CPT / HCPCS APC Group OK Adj APC Rate Eff Date Add'l Criteria 10021 A0002 59.47 07/01/07 10022 A0036 112.17 07/01/07 10040 A0010 25.75 07/01/07 * 10060 A0006 77.84 07/01/07 10061 A0006 77.84 07/01/07 10080 A0006 77.84 07/01/07 10081 A0007 603.31 07/01/07 10120 A0006 77.84 07/01/07 10140 A0007 603.31 07/01/07 10160 A0018 55.49 07/01/07 11000 A0013 59.06 07/01/07 11040 A0015 87.85 07/01/07 11041 A0015 87.85 07/01/07 11055 A0012 45.61 07/01/07 11056 A0012 45.61 07/01/07 11057 A0013 59.06 07/01/07 11100 A0018 55.49 07/01/07 11200 A0013 59.06 07/01/07 * 11400 A0019 221.34 07/01/07 * 11401 A0019 221.34 07/01/07 * 11402 A0019 221.34 07/01/07 * 11403 A0020 368.27 07/01/07 * 11420 A0020 368.27 07/01/07 * 11421 A0020 368.27 07/01/07 * 11422 A0020 368.27 07/01/07 * 11423 A0021 816.91 07/01/07 * 11440 A0019 221.34 07/01/07 * 11441 A0019 221.34 07/01/07 * 11442 A0020 368.27 07/01/07 * 11443 A0020 368.27 07/01/07 * 11600 A0019 221.34 07/01/07 11601 A0019 221.34 07/01/07 11602 A0019 221.34 07/01/07 11603 A0020 368.27 07/01/07 11620 A0020 368.27 07/01/07 11621 A0019 221.34 07/01/07 11622 A0020 368.27 07/01/07 11623 A0021 816.91 07/01/07 11640 A0020 368.27 07/01/07 11641 A0020 368.27 07/01/07 11642 A0020 368.27 07/01/07 11643 A0020 368.27 07/01/07 11720 A0009 41.89 07/01/07 11721 A0009 41.89 07/01/07 11730 A0013 59.06 07/01/07 11740 A0009 41.89 07/01/07 11750 A0019 221.34 07/01/07 11752 A0022 " 1,085.38 " 07/01/07 11755 A0019 221.34 07/01/07 11760 A0024 80.29 07/01/07 11762 A0024 80.29 07/01/07 11765 A0015 87.85 07/01/07 12001 A0024 80.29 07/01/07 12002 A0024 80.29 07/01/07 12004 A0024 80.29 07/01/07 12011 A0024 80.29 07/01/07 12013 A0024 80.29 07/01/07 12014 A0024 80.29 07/01/07 12015 A0024 80.29 07/01/07 12031 A0024 80.29 07/01/07 12032 A0024 80.29 07/01/07 12041 A0024 80.29 07/01/07 12042 A0024 80.29 07/01/07 12051 A0024 80.29 07/01/07 12052 A0024 80.29 07/01/07 12053 A0024 80.29 07/01/07 15850 A0016 144.69 07/01/07 17000 A0010 25.75 07/01/07 17004 A0011 138.83 07/01/07 17106 A0011 138.83 07/01/07 * 17107 A0011 138.83 07/01/07 * 17108 A0011 138.83 07/01/07 * 17110 A0012 45.61 07/01/07 * 17111 A0013 59.06 07/01/07 * 17250 A0013 59.06 07/01/07 * 19000 A0004 111.90 07/01/07 19260 A0021 816.91 07/01/07 20000 A0006 77.84 07/01/07 20100 A0023 228.33 07/01/07 20101 A0027 " 1,159.20 " 07/01/07 20102 A0027 " 1,159.20 " 07/01/07 20103 A0023 228.33 07/01/07 20150 A0051 " 2,222.60 " 07/01/07 20500 A0251 132.63 07/01/07 20520 A0019 221.34 07/01/07 20600 A0204 122.32 07/01/07 20605 A0204 122.32 07/01/07 20610 A0204 122.32 07/01/07 20612 A0204 122.32 07/01/07 20615 A0004 111.90 07/01/07 20982 A0051 " 2,222.60 " 07/01/07 21390 A0256 " 2,066.26 " 07/01/07 21406 A0256 " 2,066.26 " 07/01/07 21407 A0256 " 2,066.26 " 07/01/07 21470 A0256 " 2,066.26 " 07/01/07 21550 A0020 368.27 07/01/07 23600 A0043 91.19 07/01/07 24343 A0050 " 1,359.31 " 07/01/07 24357 A0050 " 1,359.31 " 07/01/07 24358 A0050 " 1,359.31 " 07/01/07 24359 A0050 " 1,359.31 " 07/01/07 25500 A0043 91.19 07/01/07 25530 A0043 91.19 07/01/07 25560 A0043 91.19 07/01/07 25652 A0063 " 2,030.51 " 07/01/07 26720 A0043 91.19 07/01/07 26725 A0043 91.19 07/01/07 27524 A0063 " 2,030.51 " 07/01/07 27767 A0043 91.19 07/01/07 27768 A0043 91.19 07/01/07 27769 A0063 " 2,030.51 " 07/01/07 28124 A0055 " 1,104.89 " 07/01/07 28190 A0019 221.34 07/01/07 28220 A0055 " 1,104.89 " 07/01/07 28230 A0055 " 1,104.89 " 07/01/07 28232 A0055 " 1,104.89 " 07/01/07 28272 A0055 " 1,104.89 " 07/01/07 28360 A0056 " 2,209.97 " 07/01/07 28430 A0043 91.19 07/01/07 28446 A0056 " 2,209.97 " 07/01/07 29044 A0426 123.21 07/01/07 29046 A0426 123.21 07/01/07 29305 A0426 123.21 07/01/07 29325 A0426 123.21 07/01/07 29345 A0426 123.21 07/01/07 29450 A0058 57.38 07/01/07 29720 A0058 57.38 07/01/07 29828 A0042 " 2,461.32 " 01/01/08 29904 A0041 " 1,548.35 " 07/01/07 29905 A0041 " 1,548.35 " 07/01/07 29906 A0041 " 1,548.35 " 07/01/07 29907 A0042 " 2,461.32 " 01/01/08 30020 A0251 132.63 07/01/07 31000 A0251 132.63 07/01/07 31002 A0252 408.45 07/01/07 31040 A0254 " 1,261.96 " 07/01/07 31231 A0072 76.02 07/01/07 31502 A0121 127.58 07/01/07 32421 A0070 196.05 07/01/07 32422 A0070 196.05 07/01/07 32550 A0652 " 1,597.96 " 01/01/08 32551 A0070 196.05 07/01/07 32560 A0070 196.05 07/01/07 33208 A0655 " 8,256.54 " 07/01/07 33210 A0106 " 3,183.81 " 07/01/07 33215 A0105 " 1,385.52 " 07/01/07 33225 A0418 " 16,621.49 " 07/01/07 33226 A0105 " 1,385.52 " 07/01/07 33234 A0105 " 1,385.52 " 07/01/07 33235 A0105 " 1,385.52 " 07/01/07 33241 A0105 " 1,385.52 " 07/01/07 33244 A0105 " 1,385.52 " 07/01/07 35180 A0093 " 1,236.82 " 07/01/07 35184 A0093 " 1,236.82 " 07/01/07 35190 A0093 " 1,236.82 " 07/01/07 35201 A0093 " 1,236.82 " 07/01/07 35206 A0093 " 1,236.82 " 07/01/07 35226 A0093 " 1,236.82 " 07/01/07 35231 A0093 " 1,236.82 " 07/01/07 35236 A0093 " 1,236.82 " 07/01/07 35256 A0093 " 1,236.82 " 07/01/07 35261 A0653 " 1,751.59 " 07/01/07 35266 A0653 " 1,751.59 " 07/01/07 35286 A0653 " 1,751.59 " 07/01/07 35321 A0093 " 1,236.82 " 07/01/07 35458 A0081 " 2,322.49 " 07/01/07 35459 A0081 " 2,322.49 " 07/01/07 35460 A0081 " 2,322.49 " 07/01/07 35470 A0081 " 2,322.49 " 07/01/07 35471 A0081 " 2,322.49 " 07/01/07 35472 A0081 " 2,322.49 " 07/01/07 35473 A0081 " 2,322.49 " 07/01/07 35474 A0081 " 2,322.49 " 07/01/07 35475 A0081 " 2,322.49 " 07/01/07 35476 A0081 " 2,322.49 " 07/01/07 35484 A0081 " 2,322.49 " 07/01/07 35485 A0081 " 2,322.49 " 07/01/07 35490 A0081 " 2,322.49 " 07/01/07 35491 A0081 " 2,322.49 " 07/01/07 35492 A0081 " 2,322.49 " 07/01/07 35493 A0081 " 2,322.49 " 07/01/07 35494 A0081 " 2,322.49 " 07/01/07 35495 A0081 " 2,322.49 " 07/01/07 35903 A0115 " 1,580.20 " 07/01/07 36420 A0035 10.82 07/01/07 36425 A0035 10.82 07/01/07 36430 A0110 187.07 07/01/07 36450 A0110 187.07 07/01/07 36455 A0110 187.07 07/01/07 36460 A0110 187.07 07/01/07 36511 A0111 633.60 07/01/07 36512 A0111 633.60 07/01/07 36513 A0111 633.60 07/01/07 36514 A0111 633.60 07/01/07 36515 A0112 " 1,634.82 " 07/01/07 36516 A0112 " 1,634.82 " 07/01/07 36597 A0621 475.17 07/01/07 37201 A0676 112.11 07/01/07 37202 A0676 112.11 07/01/07 37203 A0103 878.32 07/01/07 37204 A0115 " 1,580.20 " 07/01/07 37205 A0229 " 3,703.66 " 07/01/07 37207 A0229 " 3,703.66 " 07/01/07 37620 A0091 " 1,878.54 " 07/01/07 37765 A0092 " 1,345.85 " 07/01/07 37766 A0092 " 1,345.85 " 07/01/07 38120 A0131 " 2,355.64 " 07/01/07 38205 A0111 633.60 07/01/07 * 38206 A0111 633.60 07/01/07 * 38221 A0003 129.88 07/01/07 38230 A0123 " 1,101.21 " 07/01/07 * 38240 A0123 " 1,101.21 " 07/01/07 * 38241 A0123 " 1,101.21 " 07/01/07 * 38720 A0113 " 1,150.11 " 07/01/07 39400 A0069 " 1,727.92 " 07/01/07 40490 A0251 132.63 07/01/07 40702 A0256 " 2,066.26 " 07/01/07 40806 A0251 132.63 07/01/07 40820 A0253 888.54 07/01/07 41019 A0254 " 1,261.96 " 07/01/07 41100 A0252 408.45 07/01/07 41105 A0253 888.54 07/01/07 41108 A0252 408.45 07/01/07 41110 A0253 888.54 07/01/07 41115 A0252 408.45 07/01/07 42100 A0252 408.45 07/01/07 42104 A0253 888.54 07/01/07 42106 A0253 888.54 07/01/07 42225 A0256 " 2,066.26 " 07/01/07 42227 A0256 " 2,066.26 " 07/01/07 42800 A0252 408.45 07/01/07 42842 A0254 " 1,261.96 " 07/01/07 42844 A0256 " 2,066.26 " 07/01/07 43280 A0132 " 3,813.83 " 07/01/07 43830 A0422 " 1,393.15 " 07/01/07 43831 A0141 449.91 07/01/07 44206 A0132 " 3,813.83 " 07/01/07 44207 A0132 " 3,813.83 " 07/01/07 44208 A0132 " 3,813.83 " 07/01/07 44238 A0130 " 1,737.65 " 07/01/07 44970 A0131 " 2,355.64 " 07/01/07 45300 A0146 263.33 07/01/07 45303 A0147 462.36 07/01/07 45330 A0146 263.33 07/01/07 45520 A0098 58.41 07/01/07 45541 A0150 " 1,602.14 " 07/01/07 46070 A0155 689.07 07/01/07 46083 A0164 115.72 07/01/07 46221 A0148 274.62 07/01/07 46320 A0155 689.07 07/01/07 46500 A0155 689.07 07/01/07 46934 A0155 689.07 07/01/07 46945 A0155 689.07 07/01/07 47382 A0423 " 2,020.89 " 07/01/07 47562 A0131 " 2,355.64 " 07/01/07 47563 A0131 " 2,355.64 " 07/01/07 47564 A0131 " 2,355.64 " 07/01/07 48511 A0037 555.28 07/01/07 49021 A0037 555.28 07/01/07 49041 A0037 555.28 07/01/07 49061 A0037 555.28 07/01/07 49323 A0130 " 1,737.65 " 07/01/07 49329 A0130 " 1,737.65 " 07/01/07 * 49423 A0427 630.57 07/01/07 49429 A0105 " 1,385.52 " 07/01/07 49491 A0154 " 1,580.46 " 07/01/07 49492 A0154 " 1,580.46 " 07/01/07 49659 A0130 " 1,737.65 " 07/01/07 * 50020 A0162 " 1,291.17 " 07/01/07 50021 A0037 555.28 07/01/07 50080 A0429 " 2,331.38 " 07/01/07 50081 A0429 " 2,331.38 " 07/01/07 50391 A0126 58.89 07/01/07 50541 A0130 " 1,737.65 " 07/01/07 50542 A0132 " 3,813.83 " 07/01/07 50543 A0131 " 2,355.64 " 07/01/07 50544 A0130 " 1,737.65 " 07/01/07 50562 A0160 351.33 07/01/07 50590 A0169 " 2,355.14 " 07/01/07 50945 A0131 " 2,355.64 " 07/01/07 51100 A0164 115.72 07/01/07 51101 A0126 58.89 07/01/07 51102 A0165 982.73 07/01/07 51700 A0164 115.72 07/01/07 51720 A0164 115.72 07/01/07 51725 A0163 " 1,889.22 " 07/01/07 51784 A0126 58.89 07/01/07 51990 A0131 " 2,355.64 " 07/01/07 52649 A0429 " 2,331.38 " 07/01/07 53600 A0156 184.34 07/01/07 53601 A0126 58.89 07/01/07 53620 A0165 982.73 07/01/07 53621 A0164 115.72 07/01/07 53660 A0126 58.89 07/01/07 53661 A0126 58.89 07/01/07 54692 A0132 " 3,813.83 " 07/01/07 55000 A0004 111.90 07/01/07 55450 A0183 " 1,272.83 " 07/01/07 55860 A0165 982.73 07/01/07 56405 A0189 156.68 07/01/07 56420 A0188 69.78 07/01/07 56501 A0017 943.48 07/01/07 56605 A0019 221.34 07/01/07 56805 A0193 803.20 07/01/07 56820 A0188 69.78 07/01/07 56821 A0189 156.68 07/01/07 57022 A0007 603.31 07/01/07 57061 A0194 " 1,109.32 " 07/01/07 57100 A0192 360.21 07/01/07 57106 A0194 " 1,109.32 " 07/01/07 57310 A0202 " 2,325.38 " 07/01/07 57320 A0195 " 1,542.13 " 07/01/07 57330 A0195 " 1,542.13 " 07/01/07 57420 A0189 156.68 07/01/07 57421 A0189 156.68 07/01/07 57452 A0188 69.78 07/01/07 57454 A0189 156.68 07/01/07 57455 A0189 156.68 07/01/07 57456 A0189 156.68 07/01/07 57500 A0189 156.68 07/01/07 57505 A0189 156.68 07/01/07 57510 A0193 803.20 07/01/07 57511 A0188 69.78 07/01/07 57555 A0195 " 1,542.13 " 07/01/07 57800 A0193 803.20 07/01/07 58100 A0188 69.78 07/01/07 58301 A0188 69.78 07/01/07 58356 A0202 " 2,325.38 " 07/01/07 58552 A0131 " 2,355.64 " 07/01/07 58553 A0131 " 2,355.64 " 07/01/07 58554 A0131 " 2,355.64 " 07/01/07 58570 A0131 " 2,355.64 " 07/01/07 58571 A0131 " 2,355.64 " 07/01/07 58572 A0131 " 2,355.64 " 07/01/07 58573 A0131 " 2,355.64 " 07/01/07 58578 A0130 " 1,737.65 " 07/01/07 * 58600 A0195 " 1,542.13 " 07/01/07 58615 A0194 " 1,109.32 " 07/01/07 58679 A0130 " 1,737.65 " 07/01/07 * 58823 A0193 803.20 07/01/07 58920 A0195 " 1,542.13 " 07/01/07 58925 A0195 " 1,542.13 " 07/01/07 59000 A0198 76.93 07/01/07 59074 A0198 76.93 07/01/07 59150 A0131 " 2,355.64 " 07/01/07 59151 A0131 " 2,355.64 " 07/01/07 60100 A0004 111.90 07/01/07 60210 A0114 " 2,040.47 " 07/01/07 60212 A0114 " 2,040.47 " 07/01/07 60220 A0114 " 2,040.47 " 07/01/07 60225 A0114 " 2,040.47 " 07/01/07 60240 A0114 " 2,040.47 " 07/01/07 60252 A0256 " 2,066.26 " 07/01/07 60260 A0256 " 2,066.26 " 07/01/07 60500 A0256 " 2,066.26 " 07/01/07 63030 A0208 " 2,388.09 " 07/01/07 64612 A0204 122.32 07/01/07 * 64613 A0204 122.32 07/01/07 * 64614 A0204 122.32 07/01/07 * 65222 A0698 62.79 07/01/07 65436 A0233 823.60 07/01/07 66761 A0247 275.00 07/01/07 67041 A0672 " 2,024.61 " 01/01/08 67042 A0672 " 2,024.61 " 01/01/08 67043 A0672 " 2,024.61 " 01/01/08 67101 A0236 893.81 07/01/07 67105 A0248 275.01 07/01/07 67110 A0236 893.81 07/01/07 67145 A0248 275.01 07/01/07 67228 A0248 275.01 07/01/07 67229 A0247 275.00 07/01/07 67500 A0231 116.04 07/01/07 67505 A0238 156.61 07/01/07 67515 A0238 156.61 07/01/07 67700 A0238 156.61 07/01/07 67710 A0239 393.89 07/01/07 67800 A0238 156.61 07/01/07 67801 A0239 393.89 07/01/07 67805 A0238 156.61 07/01/07 67810 A0238 156.61 07/01/07 67840 A0239 393.89 07/01/07 67850 A0239 393.89 07/01/07 67875 A0239 393.89 07/01/07 67930 A0240 926.29 07/01/07 67938 A0698 62.79 07/01/07 68100 A0232 328.19 07/01/07 68110 A0699 778.09 07/01/07 68801 A0698 62.79 07/01/07 68840 A0698 62.79 07/01/07 69000 A0006 77.84 07/01/07 69433 A0252 408.45 07/01/07 69540 A0253 888.54 07/01/07 70170 A0264 160.04 07/01/07 70557 A0336 306.94 07/01/07 70558 A0284 331.21 07/01/07 70559 A0337 438.98 07/01/07 72291 A0274 138.17 07/01/07 73530 A0261 66.12 07/01/07 74190 A0264 160.04 07/01/07 74235 A0257 59.36 07/01/07 74300 A0263 91.72 07/01/07 74301 A0263 91.72 07/01/07 74305 A0263 91.72 07/01/07 74340 A0272 69.82 07/01/07 74355 A0263 91.72 07/01/07 74360 A0257 59.36 07/01/07 74363 A0297 196.85 07/01/07 74420 A0278 130.68 07/01/07 74425 A0278 130.68 07/01/07 74445 A0278 130.68 07/01/07 74450 A0278 130.68 07/01/07 74470 A0263 91.72 07/01/07 74775 A0278 130.68 07/01/07 75801 A0264 160.04 07/01/07 75803 A0264 160.04 07/01/07 75805 A0264 160.04 07/01/07 75807 A0264 160.04 07/01/07 75810 A0279 514.20 07/01/07 75894 A0298 453.86 07/01/07 75896 A0298 453.86 07/01/07 75898 A0263 91.72 07/01/07 75940 A0298 453.86 07/01/07 75945 A0267 133.10 07/01/07 75960 A0668 337.88 07/01/07 75970 A0668 337.88 07/01/07 75980 A0297 196.85 07/01/07 75992 A0668 337.88 07/01/07 75993 A0668 337.88 07/01/07 75994 A0668 337.88 07/01/07 75995 A0668 337.88 07/01/07 75996 A0668 337.88 07/01/07 76125 A0260 38.37 07/01/07 76932 A0301 120.60 07/01/07 76940 A0268 64.28 07/01/07 76941 A0268 64.28 07/01/07 76945 A0268 64.28 07/01/07 76975 A0266 84.42 07/01/07 76998 A0266 84.42 07/01/07 77013 A0333 261.84 07/01/07 77022 A0335 246.24 07/01/07 77401 A0300 80.19 07/01/07 77402 A0300 80.19 07/01/07 77403 A0300 80.19 07/01/07 77404 A0300 80.19 07/01/07 77406 A0300 80.19 07/01/07 77407 A0300 80.19 07/01/07 77408 A0300 80.19 07/01/07 77409 A0300 80.19 07/01/07 77411 A0301 120.60 07/01/07 77412 A0301 120.60 07/01/07 77413 A0301 120.60 07/01/07 77414 A0301 120.60 07/01/07 77416 A0301 120.60 07/01/07 77417 A0260 38.37 07/01/07 77418 A0412 296.05 07/01/07 79445 A0407 171.90 07/01/07 91034 A0361 210.35 07/01/07 92953 A0094 131.08 07/01/07 92960 A0679 298.77 07/01/07 92980 A0104 " 4,744.85 " 07/01/07 92982 A0083 " 3,180.08 " 07/01/07 92986 A0083 " 3,180.08 " 07/01/07 92990 A0083 " 3,180.08 " 07/01/07 92997 A0081 " 2,322.49 " 07/01/07 93303 A0269 173.92 07/01/07 93304 A0697 86.40 07/01/07 93307 A0269 173.92 07/01/07 93308 A0697 86.40 07/01/07 93312 A0270 338.10 07/01/07 93315 A0270 338.10 07/01/07 93318 A0270 338.10 07/01/07 93350 A0269 173.92 07/01/07 93501 A0080 " 2,004.73 " 07/01/07 93503 A0103 878.32 07/01/07 93505 A0103 878.32 07/01/07 93508 A0080 " 2,004.73 " 07/01/07 93510 A0080 " 2,004.73 " 07/01/07 93526 A0080 " 2,004.73 " 07/01/07 93531 A0080 " 2,004.73 " 07/01/07 93532 A0080 " 2,004.73 " 07/01/07 93533 A0080 " 2,004.73 " 07/01/07 93571 A0670 " 1,746.38 " 07/01/07 93580 A0434 " 4,764.02 " 07/01/07 93615 A0087 " 1,779.55 " 07/01/07 93616 A0087 " 1,779.55 " 07/01/07 93618 A0087 " 1,779.55 " 07/01/07 93619 A0085 " 1,854.31 " 07/01/07 93620 A0085 " 1,854.31 " 07/01/07 93624 A0085 " 1,854.31 " 07/01/07 93650 A0086 " 2,568.99 " 07/01/07 93651 A0086 " 2,568.99 " 07/01/07 93652 A0086 " 2,568.99 " 07/01/07 93660 A0101 231.34 07/01/07 93701 A0099 20.50 07/01/07 93741 A0689 32.47 07/01/07 93742 A0689 32.47 07/01/07 93743 A0689 32.47 07/01/07 93880 A0267 133.10 07/01/07 93922 A0096 82.77 07/01/07 93971 A0266 84.42 07/01/07 93976 A0267 133.10 07/01/07 95951 A0209 608.34 07/01/07 G0339 A0067 " 3,428.12 " 07/01/07 G0340 A0066 " 2,327.56 " 07/01/07 "* 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."