CPT / HCPCS APC OK Adj APC Rate Eff Date Add'l Criteria 10021 0002 49.00 10/01/05 10022 0036 114.36 10/01/05 10040 0010 31.02 10/01/05 * 10060 0006 79.08 10/01/05 10061 0006 79.08 10/01/05 10080 0006 79.08 10/01/05 10081 0007 611.24 10/01/05 10120 0006 79.08 10/01/05 10140 0007 611.24 10/01/05 10160 0018 57.66 10/01/05 11000 0013 55.53 01/01/07 11040 0015 85.56 10/01/05 11041 0015 85.56 10/01/05 11055 0012 44.40 10/01/05 11056 0012 44.40 10/01/05 11057 0013 55.53 10/01/05 11100 0018 57.66 10/01/05 11200 0013 55.53 10/01/05 * 11400 0019 217.24 10/01/05 * 11401 0019 217.24 10/01/05 * 11402 0019 217.24 10/01/05 * 11403 0020 363.50 10/01/05 * 11420 0020 363.50 10/01/05 * 11421 0020 363.50 10/01/05 * 11422 0020 363.50 10/01/05 * 11423 0021 785.46 01/01/07 * 11440 0019 217.24 10/01/05 * 11441 0019 217.24 10/01/05 * 11442 0020 363.50 10/01/05 * 11443 0020 363.50 10/01/05 * 11600 0019 217.24 10/01/05 11601 0019 217.24 10/01/05 11602 0019 217.24 10/01/05 11603 0020 363.50 10/01/05 11620 0020 363.50 10/01/05 11621 0019 217.24 10/01/05 11622 0020 363.50 10/01/05 11623 0021 785.46 10/01/05 11640 0020 363.50 01/01/07 11641 0020 363.50 01/01/07 11642 0020 363.50 10/01/05 11643 0020 363.50 10/01/05 11720 0009 39.34 10/01/05 11721 0009 39.34 10/01/05 11730 0013 55.53 10/01/05 11740 0009 39.34 10/01/05 11750 0019 217.24 10/01/05 11752 0022 " 1,024.96 " 10/01/05 11755 0019 217.24 10/01/05 11760 0024 81.24 10/01/05 11762 0024 81.24 10/01/05 11765 0015 85.56 10/01/05 12001 0024 81.24 10/01/05 12002 0024 81.24 10/01/05 12004 0024 81.24 10/01/05 12011 0024 81.24 10/01/05 12013 0024 81.24 10/01/05 12014 0024 81.24 10/01/05 12015 0024 81.24 10/01/05 12031 0024 81.24 10/01/05 12032 0024 81.24 10/01/05 12041 0024 81.24 10/01/05 12042 0024 81.24 10/01/05 12051 0024 81.24 10/01/05 12052 0024 81.24 10/01/05 12053 0024 81.24 10/01/05 15850 0016 131.34 10/01/05 17000 0010 31.02 10/01/05 * 17004 0011 116.64 10/01/05 * 17106 0011 116.64 10/01/05 * 17107 0011 116.64 10/01/05 * 17108 0011 116.64 10/01/05 * 17110 0013 55.53 01/01/07 * 17111 0013 55.53 01/01/07 * 17250 0013 55.53 10/01/05 * 19000 0004 93.07 10/01/05 19260 0021 785.46 10/01/05 20000 0006 79.08 10/01/05 20100 0023 249.60 10/01/05 20101 0027 952.90 10/01/05 20102 0027 952.90 10/01/05 20103 0023 249.60 10/01/05 20150 0051 " 1,917.28 " 10/01/05 20500 0251 108.87 10/01/05 20520 0019 217.24 10/01/05 20600 0204 118.70 10/01/05 20605 0204 118.70 10/01/05 20610 0204 118.70 10/01/05 20612 0204 118.70 10/01/05 20615 0004 93.07 10/01/05 20982 1557 " 1,628.00 " 10/01/05 21390 0256 " 1,937.68 " 10/01/05 21406 0256 " 1,937.68 " 10/01/05 21407 0256 " 1,937.68 " 10/01/05 21470 0256 " 1,937.68 " 10/01/05 21550 0021 785.46 10/01/05 23600 0043 90.08 10/01/05 24343 0050 " 1,253.56 " 10/01/05 25500 0043 90.08 10/01/05 25530 0043 90.08 10/01/05 25560 0043 90.08 10/01/05 25652 0046 " 1,984.04 " 10/01/05 26720 0043 90.08 10/01/05 26725 0043 90.08 10/01/05 27524 0046 " 1,984.04 " 10/01/05 28124 0055 " 1,044.11 " 10/01/05 28190 0019 217.24 10/01/05 28220 0055 " 1,044.11 " 10/01/05 28230 0055 " 1,044.11 " 10/01/05 28232 0055 " 1,044.11 " 10/01/05 28272 0055 " 1,044.11 " 10/01/05 28360 0056 " 2,123.26 " 10/01/05 28430 0043 90.08 10/01/05 29044 0426 115.98 10/01/05 29046 0426 115.98 10/01/05 29305 0426 115.98 10/01/05 29325 0426 115.98 10/01/05 29345 0426 115.98 10/01/05 29450 0058 56.58 10/01/05 29720 0058 56.58 10/01/05 30020 0251 108.87 10/01/05 31000 0251 108.87 10/01/05 31002 0252 424.37 10/01/05 31040 0254 " 1,220.81 " 10/01/05 31231 0072 75.66 10/01/05 31502 0121 117.17 10/01/05 32020 0070 168.32 10/01/05 33208 0655 " 7,166.52 " 10/01/05 33210 0106 " 2,929.36 " 10/01/05 33215 0105 " 1,151.43 " 10/01/05 33225 0418 " 8,868.88 " 01/01/07 33226 0105 " 1,151.43 " 10/01/05 33234 0105 " 1,151.43 " 10/01/05 33235 0105 " 1,151.43 " 10/01/05 33241 0105 " 1,151.43 " 10/01/05 33244 0105 " 1,151.43 " 10/01/05 35180 0093 " 1,220.74 " 10/01/05 35184 0093 " 1,220.74 " 10/01/05 35190 0093 " 1,220.74 " 10/01/05 35201 0093 " 1,220.74 " 10/01/05 35206 0093 " 1,220.74 " 10/01/05 35226 0093 " 1,220.74 " 10/01/05 35231 0093 " 1,220.74 " 10/01/05 35236 0093 " 1,220.74 " 10/01/05 35256 0093 " 1,220.74 " 10/01/05 35261 0653 " 1,934.68 " 10/01/05 35266 0653 " 1,934.68 " 10/01/05 35286 0653 " 1,934.68 " 10/01/05 35321 0093 " 1,220.74 " 10/01/05 35458 0081 " 2,213.48 " 10/01/05 35459 0081 " 2,213.48 " 10/01/05 35460 0081 " 2,213.48 " 10/01/05 35470 0081 " 2,213.48 " 10/01/05 35471 0081 " 2,213.48 " 10/01/05 35472 0081 " 2,213.48 " 10/01/05 35473 0081 " 2,213.48 " 10/01/05 35474 0081 " 2,213.48 " 10/01/05 35475 0081 " 2,213.48 " 10/01/05 35476 0081 " 2,213.48 " 10/01/05 35484 0081 " 2,213.48 " 10/01/05 35485 0081 " 2,213.48 " 10/01/05 35490 0081 " 2,213.48 " 10/01/05 35491 0081 " 2,213.48 " 10/01/05 35492 0081 " 2,213.48 " 10/01/05 35493 0081 " 2,213.48 " 10/01/05 35494 0081 " 2,213.48 " 10/01/05 35495 0081 " 2,213.48 " 10/01/05 35903 0115 " 1,936.66 " 10/01/05 36420 0035 4.36 10/01/05 36425 0035 4.36 10/01/05 36430 0110 190.72 07/01/06 36450 0110 190.72 07/01/06 36455 0110 190.72 07/01/06 36460 0110 190.72 07/01/06 36511 0111 632.46 07/01/06 36512 0111 632.46 07/01/06 36513 0111 632.46 07/01/06 36514 0111 632.46 07/01/06 36515 0112 " 1,381.25 " 01/01/07 36516 0112 " 1,381.25 " 07/01/06 36550 0676 119.10 01/01/07 36597 0621 431.07 01/01/07 37201 0676 119.10 10/01/05 37202 0676 119.10 01/01/07 37203 0103 787.78 10/01/05 37204 0115 " 1,936.66 " 10/01/05 37205 0229 " 3,474.10 " 10/01/05 37207 0229 " 3,474.10 " 10/01/05 37620 0091 " 1,512.46 " 10/01/05 37765 0091 " 1,512.46 " 10/01/05 37766 0091 " 1,512.46 " 10/01/05 38120 0131 " 2,254.51 " 10/01/05 38205 0111 632.46 01/01/07 * 38206 0111 632.46 01/01/07 * 38221 0003 140.12 10/01/05 38230 0123 " 1,282.12 " 01/01/07 * 38240 0123 " 1,282.12 " 01/01/07 * 38241 0123 " 1,282.12 " 01/01/07 * 38720 0113 " 1,121.30 " 10/01/05 39400 0069 " 1,621.06 " 10/01/05 40490 0251 108.87 01/01/07 40702 0256 " 1,937.68 " 10/01/05 40806 0251 108.87 10/01/05 40820 0253 841.79 10/01/05 41100 0252 424.37 10/01/05 41105 0253 841.79 10/01/05 41108 0252 424.37 10/01/05 41110 0253 841.79 10/01/05 41115 0252 424.37 10/01/05 42100 0252 424.37 10/01/05 42104 0253 841.79 10/01/05 42106 0253 841.79 10/01/05 42225 0256 " 1,937.68 " 10/01/05 42227 0256 " 1,937.68 " 10/01/05 42800 0253 841.79 10/01/05 42842 0254 " 1,220.81 " 10/01/05 42844 0256 " 1,937.68 " 10/01/05 43280 0132 " 3,335.21 " 10/01/05 43830 0422 " 1,259.62 " 10/01/05 43831 0141 422.43 10/01/05 44206 0132 " 3,335.21 " 10/01/05 44207 0132 " 3,335.21 " 10/01/05 44208 0132 " 3,335.21 " 10/01/05 44238 0130 " 1,669.30 " 10/01/05 44970 0131 " 2,254.51 " 10/01/05 45300 0146 246.58 10/01/05 45303 0147 417.14 01/01/07 45330 0146 246.58 10/01/05 45520 0098 59.93 10/01/05 45541 0150 " 1,250.25 " 10/01/05 46070 0155 835.29 10/01/05 46083 0148 183.54 10/01/05 46221 0148 183.54 10/01/05 46320 0148 183.54 10/01/05 46500 0155 835.29 10/01/05 46934 0155 835.29 10/01/05 46945 0155 835.29 10/01/05 47382 0423 " 2,073.22 " 10/01/05 47562 0131 " 2,254.51 " 10/01/05 47563 0131 " 2,254.51 " 10/01/05 47564 0131 " 2,254.51 " 10/01/05 48511 0037 503.29 10/01/05 49021 0037 503.29 10/01/05 49041 0037 503.29 10/01/05 49061 0037 503.29 10/01/05 49200 0130 " 1,669.30 " 10/01/05 49323 0130 " 1,669.30 " 10/01/05 49329 0130 " 1,669.30 " 10/01/05 * 49423 0427 524.27 01/01/07 49429 0105 " 1,151.43 " 10/01/05 49491 0154 " 1,500.04 " 10/01/05 49492 0154 " 1,500.04 " 10/01/05 49659 0130 " 1,669.30 " 10/01/05 * 50020 0162 " 1,222.22 " 10/01/05 50021 0037 503.29 10/01/05 50080 0429 " 2,203.72 " 01/01/07 50081 0429 " 2,203.72 " 01/01/07 50391 0156 136.80 10/01/05 50541 0130 " 1,669.30 " 10/01/05 50542 0132 " 3,335.21 " 01/01/07 50543 0131 " 2,254.51 " 10/01/05 50544 0130 " 1,669.30 " 10/01/05 50562 0160 363.38 10/01/05 50590 0169 " 2,220.86 " 10/01/05 50945 0131 " 2,254.51 " 10/01/05 51000 0164 60.75 10/01/05 51005 0164 60.75 10/01/05 51700 0164 60.75 10/01/05 51720 0156 136.80 10/01/05 51725 0156 136.80 10/01/05 51784 0164 60.75 10/01/05 51990 0131 " 2,254.51 " 10/01/05 53600 0156 136.80 10/01/05 53601 0164 60.75 10/01/05 53620 0165 865.89 10/01/05 53621 0164 60.75 10/01/05 53660 0164 60.75 10/01/05 53661 0164 60.75 10/01/05 54692 0132 " 3,335.21 " 10/01/05 55000 0004 93.07 10/01/05 55450 0183 " 1,222.83 " 10/01/05 55860 0165 865.89 10/01/05 56405 0189 124.67 01/01/07 56420 0189 124.67 10/01/05 56501 0017 942.32 10/01/05 56605 0019 217.24 10/01/05 56805 0193 766.61 01/01/07 56820 0188 66.06 10/01/05 56821 0189 124.67 10/01/05 57022 0007 611.24 10/01/05 57061 0194 " 1,081.82 " 10/01/05 57100 0192 217.84 10/01/05 57106 0194 " 1,081.82 " 10/01/05 57310 0202 " 2,159.30 " 10/01/05 57320 0195 " 1,403.36 " 10/01/05 57330 0195 " 1,403.36 " 10/01/05 57420 0189 124.67 10/01/05 57421 0189 124.67 10/01/05 57452 0189 124.67 10/01/05 57454 0189 124.67 10/01/05 57455 0189 124.67 10/01/05 57456 0189 124.67 10/01/05 57500 0192 217.84 10/01/05 57505 0189 124.67 10/01/05 57510 0193 766.61 10/01/05 57511 0189 124.67 10/01/05 57555 0195 " 1,403.36 " 10/01/05 57800 0193 766.61 10/01/05 58100 0188 66.06 10/01/05 58301 0189 124.67 10/01/05 58356 0202 " 2,159.30 " 10/01/05 58552 0131 " 2,254.51 " 10/01/05 58553 0131 " 2,254.51 " 10/01/05 58554 0131 " 2,254.51 " 10/01/05 58578 0130 " 1,669.30 " 10/01/05 * 58600 0195 " 1,403.36 " 10/01/05 58615 0194 " 1,081.82 " 10/01/05 58679 0130 " 1,669.30 " 10/01/05 * 58823 0193 766.61 10/01/05 58920 0195 " 1,403.36 " 10/01/05 58925 0195 " 1,403.36 " 10/01/05 59000 0198 71.34 10/01/05 59074 0198 71.34 10/01/05 59150 0131 " 2,254.51 " 10/01/05 59151 0131 " 2,254.51 " 10/01/05 60001 0004 93.07 10/01/05 60100 0004 93.07 10/01/05 60210 0114 " 2,118.86 " 10/01/05 60212 0114 " 2,118.86 " 10/01/05 60220 0114 " 2,118.86 " 10/01/05 60225 0114 " 2,118.86 " 10/01/05 60240 0114 " 2,118.86 " 10/01/05 60252 0256 " 1,937.68 " 10/01/05 60260 0256 " 1,937.68 " 10/01/05 60500 0256 " 1,937.68 " 10/01/05 63030 0208 " 2,226.76 " 10/01/05 64612 0204 118.70 10/01/05 * 64613 0204 118.70 10/01/05 * 64614 0204 118.70 10/01/05 * 65222 0698 64.82 10/01/05 65436 0233 767.98 10/01/05 66761 0247 263.18 10/01/05 67101 0236 889.08 01/01/07 67105 0248 247.18 10/01/05 67110 0236 889.08 10/01/05 67145 0248 247.18 10/01/05 67228 0248 247.18 10/01/05 67500 0231 100.37 10/01/05 67505 0238 136.32 10/01/05 67515 0238 136.32 10/01/05 67700 0238 136.32 10/01/05 67710 0239 369.64 10/01/05 67800 0238 136.32 10/01/05 67801 0239 369.64 10/01/05 67805 0238 136.32 10/01/05 67810 0238 136.32 10/01/05 67840 0239 369.64 10/01/05 67850 0239 369.64 10/01/05 67875 0239 369.64 10/01/05 67930 0240 943.67 10/01/05 67938 0698 64.82 10/01/05 68100 0232 362.42 10/01/05 68110 0699 469.00 10/01/05 68801 0698 64.82 10/01/05 68840 0231 100.37 10/01/05 69000 0006 79.08 01/01/07 69433 0252 424.37 10/01/05 69540 0253 841.79 10/01/05 91034 0361 186.81 10/01/05 92953 0094 128.74 10/01/05 92960 0679 287.99 10/01/05 92980 0104 " 4,230.70 " 10/01/05 92982 0083 " 2,894.69 " 10/01/05 92986 0083 " 2,894.69 " 10/01/05 92990 0083 " 2,894.69 " 10/01/05 92997 0081 " 2,213.48 " 10/01/05 93303 0269 166.33 10/01/05 93304 0697 79.19 10/01/05 93307 0269 166.33 10/01/05 93308 0697 79.19 10/01/05 93312 0270 310.91 10/01/05 93315 0270 310.91 10/01/05 93350 0269 166.33 10/01/05 93501 0080 " 1,903.07 " 10/01/05 93503 0103 787.78 10/01/05 93505 0103 787.78 10/01/05 93508 0080 " 1,903.07 " 10/01/05 93510 0080 " 1,903.07 " 10/01/05 93526 0080 " 1,903.07 " 10/01/05 93531 0080 " 1,903.07 " 10/01/05 93532 0080 " 1,903.07 " 10/01/05 93533 0080 " 1,903.07 " 10/01/05 93580 0434 " 4,529.10 " 01/01/07 93615 0087 " 1,728.59 " 10/01/05 93616 0087 " 1,728.59 " 10/01/05 93618 0087 " 1,728.59 " 10/01/05 93619 0085 " 1,791.33 " 10/01/05 93620 0085 " 1,791.33 " 10/01/05 93624 0085 " 1,791.33 " 01/01/07 93650 0086 " 2,202.14 " 10/01/05 93651 0086 " 2,202.14 " 10/01/05 93652 0086 " 2,202.14 " 10/01/05 93660 0101 220.54 10/01/05 93701 0099 19.74 10/01/05 93741 0689 29.37 10/01/05 93742 0689 29.37 10/01/05 93743 0689 29.37 10/01/05 93880 0267 133.77 10/01/05 93922 0096 83.90 10/01/05 93971 0266 83.18 01/01/07 93976 0267 133.77 10/01/05 G0339 1528 " 4,620.00 " 01/01/07 G0340 1525 " 3,300.00 " 01/01/07 "* Indicates code may require additional criteria (i.e., prior authorization, medical review, etc.) be met in" "order to be paid. If you have questions regarding coverage of a code, please check with Provider Services."