00

9392626 $19.78

9393026 $23.04

9393126 $15.58

9396526 $17.19

9397026 $33.89

9397126 $22.14

9397526 $89.64

9397626 $58.54

9397826 $32.54

9397926 $21.60

9398026 $62.24

9398126 $21.80

9399026 $12.53

9401026 $8.02

Confidential








9406026 $13.18

9407026 $28.28

9415026 $3.89

9420026 $5.33

9425026 $5.33

9437526 $14.55

9440026 $19.44

9445026 $18.72

9445226 $14.60

9445326 $18.89

9462026 $30.59

9462126 $65.00

9468026 $12.25

9468126 $9.56

9469026 $3.41

9475026 $11.09

9580526 $59.90

9580726 $62.69

9580826 $88.02

9581026 $123.24

9581126 $128.19

9581226 $55.43

9581326 $87.95

9581626 $55.43

9581926 $55.43

9582226 $55.43

9582426 $38.24

9582726 $53.55

9582926 $314.61

9586026 $50.11

9586126 $80.38

9586326 $96.41

9586426 $102.95

9586526 $83.25

9586626 $65.38

9586726 $40.60

9586826 $60.48

9586926 $19.12

9587026 $19.12

9587326 $19.12

9587426 $19.51

9587526 $56.25

9592126 $44.38

9592226 $49.91

9592326 $46.26

Confidential








9592526 $28.24

9592626 $27.91

9592726 $27.87

9592826 $76.96

9592926 $77.35

9593026 $17.97

9593326 $30.16

9593726 $34.57

9595026 $77.62

9595126 $307.00

9595326 $150.00

9595626 $157.94

9595726 $102.07

9596126 $158.36

9596226 $170.00

9596526 $404.00

9596626 $200.00

9596726 $164.00

91010TC $37.48

91020TC $98.75

91022TC $65.50

91030TC $50.50

91034TC $141.70

91035TC $393.00

91037TC $101.00

91038TC $72.00

91040TC $358.89

91065TC $52.85

91110TC $716.00

91120TC $209.17

91122TC $93.00

91132TC $116.85

91133TC $141.50

92060TC $18.50

92065TC $16.00

92081TC $17.80

92082TC $26.91

92083TC $36.75

92136TC $47.00

92235TC $63.35

92240TC $152.00

92250TC $50.58

92265TC $22.00

92270TC $29.00

92275TC $53.62

Confidential








92283TC $24.76

92284TC $29.42

92285TC $14.78

92286TC $16.35

92541TC $9.78

92542TC $9.06

92543TC $10.52

92544TC $10.14

92545TC $8.69

92546TC $71.02

92585TC $75.39

92587TC $2.86

92588TC $3.95

93024TC $52.91

93025TC $128.94

93278TC $18.16

93303TC $158.40

93304TC $76.00

93307TC $51.00

93308TC $83.18

93312TC $75.00

93314TC $183.20

93320TC $24.00

93321TC $23.99

93325TC $22.90

93350TC $97.09

93642TC $152.52

93660TC $63.35

93724TC $28.37

93880TC $74.00

93882TC $105.25

93886TC $161.05

93888TC $64.79

93890TC $102.13

93892TC $101.79

93893TC $102.13

93922TC $67.00

93923TC $49.00

93924TC $47.00

93925TC $159.00

93926TC $100.00

93930TC $152.00

93931TC $98.00

93965TC $53.00

93970TC $154.00

Confidential








93971TC $93.23

93975TC $161.05

93976TC $150.00

93978TC $102.13

93979TC $101.85

93980TC $61.52

93981TC $53.51

93990TC $102.45

94010TC $23.00

94060TC $42.20

94070TC $30.00

94150TC $8.00

94200TC $7.00

94250TC $18.50

94375TC $16.00

94400TC $22.00

94450TC $30.82

94452TC $36.00

94453TC $53.50

94620TC $25.45

94621TC $80.63

94680TC $45.85

94681TC $41.85

94690TC $45.85

94750TC $53.90

95805TC $233.00

95807TC $408.50

95808TC $513.39

95810TC $505.17

95811TC $531.05

95812TC $160.98

95813TC $187.27

95816TC $145.58

95819TC $105.00

95822TC $174.40

95827TC $94.00

95829TC $1,008.00

95860TC $37.77

95861TC $32.89

95863TC $38.57

95864TC $70.48

95865TC $25.50

95866TC $8.00

95867TC $23.00

95868TC $31.58

Confidential








95869TC $9.00

95870TC $10.15

95873TC $8.00

95874TC $8.00

95875TC $39.00

95921TC $15.00

95922TC $43.00

95923TC $63.00

95925TC $36.00

95926TC $41.26

95927TC $37.00

95928TC $92.00

95929TC $99.00

95930TC $33.52

95933TC $31.00

95937TC $17.29

95950TC $153.06

95953TC $250.00

95956TC $565.90

95957TC $64.00

95961TC $50.00

95962TC $50.00

Confidential





Documents

Reimbursement by Procedure Code 90000 - 999999 Effective · PDF file · 2015-03-13Reimbursement by Procedure Code 90000 - 999999 Effective Jan. 1, 2015 CPT Code Reimbursement 90281