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Acute Care Local Procedure Code Table

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Acute Care Local Procedure Code Table Powered By Docstoc
					                                                           Acute Care Local Procedure Code Table

Effective for dates of service on or after October 16, 2003, the following Medicaid local codes will be discontinued. Providers must bill using the national codes or
revenue codes indicated in the following table:

Local Code      Description                             Local Code National Code           Description                       National Code Comments
                                                            Pricing                                                                 Pricing
001MT           Nonemergency transportation:                                                                                                Discontinued
                for profit transportation provider
002MT           Nonemergency transportation:                                                                                                   Discontinued
                bus, intra city
003MT           Nonemergency transportation:                                                                                                   Discontinued
                bus, intra city special transit
                (demand responsive)
004MT           Nonemergency transportation:                                                                                                   Discontinued
                per mile, volunteer, interested
                individual, neighbor
005MT           Nonemergency transportation:                                                                                                   Discontinued
                air travel (private or commercial)
                intra or interstate
006MT           Nonemergency transportation:                                                                                                   Discontinued
                bus, intra or interstate carrier
007MT           Nonemergency transportation:                                                                                                   Discontinued
                shuttle
008MT           Nonemergency transportation:                                                                                                   Discontinued
                ancillary, travel expenses,
                lodging
0094X           Anesthesia for pelvic exam                3.00 RVUs 940                    Anesthesia for vaginal                 3.00 RVUs
                                                                                           procedures (including biopsy
                                                                                           of labia, vagina, cervix, or
                                                                                           endometrium); not otherwise
                                                                                           specified
0095X           Anesthesia for bone marrow                                                                                                     Discontinued
                transplant
0097X           Services provided by                                                                                                           Discontinued
                anesthesiologist assistant under
                supervision of an
                anesthesiologist
0099Y           Home health services                                                                                                           Discontinued
0999Y           Anesthesia services                                                                                                            Discontinued; TOS C
1000D   Appliance with horizontal         $250.00 D8220   Fixed appliance therapy       $250.00 Refer to the THSteps
        projections                                                                             Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1000X   MR/RC service coordination, per   $177.36 G9012   Other specified case          $177.36
        consumer, per month                               management service not
                                                          elsewhere classified
1001D   Appliance with recurved springs   $250.00 D8220   Fixed appliance therapy       $250.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.


1001X   MH service coordination (for      $142.17 G9012   Other specified case          $142.17
        people between the ages of 0                      management service not
        and 17 years), per consumer,                      elsewhere classified
        per month
1002D   Arch wires for crossbite          $595.00 D8220   Fixed appliance therapy       $595.00 Refer to the THSteps
        correction, for total treatment                                                         Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1002X   MH service coordination, (for     $112.53 G9012   Other specified case          $112.53
        people aged 18 and older), per                    management service not
        consumer, per month                               elsewhere classified
1003D   Banded maxillary expansion        $375.00 D8220   Fixed appliance therapy       $375.00 Refer to the THSteps
        appliance                                                                               Dental articles, beginning
                                                                                                on page 24, of the bulletin.


1004D   Bite plate/bite plane             $100.00 D8210   Removable appliance therapy   $100.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1005D   Bionator                          $100.00 D8210   Removable appliance therapy   $100.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1006D   Bite block                        $250.00 D8210   Removable appliance therapy   $250.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1007D   Bite plate with push springs      $250.00 D8210   Removable appliance therapy   $250.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.
1008D   Bonded expansion device              $225.00 D8220   Fixed appliance therapy       $225.00 Refer to the THSteps
                                                                                                   Dental articles, beginning
                                                                                                   on page 24, of the bulletin.

1009D   Brackets                              $20.00 D8690   Orthodontic treatment          $20.00
                                                             (alternative billing to a
                                                             contract fee)

1010D   Chateau appliance (face mask,        $275.00 D8210   Removable appliance therapy   $275.00 Refer to the THSteps
        palatal expander, and hawley)                                                              Dental articles, beginning
                                                                                                   on page 24, of the bulletin.

1011D   Coffin spring appliance              $275.00 D8210   Removable appliance therapy   $275.00 Refer to the THSteps
                                                                                                   Dental articles, beginning
                                                                                                   on page 24, of the bulletin.

1012D   Crib                                 $100.00 D8220   Fixed appliance therapy       $100.00 Refer to the THSteps
                                                                                                   Dental articles, beginning
                                                                                                   on page 24, of the bulletin.


1013D   Dental obturator, definitive         $250.00 D8210   Removable appliance therapy   $250.00 Refer to the THSteps
        (obturator)                                                                                Dental articles, beginning
                                                                                                   on page 24, of the bulletin.

1014D   Dental obturator, surgical           $250.00 D8210   Removable appliance therapy   $250.00 Refer to the THSteps
        (obturator surgical stayplate                                                              Dental articles, beginning
        immediate temporary obturator)                                                             on page 24, of the bulletin.


1015D   Distalizing appliance with springs   $250.00 D8220   Fixed appliance therapy       $250.00 Refer to the THSteps
                                                                                                   Dental articles, beginning
                                                                                                   on page 24, of the bulletin.


1016D   Expansion device                     $375.00 D8220   Fixed appliance therapy       $375.00 Refer to the THSteps
                                                                                                   Dental articles, beginning
                                                                                                   on page 24, of the bulletin.


1017D   Face mask (protraction mask)         $350.00 D8210   Removable appliance therapy   $350.00 Refer to the THSteps
                                                                                                   Dental articles, beginning
                                                                                                   on page 24, of the bulletin.
1018D   Fixed expansion appliance         $375.00 D8220   Fixed appliance therapy       $375.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1019D   Fixed lingual arch                $225.00 D8220   Fixed appliance therapy       $225.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.


1020D   Fixed mandibular holding arch     $100.00 D8220   Fixed appliance therapy       $100.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1021D   Fixed rapid palatal expander      $375.00 D8220   Fixed appliance therapy       $375.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.


1022D   Frankel appliance                 $100.00 D8210   Removable appliance therapy   $100.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1023D   Functional appliance for          $375.00 D8210   Removable appliance therapy   $375.00 Refer to the THSteps
        reduction of anterior open bite                                                         Dental articles, beginning
        and crossbite                                                                           on page 24, of the bulletin.


1024D   Head gear (face bow)              $150.00 D8210   Removable appliance therapy   $150.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1025D   Herbst appliance, fixed or        $250.00 D8220   Fixed appliance therapy       $250.00 Refer to the THSteps
        removable                                                                               Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1026D   Interocclusal cast cap surgical   $375.00 D8220   Fixed appliance therapy       $375.00 Refer to the THSteps
        splints                                                                                 Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1027D   Intrusion arch                    $100.00 D8210   Removable appliance therapy   $100.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.
1028D   Jasper jumpers                      $100.00 D8220   Fixed appliance therapy       $100.00 Refer to the THSteps
                                                                                                  Dental articles, beginning
                                                                                                  on page 24, of the bulletin.

1029D   Lingual appliance with hooks        $100.00 D8220   Fixed appliance therapy       $100.00 Refer to the THSteps
                                                                                                  Dental articles, beginning
                                                                                                  on page 24, of the bulletin.

1030D   Mandibular anterior bridge          $175.00 D8220   Fixed appliance therapy       $175.00 Refer to the THSteps
                                                                                                  Dental articles, beginning
                                                                                                  on page 24, of the bulletin.

1031D   Mandibular bihelix, similar to      $100.00 D8220   Fixed appliance therapy       $100.00 Refer to the THSteps
        quad helix for mandibular                                                                 Dental articles, beginning
        expansion to attempt                                                                      on page 24, of the bulletin.
        nonextraction

1032D   Mandibular lip bumper               $100.00 D8210   Removable appliance therapy   $100.00 Refer to the THSteps
                                                                                                  Dental articles, beginning
                                                                                                  on page 24, of the bulletin.


1036D   Mandibular lingual, 6 x 6 arch      $125.00 D8220   Fixed appliance therapy       $125.00 Refer to the THSteps
        wire                                                                                      Dental articles, beginning
                                                                                                  on page 24, of the bulletin.

1037D   Mandibular removable expander       $275.00 D8210   Removable appliance therapy   $275.00 Refer to the THSteps
        with bite plane, crozat                                                                   Dental articles, beginning
                                                                                                  on page 24, of the bulletin.

1038D   Mandibular ricketts rest position   $375.00 D8210   Removable appliance therapy   $375.00 Refer to the THSteps
        splint                                                                                    Dental articles, beginning
                                                                                                  on page 24, of the bulletin.

1039D   Mandibular splint                   $225.00 D8210   Removable appliance therapy   $225.00 Refer to the THSteps
                                                                                                  Dental articles, beginning
                                                                                                  on page 24, of the bulletin.

1040D   Maxillary anterior bridge           $175.00 D8210   Removable appliance therapy   $175.00 Refer to the THSteps
                                                                                                  Dental articles, beginning
                                                                                                  on page 24, of the bulletin.
1041D   Maxillary bite-opening              $100.00 D8210   Removable appliance therapy       $100.00 Refer to the THSteps
        appliance, with anterior springs                                                              Dental articles, beginning
                                                                                                      on page 24, of the bulletin.


1042D   Maxillary lingual arch with spurs   $100.00 D8220   Fixed appliance therapy           $100.00 Refer to the THSteps
                                                                                                      Dental articles, beginning
                                                                                                      on page 24, of the bulletin.

1043D   Maxillary-mandibular distallizing   $100.00 D8220   Fixed appliance therapy           $100.00 Refer to the THSteps
        appliance                                                                                     Dental articles, beginning
                                                                                                      on page 24, of the bulletin.


1044D   Maxillary quad helix with finger    $325.00 D8220   Fixed appliance therapy           $325.00 Refer to the THSteps
        springs                                                                                       Dental articles, beginning
                                                                                                      on page 24, of the bulletin.


1044X   Navelbine (vinorelbine), per cc      $47.00 J9390   Vinorelbine tartrate, per 10 mg    $85.47 Refer to the THSteps
                                                                                                      Dental articles, beginning
                                                                                                      on page 24, of the bulletin.


1045D   Maxillary retainer with pontics     $175.00 D8220   Fixed appliance therapy           $175.00 Refer to the THSteps
                                                                                                      Dental articles, beginning
                                                                                                      on page 24, of the bulletin.

1046D   Maxillary schwarz                   $250.00 D8210   Removable appliance therapy       $250.00 Refer to the THSteps
                                                                                                      Dental articles, beginning
                                                                                                      on page 24, of the bulletin.

1046X   Gamimune, 5 percent, 2.5 g          $142.80 J1563   Injection, immune globulin,        $68.02 Refer to the THSteps
                                                            intravenous, 1 g                          Dental articles, beginning
                                                                                                      on page 24, of the bulletin.

1047D   Maxillary splint                    $225.00 D8210   Removable appliance therapy       $225.00 Refer to the THSteps
                                                                                                      Dental articles, beginning
                                                                                                      on page 24, of the bulletin.


1048D   Mobile intraoral arch-mia           $100.00 D8210   Removable appliance therapy       $100.00 Refer to the THSteps
                                                                                                      Dental articles, beginning
                                                                                                      on page 24, of the bulletin.
1048X   Sandoglobulin, 3 g               $133.20 J1563   Injection, immune globulin,          $68.02
                                                         intravenous, 1 g

1049D   Modified quad helix appliance    $275.00 D8220   Fixed appliance therapy             $275.00 Refer to the THSteps
                                                                                                     Dental articles, beginning
                                                                                                     on page 24, of the bulletin.

1050D   Modified quad helix appliance    $275.00 D8220   Fixed appliance therapy             $275.00 Refer to the THSteps
        with appliance                                                                               Dental articles, beginning
                                                                                                     on page 24, of the bulletin.


1050X   Individual counseling services    $53.86 90806   Individual psychotherapy,            $64.10
        by LMSW-ACP and LPCs, per                        insight-oriented, behavior
        hour                                             modifying and/or support, in
                                                         an office or outpatient facility,
                                                         approximately 45 minutes,
                                                         face-to-face with patient

1051D   Nance appliance                  $100.00 D8220   Fixed appliance therapy             $100.00 Refer to the THSteps
                                                                                                     Dental articles, beginning
                                                                                                     on page 24, of the bulletin.

1051X   Group counseling services by      $13.47 90853   Group psychotherapy, other           $19.64
        LMSW-ACPs and LPCs, per                          than of a multiple-family group
        hour
1052D   Nasal stent                      $250.00 D8220   Fixed appliance therapy             $250.00 Refer to the THSteps
                                                                                                     Dental articles, beginning
                                                                                                     on page 24, of the bulletin.

1052X   Family counseling services by     $53.84 90847   Family psychotherapy,                $76.92
        LMSW-ACP and LPCs, per hour                      conjoint psychotherapy, with
                                                         patient present

1053D   Occlusal orthotic device         $175.00 D8210   Removable appliance therapy         $175.00 Refer to the THSteps
                                                                                                     Dental articles, beginning
                                                                                                     on page 24, of the bulletin.


1053X   RHO (D) immune globulin          $127.09 J2790   Injection, RHO D immune             $126.14
        (RHIG), human, per 120 mcg                       globulin, human, one dose
        (600 IU)                                         package
1054D   Orthopedic appliance             $250.00 D8210   Removable appliance therapy         $250.00 Refer to the THSteps
                                                                                                     Dental articles, beginning
                                                                                                     on page 24, of the bulletin.
1054X   RHO (D) immune globulin           $290.43 J2790   Injection, RHO D immune       $126.14
        (RHIG), human, per 300 mcg                        globulin, human, one dose
        (1,500 IU)                                        package

1055D   Other mandibular utilities        $100.00 D8210   Removable appliance therapy   $100.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1056D   Other maxillary utilities         $100.00 D8210   Removable appliance therapy   $100.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.


1057D   Palatal bar                       $225.00 D8220   Fixed appliance therapy       $225.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1058D   Post-surgical retainer            $125.00 D8210   Removable appliance therapy   $125.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.


1059D   Quad helix appliance held with    $275.00 D8220   Fixed appliance therapy       $275.00 Refer to the THSteps
        transpalatal arch horizontal                                                            Dental articles, beginning
        projections                                                                             on page 24, of the bulletin.

1060D   Quad helix maintainer             $275.00 D8220   Fixed appliance therapy       $275.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1061D   Rapid palatal expander RPE i.e.   $350.00 D8220   Fixed appliance therapy       $350.00 Refer to the THSteps
        quad helix, haas, or menne                                                              Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1062D   Removable bite plate              $100.00 D8210   Removable appliance therapy   $100.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1063D   Removable mandibular retainer     $100.00 D8210   Removable appliance therapy   $100.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.
1064D   Removable maxillary retainer      $100.00 D8210   Removable appliance therapy   $100.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.


1065D   Removable prosthesis              $175.00 D8210   Removable appliance therapy   $175.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1065X   Injection, baclofen, 2 ampules;   $382.21 J0475   Injection, baclofen, 10 mg    $209.16
        10 mg/5 mL
1066D   Sagittal appliance, 2-way         $250.00 D8210   Removable appliance therapy   $250.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1066X   Injection, baclofen, 4 ampules;   $695.49 J0475   Injection, baclofen, 10 mg    $209.16
        10 mg/5 mL
1067D   Sagittal appliance, 3-way         $350.00 D8210   Removable appliance therapy   $350.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1068D   Stapled palatal expansion         $375.00 D8220   Fixed appliance therapy       $375.00 Refer to the THSteps
        appliance                                                                               Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1068X   RHO (D) immune globulin           $119.93 J2790   Injection, RHO D immune       $126.14 Bill the appropriate
        (RHIG), human, per 120 mcg                        globulin, human, one dose             quantity based on the
        (600 IU)                                          package                               dosage administered.
1069D   Surgical arch wires               $250.00 D8210   Removable appliance therapy   $250.00 Refer to the THSteps
                                                                                                Dental articles, beginning
                                                                                                on page 24, of the bulletin.

1069X   RHO (D) immune globulin           $273.87 J2790   Injection, RHO D immune       $126.14 Bill the appropriate
        (RHIG), human, per 300 mcg                        globulin, human, one dose             quantity based on the
        (1500 IU)                                         package                               dosage administered.
1070D   Surgical splints (surgical        $250.00 D8210   Removable appliance therapy   $250.00 Refer to the THSteps
        stent/wafer)                                                                            Dental articles, beginning
                                                                                                on page 24, of the bulletin.


1070X   RHO (D) immune globulin           $912.90 J2790   Injection, RHO D immune       $126.14 Bill the appropriate
        (RHIG), human, per 1,000 mcg                      globulin, human, one dose             quantity based on the
        (5,000 IU)                                        package                               dosage administered.
1071D   Surgical stabilizing appliance     $250.00 D8210   Removable appliance therapy       $250.00 Refer to the THSteps
                                                                                                     Dental articles, beginning
                                                                                                     on page 24, of the bulletin.


1071X   RHO (D) immune globulin,            $43.50 J2790   Injection, RHO D immune           $126.14 Bill the appropriate
        human, per dose, 50 mcg                            globulin, human, one dose                 quantity based on the
                                                           package                                   dosage administered.
1072D   Thumb-sucking appliance            $175.00 D8220   Fixed appliance therapy           $175.00 Refer to the THSteps
                                                                                                     Dental articles, beginning
                                                                                                     on page 24, of the bulletin.


1072X   Acyclovir sodium (Zovirax), 500     $43.01 S0071   Injection, acyclovir sodium, 50     $4.73 Bill the appropriate
        mg                                                 mg                                        quantity based on the
                                                                                                     dosage administered.
1073D   Tongue thrust appliance            $100.00 D8210   Removable appliance therapy       $100.00 Refer to the THSteps
                                                                                                     Dental articles, beginning
                                                                                                     on page 24, of the bulletin.


1074D   Tooth positioner (full maxillary   $325.00 D8210   Removable appliance therapy       $325.00 Refer to the THSteps
        and mandibular)                                                                              Dental articles, beginning
                                                                                                     on page 24, of the bulletin.


1074X   Marcaine (bupivacaine HCL), 5        $1.06 S0020   Injection, bupivicaine              $6.36 Bill the appropriate
        cc                                                 hydrochloride, 30 mL                      quantity based on the
                                                                                                     dosage administered.
1075D   Tooth positioner with arch         $100.00 D8210   Removable appliance therapy       $100.00 Refer to the THSteps
                                                                                                     Dental articles, beginning
                                                                                                     on page 24, of the bulletin.


1075X   Potassium phosphate, 5 mL vial                                                                Discontinued
        (4.4 mEq/mL)

1076D   Transpalatal arch                  $100.00 D8220   Fixed appliance therapy           $100.00 Refer to the THSteps
                                                                                                     Dental articles, beginning
                                                                                                     on page 24, of the bulletin.


1076X   Sincalide (kinevac), 1 mcg/mL                                                                 Discontinued
1077D   Two bands with transpalatal        $175.00 D8220   Fixed appliance therapy           $175.00 Refer to the THSteps
        arch and horizontal projections                                                              Dental articles, beginning
        forward                                                                                      on page 24, of the bulletin.
1077X   Sodium bicarbonate, 50 mEq or                                                                       Discontinued
        50 mL

1078D   W-appliance                           $275.00 D8220    Fixed appliance therapy            $275.00 Refer to the THSteps
                                                                                                          Dental articles, beginning
                                                                                                          on page 24, of the bulletin.


1078X   Stadol (butorphanol), 2 mg              $6.51 S0009    Injection, butorphanol tartrate,     $3.26 Bill the appropriate
                                                               1 mg                                       quantity based on the
                                                                                                          dosage administered.

1079X   Tagamet (cimetidine), 300 mg            $3.02 S0023    Injection, cimetidine                $3.02
                                                               hydrochloride, 300 mg
1083X   Rituxan carton (rituximab), 500      $1,778.81 J9310   Rituximab, 100 mg                  $406.81
        mg
1089X   Injection, betameth acetate and         $4.44 J0702    Injection, betamethasone             $3.48
        betameth sodium phosphate                              acetate and betamethasone
        (e.g., celestone soluspan); 6                          sodium phosphate, per 3 mg
        mg/mL, per mL
1092X   Injection, leuprolide acetate        $1,461.08 J9217   Leuprolide acetate (for depot      $547.34 Bill the appropriate
        (e.g., lupron depot), 3-month kit,                     suspension), 7.5 mg                        quantity based on the
        22.5 mg                                                                                           dosage administered.

1094X   Injection, leuprolide acetate        $1,946.31 J9217   Leuprolide acetate (for depot      $547.34 Bill the appropriate
        (e.g., lupron depot), 4-month kit,                     suspension), 7.5 mg                        quantity based on the
        30 mg                                                                                             dosage administered.
1150X   Individual counseling services         $53.86 90806    Individual psychotherapy,           $64.10
        by LMFT, per hour                                      insight-oriented, behavior-
                                                               modifying and/or supportive,
                                                               in an office facility or
                                                               outpatient facility,
                                                               approximately 45 to 50
                                                               minutes, face-to-face with
                                                               patient

1151X   Group counseling service by            $13.47 90853    Group psychotherapy, other          $19.64
        LMFT, per hour                                         than of a multiple-family group

1152X   Family counseling services by          $53.84 90847    Family psychotherapy,               $76.92
        LMFT, per hour                                         conjoint psychotherapy, with
                                                               patient present

1170Y   Omnipaque 240, 50 mL                                                                                Discontinued; not payable
                                                                                                            separately
1171Y   Optiray 240, 50 mL                   Discontinued; not payable
                                             separately

1172Y   Optiray 240, 100 mL                  Discontinued; not payable
                                             separately
1173Y   Isovue 200, 50 mL                    Discontinued; not payable
                                             separately

1174Y   Omnipaque 300, 50 mL                 Discontinued; not payable
                                             separately
1175Y   Omnipaque 300, 100 mL                Discontinued; not payable
                                             separately
1176Y   Omnipaque 350, 100 mL                Discontinued; not payable
                                             separately

1177Y   Optiray 320, 50 mL                   Discontinued; not payable
                                             separately
1178Y   Optiray 320, 100 mL                  Discontinued; not payable
                                             separately
1179Y   Isovue 300, 50 mL                    Discontinued; not payable
                                             separately
1180Y   Isovue 300, 100 mL                   Discontinued; not payable
                                             separately
1700Y   Second newborn                       Discontinued; not payable
        hered/metabolic testing,             separately
        completed elsewhere
1701Y   Second newborn                       Discontinued
        hered/metabolic testing,
        completed this visit, results
        pending
1702Y   Second newborn                       Discontinued
        hered/metabolic testing, normal
1703Y   Second newborn                       Discontinued
        hered/metabolic testing,
        abnormal
1999Y   Integumentary system                 Discontinued

2000V   HMO vas for members 21 years         Discontinued
        and older, first frame only
2001V   HMO vas for members 21 years         Discontinued
        and older, first frame with single
        lens
2002V   HMO vas for members 21 years          Discontinued
        and older, first frame with bifocal
        lens
2003V   HMO vas for members 21 years          Discontinued
        and older, first frame with
        trifocal lens

2004V   HMO vas for members 21 years          Discontinued
        and older, subsequent frame

2005V   HMO vas for members 21 years          Discontinued
        and older, upgraded frame
2012V   HMO vas polycarbonate lenses          Discontinued

2013V   HMO vas progressive bifocal           Discontinued
        lenses, pair

2014V   HMO vas antireflection coating,       Discontinued
        pair

2015V   HMO vas polaroid, pair                Discontinued
2016V   HMO vas scratchguard,                 Discontinued
        multifocal

2017V   HMO vas scratchguard, single          Discontinued
        vision
2018V   HMO vas ultraviolet coating           Discontinued
2019V   HMO vas premier frames                Discontinued
2020V   HMO vas frames                        Discontinued

2021V   HMO vas contact lens, pair            Discontinued
2022V   HMO vas lenticular lenses, pair       Discontinued

2023V   HMO vas trifocal lens, pair           Discontinued

2024V   HMO vas bifocal lenses, pair          Discontinued

2025V   HMO vas single vision lenses,         Discontinued
        pair

2026V   HMO vas exam by optometrist           Discontinued
2027V   HMO vas exam by                       Discontinued
        ophthalmologist

2028V   Frame up to $125.00 retail value      Discontinued
2029V   HMO vas zylonite frame with                                                                                        Discontinued
        polycarbonate single vision
        lenses

2030V   HMO vas zylonite frame with                                                                                        Discontinued
        polycarbonate bifocal vision
        lenses

2031V   HMO vas zylonite frame with                                                                                        Discontinued
        polycarbonate trifocal lenses

2032V   HMO vas unbreakable (nylon)                                                                                        Discontinued
        with standard clear glass
2033V   HMO vas sports glasses (plastic                                                                                    Discontinued
        or goggle type with standard
        clear or plastic sv lenses)

2069X   Preconstruction, application,                 TOS 2: 20692   Application of a multiplane       TOS 2: $329.88,
        adjustment and removal of           $3,146.50 TOS            (pins or wires in more than              $328.68,
        ilizarov device                       8: Not a benefit       one plane), unilateral,           $231.03; TOS 8:
                                                                     external fixation system (e.g.,      Not a benefit;
                                                                     ilizarov, monticelli type)          TOS F: 20693,
                                                                                                        20694 (Group 1)
                                                            and      and
                                                            20693    Adjustment or revision of
                                                                     external fixation system
                                                                     requiring anesthesia (e.g.,
                                                                     new pin[s] or wire[s] and/or
                                                                     new ring[s] or bar[s])
                                                            and      and
                                                            20694    Removal, under anesthesia,
                                                                     of external fixation system
                                                            and      and
                                                            20999    Unlisted procedure,
                                                                     musculoskeletal system

2347N   Nutritionist visit                           $30.00 S9470    Nutritional counseling,                     $30.45 Family Planning Program,
                                                                     dietitian visit                                    Title V, Program 300 only

2500Y   TB skin test administered this         Informational 86580   Skin test; tuberculosis,             Informational Refer to the THSteps
        visit, results pending or patient          procedure         intradermal                              procedure Medical section,
        did not return                                                                                                  beginning on page 53, of
                                                                                                                        the bulletin.
2501Y   Tuberculosis skin test                                                                           Discontinued
        administered, results negative

2502Y   Tuberculosis skin test                                                                           Discontinued
        administered, results positive
2503Y   Tuberculosis skin test                                                                           Discontinued
        questionnaire completed or skin
        test administered in last 11
        months

2504Y   Tuberculosis skin test                                                                           Discontinued
        administered and documented
        within past 11 months

2505Y   Tuberculosis skin test                                                                           Discontinued
        questionnaire completed and
        documented within the past 11
        months

2506Y   Tuberculosis skin test not                                                                       Discontinued
        administered, parental refusal or
        child uncooperative

2999Y   Musculoskeletal system                                                                           Discontinued

3002X   Outpatient group counseling,        $16.00 H0005        Alcohol and/or drug services;     $16.00 Bill the appropriate
        per hour                                                group counseling by a clinician          quantity in hours.

                                                  with          with
                                                  modifier HF   Substance abuse program
3003X   Outpatient individual counseling,   $47.00 H0004        Behavioral health counseling      $11.75 Bill the appropriate
        per hour                                                and therapy, per 15 minutes              quantity based on 15-
                                                                                                         minute increments
                                                                                                         (quantity 4 = 1 hour).
                                                  with          with
                                                  modifier HF   Substance abuse program
3064V   Pregnancy induced                                                                                Discontinued
        hypertension level 1

3100Y   Immunizations up to date                                                                         Discontinued

3101Y   No immunizations administered,                                                                   Discontinued
        medically contraindicated
32A0Y   Administration of DTP #1   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                 (includes percutaneous,                  Medical section,
                                                 intradermal, subcutaneous,               beginning on page 53, in
                                                 intramuscular, and jet                   the bulletin.
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90701    Diphtheria, tetanus toxoids,
                                                 and whole cell pertussis
                                                 vaccine (DTP), for
                                                 intramuscular use
32B0Y   Administration of DTP #2   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                 (includes percutaneous,                  Medical section,
                                                 intradermal, subcutaneous,               beginning on page 53, in
                                                 intramuscular, and jet                   the bulletin.
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90701    Diphtheria, tetanus toxoids,
                                                 and whole cell pertussis
                                                 vaccine (DTP), for
                                                 intramuscular use
32C0Y   Administration of DTP #3   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                 (includes percutaneous,                  Medical section,
                                                 intradermal, subcutaneous,               beginning on page 53, in
                                                 intramuscular, and jet                   the bulletin.
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure

                                        with     with
                                        90701    Diphtheria, tetanus toxoids,
                                                 and whole cell pertussis
                                                 vaccine (DTP), for
                                                 intramuscular use
32D0Y   Administration of DTP #4   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                 (includes percutaneous,                  Medical section,
                                                 intradermal, subcutaneous,               beginning on page 53, in
                                                 intramuscular, and jet                   the bulletin.
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90701    Diphtheria, tetanus toxoids,
                                                 and whole cell pertussis
                                                 vaccine (DTP), for
                                                 intramuscular use
32E0Y   Administration of DTP #5   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                 (includes percutaneous,                  Medical section,
                                                 intradermal, subcutaneous,               beginning on page 53, in
                                                 intramuscular, and jet                   the bulletin.
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                            or       or
                                            90472    Each additional vaccine
                                                     (single or combination
                                                     vaccine/toxoid), list separately
                                                     in addition to code for primary
                                                     procedure
                                            with     with
                                            90701    Diphtheria, tetanus toxoids,
                                                     and whole cell pertussis
                                                     vaccine (DTP), for
                                                     intramuscular use
3396X   Removal of cannula for       $127.79 33999   Unlisted procedure, cardiac        Manually
        prolonged extracorporeal                     surgery                            reviewed
        circulation for cardiopulm
        insufficiency
33A0Y   Administration of OPV #1       $5.00 90473   Immunization administration           $5.00 Refer to the THSteps
                                                     by intranasal or oral route;                Medical section,
                                                     one vaccine (single or                      beginning on page 53, in
                                                     combination vaccine/toxoid)                 the bulletin.
                                            or       or
                                            90474    Each additional vaccine
                                                     (single or combination
                                                     vaccine/toxoid), list separately
                                                     in addition to code for primary
                                                     procedure
                                            with     with
                                            90712    Poliovirus vaccine, (any
                                                     type[s]) (OPV), live, for oral
                                                     use
33B0Y   Administration of OPV #2       $5.00 90473   Immunization administration           $5.00 Refer to the THSteps
                                                     by intranasal or oral route;                Medical section,
                                                     one vaccine (single or                      beginning on page 53, in
                                                     combination vaccine/toxoid)                 the bulletin.
                                            or       or
                                            90474    Each additional vaccine
                                                     (single or combination
                                                     vaccine/toxoid), list separately
                                                     in addition to code for primary
                                                     procedure
                                            with     with
                                              90712    Poliovirus vaccine, (any
                                                       type[s]) (OPV), live, for oral
                                                       use
33C0Y   Administration of OPV #3         $5.00 90473   Immunization administration        $5.00 Refer to the THSteps
                                                       by intranasal or oral route;             Medical section,
                                                       one vaccine (single or                   beginning on page 53, in
                                                       combination vaccine/toxoid)              the bulletin.
                                              or       or
                                              90474    Each additional vaccine
                                                       (single or combination
                                                       vaccine/toxoid), list separately
                                                       in addition to code for primary
                                                       procedure
                                              with     with
                                              90712    Poliovirus vaccine, (any
                                                       type[s]) (OPV), live, for oral
                                                       use
33D0Y   Administration of OPV #4 (do     $5.00 90473   Immunization administration        $5.00 Refer to the THSteps
        not give prior to age 4)                       by intranasal or oral route;             Medical section,
                                                       one vaccine (single or                   beginning on page 53, in
                                                       combination vaccine/toxoid)              the bulletin.
                                              or       or
                                              90474    Each additional vaccine
                                                       (single or combination
                                                       vaccine/toxoid), list separately
                                                       in addition to code for primary
                                                       procedure
                                              with     with
                                              90712    Poliovirus vaccine, (any
                                                       type[s]) (OPV), live, for oral
                                                       use
33E0Y   Administration of OPV #5 (for    $5.00 90473   Immunization administration        $5.00 Refer to the THSteps
        children off current schedule)                 by intranasal or oral route;             Medical section,
                                                       one vaccine (single or                   beginning on page 53, in
                                                       combination vaccine/toxoid)              the bulletin.
                                              or       or
                                              90474    Each additional vaccine
                                                       (single or combination
                                                       vaccine/toxoid), list separately
                                                       in addition to code for primary
                                                       procedure
                                              with     with
                                              90712    Poliovirus vaccine, (any
                                                       type[s]) (OPV), live, for oral
                                                       use
34A0Y   Administration of DT/Td #1   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                   (includes percutaneous,                  Medical section,
                                                   intradermal, subcutaneous,               beginning on page 53, in
                                                   intramuscular, and jet                   the bulletin.
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine/toxoid), list separately
                                                   in addition to code for primary
                                                   procedure
                                          with     with
                                          90702    Diphtheria and tetanus
                                                   toxoids (DT) adsorbed for use
                                                   in individuals younger than 7
                                                   years, for intramuscular use

                                          or       or
                                          90718    Tetanus and diphtheria
                                                   toxoids (Td) adsorbed for use
                                                   in individuals 7 years or older,
                                                   for intramuscular or jet
                                                   injection
34B0Y   Administration of DT/Td #2   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                   (includes percutaneous,                  Medical section,
                                                   intradermal, subcutaneous,               beginning on page 53, in
                                                   intramuscular, and jet                   the bulletin.
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine/toxoid), list separately
                                                   in addition to code for primary
                                                   procedure
                                          with     with
                                          90702    Diphtheria and tetanus
                                                   toxoids (DT) adsorbed for use
                                                   in individuals younger than 7
                                                   years, for intramuscular use

                                          or       or
                                          90718    Tetanus and diphtheria
                                                   toxoids (Td) adsorbed for use
                                                   in individuals 7 years or older,
                                                   for intramuscular or jet
                                                   injection
34C0Y   Administration of DT/Td #3   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                   (includes percutaneous,                  Medical section,
                                                   intradermal, subcutaneous,               beginning on page 53, in
                                                   intramuscular, and jet                   the bulletin.
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine/toxoid), list separately
                                                   in addition to code for primary
                                                   procedure
                                          with     with
                                          90702    Diphtheria and tetanus
                                                   toxoids (DT) adsorbed for use
                                                   in individuals younger than 7
                                                   years, for intramuscular use

                                          or       or
                                          90718    Tetanus and diphtheria
                                                   toxoids (Td) adsorbed for use
                                                   in individuals 7 years or older,
                                                   for intramuscular or jet
                                                   injection
34D0Y   Administration of DT/Td #4   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                   (includes percutaneous,                  Medical section,
                                                   intradermal, subcutaneous,               beginning on page 53, in
                                                   intramuscular, and jet                   the bulletin.
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine/toxoid), list separately
                                                   in addition to code for primary
                                                   procedure
                                          with     with
                                          90702    Diphtheria and tetanus
                                                   toxoids (DT) adsorbed for use
                                                   in individuals younger than 7
                                                   years, for intramuscular use
                                          or       or
                                          90718    Tetanus and diphtheria
                                                   toxoids (Td) adsorbed for use
                                                   in individuals 7 years or older,
                                                   for intramuscular or jet
                                                   injection
34E0Y   Administration of DT/Td #5   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                   (includes percutaneous,                  Medical section,
                                                   intradermal, subcutaneous,               beginning on page 53, in
                                                   intramuscular, and jet                   the bulletin.
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine/toxoid), list separately
                                                   in addition to code for primary
                                                   procedure
                                          with     with
                                          90702    Diphtheria and tetanus
                                                   toxoids (DT) adsorbed for use
                                                   in individuals younger than 7
                                                   years, for intramuscular use

                                          or       or
                                          90718    Tetanus and diphtheria
                                                   toxoids (Td) adsorbed for use
                                                   in individuals 7 years or older,
                                                   for intramuscular or jet
                                                   injection
35A0Y   Administration of MMR #1     $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                   (includes percutaneous,                  Medical section,
                                                   intradermal, subcutaneous,               beginning on page 53, in
                                                   intramuscular, and jet                   the bulletin.
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine/toxoid), list separately
                                                   in addition to code for primary
                                                   procedure
                                          with     with
                                          90707    Measles, mumps, and rubella
                                                   virus vaccine (MMR), live, for
                                                   subcutaneous or jet injection
                                                   use
35B0Y   Administration of MMR #2     $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                   (includes percutaneous,                  Medical section,
                                                   intradermal, subcutaneous,               beginning on page 53, in
                                                   intramuscular, and jet                   the bulletin.
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine/toxoid), list separately
                                                   in addition to code for primary
                                                   procedure
                                          with     with
                                          90707    Measles, mumps, and rubella
                                                   virus vaccine (MMR), live, for
                                                   subcutaneous or jet injection
                                                   use
36A0Y   Administration of HibCV #1   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                   (includes percutaneous,                  Medical section,
                                                   intradermal, subcutaneous,               beginning on page 53, in
                                                   intramuscular, and jet                   the bulletin.
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine/toxoid), list separately
                                                   in addition to code for primary
                                                   procedure
                                          with     with
                                          90645    Haemophilus influenzae b
                                                   vaccine (Hib), HBOC
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use
                                          or       or
                                          90646    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-D
                                                   conjugate, for booster use
                                                   only, intramuscular use
                                          or       or
                                          90647    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-OMP
                                                   conjugate (3-dose schedule),
                                                   for intramuscular use

                                          or       or
                                          90648    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-T
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use

36B0Y   Administration of HibCV #2   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                   (includes percutaneous,                  Medical section,
                                                   intradermal, subcutaneous,               beginning on page 53, in
                                                   intramuscular, and jet                   the bulletin.
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine/toxoid), list separately
                                                   in addition to code for primary
                                                   procedure
                                          with     with
                                          90645    Haemophilus influenzae b
                                                   vaccine (Hib), HBOC
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use

                                          or       or
                                          90646    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-D
                                                   conjugate, for booster use
                                                   only, intramuscular use
                                          or       or
                                          90647    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-OMP
                                                   conjugate (3-dose schedule),
                                                   for intramuscular use
                                          or       or
                                          90648    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-T
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use

36C0Y   Administration of HibCV #3   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                   (includes percutaneous,                  Medical section,
                                                   intradermal, subcutaneous,               beginning on page 53, in
                                                   intramuscular, and jet                   the bulletin.
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine/toxoid), list separately
                                                   in addition to code for primary
                                                   procedure
                                          with     with
                                          90645    Haemophilus influenzae b
                                                   vaccine (Hib), HBOC
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use

                                          or       or
                                          90646    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-D
                                                   conjugate, for booster use
                                                   only, intramuscular use
                                          or       or
                                          90647    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-OMP
                                                   conjugate (3-dose schedule),
                                                   for intramuscular use

                                          or       or
                                          90648    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-T
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use
36D0Y   Administration of HibCV #4      $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                      (includes percutaneous,                  Medical section,
                                                      intradermal, subcutaneous,               beginning on page 53, in
                                                      intramuscular, and jet                   the bulletin.
                                                      injections); one vaccine
                                                      (single or combination
                                                      vaccine/toxoid)
                                             or       or
                                             90472    Each additional vaccine
                                                      (single or combination
                                                      vaccine/toxoid), list separately
                                                      in addition to code for primary
                                                      procedure
                                             with     with
                                             90645    Haemophilus influenzae b
                                                      vaccine (Hib), HBOC
                                                      conjugate (4-dose schedule),
                                                      for intramuscular use

                                             or       or
                                             90646    Haemophilus influenzae b
                                                      vaccine (Hib), PRP-D
                                                      conjugate, for booster use
                                                      only, intramuscular use
                                             or       or
                                             90647    Haemophilus influenzae b
                                                      vaccine (Hib), PRP-OMP
                                                      conjugate (3-dose schedule),
                                                      for intramuscular use

                                             or       or
                                             90648    Haemophilus influenzae b
                                                      vaccine (Hib), PRP-T
                                                      conjugate (4-dose schedule),
                                                      for intramuscular use

37A0Y   Administration of Hepatitis A   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
        vaccine                                       (includes percutaneous,                  Medical section,
                                                      intradermal, subcutaneous,               beginning on page 53, in
                                                      intramuscular, and jet                   the bulletin.
                                                      injections); one vaccine
                                                      (single or combination
                                                      vaccine/toxoid)
                                             or       or
                                              90472    Each additional vaccine
                                                       (single or combination
                                                       vaccine/toxoid), list separately
                                                       in addition to code for primary
                                                       procedure
                                              with     with
                                              90632    Hepatitis A vaccine, adult
                                                       dosage, for intramuscular use

                                              or       or
                                              90633    Hepatitis A vaccine,
                                                       pediatric/adolescent dosage
                                                       (2-dose schedule), for
                                                       intramuscular use
3700Y   No immunizations administered,                                                          Discontinued
        religious exemptions

3701Y   No immunizations administered,                                                          Discontinued
        parent refusal or child
        uncooperative
38A0Y   Administration of HEPT B #1      $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                       (includes percutaneous,                  Medical section,
                                                       intradermal, subcutaneous,               beginning on page 53, in
                                                       intramuscular, and jet                   the bulletin.
                                                       injections); one vaccine
                                                       (single or combination
                                                       vaccine/toxoid)
                                              or       or
                                              90472    Each additional vaccine
                                                       (single or combination
                                                       vaccine/toxoid), list separately
                                                       in addition to code for primary
                                                       procedure
                                              with     with
                                              90744    Hepatitis B vaccine,
                                                       pediatric/adolescent dosage
                                                       (3-dose schedule), for
                                                       intramuscular use
                                              or       or
                                              90746    Hepatitis B vaccine, adult
                                                       dosage, for intramuscular use
38B0Y   Administration of HEPT B #2   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                    (includes percutaneous,                  Medical section,
                                                    intradermal, subcutaneous,               beginning on page 53, in
                                                    intramuscular, and jet                   the bulletin.
                                                    injections); one vaccine
                                                    (single or combination
                                                    vaccine/toxoid)
                                           or       or
                                           90472    Each additional vaccine
                                                    (single or combination
                                                    vaccine/toxoid), list separately
                                                    in addition to code for primary
                                                    procedure
                                           with     with
                                           90744    Hepatitis B vaccine,
                                                    pediatric/adolescent dosage
                                                    (3-dose schedule), for
                                                    intramuscular use
                                           or       or
                                           90746    Hepatitis B vaccine, adult
                                                    dosage, for intramuscular use

38C0Y   Administration of HEPT B #3   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                    (includes percutaneous,                  Medical section,
                                                    intradermal, subcutaneous,               beginning on page 53, in
                                                    intramuscular, and jet                   the bulletin.
                                                    injections); one vaccine
                                                    (single or combination
                                                    vaccine/toxoid)
                                           or       or
                                           90472    Each additional vaccine
                                                    (single or combination
                                                    vaccine/toxoid), list separately
                                                    in addition to code for primary
                                                    procedure
                                           with     with
                                           90744    Hepatitis B vaccine,
                                                    pediatric/adolescent dosage
                                                    (3-dose schedule), for
                                                    intramuscular use
                                           or       or
                                           90746    Hepatitis B vaccine, adult
                                                    dosage, for intramuscular use

3999Y   Respiratory, cardiovascular                                                          Discontinued
        system
4000X   TCB case management, monthly    $92.86 G9012        Other specified case              $92.86
                                                            management service not
                                                            elsewhere classified
4001X   Face-to-face case management,   $54.58 G9012        Other specified case              $54.58 Refer to the PWI section
        pregnant adolescent or woman                        management service not                   on page 48 in the bulletin.
                                                            elsewhere classified
                                              with          with
                                              modifier U5   Medicaid level of care 5, as
                                                            defined by each state (face-to-
                                                            face)
                                              and           and
                                              TH            Obstetrical
                                                            treatment/services, prenatal
                                                            or postpartum
                                              and           and
                                              U1            Medicaid level of care 1, as
                                                            defined by each state (initial
                                                            intake)
                                              or            or
                                              U2            Medicaid level of care 2, as
                                                            defined by each state
                                                            (comprehensive needs
                                                            assessment)
                                              or            or
                                              U3            Medicaid level of care 3, as
                                                            defined by each state (service
                                                            plan/plan of care)
                                              or            or
                                              U4            Medicaid level of care 4, as
                                                            defined by each state
                                                            (reassessment)
                                               or           or
                                               TS           Follow-up service
4002X   Face-to-face case management,   $54.58 G9012        Other specified case              $54.58 Refer to the PWI section
        infant                                              management service not                   on page 48 in the bulletin.
                                                            elsewhere classified
                                              with          with
                                              modifier U5   Medicaid level of care 5, as
                                                            defined by each state (face to
                                                            face)
                                              and           and
                                              U1            Medicaid level of care 1, as
                                                            defined by each state (initial
                                                            intake)
                                              or            or
                                             U2            Medicaid level of care 2, as
                                                           defined by each state
                                                           (comprehensive needs
                                                           assessment)
                                             or            or
                                             U3            Medicaid level of care 3, as
                                                           defined by each state (service
                                                           plan/plan of care)
                                             or            or
                                             U4            Medicaid level of care 4, as
                                                           defined by each state
                                                           (reassessment)
                                              or           or
                                              TS           Follow-up service
4003X   Telephone case management,     $18.00 G9012        Other specified case             $18.00 Refer to the PWI section
        pregnant adolescent or woman                       management service not                  on page 48 in the bulletin.
                                                           elsewhere classified
                                             with          with
                                             modifier TH   Obstetrical
                                                           treatment/services, prenatal
                                                           or postpartum
                                             and           and
                                             U1            Medicaid level of care 1, as
                                                           defined by each state (initial
                                                           intake)
                                              or           or
                                              TS           Follow-up service
4004X   Telephone case management,     $18.00 G9012        Other specified case             $18.00 Refer to the PWI section
        infant                                             management service not                  on page 48 in the bulletin.
                                                           elsewhere classified
                                             with          with
                                             modifier U1   Medicaid level of care 1, as
                                                           defined by each state (initial
                                                           intake)
                                              or           or
                                              TS           Follow-up service
40A0Y   Administration of DTaP #1       $5.00 90471        Immunization administration       $5.00 Refer to the THSteps
                                                           (includes percutaneous,                 Medical section,
                                                           intradermal, subcutaneous,              beginning on page 53, in
                                                           intramuscular, and jet                  the bulletin.
                                                           injections); one vaccine
                                                           (single or combination
                                                           vaccine/toxoid)
                                             or            or
                                         90472    Each additional vaccine
                                                  (single or combination
                                                  vaccine/toxoid), list separately
                                                  in addition to code for primary
                                                  procedure
                                         with     with
                                         90700    Diphtheria, tetanus toxoids,
                                                  and acellular pertussis
                                                  vaccine (DTaP), for
                                                  intramuscular use
40B0Y   Administration of DTaP #2   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                  (includes percutaneous,                  Medical section,
                                                  intradermal, subcutaneous,               beginning on page 53, in
                                                  intramuscular, and jet                   the bulletin.
                                                  injections); one vaccine
                                                  (single or combination
                                                  vaccine/toxoid)
                                         or       or
                                         90472    Each additional vaccine
                                                  (single or combination
                                                  vaccine/toxoid), list separately
                                                  in addition to code for primary
                                                  procedure
                                         with     with
                                         90700    Diphtheria, tetanus toxoids,
                                                  and acellular pertussis
                                                  vaccine (DTaP), for
                                                  intramuscular use
41A0Y   Administration of Td #1     $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                  (includes percutaneous,                  Medical section,
                                                  intradermal, subcutaneous,               beginning on page 53, in
                                                  intramuscular, and jet                   the bulletin.
                                                  injections); one vaccine
                                                  (single or combination
                                                  vaccine/toxoid)
                                         or       or
                                         90472    Each additional vaccine
                                                  (single or combination
                                                  vaccine/toxoid), list separately
                                                  in addition to code for primary
                                                  procedure
                                         with     with
                                         90702    Diphtheria and tetanus
                                                  toxoids (DT) adsorbed for use
                                                  in individuals younger than 7
                                                  years, for intramuscular use
                                            or       or
                                            90718    Tetanus and diphtheria
                                                     toxoids (Td) adsorbed for use
                                                     in individuals 7 years or older,
                                                     for intramuscular or jet
                                                     injection
42A0Y   Administration of DTP/Hib #1   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                     (includes percutaneous,                  Medical section,
                                                     intradermal, subcutaneous,               beginning on page 53, in
                                                     intramuscular, and jet                   the bulletin.
                                                     injections); one vaccine
                                                     (single or combination
                                                     vaccine/toxoid)
                                            or       or
                                            90472    Each additional vaccine
                                                     (single or combination
                                                     vaccine/toxoid), list separately
                                                     in addition to code for primary
                                                     procedure
                                            with     with
                                            90720    Diphtheria, tetanus toxoids,
                                                     and whole cell pertussis
                                                     vaccine and Haemophilus
                                                     influenzae b vaccine (DTP-
                                                     Hib), for intramuscular use
42B0Y   Administration of DTP/Hib #2   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                     (includes percutaneous,                  Medical section,
                                                     intradermal, subcutaneous,               beginning on page 53, in
                                                     intramuscular, and jet                   the bulletin.
                                                     injections); one vaccine
                                                     (single or combination
                                                     vaccine/toxoid)
                                            or       or
                                            90472    Each additional vaccine
                                                     (single or combination
                                                     vaccine/toxoid), list separately
                                                     in addition to code for primary
                                                     procedure
                                            with     with
                                            90720    Diphtheria, tetanus toxoids,
                                                     and whole cell pertussis
                                                     vaccine and Haemophilus
                                                     influenzae b vaccine (DTP-
                                                     Hib), for intramuscular use
42C0Y   Administration of DTP/Hib #3   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                     (includes percutaneous,                  Medical section,
                                                     intradermal, subcutaneous,               beginning on page 53, in
                                                     intramuscular, and jet                   the bulletin.
                                                     injections); one vaccine
                                                     (single or combination
                                                     vaccine/toxoid)
                                            or       or
                                            90472    Each additional vaccine
                                                     (single or combination
                                                     vaccine/toxoid), list separately
                                                     in addition to code for primary
                                                     procedure
                                            with     with
                                            90720    Diphtheria, tetanus toxoids,
                                                     and whole cell pertussis
                                                     vaccine and Haemophilus
                                                     influenzae b vaccine (DTP-
                                                     Hib), for intramuscular use
42D0Y   Administration of DTP/Hib #4   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                     (includes percutaneous,                  Medical section,
                                                     intradermal, subcutaneous,               beginning on page 53, in
                                                     intramuscular, and jet                   the bulletin.
                                                     injections); one vaccine
                                                     (single or combination
                                                     vaccine/toxoid)
                                            or       or
                                            90472    Each additional vaccine
                                                     (single or combination
                                                     vaccine/toxoid), list separately
                                                     in addition to code for primary
                                                     procedure
                                            with     with
                                            90720    Diphtheria, tetanus toxoids,
                                                     and whole cell pertussis
                                                     vaccine and Haemophilus
                                                     influenzae b vaccine (DTP-
                                                     Hib), for intramuscular use
43A0Y   Administration of EIPV #1      $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                     (includes percutaneous,                  Medical section,
                                                     intradermal, subcutaneous,               beginning on page 53, in
                                                     intramuscular, and jet                   the bulletin.
                                                     injections); one vaccine
                                                     (single or combination
                                                     vaccine/toxoid)
                                            or       or
                                         90472    Each additional vaccine
                                                  (single or combination
                                                  vaccine/toxoid), list separately
                                                  in addition to code for primary
                                                  procedure
                                         with     with
                                         90713    Poliovirus vaccine,
                                                  inactivated, (IPV), for
                                                  subcutaneous use
43B0Y   Administration of EIPV #2   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                  (includes percutaneous,                  Medical section,
                                                  intradermal, subcutaneous,               beginning on page 53, in
                                                  intramuscular, and jet                   the bulletin.
                                                  injections); one vaccine
                                                  (single or combination
                                                  vaccine/toxoid)
                                         or       or
                                         90472    Each additional vaccine
                                                  (single or combination
                                                  vaccine/toxoid), list separately
                                                  in addition to code for primary
                                                  procedure
                                         with     with
                                         90713    Poliovirus vaccine,
                                                  inactivated, (IPV), for
                                                  subcutaneous use
43C0Y   Administration of EIPV #3   $5.00 90471   Immunization administration        $5.00 Refer to the THSteps
                                                  (includes percutaneous,                  Medical section,
                                                  intradermal, subcutaneous,               beginning on page 53, in
                                                  intramuscular, and jet                   the bulletin.
                                                  injections); one vaccine
                                                  (single or combination
                                                  vaccine/toxoid)
                                         or       or
                                         90472    Each additional vaccine
                                                  (single or combination
                                                  vaccine/toxoid), list separately
                                                  in addition to code for primary
                                                  procedure
                                         with     with
                                         90713    Poliovirus vaccine,
                                                  inactivated, (IPV), for
                                                  subcutaneous use
43D0Y   Administration of EIPV #4                     $5.00 90471           Immunization administration              $5.00 Refer to the THSteps
                                                                            (includes percutaneous,                        Medical section,
                                                                            intradermal, subcutaneous,                     beginning on page 53, in
                                                                            intramuscular, and jet                         the bulletin.
                                                                            injections); one vaccine
                                                                            (single or combination
                                                                            vaccine/toxoid)
                                                              or            or
                                                              90472         Each additional vaccine
                                                                            (single or combination
                                                                            vaccine/toxoid), list separately
                                                                            in addition to code for primary
                                                                            procedure
                                                              with          with
                                                              90713         Poliovirus vaccine,
                                                                            inactivated, (IPV), for
                                                                            subcutaneous use
4600Z   Female condom, one unit (three                $6.00 A4268           Contraceptive supply,                    $2.00 Program 100 (Medicaid),
        condoms, lubricant, instructions)                                   condom, female, each                           200 (Managed Care), and
                                                                                                                           300 (Family Planning;
                                                                                                                           Title V, XX) Id
4713X   Liver, small bowel transplant                 TOS 2: S2053          Transplantation of small               TOS 2:
                                            $12,180.00; TOS                 intestine and liver allografts     $12,180.00;
                                                 8: $1,948.80                                                      TOS 8:
                                                                                                                 $1,948.80
4738Z   SHARS special transportation,                $19.03 T2003           Nonemergency transport                  $19.03
        round trip                                                          encounter
4836X   Furnish and fit diaphragm                    $48.01 57170           Diaphragm or cervical cap              $38.00 Program 100 (Medicaid)
                                                                            fitting with instructions                     and 200 (Managed Care)
                                                                            (contraceptive device,                        must bill the device and
                                                                            diaphragm)                                    fitting together.
                                                              and           and                                       and
                                                              A4266         Diaphragm for contraceptive            $10.01
                                                                            use
4837X   Furnish and fit cervical cap                 $62.22 57170           Diaphragm or cervical cap              $38.00 Program 100 (Medicaid)
                                                                            fitting with instructions                     and 200 (Managed Care)
                                                                            (contraceptive device,                        must bill the device and
                                                                            diaphragm)                                    fitting together.
                                                              and           and                                       and
                                                              A4261         Cervical cap for contraceptive         $24.22
                                                                            use
4838Z   Cystic fibrosis                             $152.25           84999 Unlisted chemistry procedure         Manually    Enter the local code in
                                                                                                                 reviewed    the Comments field.
4839Z   Duchenne muscular dystrophy                 $304.50           84999 Unlisted chemistry procedure         Manually    Enter the local code in
                                                                                                                 reviewed    the Comments field.
4840Z   Fragile X mental retardation           $253.75   84999 Unlisted chemistry procedure   Manually   Enter the local code in
                                                                                              reviewed   the Comments field.
4841Z   Myotonic dystrophy                     $253.75   84999 Unlisted chemistry procedure   Manually   Enter the local code in
                                                                                              reviewed   the Comments field.
4842Z   Sickle cell hemoglobinopathy           $253.75   84999 Unlisted chemistry procedure   Manually Enter the local code in
                                                                                              reviewed the Comments field.
4843Z   Ornithine transcarbamylase             $355.25   84999 Unlisted chemistry procedure   Manually Enter the local code in
        deficiency                                                                            reviewed the Comments field.

4844Z   Phenylketonuria                        $355.25   84999 Unlisted chemistry procedure   Manually Enter the local code in
                                                                                              reviewed the Comments field.
4845Z   Thalassemia (alpha)                    $355.25   84999 Unlisted chemistry procedure   Manually Enter the local code in
                                                                                              reviewed the Comments field.
4846Z   Thalassemia (beta)                     $355.25   84999 Unlisted chemistry procedure   Manually Enter the local code in
                                                                                              reviewed the Comments field.

4847Z   Factor VIII deficiency                 $304.50   84999 Unlisted chemistry procedure   Manually Enter the local code in
                                                                                              reviewed the Comments field.

4848Z   Factor IX deficiency                   $304.50   84999 Unlisted chemistry procedure   Manually Enter the local code in
                                                                                              reviewed the Comments field.

4849Z   21-hydroxylase deficiency              $304.50   84999 Unlisted chemistry procedure   Manually Enter the local code in
                                                                                              reviewed the Comments field.

4850Z   Lesch nyhan syndrome (HPRT             $355.25   84999 Unlisted chemistry procedure   Manually Enter the local code in
        deficiency)                                                                           reviewed the Comments field.

4851Z   Other miscellaneous DNA               Manually   84999 Unlisted chemistry procedure   Manually Enter the local code in
        testing                               reviewed                                        reviewed the Comments field.
4852Z   Cystic fibrosis (fetal DNA testing)    $152.25   84999 Unlisted chemistry procedure   Manually Enter the local code in
                                                                                              reviewed the Comments field.

4853Z   Duchenne muscular dystrophy            $304.50   84999 Unlisted chemistry procedure   Manually Enter the local code in
        (fetal DNA testing)                                                                   reviewed the Comments field.

4854Z   Fragile X mental retardation           $253.75   84999 Unlisted chemistry procedure   Manually Enter the local code in
        (fetal DNA testing)                                                                   reviewed the Comments field.

4855Z   Myotonic dystrophy (fetal DNA          $253.75   84999 Unlisted chemistry procedure   Manually Enter the local code in
        testing)                                                                              reviewed the Comments field.

4856Z   Sickle cell hemoglobinopathy           $253.75   84999 Unlisted chemistry procedure   Manually Enter the local code in
        (fetal DNA testing)                                                                   reviewed the Comments field.
4857Z   Ornithine transcarbamylase           $355.25                 84999 Unlisted chemistry procedure    Manually Enter the local code in
        deficiency (fetal DNA testing)                                                                     reviewed the Comments field.
4858Z   Phenylketonuria (fetal DNA           $355.25                 84999 Unlisted chemistry procedure    Manually Enter the local code in
        testing)                                                                                           reviewed the Comments field.
4859Z   Thalassemia (alpha) (fetal DNA       $355.25                 84999 Unlisted chemistry procedure    Manually Enter the local code in
        testing)                                                                                           reviewed the Comments field.
4860Z   Thalassemia (beta)                   $355.25                 84999 Unlisted chemistry procedure    Manually Enter the local code in
                                                                                                           reviewed the Comments field.
4861Z   Factor VIII deficiency (fetal DNA    $304.50                 84999 Unlisted chemistry procedure    Manually Enter the local code in
        testing)                                                                                           reviewed the Comments field.
4862Z   Factor IX deficiency (fetal DNA      $304.50                 84999 Unlisted chemistry procedure    Manually   Enter the local code in
        testing)                                                                                           reviewed   the Comments field.
4863Z   21-hydroxylase deficiency (fetal     $304.50                 84999 Unlisted chemistry procedure    Manually   Enter the local code in
        DNA testing)                                                                                       reviewed   the Comments field.

4864Z   Lesch nyhan syndrome (HPRT           $355.25                 84999 Unlisted chemistry procedure    Manually Enter the local code in
        deficiency) (fetal DNA testing)                                                                    reviewed the Comments field.

4865Z   Other miscellaneous DNA             Manually                 84999 Unlisted chemistry procedure    Manually Enter a specific
        testing (fetal DNA testing)         reviewed                                                       reviewed description of the service
                                                                                                                    rendered.
4999Y   Digestive system                                                                                            Discontinued

5000X   Unlisted medication for CCP                                                                                   Discontinued

5002X   LVN, independently enrolled,          $20.00 T1000                 Private duty/independent           $5.00 Bill the appropriate
        private duty nursing, per hour                                     nursing service(s), licensed,            quantity; 15 minutes =
                                                                           up to 15 minutes                         quantity of 1.
                                                     with                  with
                                                     modifier TE           LPN/LVN
5003X   RN, independently enrolled,           $25.00 T1000                 Private duty/independent           $6.25 Bill the appropriate
        private duty nursing, per hour                                     nursing service(s), licensed,            quantity; 15 minutes =
                                                                           up to 15 minutes                         quantity of 1.
                                                       with                with
                                                       modifier TD         RN
5043X   Addition for HALO, sheepskin                                                                                  Discontinued
        liner
5044X   Addition for AFO, malleolar           $46.61 L2270                 Addition to lower extremity,      $31.98
        padding                                                            varus/ valgus correction T-
                                                                           strap, padded/lined or malle
5045X   Addition to TLSO, soft interface                                                                              Discontinued
5046X   Addition to AFO, instep strap,      $30.40 L2270   Addition to lower extremity,     $31.98
        each                                               varus/ valgus correction T-
                                                           strap, padded/lined or malle

5047X   Addition to AFO, ankle strap,       $30.40 L2270   Addition to lower extremity,     $31.98
        each                                               varus/ valgus correction T-
                                                           strap, padded/lined or malle
5048X   Addition to AFO leather anklet                                                               Discontinued


5049X   AFO, supramalleolar, molded to     $277.50 L1940   Ankle foot orthosis, plastic,   $316.47
        patient model, plastic                             custom-fabricated

5050X   AFO, tone reducing,                $372.30 L1940   Ankle foot orthosis, plastic,   $316.47
        supramalleolar, plastic molded                     custom-fabricated
        to patient model
5051X   Upper extremity addition, quick    $129.00 L6628   Upper extremity addition,       $366.57
        disconnect hook adapter, otto                      quick disconnect hook
        bock or equal                                      adapter, otto bock or equal
5052X   Addition to lower extremity                                                                  Discontinued
        orthosis, carbon inserts (pair)
5054X   Addition to lower extremity                                                                  Discontinued; not payable
        orthosis anterior shell for AFO                                                              separately

5055X   Addition to lower extremity                                                                  Discontinued
        orthosis, forefoot velcro strap
        (each)
5056X   Addition to inhibitive AFO-toe,                                                              Discontinued; not payable
        velcro strap padded                                                                          separately


5062X   AFO, tone reducing, plastic,                                                                 Discontinued
        molded to patient model
5063X   Full toe plate                                                                               Discontinued

5068X   Comprehensive outpatient                                                                     Discontinued
        therapy evaluation, per hour
5130X   Level 1 high-risk pregnancy                                                                  Discontinued
        management, per day
5131X   Level 2 high-risk pregnancy                                                                  Discontinued
        management, per day
5141X   Helmet                            Manually E0700   Safety equipment (e.g., belt,    $26.00
                                          reviewed         harness, or vest)
5180X   Dynasplint (knee, elbow, wrist,   $1,091.00 E1800   Dynamic adjustable elbow         Manually priced
        ankle)                                              extension/flexion device,
                                                            includes soft interface material

                                                   or       or
                                                   E1805    Wrist extension/flexion
                                                            device, includes soft interface
                                                            material
                                                   or       or
                                                   E1810    Knee extension/flexion
                                                            device, includes soft interface
                                                            material
                                                   or       or
                                                   E1815    Ankle extension/flexion
                                                            device, includes soft interface
                                                            material
5191X   Knee immobilizer                  Manually A4570    Splint                                    $21.39
                                          reviewed
5192X   Shoulder immobilizer              Manually A4570    Splint                                    $21.39
                                          reviewed
5193X   Counter rotation system (CSR)                                                                          Discontinued
        with shoes
5197X   Anaphylaxis emergency kit, EPT-                                                                        Discontinued
        PEN
5233X   Heparin lock (solution), 30 mL                                                                         Discontinued
        each
5292X   Counter rotation system (CRS)      $175.00 L3150    Foot, abduction rotation bars,            $65.77
        without shoes                                       without shoes
5294X   Nutritional counseling by           $30.45 S9470    Nutritional counseling, dietitian         $30.45
        licensed dietitian, per hour
5344X   Bebax shoes, each shoe                                                                                 Discontinued; not payable
                                                                                                               separately
5346X   Discontinued local code -                                                                              Discontinued
        discontinue and do not map;
        serial casting by PT/OT
5380X   PT evaluation, per session          $45.28 97001    Physical therapy evaluation               $45.28


5381X   OT evaluation, per session          $45.28 97003    Occupational therapy                      $45.28
                                                            evaluation
5382X   SLP evaluation, per session         $41.46 92506    Evaluation of speech,                     $41.46
                                                            language, voice,
                                                            communication, auditory
                                                            processing, and/or aural
                                                            rehabilitation status
5383X   Physical therapy assistive                    $40.60 97535         Self-care/home management                  $14.18 Bill the appropriate
        technology (equipment training),                                   training (e.g., activities of                     quantity based on 15-
        per session                                                        daily living [ADL] and                            minute increments (4
                                                                           compensatory training, meal                       units = 1 hour).
                                                                           preparation, safety
                                                                           procedures, and instructions
                                                                           in use of assistive technology
                                                                           devices/adaptive equipment)
                                                                           direct one-on-one contact by
                                                                           provider, each 15 minutes
5384X   Occupational therapy assistive                $40.60 97535         Self-care/home management                  $14.18 Bill the appropriate
        technology (equipment training),                                   training (e.g., ADL and                           quantity based on 15-
        per session                                                        compensatory training, meal                       minute increments (4
                                                                           preparation, safety                               units = 1 hour).
                                                                           procedures, and instructions
                                                                           in use of assistive technology
                                                                           devices/adaptive equipment)
                                                                           direct one-on-one contact by
                                                                           provider, each 15 minutes
5385X   SLP assistive technology                      $40.60 97535         Self-care/home management                  $14.18 Bill the appropriate
        (equipment training), per session                                  training (e.g., ADL and                           quantity based on 15-
                                                                           compensatory training, meal                       minute increments (4
                                                                           preparation, safety                               units = 1 hour).
                                                                           procedures, and instructions
                                                                           in use of assistive technology
                                                                           devices/adaptive equipment)
                                                                           direct one-on-one contact by
                                                                           provider, each 15 minutes
5392X   Comprehensive outpatient            Provider-specific 424          Physical therapy, evaluation/    Provider-specific Bill the appropriate
        therapy evaluation (CORF)                 interim rate                                                    interim rate revenue code.

                                                             or            or
                                                             434           Occupational therapy,
                                                                           evaluation/re-evaluation
                                                             or            or
                                                             444           Speech-language pathology,
                                                                           evaluation/re-evaluation
5426X   Replacement of silsoft aphakic              $107.23 92396          Supply of permanent                        $61.37 Bill the appropriate
        contact lens (unilateral)                                          prosthesis for aphakia;                           quantity based on lenses
                                                                           contact lenses                                    dispensed.
                                                             with          with
                                                             modifier RP   Replacement and repair
5438X   Nutrition assessment by            $40.60 97802        Medical nutrition therapy;          $10.15 Bill the appropriate
        licensed dietitian, per hour                           initial assessment and                     quantity based on 15-
                                                               intervention, individual, face-            minute increments (4
                                                               to-face with the patient, each             units = 1 hour).
                                                               15 minutes
                                                 or            or
                                                 97803         Medical nutrition therapy;
                                                               reassessment and
                                                               intervention, individual, face-
                                                               to-face with the patient, each
                                                               15 minutes
5454X   PT re-evaluation, per session      $40.60 97002        Physical therapy re-evaluation      $27.00


5455X   OT re-evaluation, per session      $40.60 97004        Occupational therapy re-            $35.46
                                                               evaluation

5456X   SLP re-evaluation, per session     $40.60 92506        Evaluation of speech,               $40.60
                                                               language, voice,
                                                               communication, auditory
                                                               processing, and/or aural
                                                               rehabilitation status
                                                 with          with
                                                 modifier U4   Medicaid level of care 4, as
                                                               defined by each state
                                                               (reassessment)
5494X   High-powered lenses              Manually V2102,       Sphere, single vision; plus or    Manually High-powered lenses are
                                         reviewed              minus 7.12D to plus or minus      reviewed defined as greater than
                                                               20.00D, per lens,                          plus or minus 7.00D
                                                 V2105,        ...4.00D sphere, 4.25D to                  sphere or greater than
                                                               6.00D cylinder, per lens,                  4.00D cylinder. It was
                                                 V2106,        ...4.00D sphere, over 6.00D                  previously defined as
                                                               cylinder, per lens,                          greater than plus or minus
                                                 V2109,        ...4.25D to 7.00D sphere,                     6.00D sphere or greater
                                                               4.25D to 6.00D cylinder, per                 than 4.00D cylinder.
                                                               lens,
                                                 V2110,        ...4.25D to 7.00D sphere,
                                                               over 6.00D cylinder, per lens,
                                                 V2111,        ...7.25D to 12.00D sphere,
                                                               0.25D to 2.25D cylinder, per
                                                               lens,
                                                 V2112,        ...7.25D to 12.00D sphere,
                                                               2.25D to 4.00D cylinder, per
                                                               lens,
                                                 V2113,        ...7.25D to 12.00D sphere,
                                                               4.25D to 6.00D cylinder, per
                                                               lens,
V2114    ...12.00D, per lens
or       or
V2202,   Sphere, bifocal; plus or minus
         7.12D to plus or minus
         20.00D, per lens,
V2205,   ...4.00D sphere, 4.25D to
         6.00D cylinder, per lens,
V2206,   ...4.00D sphere, over 6.00D
         cylinder, per lens,
V2209,   ...4.25D to 7.00D sphere,
         4.25D to 6.00D cylinder, per
         lens,
V2210,   ...4.25D to 7.00D sphere,
         over 6.00D cylinder, per lens,
V2211,   ...7.25D to 12.00D sphere,
         0.25D to 2.25D cylinder, per
         lens,
V2212,   ...7.25D to 12.00D sphere,
         2.25D to 4.00D cylinder, per
         lens,
V2213    ...7.25D to 12.00D sphere,
         4.25D to 6.00D cylinder, per
         lens,
V2214    ...12.00D, per lens
or       or
V2302,   Sphere, trifocal; plus or minus
         7.12D to plus or minus
         20.00D, per lens,
V2305,   ...4.00D sphere, 4.25D to
         6.00D cylinder, per lens,
V2306,   ...4.00D sphere, over 6.00D
         cylinder, per lens,
V2309,   ...4.25D to 7.00D sphere,
         4.25D to 6.00D cylinder, per
         lens,
V2310,   ...4.25D to 7.00D sphere,
         over 6.00D cylinder, per lens,
V2311,   ...7.25D to 12.00D sphere,
         0.25D to 2.25D cylinder, per
         lens,
V2312,   ...7.25D to 12.00D sphere,
         2.25D to 4.00D cylinder, per
         lens,
V2313,   ...7.25D to 12.00D sphere,
         4.25D to 6.00D cylinder, per
         lens,
V2314    ...12.00D, per lens
5498X   Administration of the                $5.00 90471   Immunization administration           $5.00 Refer to the THSteps
        pneumococcal conjugate                             (includes percutaneous,                     Medical section,
        vaccine, polyvalent                                intradermal, subcutaneous,                  beginning on page 53, in
                                                           intramuscular, and jet                      the bulletin.
                                                           injections); one vaccine
                                                           (single or combination
                                                           vaccine/toxoid)
                                                  or       or
                                                  90472    Each additional vaccine
                                                           (single or combination
                                                           vaccine/toxoid), list separately
                                                           in addition to code for primary
                                                           procedure
                                                  with     with
                                                  90669    Pneumococcal conjugate
                                                           vaccine, polyvalent, for
                                                           children 5 years old and
                                                           younger, for intramuscular use

5600X   Multivitamins, tabs, per 100         $3.01 A9150   Nonprescription drugs              Manually
                                                                                              reviewed
5601X   Multivitamins, chewables, per        $3.29 A9150   Nonprescription drugs              Manually
        100                                                                                   reviewed
5602X   Multivitamins, drops, 50 mL          $4.54 A9150   Nonprescription drugs              Manually
                                                                                              reviewed
5603X   Multivitamins with iron, tabs, per   $3.06 A9150   Nonprescription drugs              Manually
        100                                                                                   reviewed
5604X   Multivitamins with iron,             $3.32 A9150   Nonprescription drugs              Manually
        chewables, per 100                                                                    reviewed
5605X   Multivitamins with iron, drops,      $4.17 A9150   Nonprescription drugs              Manually
        50 mL                                                                                 reviewed
5606X   Vitamin C, chewables, 250 mg,        $2.58 A9150   Nonprescription drugs              Manually
        per 100                                                                               reviewed
5607X   Vitamin C, tabs, 250 mg, per 100     $1.96 A9150   Nonprescription drugs              Manually
                                                                                              reviewed
5608X   Vitamin C, chewables, 500 mg,        $3.70 A9150   Nonprescription drugs              Manually
        per 100                                                                               reviewed
5609X   Vitamin C, tabs, 500 mg, per 100     $2.99 A9150   Nonprescription drugs              Manually
                                                                                              reviewed
5610X   Vitamin E, caps, 400 IU, per 100     $5.47 A9150   Nonprescription drugs              Manually
                                                                                              reviewed
5611X   Vitamin B12, tabs, 100 mcg, per      $2.42 A9150   Nonprescription drugs   Manually
        100                                                                        reviewed

5612X   Multiple vitamin with additional     $3.61 A9150   Nonprescription drugs   Manually
        minerals, caps or tabs, per 100                                            reviewed
5614X   Vitamin E, liquid, oral              $3.99 A9150   Nonprescription drugs   Manually
                                                                                   reviewed
5615X   Unspecified vitamin/mineral                                                           Discontinued
5616X   Vitamin A, 100 capsules              $2.05 A9150   Nonprescription drugs   Manually
                                                                                   reviewed
5618X   Folic acid, tabs, 400 mcg, per       $1.86 A9150   Nonprescription drugs   Manually
        100                                                                        reviewed
5619X   Vitamin E, caps, 100 national        $2.50 A9150   Nonprescription drugs   Manually
        units, per 100                                                             reviewed
5620X   Multiple vitamins, 100 caps          $3.50 A9150   Nonprescription drugs   Manually
                                                                                   reviewed
5621X   Multiple vitamins, chewable, 60      $2.63 A9150   Nonprescription drugs   Manually
        tabs                                                                       reviewed

5624X   Biotin, 100 tabs, 300 mcg,           $2.27 A9150   Nonprescription drugs   Manually
                                                                                   reviewed
5627X   Magnesium oxide, 120 tabs, 400       $9.17 A9150   Nonprescription drugs   Manually
        mg                                                                         reviewed

5628X   Thiamine, (B1), 100 tabs, 100        $2.36 A9150   Nonprescription drugs   Manually
        mg                                                                         reviewed
5629X   Thiamine (B1), 100 tabs, 250 mg      $3.76 A9150   Nonprescription drugs   Manually
                                                                                   reviewed
5630X   Riboflavin, (B2), 100 tabs, 50 mg    $2.65 A9150   Nonprescription drugs   Manually
                                                                                   reviewed
5631X   Riboflavin, (B2), 100 tabs, 100      $3.34 A9150   Nonprescription drugs   Manually
        mg                                                                         reviewed
5632X   Dical-D wafers, box of 50           $11.31 A9150   Nonprescription drugs   Manually
                                                                                   reviewed
5636X   Adeks, 60 tablets                   $16.21 A9150   Nonprescription drugs   Manually
                                                                                   reviewed
5639X   Multiple vitamin with additional     $6.30 A9150   Nonprescription drugs   Manually
        minerals, liquid                                                           reviewed

5640X   Aqua sol A drops, 30 mL             $41.56 A9150   Nonprescription drugs   Manually
                                                                                   reviewed
5641X   Adeks pediatric drops, 60 mL   $7.71 A9150   Nonprescription drugs              Manually
                                                                                        reviewed

5701X   Administration of DTP #1       $5.00 90471   Immunization administration           $5.00
                                                     (includes percutaneous,
                                                     intradermal, subcutaneous,
                                                     intramuscular, and jet
                                                     injections); one vaccine
                                                     (single or combination
                                                     vaccine/toxoid)
                                            or       or
                                            90472    Each additional vaccine
                                                     (single or combination
                                                     vaccine/toxoid), list separately
                                                     in addition to code for primary
                                                     procedure
                                            with     with
                                            90701    Diphtheria, tetanus toxoids,
                                                     and whole cell pertussis
                                                     vaccine (DTP), for
                                                     intramuscular use
5702X   Administration of DTP #2       $5.00 90471   Immunization administration           $5.00
                                                     (includes percutaneous,
                                                     intradermal, subcutaneous,
                                                     intramuscular, and jet
                                                     injections); one vaccine
                                                     (single or combination
                                                     vaccine/toxoid)
                                            or       or
                                            90472    Each additional vaccine
                                                     (single or combination
                                                     vaccine/toxoid), list separately
                                                     in addition to code for primary
                                                     procedure
                                            with     with
                                            90701    Diphtheria, tetanus toxoids,
                                                     and whole cell pertussis
                                                     vaccine (DTP), for
                                                     intramuscular use
5703X   Administration of DTP #3       $5.00 90471   Immunization administration           $5.00
                                                     (includes percutaneous,
                                                     intradermal, subcutaneous,
                                                     intramuscular, and jet
                                                     injections); one vaccine
                                                     (single or combination
                                                     vaccine/toxoid)
                                            or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90701    Diphtheria, tetanus toxoids,
                                                 and whole cell pertussis
                                                 vaccine (DTP), for
                                                 intramuscular use
5704X   Administration of DTP #4   $5.00 90471   Immunization administration        $5.00
                                                 (includes percutaneous,
                                                 intradermal, subcutaneous,
                                                 intramuscular, and jet
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90701    Diphtheria, tetanus toxoids,
                                                 and whole cell pertussis
                                                 vaccine (DTP), for
                                                 intramuscular use
5705X   Administration of DTP #5   $5.00 90471   Immunization administration        $5.00
                                                 (includes percutaneous,
                                                 intradermal, subcutaneous,
                                                 intramuscular, and jet
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90701    Diphtheria, tetanus toxoids,
                                                 and whole cell pertussis
                                                 vaccine (DTP), for
                                                 intramuscular use
5706X   Administration of DT #1   $5.00 90471   Immunization administration        $5.00
                                                (includes percutaneous,
                                                intradermal, subcutaneous,
                                                intramuscular, and jet
                                                injections); one vaccine
                                                (single or combination
                                                vaccine/toxoid)
                                       or       or
                                       90472    Each additional vaccine
                                                (single or combination
                                                vaccine/toxoid), list separately
                                                in addition to code for primary
                                                procedure
                                       with     with
                                       90702    Diphtheria and tetanus
                                                toxoids (DT) adsorbed for use
                                                in individuals younger than 7
                                                years, for intramuscular use

5707X   Administration of DT #2   $5.00 90471   Immunization administration        $5.00
                                                (includes percutaneous,
                                                intradermal, subcutaneous,
                                                intramuscular, and jet
                                                injections); one vaccine
                                                (single or combination
                                                vaccine/toxoid)
                                       or       or
                                       90472    Each additional vaccine
                                                (single or combination
                                                vaccine/toxoid), list separately
                                                in addition to code for primary
                                                procedure
                                       with     with
                                       90702    Diphtheria and tetanus
                                                toxoids (DT) adsorbed for use
                                                in individuals younger than 7
                                                years, for intramuscular use

5708X   Administration of DT #3   $5.00 90471   Immunization administration        $5.00
                                                (includes percutaneous,
                                                intradermal, subcutaneous,
                                                intramuscular, and jet
                                                injections); one vaccine
                                                (single or combination
                                                vaccine/toxoid)
                                       or       or
                                       90472           Each additional vaccine
                                                       (single or combination
                                                       vaccine/toxoid), list separately
                                                       in addition to code for primary
                                                       procedure
                                       with            with
                                       90702           Diphtheria and tetanus
                                                       toxoids (DT) adsorbed for use
                                                       in individuals younger than 7
                                                       years, for intramuscular use

5709X   Administration of DT #4   $5.00 90471         Immunization administration         $5.00
                                                      (includes percutaneous,
                                                      intradermal, subcutaneous,
                                                      intramuscular, and jet
                                                      injections); one vaccine
                                                      (single or combination
                                                      vaccine/toxoid)
                                       or             or
                                       90472          Each additional vaccine
                                                      (single or combination
                                                      vaccine/toxoid), list separately
                                                      in addition to code for primary
                                                      procedure
                                       with           with
                                                90702 Diphtheria and tetanus
                                                      toxoids (DT) adsorbed for use
                                                      in individuals younger than 7
                                                      years, for intramuscular use

5710X   Administration of DT #5   $5.00 90471          Immunization administration        $5.00
                                                       (includes percutaneous,
                                                       intradermal, subcutaneous,
                                                       intramuscular, and jet
                                                       injections); one vaccine
                                                       (single or combination
                                                       vaccine/toxoid)
                                       or              or
                                       90472           Each additional vaccine
                                                       (single or combination
                                                       vaccine/toxoid), list separately
                                                       in addition to code for primary
                                                       procedure
                                       with            with
                                        90702    Diphtheria and tetanus
                                                 toxoids (DT) adsorbed for use
                                                 in individuals younger than 7
                                                 years, for intramuscular use

5711X   Administration of DTaP#1   $5.00 90471   Immunization administration        $5.00
                                                 (includes percutaneous,
                                                 intradermal, subcutaneous,
                                                 intramuscular, and jet
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90700    Diphtheria, tetanus toxoids,
                                                 and acellular pertussis
                                                 vaccine (DTaP), for
                                                 intramuscular use
5712X   Administration of DTaP#2   $5.00 90471   Immunization administration        $5.00
                                                 (includes percutaneous,
                                                 intradermal, subcutaneous,
                                                 intramuscular, and jet
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90700    Diphtheria, tetanus toxoids,
                                                 and acellular pertussis
                                                 vaccine (DTaP), for
                                                 intramuscular use
5713X   Administration of IPV #4         $5.00 90471   Immunization administration        $5.00
                                                       (includes percutaneous,
                                                       intradermal, subcutaneous,
                                                       intramuscular, and jet
                                                       injections); one vaccine
                                                       (single or combination
                                                       vaccine/toxoid)
                                              or       or
                                              90472    Each additional vaccine
                                                       (single or combination
                                                       vaccine/toxoid), list separately
                                                       in addition to code for primary
                                                       procedure
                                              with     with
                                              90713    Poliovirus vaccine,
                                                       inactivated, (IPV), for
                                                       subcutaneous use
5714X   Administration of OPV #4         $5.00 90473   Immunization administration        $5.00
                                                       by intranasal or oral route;
                                                       one vaccine (single or
                                                       combination vaccine/toxoid)
                                              or       or
                                              90474    Immunization administration
                                                       by intranasal or oral route;
                                                       each additional vaccine
                                                       (single or combination
                                                       vaccine/toxoid), list separately
                                                       in addition to code for primary
                                                       procedure
                                              with     with
                                              90712    Poliovirus vaccine, any
                                                       type(s), (OPV), live, for oral
                                                       use
5715X   Administration of OPV #5 (for    $5.00 90473   Immunization administration        $5.00
        children off current schedule)                 by intranasal or oral route;
                                                       one vaccine (single or
                                                       combination vaccine/toxoid)
                                              or       or
                                              90474    Immunization administration
                                                       by intranasal or oral route;
                                                       each additional vaccine
                                                       (single or combination
                                                       vaccine/toxoid), list separately
                                                       in addition to code for primary
                                                       procedure
                                              with     with
                                          90712    Poliovirus vaccine, any
                                                   type(s), (OPV), live, for oral
                                                   use
5716X   Administration of HibCV #1   $5.00 90471   Immunization administration      $5.00
                                                   (includes percutaneous,
                                                   intradermal, subcutaneous,
                                                   intramuscular, and jet
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine, toxoid), list
                                                   separately in addition to code
                                                   for primary procedure
                                          with     with
                                          90645    Haemophilus influenzae b
                                                   vaccine (Hib), HBOC
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use

                                          or       or
                                          90646    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-D
                                                   conjugate, for booster use
                                                   only, intramuscular use
                                          or       or
                                          90647    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-OMP
                                                   conjugate (3-dose schedule),
                                                   for intramuscular use

                                          or       or
                                          90648    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-T
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use

5717X   Administration of HibCV #2   $5.00 90471   Immunization administration      $5.00
                                                   (includes percutaneous,
                                                   intradermal, subcutaneous,
                                                   intramuscular, and jet
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine, toxoid), list
                                                   separately in addition to code
                                                   for primary procedure
                                          with     with
                                          90645    Haemophilus influenzae b
                                                   vaccine (Hib), HBOC
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use

                                          or       or
                                          90646    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-D
                                                   conjugate, for booster use
                                                   only, intramuscular use
                                          or       or
                                          90647    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-OMP
                                                   conjugate (3-dose schedule),
                                                   for intramuscular use

                                          or       or
                                          90648    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-T
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use

5718X   Administration of HibCV #3   $5.00 90471   Immunization administration      $5.00
                                                   (includes percutaneous,
                                                   intradermal, subcutaneous,
                                                   intramuscular, and jet
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine, toxoid), list
                                                   separately in addition to code
                                                   for primary procedure
                                          with     with
                                          90645    Haemophilus influenzae b
                                                   vaccine (Hib), HBOC
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use
                                          or       or
                                          90646    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-D
                                                   conjugate, for booster use
                                                   only, intramuscular use
                                          or       or
                                          90647    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-OMP
                                                   conjugate (3-dose schedule),
                                                   for intramuscular use

                                          or       or
                                          90648    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-T
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use

5719X   Administration of HibCV #4   $5.00 90471   Immunization administration      $5.00
                                                   (includes percutaneous,
                                                   intradermal, subcutaneous,
                                                   intramuscular, and jet
                                                   injections); one vaccine
                                                   (single or combination
                                                   vaccine/toxoid)
                                          or       or
                                          90472    Each additional vaccine
                                                   (single or combination
                                                   vaccine, toxoid), list
                                                   separately in addition to code
                                                   for primary procedure
                                          with     with
                                          90645    Haemophilus influenzae b
                                                   vaccine (Hib), HBOC
                                                   conjugate (4-dose schedule),
                                                   for intramuscular use

                                          or       or
                                          90646    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-D
                                                   conjugate, for booster use
                                                   only, intramuscular use
                                          or       or
                                          90647    Haemophilus influenzae b
                                                   vaccine (Hib), PRP-OMP
                                                   conjugate (3-dose schedule),
                                                   for intramuscular use
                                        or       or
                                        90648    Haemophilus influenzae b
                                                 vaccine (Hib), PRP-T
                                                 conjugate (4-dose schedule),
                                                 for intramuscular use

5720X   Administration of OPV #1   $5.00 90473   Immunization administration      $5.00
                                                 by intranasal or oral route;
                                                 one vaccine (single or
                                                 combination vaccine/toxoid)
                                        or       or
                                        90474    Each additional vaccine
                                                 (single or combination
                                                 vaccine/ toxoid), list
                                                 separately in addition to code
                                                 for primary procedure
                                        with     with
                                        90712    Poliovirus vaccine, (any
                                                 type[s)] (OPV), live, for oral
                                                 use
5721X   Administration of OPV #2   $5.00 90473   Immunization administration      $5.00
                                                 by intranasal or oral route;
                                                 one vaccine (single or
                                                 combination vaccine/toxoid)
                                        or       or
                                        90474    Each additional vaccine
                                                 (single or combination
                                                 vaccine/ toxoid), list
                                                 separately in addition to code
                                                 for primary procedure
                                        with     with
                                        90712    Poliovirus vaccine, (any
                                                 type[s)] (OPV), live, for oral
                                                 use
5722X   Administration of OPV #3   $5.00 90473   Immunization administration      $5.00
                                                 by intranasal or oral route;
                                                 one vaccine (single or
                                                 combination vaccine/toxoid)
                                        or       or
                                        90474    Each additional vaccine
                                                 (single or combination
                                                 vaccine/ toxoid), list
                                                 separately in addition to code
                                                 for primary procedure
                                        with     with
                                        90712    Poliovirus vaccine, (any
                                                 type[s)] (OPV), live, for oral
                                                 use
5723X   Administration of IPV #1   $5.00 90471   Immunization administration        $5.00
                                                 (includes percutaneous,
                                                 intradermal, subcutaneous,
                                                 intramuscular, and jet
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90713    Poliovirus vaccine,
                                                 inactivated, (IPV), for
                                                 subcutaneous use
5724X   Administration of IPV #2   $5.00 90471   Immunization administration        $5.00
                                                 (includes percutaneous,
                                                 intradermal, subcutaneous,
                                                 intramuscular, and jet
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90713    Poliovirus vaccine,
                                                 inactivated, (IPV), for
                                                 subcutaneous use
5725X   Administration of IPV #3   $5.00 90471   Immunization administration        $5.00
                                                 (includes percutaneous,
                                                 intradermal, subcutaneous,
                                                 intramuscular, and jet
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90713    Poliovirus vaccine,
                                                 inactivated, (IPV), for
                                                 subcutaneous use
5726X   Administration of MMR #1   $5.00 90471   Immunization administration        $5.00
                                                 (includes percutaneous,
                                                 intradermal, subcutaneous,
                                                 intramuscular, and jet
                                                 injections); one vaccine
                                                 (single or combination)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine, toxoid), list
                                                 separately in addition to code
                                                 for primary procedure
                                        with     with
                                        90707    Measles, mumps, and rubella
                                                 virus vaccine (MMR), live, for
                                                 subcutaneous or jet injection
                                                 use
5727X   Administration of MMR #2   $5.00 90471   Immunization administration        $5.00
                                                 (includes percutaneous,
                                                 intradermal, subcutaneous,
                                                 intramuscular, and jet
                                                 injections); one vaccine
                                                 (single or combination)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine, toxoid), list
                                                 separately in addition to code
                                                 for primary procedure
                                        with     with
                                        90707    Measles, mumps, and rubella
                                                 virus vaccine (MMR), live, for
                                                 subcutaneous or jet injection
                                                 use
5729X   Administration of Hepatitis B #1   $5.00 90471   Immunization administration      $5.00
                                                         (includes percutaneous,
                                                         intradermal, subcutaneous,
                                                         intramuscular, and jet
                                                         injections); one vaccine
                                                         (single or combination
                                                         vaccine/toxoid)
                                                or       or
                                                90472    Each additional vaccine
                                                         (single or combination
                                                         vaccine, toxoid), list
                                                         separately in addition to code
                                                         for primary procedure
                                                with     with
                                                90744    Hepatitis B vaccine,
                                                         pediatric/adolescent dosage
                                                         (3-dose schedule), for
                                                         intramuscular use
                                                or       or
                                                90746    Hepatitis B vaccine, adult
                                                         dosage, for intramuscular use
5730X   Administration of Hepatitis B #2   $5.00 90471   Immunization administration      $5.00
                                                         (includes percutaneous,
                                                         intradermal, subcutaneous,
                                                         intramuscular, and jet
                                                         injections); one vaccine
                                                         (single or combination
                                                         vaccine/toxoid)
                                                or       or
                                                90472    Each additional vaccine
                                                         (single or combination
                                                         vaccine, toxoid), list
                                                         separately in addition to code
                                                         for primary procedure
                                                with     with
                                                90744    Hepatitis B vaccine,
                                                         pediatric/adolescent dosage
                                                         (3-dose schedule), for
                                                         intramuscular use
                                                or       or
                                                90746    Hepatitis B vaccine, adult
                                                         dosage, for intramuscular use
5731X   Administration of Hepatitis B #3   $5.00 90471   Immunization administration      $5.00
                                                         (includes percutaneous,
                                                         intradermal, subcutaneous,
                                                         intramuscular, and jet
                                                         injections); one vaccine
                                                         (single or combination
                                                         vaccine/toxoid)
                                                or       or
                                                90472    Each additional vaccine
                                                         (single or combination
                                                         vaccine, toxoid), list
                                                         separately in addition to code
                                                         for primary procedure
                                                with     with
                                                90744    Hepatitis B vaccine,
                                                         pediatric/adolescent dosage
                                                         (3-dose schedule), for
                                                         intramuscular use
                                                or       or
                                                90746    Hepatitis B vaccine, adult
                                                         dosage, for intramuscular use

5732X   Administration of DTP/Hib #1       $5.00 90471   Immunization administration      $5.00
                                                         (includes percutaneous,
                                                         intradermal, subcutaneous,
                                                         intramuscular, and jet
                                                         injections); one vaccine
                                                         (single or combination
                                                         vaccine, toxoid)
                                                or       or
                                                90472    Each additional vaccine
                                                         (single or combination
                                                         vaccine, toxoid), list
                                                         separately in addition to code
                                                         for primary procedure
                                                with     with
                                                90720    Diphtheria, tetanus toxoids,
                                                         and whole cell pertussis
                                                         vaccine and Haemophilus
                                                         influenzae b vaccine (DTP-
                                                         Hib), for intramuscular use
5733X   Administration of DTP/Hib #2   $5.00 90471   Immunization administration      $5.00
                                                     (includes percutaneous,
                                                     intradermal, subcutaneous,
                                                     intramuscular, and jet
                                                     injections); one vaccine
                                                     (single or combination
                                                     vaccine, toxoid)
                                            or       or
                                            90472    Each additional vaccine
                                                     (single or combination
                                                     vaccine, toxoid), list
                                                     separately in addition to code
                                                     for primary procedure
                                            with     with
                                            90720    Diphtheria, tetanus toxoids,
                                                     and whole cell pertussis
                                                     vaccine and Haemophilus
                                                     influenzae b vaccine (DTP-
                                                     Hib), for intramuscular use
5734X   Administration of DTP/Hib #3   $5.00 90471   Immunization administration      $5.00
                                                     (includes percutaneous,
                                                     intradermal, subcutaneous,
                                                     intramuscular, and jet
                                                     injections); one vaccine
                                                     (single or combination
                                                     vaccine, toxoid)
                                            or       or
                                            90472    Each additional vaccine
                                                     (single or combination
                                                     vaccine, toxoid), list
                                                     separately in addition to code
                                                     for primary procedure
                                            with     with
                                            90720    Diphtheria, tetanus toxoids,
                                                     and whole cell pertussis
                                                     vaccine and Haemophilus
                                                     influenzae b vaccine (DTP-
                                                     Hib), for intramuscular use

5735X   Administration of DTP/Hib #4   $5.00 90471   Immunization administration      $5.00
                                                     (includes percutaneous,
                                                     intradermal, subcutaneous,
                                                     intramuscular, and jet
                                                     injections); one vaccine
                                                     (single or combination
                                                     vaccine, toxoid)
                                            or       or
                                       90472    Each additional vaccine
                                                (single or combination
                                                vaccine, toxoid), list
                                                separately in addition to code
                                                for primary procedure
                                       with     with
                                       90720    Diphtheria, tetanus toxoids,
                                                and whole cell pertussis
                                                vaccine and Haemophilus
                                                influenzae b vaccine (DTP-
                                                Hib), for intramuscular use
5736X   Administration of Td#1    $5.00 90471   Immunization administration        $5.00
                                                (includes percutaneous,
                                                intradermal, subcutaneous,
                                                intramuscular, and jet
                                                injections); one vaccine
                                                (single or combination
                                                vaccine/toxoid)
                                       or       or
                                       90472    Each additional vaccine
                                                (single or combination
                                                vaccine, toxoid), list
                                                separately in addition to code
                                                for primary procedure
                                       with     with
                                       90718    Tetanus and diphtheria
                                                toxoids (Td) adsorbed for use
                                                in individuals 7 years or older,
                                                for intramuscular or jet
                                                injection
5739X   Administration of other   $5.00 90471   Immunization administration        $5.00
        immunization                            (includes percutaneous,
                                                intradermal, subcutaneous,
                                                intramuscular, and jet
                                                injections); one vaccine
                                                (single or combination
                                                vaccine, toxoid)
                                       or       or
                                       90472    Each additional vaccine
                                                (single or combination
                                                vaccine, toxoid), list
                                                separately in addition to code
                                                for primary procedure
                                       with     with
                                       90749    Unlisted vaccine/toxoid
5741X   Administration of Hepatitis A   $5.00 90471   Immunization administration      $5.00
                                                      (includes percutaneous,
                                                      intradermal, subcutaneous,
                                                      intramuscular, and jet
                                                      injections); one vaccine
                                                      (single or combination
                                                      vaccine/toxoid)
                                             or       or
                                             90472    Each additional vaccine
                                                      (single or combination
                                                      vaccine, toxoid), list
                                                      separately in addition to code
                                                      for primary procedure
                                             with     with
                                             90632    Hepatitis A vaccine, adult
                                                      dosage, for intramuscular use

                                             or       or
                                             90633    Hepatitis A vaccine,
                                                      pediatric/adolescent dosage
                                                      (2-dose schedule), for
                                                      intramuscular use
5743X   Administration of varicella     $5.00 90471   Immunization administration      $5.00
        vaccine                                       (includes percutaneous,
                                                      intradermal, subcutaneous,
                                                      intramuscular, and jet
                                                      injections); one vaccine
                                                      (single or combination
                                                      vaccine/toxoid)
                                             or       or
                                             90472    Each additional vaccine
                                                      (single or combination
                                                      vaccine, toxoid), list
                                                      separately in addition to code
                                                      for primary procedure
                                             with     with
                                             90716    Varicella virus vaccine, live,
                                                      for subcutaneous use
5745X   Administration of DTaP#1        $5.00 90471   Immunization administration      $5.00
                                                      (includes percutaneous,
                                                      intradermal, subcutaneous,
                                                      intramuscular, and jet
                                                      injections); one vaccine
                                                      (single or combination
                                                      vaccine/toxoid)
                                             or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90700    Diphtheria, tetanus toxoids,
                                                 and acellular pertussis
                                                 vaccine (DTaP), for
                                                 intramuscular use
5746X   Administration of DTaP#2   $5.00 90471   Immunization administration        $5.00
                                                 (includes percutaneous,
                                                 intradermal, subcutaneous,
                                                 intramuscular, and jet
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90700    Diphtheria, tetanus toxoids,
                                                 and acellular pertussis
                                                 vaccine (DTaP), for
                                                 intramuscular use
5747X   Administration of DTaP#3   $5.00 90471   Immunization administration        $5.00
                                                 (includes percutaneous,
                                                 intradermal, subcutaneous,
                                                 intramuscular, and jet
                                                 injections); one vaccine
                                                 (single or combination
                                                 vaccine/toxoid)
                                        or       or
                                        90472    Each additional vaccine
                                                 (single or combination
                                                 vaccine/toxoid), list separately
                                                 in addition to code for primary
                                                 procedure
                                        with     with
                                        90700    Diphtheria, tetanus toxoids,
                                                 and acellular pertussis
                                                 vaccine (DTaP), for
                                                 intramuscular use
5748X   Administration of DTaP#4        $5.00 90471           Immunization administration           $5.00
                                                              (includes percutaneous,
                                                              intradermal, subcutaneous,
                                                              intramuscular, and jet
                                                              injections); one vaccine
                                                              (single or combination
                                                              vaccine/toxoid)
                                                or            or
                                                90472         Each additional vaccine
                                                              (single or combination
                                                              vaccine/toxoid), list separately
                                                              in addition to code for primary
                                                              procedure
                                                with          with
                                                90700         Diphtheria, tetanus toxoids,
                                                              and acellular pertussis
                                                              vaccine (DTaP), for
                                                              intramuscular use
5749X   Administration of DTaP #5       $5.00 90471           Immunization administration           $5.00
                                                              (includes percutaneous,
                                                              intradermal, subcutaneous,
                                                              intramuscular, and jet
                                                              injections); one vaccine
                                                              (single or combination
                                                              vaccine/toxoid)
                                                or            or
                                                90472         Each additional vaccine
                                                              (single or combination
                                                              vaccine/toxoid), list separately
                                                              in addition to code for primary
                                                              procedure
                                                with          with
                                                90700         Diphtheria, tetanus toxoids,
                                                              and acellular pertussis
                                                              vaccine (DTaP), for
                                                              intramuscular use
5750X   Black widow spider species   Manually           99199 Unlisted special service,          Manually
        antivenin                    reviewed                 procedure or report                reviewed

5753X   Staphage lysate              Manually           99199 Unlisted special service,          Manually
                                     reviewed                 procedure or report                reviewed
5754X   Meningococcal polysaccharide        $61.08 90471   Immunization administration          $5.00
                                                           (includes percutaneous,
                                                           intradermal, subcutaneous,
                                                           intramuscular, and jet
                                                           injections); one vaccine
                                                           (single or combination
                                                           vaccine, toxoid)
                                                  or       or                                      or
                                                  90472    Each additional vaccine              $5.00
                                                           (single or combination
                                                           vaccine, toxoid), list
                                                           separately in addition to code
                                                           for primary procedure
                                                  with     with                                  with
                                                  90733    Meningococcal                       $56.08
                                                           polysaccharide vaccine (any
                                                           group[s]), for subcutaneous or
                                                           jet injection use
5802X   Home health agency, private         $33.00 T1002   RN services, up to 15 minutes        $8.25 Bill the appropriate
        duty nursing, per hour                                                                        quantity based on
                                                  or       or                                         15-minute increments
                                                  T1003    LPN/LVN services, up to 15                 (4 units = 1 hour).
                                                           minutes
5821X   Sandimune, cyclosporin              $24.62 J7516   Cyclosporine, parenteral, 250       $26.10
        injection, 250 mg/5 mL amp                         mg
5823X   Abbokinase-urokinase injection,    $387.86 J3365   Injection, IV, urokinase,          $439.17
        250,000 IU                                         250,000 IU vial
5831X   Customized myoelectric,           Manually L6945   Elbow disarticulation, external   Manually
        prosthetic, arm                   reviewed         power, molded inner socket,       reviewed
                                                           removable humeral shell,
                                                           outside locking hinges,
                                                           forearm, otto bock or equal
                                                           electrodes, cables, two
                                                           batteries and one charger,
                                                           myoelectronic control of
                                                           terminal device
                                                  or       or
                                           L6955   Above elbow, external power,
                                                   molded inner socket,
                                                   removable humeral shell,
                                                   internal locking elbow,
                                                   forearm, otto bock or equal
                                                   electrodes, cables, two
                                                   batteries and one charger,
                                                   myoelectronic control of
                                                   terminal device
                                           or      or
                                           L6965   Shoulder disarticulation,
                                                   external power, molded inner
                                                   socket, removable shoulder
                                                   shell, shoulder bulkhead,
                                                   humeral section, mechanical
                                                   elbow, forearm, otto bock or
                                                   equal electrodes, cables, two
                                                   batteries and one charger,
                                                   myoelectronic control of
                                                   terminal device

                                           or      or
                                           L6975   Interscapular-thoracic,
                                                   external power, molded inner
                                                   socket, removable shoulder
                                                   shell, shoulder bulkhead,
                                                   humeral section, mechanical
                                                   elbow, forearm, otto bock or
                                                   equal electrodes, cables, two
                                                   batteries and one charger,
                                                   myoelectronic control of
                                                   terminal device

5836X   Physical therapy developmental                                             Discontinued
        treatment, initial 30 minutes
5837X   Physical therapy group                                                     Discontinued
        treatment, per session
5841X   Occupational therapy                                                       Discontinued
        developmental treatment, initial
        30 minutes
5842X   Occupational therapy group                                                 Discontinued
        treatment, per session
5846X   SLP developmental treatment,                                               Discontinued
        initial 30 minutes
5847X   SLP group treatment, per                                                                    Discontinued
        session
5849X   Physical therapy developmental                                                              Discontinued
        treatment, additional 15 minutes
5850X   Occupational therapy                                                                        Discontinued
        developmental treatment,
        additional 15 minutes
5851X   SLP developmental treatment,                                                                Discontinued
        additional 15 minutes
5852X   Physical therapy developmental                                                              Discontinued
        treatment session, more than 1
        hour
5853X   Occupational therapy                                                                        Discontinued
        developmental treatment
        session, more than 1 hour
5854X   SLP developmental treatment                                                                 Discontinued
        session, more than 1 hour
5856X   Cranial remodeling band, global                                                             Discontinued
        fee

5905T   Vaginal delivery only, without     $201.54 59409   Vaginal delivery only (with or   $546.19 Refer to the Birthing
        episiotomy, birthing center                        without episiotomy and/or                Centers section on page
                                                           forceps)                                 18 in the bulletin.
and     and                                    and
59410   Vaginal delivery only, with        $313.44
        episiotomy and episiorrhaphy,
        birthing center
5908T   Vaginal delivery with antepartum                                                            Discontinued; refer to the
        and postpartum care without                                                                 Birthing Centers section
        episiotomy, birthing center                                                                 on page 18 in the bulletin.

and     and
59400   Vaginal delivery with antepartum
        and postpartum care with
        episiotomy and episiorrhaphy,
        birthing center
59430   Postpartum care only, birthing                                                              Discontinued; refer to the
        center                                                                                      Birthing Centers section
                                                                                                    on page 18 in the bulletin.
5999Y   Urinary, laparoscopy,                                                                       Discontinued
        hysteroscopy, male/female
        genital system
6000X   Case management contact,                    $141.83 G9012    Other specified case                     $141.83
        monthly                                                      management service not
                                                                     elsewhere classified
6235X   Implantation, revise or reposition   TOS 2: $293.49; 62350   Implantation, revision or        TOS 2: $293.49;
        intrathecal or epidural catheter;      TOS 8: Not a          repositioning of tunneled          TOS 8: Not a
        without laminectomy                           benefit        intrathecal or epidural                   benefit
                                                                     catheter, for long-term
                                                                     medication administration via
                                                                     an external pump or
                                                                     implantable reservoir/infusion
                                                                     pump; without laminectomy
6235X   Implantation, revise or reposition   TOS F: Group 2 62350    Implantation, revision or         TOS F: Group 2
        intrathecal or epidural catheter;                            repositioning of tunneled
        without laminectomy                                          intrathecal or epidural
                                                                     catheter, for long-term
                                                                     medication administration via
                                                                     an external pump or
                                                                     implantable reservoir/infusion
                                                                     pump; without laminectomy
6378X   Insert/replace, subarachnoid or      TOS 2: $747.04; 62350   Implantation, revision or        TOS 2: $293.49,
        epidural catheter with reservoir       TOS 8: Not a          repositioning of tunneled                $94.10,
        and/or pump, without                          benefit        intrathecal or epidural                 $225.30,
        laminectomy                                                  catheter, for long-term          $295.13; TOS 8:
                                                                     medication administration via        Not a benefit
                                                                     an external pump or
                                                                     implantable reservoir/infusion
                                                                     pump; without laminectomy
                                                            and      and
                                                            62360    Implantation or replacement
                                                                     of device for intrathecal or
                                                                     epidural drug infusion;
                                                                     subcutaneous reservoir
                                                            or       or
                                                            62361    Nonprogrammable pump
                                                            or       or
                                                            62362    Programmable pump,
                                                                     including preparation of
                                                                     pump, with or without
                                                                     programming
6378X   Insert/replace, subarachnoid or    TOS F: Group 2 62350    Implantation, revision or         TOS F: Group 2
        epidural catheter with reservoir                           repositioning of tunneled
        and/or pump, without                                       intrathecal or epidural
        laminectomy                                                catheter, for long-term
                                                                   medication administration via
                                                                   an external pump or
                                                                   implantable reservoir, infusion
                                                                   pump; without laminectomy
6379X   Insert/replace, subarachnoid or             TOS 2: 62351   Implantation, revision or       TOS 2: $433.96,
        epidural catheter with reservoir   $1,249.47; TOS          repositioning of tunneled               $94.10,
        and/or pump, with laminectomy       8: Not a benefit       intrathecal or epidural                $225.30,
                                                                   catheter, for long-term         $295.13; TOS 8:
                                                                   medication administration via       Not a benefit
                                                                   an external pump or
                                                                   implantable reservoir, infusion
                                                                   pump; with laminectomy
                                                          and      and
                                                          62360    Implantation or replacement
                                                                   of device for intrathecal or
                                                                   epidural drug infusion;
                                                                   subcutaneous reservoir
                                                          or       or
                                                          62361    Nonprogrammable pump
                                                          or       or
                                                          62362    Programmable pump,
                                                                   including preparation of
                                                                   pump, with or without
                                                                   programming
6379X   Insert/replace, subarachnoid or    TOS F: Group 2 62351    Implantation, revision or         TOS F: Group 2
        epidural catheter with reservoir                           repositioning of tunneled
        and/or pump, with laminectomy                              intrathecal or epidural
                                                                   catheter, for long-term
                                                                   medication administration via
                                                                   an external pump or
                                                                   implantable reservoir, infusion
                                                                   pump; with laminectomy
6999Y   Endocrine, nervous, eye and                                                                                    Discontinued
        ocular, auditory system
7007X   Audiology services, each 15                $11.86 92506    Evaluation of speech,                     $11.86 Refer to the SHARS
        minutes                                                    language, voice,                                 section on page 50 in the
                                                                   communication, auditory                          bulletin.
                                                                   processing, and/or aural
                                                                   rehabilitation status
                                                          or       or
                                                92507    Treatment of speech,
                                                         language, voice,
                                                         communication, and/or
                                                         auditory processing disorder
                                                         (includes aural rehabilitation);
                                                         individual
7008X   Counseling services, each 15      $19.04 H0004   Behavioral health counseling       $19.04 Refer to the SHARS
        minutes                                          and therapy, per 15 minutes               section on page 50 in the
                                                                                                   bulletin.
7009X   Occupational therapy, each 15     $12.05 97003   Occupational therapy               $12.05 Refer to the SHARS
        minutes                                          evaluation                                section on page 50 in the
                                                                                                   bulletin.
                                                or       or
                                                97530    Therapeutic activities, direct
                                                         (one-on-one) patient contact
                                                         by the provider (use of
                                                         dynamic activities to improve
                                                         functional performance), each
                                                         15 minutes

7010X   Physical therapy, each 15         $12.05 97001   Physical therapy evaluation        $12.05 Refer to the SHARS
        minutes                                          procedure, one or more                    section on page 50 in the
                                                         areas, each 15 minutes                    bulletin.
                                                or       or
                                                97110    Therapeutic exercises to
                                                         develop strength and
                                                         endurance, range of motion
                                                         and flexibility
7011X   Psychological services, each 15   $14.67 96100   Psychological testing                TBD Refer to the SHARS
        minutes                                          (includes psychodiagnostic               section on page 50 in the
                                                         assessment of personality,               bulletin.
                                                         psychopathology,
                                                         emotionality, intellectual
                                                         abilities, i.e., Wais-R,
                                                         Rorschach, MMPI) with
                                                         interpretation and report, per
                                                         hour
                                                or       or                                     or
                                                H0004    Behavioral health counseling       $19.04
                                                         and therapy, per 15 minutes
7012X   Speech therapy, each 15           $11.86 92506   Evaluation of speech,              $11.86 Refer to the SHARS
        minutes                                          language, voice,                          section on page 50 in the
                                                         communication, auditory                   bulletin.
                                                         processing, and/or aural
                                                         rehabilitation status
                                                or       or
                                                92507         Treatment of speech,
                                                              language, voice,
                                                              communication, and/or
                                                              auditory processing disorder
                                                              (includes aural rehabilitation);
                                                              individual
                                                with          with
                                                modifier GN   Services delivered under an
                                                              outpatient speech language
                                                              pathology plan of care
7013X   Medical services, each 15         $62.71 99499        Unlisted evaluation and            $62.71 Refer to the SHARS
        minutes                                               management service                        section on page 50 in the
                                                                                                        bulletin.
7014X   School health services, each 15   $13.06 T1002        RN services, up to 15 minutes      $13.06 Refer to the SHARS
        minutes                                                                                         section on page 50 in the
                                                                                                        bulletin.
                                                or            or
                                                T1003         LPN/LVN services, up to 15
                                                              minutes
                                                or            or
                                                T1004         Services of a qualified nursing
                                                              aide, up to 15 minutes

                                                or            or
                                                99202         Office or other outpatient visit
                                                              for the evaluation and
                                                              management of a new
                                                              patient, which requires these
                                                              three key components: an
                                                              expanded problem-focused
                                                              history; an expanded problem-
                                                              focused examination; and
                                                              straightforward medical
                                                              decision making

                                                or            or
                                                     99213    Office or other outpatient visit
                                                              for the evaluation and
                                                              management of an
                                                              established patient, which
                                                              requires at least two of these
                                                              three key components: an
                                                              expanded problem-focused
                                                              history; an expanded problem-
                                                              focused examination; medical
                                                              decision making of low
                                                              complexity

7015X   Assessment, each 15 minutes            $19.47 96150   Health and behavior                         $19.47 Refer to the SHARS
                                                              assessment (e.g., health-                          section on page 50 in the
                                                              focused clinical interview,                        bulletin.
                                                              behavioral observations,
                                                              psychophysicological
                                                              monitoring, health-oriented
                                                              questionnaires), each 15
                                                              minutes, face-to-face with the
                                                              patient; initial
7681W   Ultrasound, pregnant uterus,        TOS G, 4: 76811   Ultrasound, pregnant uterus,       TOS G: $177.63
        complete exam-complete basic   $177.63; TOS I:        real time with image                           TOS
        (76805) plus detailed fetal    $72.83; TOS T:         documentation, fetal and             4, I, T: TBD
        anatomic survey                        $104.80        maternal evaluation plus
                                                              detailed fetal anatomic
                                                              examination, transabdominal
                                                              approach, single or first
                                                              gestation
                                                     or       or
                                                     76812    Ultrasound, pregnant uterus,
                                                              real time with image
                                                              documentation, fetal and
                                                              maternal evaluation plus
                                                              detailed fetal anatomic
                                                              examination, transabdominal
                                                              approach, each additional
                                                              gestation, list separately in
                                                              addition to code for primary
                                                              procedure
7682W   Ultrasound, pregnant uterus,          TOS G, 4: 76811        Ultrasound, pregnant uterus,    TOS G: $97.44
        comprehensive exam, follow-up     $97.44; TOS I:             real time with image
        or repeat                        $39.95; TOS T:              documentation, fetal and        TOS 4, I, T: TBD
                                                 $104.80             maternal evaluation plus
                                                                     detailed fetal anatomic
                                                                     examination, transabdominal
                                                                     approach, single or first
                                                                     gestation
                                                       or            or
                                                       76812         Ultrasound, pregnant uterus,
                                                                     real time with image
                                                                     documentation, fetal and
                                                                     maternal evaluation plus
                                                                     detailed fetal anatomic
                                                                     examination, transabdominal
                                                                     approach, each additional
                                                                     gestation, list separately in
                                                                     addition to code for primary
                                                                     procedure
                                                       with          To indicate follow-up, use with
                                                       modifier TS   Follow-up service
7999Y   Radiology                                                                                                       Discontinued
8000Y   THSteps medical screen, normal          $70.00 99381,        Initial comprehensive                    $70.00 Refer to the THSteps
                                                                     preventive medicine                             Medical section,
                                                                     evaluation and management                       beginning on page 53, in
                                                                     of an individual including an                   the bulletin.
                                                                     age and gender appropriate
                                                                     history, examination,
                                                                     counseling/anticipatory
                                                                     guidance, risk factor reduction
                                                                     interventions, and the
                                                                     ordering of appropriate
                                                                     immunization(s), laboratory,
                                                                     diagnostic procedures, new
                                                                     patient; infant (younger than 1
                                                                     year),
                                                       99382,        ...Early childhood (age 1
                                                                     through 4 years),
                                                       99383,        ...Late childhood (age 5
                                                                     through 11 years),
                                                       99384,        ...Adolescent (age 12 through
                                                                     17 years),
                                                       99385         ...18 through 39 years
                                                       or            or
                                              99391,              Periodic comprehensive
                                                                  preventive medicine re-
                                                                  evaluation and management
                                                                  of an individual including an
                                                                  age and gender appropriate
                                                                  history, examination,
                                                                  counseling/anticipatory
                                                                  guidance, risk factor reduction
                                                                  interventions, and the
                                                                  ordering of appropriate
                                                                  immunization(s), laboratory,
                                                                  diagnostic procedures,
                                                                  established patient; infant
                                                                  (younger than 1 year),
                                              99392,              ...Early childhood (age 1
                                                                  through 4 years),
                                              99393,              ...Late childhood (age 5
                                                                  through 11 years),
                                              99394,              ...Adolescent (age 12 through
                                                                  17 years),
                                              99395               ...18 through 39 years
                                              with certification  with certification condition
                                              condition indicator indicator
                                              N                   No - EPSDT referral was not
                                                                  given to the patient
                                              and condition code and condition code

                                               NU                 Not used
8002Y   THSteps adolescent preventive                                                                      Discontinued
        visit, normal
8004Y   THSteps exception to            $70.00 99381,             Initial comprehensive             $70.00 Refer to the THSteps
        periodicity, normal                                       preventive medicine                      Medical section,
                                                                  evaluation and management                beginning on page 53, in
                                                                  of an individual including an            the bulletin.
                                                                  age and gender appropriate
                                                                  history, examination,
                                                                  counseling/anticipatory
                                                                  guidance, risk factor reduction
                                                                  interventions, and the
                                                                  ordering of appropriate
                                                                  immunization(s), laboratory,
                                                                  diagnostic procedures, new
                                                                  patient; infant (younger than 1
                                                                  year),
                                              99383,              ...Early childhood (age 1
                                                                  through 4 years),
99382,             ...Late childhood (age 5
                   through 11 years),
99384,             ...Adolescent (age 12 through
                   17 years),
99385              ...18 through 39 years
or                 or
99391,             Periodic comprehensive
                   preventive medicine re-
                   evaluation and management
                   of an individual including an
                   age and gender appropriate
                   history, examination,
                   counseling/anticipatory
                   guidance, risk factor reduction
                   interventions, and the
                   ordering of appropriate
                   immunization(s), laboratory,
                   diagnostic procedures,
                   established patient; infant
                   (younger than 1 year),
99392,             ...Early childhood (age 1
                   through 4 years),
99393,             ...Late childhood (age 5
                   through 11 years),
99394,             ...Adolescent (age 12 through
                   17 years),
99395              ...18 through 39 years
with               with
modifier 23        Unusual anesthesia:
                   occasional
or                 or
32                 Mandated services: services
                   related to mandated
                   consultation and/or related
                   services (e.g., PRO, third
                   party payer, governmental,
                   legislative or regulatory
                   requirement)
or                 or
SC                 Medically necessary service
                   or supply
with               with
certification      certification condition indicator
condition indicator
 N                  No - EPSDT referral was not
                    given to the patient
                                               and condition code and condition code

                                               NU                 Not used
8005Y   THSteps follow-up visit,         $6.00 99211              Office or other outpatient visit    $6.00 Refer to the THSteps
        repeated laboratory work                                  for the evaluation and                    Medical section,
                                                                  management of an                          beginning on page 53, in
                                                                  established patient, that may             the bulletin.
                                                                  not require the presence of a
                                                                  physician
8010X   Individual, community support   $34.56 H0046              Mental health services, not        $34.56 Refer to the MHMR
        services by professional (MH                              otherwise specified                       section, beginning on
        rehab)                                                                                              page 45, in the bulletin.
                                               with               with
                                               modifier HN        Bachelor’s degree level
                                               or                 or
                                               HO                 Master’s degree level
                                               or                 or
                                               HP                 Doctoral level
                                               or                 or
                                               TD                 RN
8011X   Individual, community support   $25.10 H0046              Mental health services, not        $25.10 Refer to the MHMR
        services by paraprofessional                              otherwise specified                       section, beginning on
        (MH rehab)                                                                                          page 45, in the bulletin.
                                               with               with
                                               modifier HM        Less than bachelor’s degree
                                                                  level
                                               or                 or
                                               TE                 LPN/LVN
8012X   Group, community support         $9.49 H0046              Mental health services, not         $9.49 Refer to the MHMR
        services by professional (MH                              otherwise specified                       section, beginning on
        rehab)                                                                                              page 45, in the bulletin.
                                               with               with
                                               modifier HQ        Group setting
                                               and                and
                                               HN                 Bachelor’s degree level
                                               or                 or
                                               HO                 Master’s degree level
                                               or                 or
                                               HP                 Doctoral level
                                               or                 or
                                               TD                 RN
8013X   Group, community support         $6.54 H0046              Mental health services, not         $6.54 Refer to the MHMR
        services by paraprofessional                              otherwise specified                       section, beginning on
        (MH rehab)                                                                                          page 45, in the bulletin.
                                               with               with
                                               modifier HQ        Group setting
                                                    and           and
                                                    HM            Less than bachelor’s degree
                                                                  level
                                                    or            or
                                                    TE            LPN/LVN
8014X   Adult, day program for acute         $20.87 G0177         Training and educational       $20.87 Refer to the MHMR
        needs (MH rehab)                                          services related to the care          section, beginning on
                                                                  and treatment of patient’s            page 45, in the bulletin.
                                                                  disabling mental health
                                                                  problems per session, 45
                                                                  minutes or more
                                                    with          with
                                                    modifier AT   Acute treatment
8015X   Adult, day program skills            $11.89 G0177         Training and educational       $11.89 Refer to the MHMR
        training (MH rehab)                                       services related to the care          section, beginning on
                                                                  and treatment of patient’s            page 45, in the bulletin.
                                                                  disabling mental health
                                                                  problems per session, 45
                                                                  minutes or more
                                                    with          with
                                                    modifier TG   Complex/high level of care
8016X   Adult day program skills             $12.43 G0177         Training and educational       $12.43 Refer to the MHMR
        maintenance (MH rehab)                                    services related to the care          section, beginning on
                                                                  and treatment of patient’s            page 45, in the bulletin.
                                                                  disabling mental health
                                                                  problems per session, 45
                                                                  minutes or more
                                                    with          with
                                                    modifier TF   Intermediate level of care
8017X   Child, day program for acute         $20.87 G0177         Training and educational       $20.87 Refer to the MHMR
        needs (MH rehab)                                          services related to the care          section, beginning on
                                                                  and treatment of patient’s            page 45, in the bulletin.
                                                                  disabling mental health
                                                                  problems per session, 45
                                                                  minutes or more
                                                    with          with
                                                    modifier AT   Acute treatment
                                                    and           and
                                                    HA            Child/adolescent program
8018X   Child, day program skills training   $24.17 G0177         Training and educational       $24.17 Refer to the MHMR
        (MH rehab)                                                services related to the care          section, beginning on
                                                                  and treatment of patient’s            page 45, in the bulletin.
                                                                  disabling mental health
                                                                  problems per session, 45
                                                                  minutes or more
                                                    with          with
                                                    modifier TG   Complex/high level of care
                                            and      and
                                            HA       Child/adolescent program
8019X   Plan of care oversight (MH   $35.36 H0002    Behavioral health screening       $35.36 Refer to the MHMR
        rehab)                                       to determine eligibility for             section, beginning on
                                                     admission to treatment                   page 45, in the bulletin.
                                                     program
8099Y   Pathology and laboratory                                                              Discontinued

8100Y   THSteps medical screen,      $70.00 99381,   Initial comprehensive             $70.00 Refer to the THSteps
        abnormal, treatment not                      preventive medicine                      Medical section,
        necessary                                    evaluation and management                beginning on page 53, in
                                                     of an individual including an            the bulletin.
                                                     age and gender appropriate
                                                     history, examination,
                                                     counseling/anticipatory
                                                     guidance, risk factor reduction
                                                     interventions, and the
                                                     ordering of appropriate
                                                     immunization(s), laboratory,
                                                     diagnostic procedures, new
                                                     patient; infant (younger than 1
                                                     year),
                                           99382,    ...Early childhood (age 1
                                                     through 4 years),
                                           99383,    ...Late childhood (age 5
                                                     through 11 years),
                                           99384,    ...Adolescent (age 12 through
                                                     17 years),
                                           99385     ...18 through 39 years
                                           or        or
                                           99391,    Periodic comprehensive
                                                     preventive medicine re-
                                                     evaluation and management
                                                     of an individual including an
                                                     age and gender appropriate
                                                     history, examination,
                                                     counseling/anticipatory
                                                     guidance, risk factor reduction
                                                     interventions, and the
                                                     ordering of appropriate
                                                     immunization(s), laboratory,
                                                     diagnostic procedures,
                                                     established patient; infant
                                                     (younger than 1 year),
                                           99392,    ...Early childhood (age 1
                                                     through 4 years),
                                                99393,              ...Late childhood (age 5
                                                                    through 11 years),
                                                99394,              ...Adolescent (age 12 through
                                                                    17 years),
                                                99395               ...18 through 39 years
                                                with certification  with certification condition
                                                condition indicator indicator
                                                N                   No - EPSDT referral was not
                                                                    given to the patient
                                                and condition code and condition code

                                                NU                 Not used
8102Y   THSteps adolescent preventive                                                                       Discontinued
        visit, abnormal, treatment not
        necessary
8104Y   THSteps exception to              $70.00 99381,            Initial comprehensive             $70.00 Refer to the THSteps
        periodicity, abnormal treatment                            preventive medicine                      Medical section,
        not necessary                                              evaluation and management                beginning on page 53, in
                                                                   of an individual including an            the bulletin.
                                                                   age and gender appropriate
                                                                   history, examination,
                                                                   counseling/anticipatory
                                                                   guidance, risk factor reduction
                                                                   interventions, and the
                                                                   ordering of appropriate
                                                                   immunization(s), laboratory,
                                                                   diagnostic procedures, new
                                                                   patient; infant (younger than 1
                                                                   year),
                                                99382,             ...Early childhood (age 1
                                                                   through 4 years),
                                                99383,             ...Late childhood (age 5
                                                                   through 11 years),
                                                99384,             ...Adolescent (age 12 through
                                                                   17 years),
                                                99385              ...18 through 39 years
                                                or                 or
99391,             Periodic comprehensive
                   preventive medicine re-
                   evaluation and management
                   of an individual including an
                   age and gender appropriate
                   history, examination,
                   counseling/anticipatory
                   guidance, risk factor reduction
                   interventions, and the
                   ordering of appropriate
                   immunization(s), laboratory,
                   diagnostic procedures,
                   established patient; infant
                   (younger than 1 year),
99392,             ...Early childhood (age 1
                   through 4 years),
99393,             ...Late childhood (age 5
                   through 11 years),
99394,             ...Adolescent (age 12 through
                   17 years),
99395              ...18 through 39 years
with               with
modifier 23        Unusual anesthesia:
                   occasionally, a procedure,
                   which usually requires either
                   no anesthesia or local
                   anesthesia, because of
                   unusual circumstances must
                   be done under general
                   anesthesia
or                 or
32                 Mandated services: services
                   related to mandated
                   consultation and/or related
                   services (e.g., PRO, third
                   party payer, governmental,
                   legislative or regulatory
                   requirement)
or                 or
SC                 Medically necessary service
with certification or supply
                   with certification condition
condition indicator indicator
N                   No - EPSDT referral was not
                    given to patient
and condition code and condition code
                                                  NU            Not used


8105Y   THSteps follow-up visits,         $6.00 99211           Office or other outpatient visit     $6.00 Refer to the THSteps
        complete immunizations                                  for the evaluation and                     Medical section,
                                                                management of an                           beginning on page 53, in
                                                                established patient, that may              the bulletin.
                                                                not require the presence of a
                                                                physician
8110D   Crossbite therapy, removable    $250.00 D8050           Interceptive orthodontic           $340.00 Bill the appropriate code
        appliance                                               treatment; of the primary                  based on dentition.
                                                                dentition
and
Z2018   Crossbite workup                 $50.00
or      or                                      or              or
8120D   Crossbite therapy, fixed        $300.00 D8060           Interceptive orthodontic
        appliance                                               treatment; of the transitional
                                                                dentition
and     and
Z2018   Crossbite workup                 $50.00
8111X   Initial exam, level 1,           $26.53 99204           Office or other outpatient visit    $26.53 Refer to the TB Clinics
        nonphysician services only,                             for the evaluation and                     section, beginning on
        client class 1 or 2                                     management of a new                        page 58, in the bulletin.
                                                                patient, which requires these
                                                                three key components: a
                                                                comprehensive history; a
                                                                comprehensive examination;
                                                                and medical decision making
                                                                of moderate complexity


                                                with            with
                                                modifier TF     Intermediate level of care
8116X   Initial exam, level 6,           $52.90 99204           Office or other outpatient visit    $52.90 Refer to the TB Clinics
        nonphysician and physician                              for the evaluation and                     section, beginning on
        services, client class 1 or 2                           management of a new                        page 58, in the bulletin.
                                                                patient, which requires these
                                                                three key components: a
                                                                comprehensive history; a
                                                                comprehensive examination;
                                                                and medical decision making
                                                                of moderate complexity


                                                  with          with
                                                  modifier TF   Intermediate level of care
                                                and           and
                                                AM            Physician, team member
                                                              service
8118X   Initial exam, level 8,           $54.10 99205         Office or other outpatient visit   $54.10 Refer to the TB Clinics
        nonphysician and physician                            for the evaluation and                    section, beginning on
        services and prescribed meds                          management of a new                       page 58, in the bulletin.
        (preventive treatment), client                        patient, which requires these
        class 1 or 2                                          three key components: a
                                                              comprehensive history; a
                                                              comprehensive examination;
                                                              and medical decision making
                                                              of high complexity

                                                with          with
                                                modifier TF   Intermediate level of care
8131X   Initial exam level 1,            $43.27 99204         Office or other outpatient visit   $43.27 Refer to the TB Clinics
        nonphysician services only,                           for the evaluation and                    section, beginning on
        client class 3 or 5                                   management of a new                       page 58, in the bulletin.
                                                              patient, which requires these
                                                              three key components: a
                                                              comprehensive history; a
                                                              comprehensive examination;
                                                              and medical decision making
                                                              of moderate complexity


                                                with          with
                                                modifier TG   Complex/high level of care
8136X   Initial exam, level 6,           $73.51 99204         Office or other outpatient visit   $73.51 Refer to the TB Clinics
        nonphysician and physician                            for the evaluation and                    section, beginning on
        services, client class 3 or 5                         management of a new                       page 58, in the bulletin.
                                                              patient, which requires these
                                                              three key components: a
                                                              comprehensive history; a
                                                              comprehensive examination;
                                                              and medical decision making
                                                              of moderate complexity


                                                with          with
                                                modifier TG   Complex/high level of care
                                                and           and
                                                AM            Physician, team member
                                                              service
8137X   Initial exam, level 7,                $253.99 99205         Office or other outpatient visit   $253.99 Refer to the TB Clinics
        nonphysician and physician                                  for the evaluation and                     section, beginning on
        services and prescribed meds                                management of a new                        page 58, in the bulletin.
        (initial treatment), client class 3                         patient, which requires these
        or 5                                                        three key components: a
                                                                    comprehensive history; a
                                                                    comprehensive examination;
                                                                    and medical decision making
                                                                    of high complexity

                                                      with          with
                                                      modifier TG   Complex/high level of care
8200Y   THSteps medical screen,                $70.00 99381,        Initial comprehensive               $70.00 Refer to the THSteps
        abnormal, treatment initiated                               preventive medicine                        Medical section,
                                                                    evaluation and management                  beginning on page 53, in
                                                                    of an individual including an              the bulletin.
                                                                    age and gender appropriate
                                                                    history, examination,
                                                                    counseling/anticipatory
                                                                    guidance, risk factor reduction
                                                                    interventions, and the
                                                                    ordering of appropriate
                                                                    immunization(s), laboratory,
                                                                    diagnostic procedures, new
                                                                    patient; infant (younger than 1
                                                                    year),
                                                      99382,        ...Early childhood (age 1
                                                                    through 4 years),
                                                      99383,        ...Late childhood (age 5
                                                                    through 11 years),
                                                      99384,        ...Adolescent (age 12 through
                                                                    17 years),
                                                      99385         ...18 through 39 years
                                                      or            or
                                                 99391,              Periodic comprehensive
                                                                     preventive medicine re-
                                                                     evaluation and management
                                                                     of an individual including an
                                                                     age and gender appropriate
                                                                     history, examination,
                                                                     counseling/anticipatory
                                                                     guidance, risk factor reduction
                                                                     interventions, and the
                                                                     ordering of appropriate
                                                                     immunization(s), laboratory,
                                                                     diagnostic procedures,
                                                                     established patient; infant
                                                                     (younger than 1 year),
                                                 99392,              ...Early childhood (age 1
                                                                     through 4 years),
                                                 99393,              ...Late childhood (age 5
                                                                     through 11 years),
                                                 99394,              ...Adolescent (age 12 through
                                                                     17 years),
                                                 99395               ...18 through 39 years
                                                 with certification  with certification condition
                                                 condition indicator indicator
                                                 N                   No - EPSDT referral was not
                                                                     given to patient
                                                 and condition code and condition code
                                                 NU                  Not used
8202Y   THSteps adolescent preventive                                                                         Discontinued
        visit, abnormal, treatment
        initiated
8204Y   THSteps exception to               $70.00 99381,             Initial comprehensive             $70.00 Refer to the THSteps
        periodicity, abnormal, treatment                             preventive medicine                      Medical section,
        initiated                                                    evaluation and management                beginning on page 53, in
                                                                     of an individual including an            the bulletin.
                                                                     age and gender appropriate
                                                                     history, examination,
                                                                     counseling/anticipatory
                                                                     guidance, risk factor reduction
                                                                     interventions, and the
                                                                     ordering of appropriate
                                                                     immunization(s), laboratory,
                                                                     diagnostic procedures, new
                                                                     patient; infant (younger than 1
                                                                     year),
                                                 99382,              ...Early childhood (age 1
                                                                     through 4 years),
99383,        ...Late childhood (age 5
              through 11 years),
99384,        ...Adolescent (age 12 through
              17 years),
99385         ...18 through 39 years
or            or
99391,        Periodic comprehensive
              preventive medicine re-
              evaluation and management
              of an individual including an
              age and gender appropriate
              history, examination,
              counseling/anticipatory
              guidance, risk factor reduction
              interventions, and the
              ordering of appropriate
              immunization(s), laboratory,
              diagnostic procedures,
              established patient; infant
              (younger than 1 year),
99392,        ...Early childhood (age 1
              through 4 years),
99393,        ...Late childhood (age 5
              through 11 years),
99394,        ...Adolescent (age 12 through
              17 years),
99395         ...18 through 39 years
and           and
modifier 12   Unusual anesthesia:
              occasionally, a procedure,
              which usually requires either
              no anesthesia or local
              anesthesia, because of
              unusual circumstances must
              be done under general
              anesthesia
or            or
32            Mandated services: services
              related to mandated
              consultation and/or related
              services (e.g., PRO, third
              party payer, governmental,
              legislative or regulatory
              requirement)
or            or
SC            Medically necessary service
              or supply
                                                 with certification with certification condition
                                                 indicator          indicator
                                                 N                  No - EPSDT referral was not
                                                                    given to patient
                                                 and condition code and condition code
                                                 NU                 Not used
8205Y   THSteps follow-up visit,           $6.00 99211              Office or other outpatient visit      $6.00 Refer to the THSteps
        presumptive positive tuberculin                             for the evaluation and                      Medical section,
        skin test reaction                                          management of an                            beginning on page 53, in
                                                                    established patient, that may               the bulletin.
                                                                    not require the presence of a
                                                                    physician
8216X   Physician exam, level 6,          $37.48 99201                Office or other outpatient visit   $37.48 Refer to the TB Clinics
        nonphysician and physician                                    for the evaluation and                    section, beginning on
        services, client class 1 or 2                                 management of a new                       page 58, in the bulletin.
                                                                      patient, which requires these
                                                                      three key components: a
                                                                      problem-focused history; a
                                                                      problem-focused
                                                                      examination; and
                                                                      straightforward medical
                                                                      decision making
                                                 with                 with
                                                 modifier TF          Intermediate level of care
8218X   Physician exam, level 8,          $38.68 99202                Office or other outpatient visit   $38.68 Refer to the TB Clinics
        nonphysician and physician                                    for the evaluation and                    section, beginning on
        services, prescribed meds                                     management of a new                       page 58, in the bulletin.
        (preventive treatment), client                                patient, which requires these
        class 1 or 2                                                  three key components: an
                                                                      expanded problem-focused
                                                                      history; an expanded problem-
                                                                      focused examination; and
                                                                      straightforward medical
                                                                      decision making

                                                 with                 with
                                                 modifier TF          Intermediate level of care
8236X   Physician exam, level 6,             $38.51 99201         Office or other outpatient visit    $38.51 Refer to the TB Clinics
        nonphysician and physician                                for the evaluation and                     section, beginning on
        services, client class 3 or 5                             management of a new                        page 58, in the bulletin.
                                                                  patient, which requires these
                                                                  three key components: a
                                                                  problem-focused history; a
                                                                  problem-focused
                                                                  examination; and straight
                                                                  forward medical decision
                                                                  making
                                                    with          with
                                                    modifier TG   Complex/high level of care
8237X   Physician exam, level 7,            $218.99 99202         Office or other outpatient visit   $218.99 Refer to the TB Clinics
        nonphysician and physician                                for the evaluation and                     section, beginning on
        services prescribed meds (initial                         management of a new                        page 58, in the bulletin.
        treatment), client class 3 or 5                           patient, which requires these
                                                                  three key components: an
                                                                  expanded problem-focused
                                                                  history; an expanded problem-
                                                                  focused examination; and
                                                                  straightforward medical
                                                                  decision making

                                                    with          with
                                                    modifier TG   Complex/high level of care
8300Y   THSteps medical screen,              $70.00 99381,        Initial comprehensive               $70.00 Refer to the THSteps
        abnormal, referred to primary                             preventive medicine                        Medical section,
        care physician                                            evaluation and management                  beginning on page 53, in
                                                                  of an individual including an              the bulletin.
                                                                  age and gender appropriate
                                                                  history, examination,
                                                                  counseling, anticipatory
                                                                  guidance, risk factor reduction
                                                                  interventions, and the
                                                                  ordering of appropriate
                                                                  immunization(s), laboratory,
                                                                  diagnostic procedures, new
                                                                  patient; infant (younger than 1
                                                                  year),
                                                    99382,        ...Early childhood (age 1
                                                                  through 4 years),
                                                    99383,        ...Late childhood (age 5
                                                                  through 11 years),
                                                    99384,        ...Adolescent (age 12 through
                                                                  17 years),
                                                    99385         ...18 through 39 years
                                                    or            or
                                                   99391,              Periodic comprehensive
                                                                       preventive medicine re-
                                                                       evaluation and management
                                                                       of an individual including an
                                                                       age and gender appropriate
                                                                       history, examination,
                                                                       counseling, anticipatory
                                                                       guidance, risk factor reduction
                                                                       interventions, and the
                                                                       ordering of appropriate
                                                                       immunization(s), laboratory,
                                                                       diagnostic procedures,
                                                                       established patient; infant
                                                                       (younger than 1 year),
                                                   99392,              ...Early childhood (age 1
                                                                       through 4 years),
                                                   99393,              ...Late childhood (age 5
                                                                       through 11 years),
                                                   99394,              ...Adolescent (age 12 through
                                                                       17 years),
                                                   99395               ...18 through 39 years
                                                   with certification  with certification condition
                                                   condition indicator indicator
                                                   Y                   Yes - EPSDT referral was
                                                                       given to patient
                                                   and condition code and condition code

                                                   ST                  New services requested
8302Y   THSteps adolescent preventive                                                                           Discontinued
        visit, abnormal, referred to
        primary care physician
8304Y   THSteps exception to                 $70.00 99381,             Initial comprehensive             $70.00 Refer to the THSteps
        periodicity, abnormal, referred to                             preventive medicine                      Medical section,
        primary care physician                                         evaluation and management                beginning on page 53.
                                                                       of an individual including an
                                                                       age and gender appropriate
                                                                       history, examination,
                                                                       counseling, anticipatory
                                                                       guidance, risk factor reduction
                                                                       interventions, and the
                                                                       ordering of appropriate
                                                                       immunization(s), laboratory,
                                                                       diagnostic procedures, new
                                                                       patient; infant (younger than 1
                                                                       year),
99382,              ...Early childhood (age 1
                    through 4 years),
99383,              ...Late childhood (age 5
                    through 11 years),
99384,              ...Adolescent (age 12 through
                    17 years),
99385               ...18 through 39 years
or                  or
99391,              Periodic comprehensive
                    preventive medicine re-
                    evaluation and management
                    of an individual including an
                    age and gender appropriate
                    history, examination,
                    counseling, anticipatory
                    guidance, risk factor reduction
                    interventions, and the
                    ordering of appropriate
                    immunization(s), laboratory,
                    diagnostic procedures,
                    established patient; infant
                    (younger than 1 year),
99392,              ...Early childhood (age 1
                    through 4 years),
99393,              ...Late childhood (age 5
                    through 11 years),
99394,              ...Adolescent (age 12 through
                    17 years),
99395               ...18 through 39 years
and                 and
modifier 23         Unusual anesthesia:
                    occasional
or                  or
32                  Mandated services: services
                    related to mandated
                    consultation and/or related
                    services (e.g., PRO, third
                    party payer, governmental,
                    legislative or regulatory
                    requirement)
or                  or
SC                  Medically necessary service
                    or supply
with certification  with certification condition
condition indicator indicator
Y                   Yes - EPSDT referral was
                    given to patient
                                                and condition code and condition code

                                                ST                 New services requested
8305Y   THSteps follow-up visit, other    $6.00 99211              Office or other outpatient visit    $6.00 Refer to the THSteps
                                                                   for the evaluation and                    Medical section,
                                                                   management of an                          beginning on page 53, in
                                                                   established patient, that may             the bulletin.
                                                                   not require the presence of a
                                                                   physician
8311X   Follow-up exam, level 1,         $22.12 99214              Office or other outpatient visit   $22.12 Refer to the TB Clinics
        nonphysician services only,                                for the evaluation and                    section, beginning on
        client class 1 or 2                                        management of an                          page 58, in the bulletin.
                                                                   established patient, which
                                                                   requires at least two of these
                                                                   three key components: a
                                                                   detailed history; a detailed
                                                                   examination; medical decision
                                                                   making of moderate
                                                                   complexity

                                                with               with
                                                modifier TF        Intermediate level of care
8316X   Follow-up exam, level 6,         $46.37 99214              Office or other outpatient visit   $46.37 Refer to the TB Clinics
        nonphysician and physician                                 for the evaluation and                    section, beginning on
        services, client class 1 or 2                              management of an                          page 58, in the bulletin.
                                                                   established patient, which
                                                                   requires at least two of these
                                                                   three key components: a
                                                                   detailed history; a detailed
                                                                   examination; medical decision
                                                                   making of moderate
                                                                   complexity

                                                with               with
                                                modifiers TF       Intermediate level of care
                                                and                and
                                                AM                 Physician, team member
                                                                   service
8331X   Follow-up exam, level 1,           $27.12 99214         Office or other outpatient visit   $27.12 Refer to the TB Clinics
        nonphysician services only,                             for the evaluation and                    section, beginning on
        client class 3 or 5                                     management of an                          page 58, in the bulletin.
                                                                established patient, which
                                                                requires at least two of these
                                                                three key components: a
                                                                detailed history; a detailed
                                                                examination; medical decision
                                                                making of moderate
                                                                complexity

                                                  with          with
                                                  modifier TG   Complex/high level of care
8336X   Follow-up exam, level 6,           $51.59 99214         Office or other outpatient visit   $51.59 Refer to the TB Clinics
        nonphysician and physician                              for the evaluation and                    section, beginning on
        services, client class 3 or 5                           management of an                          page 58, in the bulletin.
                                                                established patient, which
                                                                requires at least two of these
                                                                three key components: a
                                                                detailed history; a detailed
                                                                examination; medical decision
                                                                making of moderate
                                                                complexity

                                                  with          with
                                                  modifier TG   Complex/high level of care
                                                  and           and
                                                  AM            Physician, team member
                                                                service
8400Y   THSteps medical screen,            $70.00 99381,        Initial comprehensive              $70.00 Refer to the THSteps
        abnormal, referred to specialist                        preventive medicine                       Medical section,
                                                                evaluation and management                 beginning on page 53, in
                                                                of an individual including an             the bulletin.
                                                                age and gender appropriate
                                                                history, examination,
                                                                counseling/anticipatory
                                                                guidance, risk factor reduction
                                                                interventions, and the
                                                                ordering of appropriate
                                                                immunization(s), laboratory,
                                                                diagnostic procedures, new
                                                                patient; infant (younger than 1
                                                                year),
                                                  99382,        ...Early childhood (age 1
                                                                through 4 years),
                                        99383,             ...Late childhood (age 5
                                                           through 11 years),
                                        99384,             ...Adolescent (age 12 through
                                                           17 years),
                                        99385              ...18 through 39 years
                                        or                 or
                                        99391,             Periodic comprehensive
                                                           preventive medicine re-
                                                           evaluation and management
                                                           of an individual including an
                                                           age and gender appropriate
                                                           history, examination,
                                                           counseling/anticipatory
                                                           guidance, risk factor reduction
                                                           interventions, and the
                                                           ordering of appropriate
                                                           immunization(s), laboratory,
                                                           diagnostic procedures,
                                                           established patient; infant
                                                           (younger than 1 year),
                                        99392,              ...Early childhood (age 1
                                                            through 4 years),
                                        99393,              ...Late childhood (age 5
                                                            through 11 years),
                                        99394,              ...Adolescent (age 12 through
                                                            17 years),
                                        99395               ...18 through 39 years
                                        with certification  with certification condition
                                        condition indicator indicator
                                        Y                   Yes - EPSDT referral was
                                                            given to the patient
                                        and condition code and condition code
                                        ST                  New services requested
8402Y   THSteps adolescent preventive                                                        Discontinued
        visit, abnormal, referred to
        specialist
8404Y   THSteps exception to                 $70.00 99381,   Initial comprehensive             $70.00 Refer to the THSteps
        periodicity, abnormal, referred to                   preventive medicine                      Medical section,
        specialist                                           evaluation and management                beginning on page 53, in
                                                             of an individual including an            the bulletin.
                                                             age and gender appropriate
                                                             history, examination,
                                                             counseling/anticipatory
                                                             guidance, risk factor reduction
                                                             interventions, and the
                                                             ordering of appropriate
                                                             immunization(s), laboratory,
                                                             diagnostic procedures, new
                                                             patient; infant (younger than 1
                                                             year),
                                                   99382,    ...Early childhood (age 1
                                                             through 4 years),
                                                   99383,    ...Late childhood (age 5
                                                             through 11 years),
                                                   99384,    ...Adolescent (age 12 through
                                                             17 years),
                                                   99385     ...18 through 39 years
                                                   or        or
                                                   99391,    Periodic comprehensive
                                                             preventive medicine re-
                                                             evaluation and management
                                                             of an individual including an
                                                             age and gender appropriate
                                                             history, examination,
                                                             counseling/anticipatory
                                                             guidance, risk factor reduction
                                                             interventions, and the
                                                             ordering of appropriate
                                                             immunization(s), laboratory,
                                                             diagnostic procedures,
                                                             established patient; infant
                                                             (younger than 1 year),
                                                   99392,    ...Early childhood (age 1
                                                             through 4 years),
                                                   99393,    ...Late childhood (age 5
                                                             through 11 years),
                                                   99394,    ...Adolescent (age 12 through
                                                             17 years),
                                                   99395     ...18 through 39 years
                                                   and       and
                                                modifier 23         Unusual anesthesia:
                                                                    occasionally, a procedure,
                                                                    which usually requires either
                                                                    no anesthesia or local
                                                                    anesthesia, because of
                                                                    unusual circumstances must
                                                                    be done under general
                                                                    anesthesia
                                                or                  or
                                                32                  Mandated services: services
                                                                    related to mandated
                                                                    consultation and/or related
                                                                    services (e.g., PRO, third
                                                                    party payer, governmental,
                                                                    legislative or regulatory
                                                                    requirement)
                                                or                  or
                                                SC                  Medically necessary service
                                                                    or supply
                                                with certification  with certification condition
                                                condition indicator indicator
                                                Y                   Yes - EPSDT referral was
                                                                    given to patient
                                                and condition code and condition code

                                                ST                  New services requested
8413X   Monthly exam, level 3,            $13.54 99212              Office or other outpatient visit   $13.54 Refer to the TB Clinics
        nonphysician services and                                   for the evaluation and                    section, beginning on
        prescribed meds (preventive                                 management of an                          page 58, in the bulletin.
        treatment), client class 1 or 2                             established patient, which
                                                                    requires at least two of these
                                                                    three key components: a
                                                                    problem-focused history; a
                                                                    problem-focused
                                                                    examination; straightforward
                                                                    medical decision making

                                                with                with
                                                modifier TF         Intermediate level of care
8418X   Monthly exam, level 8,                 $47.57 99212          Office or other outpatient visit    $47.57 Refer to the TB Clinics
        nonphysician and physician                                   for the evaluation and                     section, beginning on
        services and prescribed meds                                 management of an                           page 58, in the bulletin.
        (preventive treatment), client                               established patient, which
        class 1 or 2                                                 requires at least two of these
                                                                     three key components: a
                                                                     problem-focused history; a
                                                                     problem-focused
                                                                     examination; straightforward
                                                                     medical decision making

                                                      with           with
                                                      modifiers TF   Intermediate level of care
                                                      and            and
                                                      AM             Physician, team member
                                                                     service
8432X   Monthly exam, level 2,                $202.38 99212          Office or other outpatient visit   $202.38 Refer to the TB Clinics
        nonphyscian and physician                                    for the evaluation and                     section, beginning on
        services and prescribed meds                                 management of an                           page 58, in the bulletin.
        (initial treatment), client class 3                          established patient, which
        or 5                                                         requires at least two of these
                                                                     three key components: a
                                                                     problem-focused history; a
                                                                     problem-focused
                                                                     examination; straightforward
                                                                     medical decision making

                                                      with           with
                                                      modifier TG    Complex/high level of care
8434X   Monthly exam, level 4,                 $45.30 99213          Office or other outpatient visit    $45.30 Refer to the TB Clinics
        nonphysician services and                                    for the evaluation and                     section, beginning on
        prescribed meds (maintenance                                 management of an                           page 58, in the bulletin.
        treatment), client class 3 or 5                              established patient, which
                                                                     requires at least two of these
                                                                     three key components: an
                                                                     expanded problem-focused
                                                                     history; an expanded problem-
                                                                     focused examination; medical
                                                                     decision making of low
                                                                     complexity

                                                      with           with
                                                      modifier TG    Complex/high level of care
8435X   Monthly exam, level 5,                $809.94 99215          Office or other outpatient visit   $809.94 Refer to the TB Clinics
        nonphysician services and                                    for the evaluation and                     section, beginning on
        prescribed meds, (advanced                                   management of an                           page 58, in the bulletin.
        treatment), client class 3 or 5                              established patient, which
                                                                     requires at least two of these
                                                                     three key components: a
                                                                     comprehensive history; a
                                                                     comprehensive examination;
                                                                     medical decision making of
                                                                     high complexity

                                                      with           with
                                                      modifier TG    Complex/high level of care
8437X   Monthly exam, level 7,                $212.27 99212          Office or other outpatient visit   $212.27 Refer to the TB Clinics
        nonphyscian and physician                                    for the evaluation and                     section, beginning on
        services and prescribed meds                                 management of an                           page 58, in the bulletin.
        (initial treatment), client class 3                          established patient, which
        or 5                                                         requires at least two of these
                                                                     three key components: a
                                                                     problem-focused history; a
                                                                     problem-focused
                                                                     examination; straightforward
                                                                     medical decision making

                                                      with           with
                                                      modifiers TG   Complex/high level of care
                                                      and            and
                                                      AM             Physician, team member
                                                                     service
8439X   Monthly exam, level 9,                 $55.19 99213          Office or other outpatient visit    $55.19 Refer to the TB Clinics
        nonphyscian and physician                                    for the evaluation and                     section, beginning on
        services and prescribed meds,                                management of an                           page 58, in the bulletin.
        maintenance treatment, client                                established patient, which
        class 3 or 5                                                 requires at least two of these
                                                                     three key components: an
                                                                     expanded problem-focused
                                                                     history; an expanded problem-
                                                                     focused examination; medical
                                                                     decision making of low
                                                                     complexity

                                                      with           with
                                                      modifiers TG   Complex/high level of care
                                                      and            and
                                                      AM             Physician, team member
                                                                     service
8450X   Monthly exam, level 10,        $819.83 99215         Office or other outpatient visit   $819.83 Refer to the TB Clinics
        nonphyscian and physician                            for the evaluation and                     section, beginning on
        services and prescribed meds                         management of an                           page 58, in the bulletin.
        (advanced treatment), client                         established patient, which
        class 3 or 5                                         requires at least two of these
                                                             three key components: a
                                                             comprehensive history; a
                                                             comprehensive examination;
                                                             medical decision making of
                                                             high complexity

                                              with           with
                                              modifiers TG   Complex/high level of care
                                              and            and
                                              AM             Physician, team member
                                                             service
8500Y   THSteps medical screen,         $70.00 99381,        Initial comprehensive               $70.00 Refer to the TB Clinics
        abnormal, referred to other                          preventive medicine                        section, beginning on
        health agency                                        evaluation and management                  page 58, in the bulletin.
                                                             of an individual including an
                                                             age and gender appropriate
                                                             history, examination,
                                                             counseling/anticipatory
                                                             guidance, risk factor reduction
                                                             interventions, and the
                                                             ordering of appropriate
                                                             immunization(s), laboratory,
                                                             diagnostic procedures, new
                                                             patient; infant (younger than 1
                                                             year),
                                              99382,         ...Early childhood (age 1
                                                             through 4 years),
                                              99383,         ...Late childhood (age 5
                                                             through 11 years),
                                              99384,         ...Adolescent (age 12 through
                                                             17 years),
                                              99385          ...18 through 39 years
                                              or             or
                                                   99391,              Periodic comprehensive
                                                                       preventive medicine re-
                                                                       evaluation and management
                                                                       of an individual including an
                                                                       age and gender appropriate
                                                                       history, examination,
                                                                       counseling/anticipatory
                                                                       guidance, risk factor reduction
                                                                       interventions, and the
                                                                       ordering of appropriate
                                                                       immunization(s), laboratory,
                                                                       diagnostic procedures,
                                                                       established patient; infant
                                                                       (younger than 1 year),
                                                   99392,              ...Early childhood (age 1
                                                                       through 4 years),
                                                   99393,              ...Late childhood (age 5
                                                                       through 11 years),
                                                   99394,              ...Adolescent (age 12 through
                                                                       17 years),
                                                   99395               ...18 through 39 years
                                                   with certification  with certification condition
                                                   condition indicator indicator
                                                   N                   No - EPSDT referral was not
                                                                       given to patient
                                                   and condition code and condition code
                                                   NU                  Not used
8502Y   THSteps adolescent preventive                                                                           Discontinued
        visit, abnormal, referred to other
        health agency

8504Y   THSteps exception to                 $70.00 99381,             Initial comprehensive             $70.00 Refer to the THSteps
        periodicity, abnormal, referred to                             preventive medicine                      Medical section,
        other health agency                                            evaluation and management                beginning on page 53, in
                                                                       of an individual including an            the bulletin.
                                                                       age and gender appropriate
                                                                       history, examination,
                                                                       counseling/anticipatory
                                                                       guidance, risk factor reduction
                                                                       interventions, and the
                                                                       ordering of appropriate
                                                                       immunization(s), laboratory,
                                                                       diagnostic procedures, new
                                                                       patient; infant (younger than 1
                                                                       year),
                                                   99382,              ...Early childhood (age 1
                                                                       through 4 years),
99383,        ...Late childhood (age 5
              through 11 years),
99384,        ...Adolescent (age 12 through
              17 years),
99385         ...18 through 39 years
or            or
99391,        Periodic comprehensive
              preventive medicine re-
              evaluation and management
              of an individual including an
              age and gender appropriate
              history, examination,
              counseling/anticipatory
              guidance, risk factor reduction
              interventions, and the
              ordering of appropriate
              immunization(s), laboratory,
              diagnostic procedures,
              established patient; infant
              (younger than 1 year),
99392,        ...Early childhood (age 1
              through 4 years),
99393,        ...Late childhood (age 5
              through 11 years),
99394,        ...Adolescent (age 12 through
              17 years),
99395         ...18 through 39 years
and           and
modifier 23   Unusual anesthesia:
              occasionally, a procedure,
              which usually requires either
              no anesthesia or local
              anesthesia, because of
              unusual circumstances must
              be done under general
              anesthesia
or            or
32            Mandated services: services
              related to mandated
              consultation and/or related
              services (e.g., PRO, third
              party payer, governmental,
              legislative, or regulatory
              requirement)
or            or
                                             SC                  Medically necessary service
                                                                 or supply
                                             with certification  with certification condition
                                             condition indicator indicator
                                              N                  No - EPSDT referral was not
                                                                 given to patient
                                             and condition code and condition code

                                             NU                 Not used
8511X   DOT/DOPT exam, level 1,        $9.69 99211              Office or other outpatient visit    $9.69 Refer to the TB Clinics
        nonphysician services only,                             for the evaluation and                    section, beginning on
        client class 1 or 2                                     management of an                          page 58, in the bulletin.
                                                                established patient, that may
                                                                not require the presence of a
                                                                physician; usually, the
                                                                presenting problem(s) are
                                                                minimal
                                             with               with
                                             modifier TF        Intermediate level of care
8531X   DOT/DOPT exam, level 1,       $15.77 99211              Office or other outpatient visit   $15.77 Refer to the TB Clinics
        nonphysician services only,                             for the evaluation and                    section, beginning on
        client class 3 or 5                                     management of an                          page 58, in the bulletin.
                                                                established patient, that may
                                                                not require the presence of a
                                                                physician; usually, the
                                                                presenting problem(s) are
                                                                minimal
                                             with               with
                                             modifier TG        Complex/high level of care
8600Y   THSteps medical screen,       $70.00 99381,             Initial comprehensive              $70.00 Refer to the THSteps
        abnormal, condition under                               preventive medicine                       Medical section,
        treatment                                               evaluation and management                 beginning on page 53, in
                                                                of an individual including an             the bulletin.
                                                                age and gender appropriate
                                                                history, examination,
                                                                counseling/anticipatory
                                                                guidance, risk factor reduction
                                                                interventions, and the
                                                                ordering of appropriate
                                                                immunization(s), laboratory,
                                                                diagnostic procedures, new
                                                                patient; infant (younger than 1
                                                                year),
                                             99382,             ...Early childhood (age 1
                                                                through 4 years),
                                             99383,             ...Late childhood (age 5
                                                                through 11 years),
                                           99384,              ...Adolescent (age 12 through
                                                               17 years),
                                           99385               ...18 through 39 years
                                           or                  or
                                           99391,              Periodic comprehensive
                                                               preventive medicine re-
                                                               evaluation and management
                                                               of an individual including an
                                                               age and gender appropriate
                                                               history, examination,
                                                               counseling/anticipatory
                                                               guidance, risk factor reduction
                                                               interventions, and the
                                                               ordering of appropriate
                                                               immunization(s), laboratory,
                                                               diagnostic procedures,
                                                               established patient; infant
                                                               (younger than 1 year),
                                           99392,              ...Early childhood (age 1
                                                               through 4 years),
                                           99393,              ...Late childhood (age 5
                                                               through 11 years),
                                           99394,              ...Adolescent (age 12 through
                                                               17 years),
                                           99395               ...18 through 39 years
                                           with certification  with certification condition
                                           condition indicator indicator
                                           Y                   Yes - EPSDT referral was
                                                               given to patient
                                           and condition code and condition code

                                           S2                  Under treatment
8602Y   THSteps adolescent preventive                                                            Discontinued
        visit, abnormal, condition under
        treatment
8604Y   THSteps exception to               $70.00 99381,   Initial comprehensive             $70.00 Refer to the THSteps
        periodicity, abnormal, condition                   preventive medicine                      Medical section,
        under treatment                                    evaluation and management                beginning on page 53, in
                                                           of an individual including an            the bulletin.
                                                           age and gender appropriate
                                                           history, examination,
                                                           counseling/anticipatory
                                                           guidance, risk factor reduction
                                                           interventions, and the
                                                           ordering of appropriate
                                                           immunization(s), laboratory,
                                                           diagnostic procedures, new
                                                           patient; infant (younger than 1
                                                           year),
                                                 99382,    ...Early childhood (age 1
                                                           through 4 years),
                                                 99383,    ...Late childhood (age 5
                                                           through 11 years),
                                                 99384,    ...Adolescent (age 12 through
                                                           17 years),
                                                 99385     ...18 through 39 years
                                                 or        or
                                                 99391,    Periodic comprehensive
                                                           preventive medicine re-
                                                           evaluation and management
                                                           of an individual including an
                                                           age and gender appropriate
                                                           history, examination,
                                                           counseling/anticipatory
                                                           guidance, risk factor reduction
                                                           interventions, and the
                                                           ordering of appropriate
                                                           immunization(s), laboratory,
                                                           diagnostic procedures,
                                                           established patient; infant
                                                           (younger than 1 year),
                                                 99392,    ...Early childhood (age 1
                                                           through 4 years),
                                                 99393,    ...Late childhood (age 5
                                                           through 11 years),
                                                 99394,    ...Adolescent (age 12 through
                                                           17 years),
                                                 99395     ...18 through 39 years
                                                 and       and
                                            modifier 23         Unusual anesthesia:
                                                                occasionally, a procedure,
                                                                which usually requires either
                                                                no anesthesia or local
                                                                anesthesia, because of
                                                                unusual circumstances must
                                                                be done under general
                                                                anesthesia
                                            or                  or
                                            32                  Mandated services: services
                                                                related to mandated
                                                                consultation and/or related
                                                                services (e.g., PRO, third
                                                                party payer, governmental,
                                                                legislative or regulatory
                                                                requirement)
                                            or                  or
                                            SC                  Medically necessary service
                                                                or supply
                                            with certification  with certification condition
                                            condition indicator indicator
                                            Y                   Yes - EPSDT referral was
                                                                given to patient
                                            and condition code and condition code

                                             S2                 Under treatment
8700Y   THSteps medical screen,       $70.00 99381,             Initial comprehensive             $70.00 Refer to the THSteps
        referred to Family Planning                             preventive medicine                      Medical section,
                                                                evaluation and management                beginning on page 53, in
                                                                of an individual including an            the bulletin.
                                                                age and gender appropriate
                                                                history, examination,
                                                                counseling/anticipatory
                                                                guidance, risk factor reduction
                                                                interventions, and the
                                                                ordering of appropriate
                                                                immunization(s), laboratory,
                                                                diagnostic procedures, new
                                                                patient; infant (younger than 1
                                                                year),
                                            99382,              ...Early childhood (age 1
                                                                through 4 years),
                                            99383,              ...Late childhood (age 5
                                                                through 11 years),
                                            99384,              ...Adolescent (age 12 through
                                                                17 years),
                                            99385               ...18 through 39 years
                                                   or                  or
                                                   99391,              Periodic comprehensive
                                                                       preventive medicine re-
                                                                       evaluation and management
                                                                       of an individual including an
                                                                       age and gender appropriate
                                                                       history, examination,
                                                                       counseling/anticipatory
                                                                       guidance, risk factor reduction
                                                                       interventions, and the
                                                                       ordering of appropriate
                                                                       immunization(s), laboratory,
                                                                       diagnostic procedures,
                                                                       established patient; infant
                                                                       (younger than 1 year),
                                                   99392,              ...Early childhood (age 1
                                                                       through 4 years),
                                                   99393,              ...Late childhood (age 5
                                                                       through 11 years),
                                                   99394,              ...Adolescent (age 12 through
                                                                       17 years),
                                                   99395               ...18 through 39 years
                                                   with certification  with certification condition
                                                   condition indicator indicator
                                                   N                   No - EPSDT referral was not
                                                                       given to patient
                                                   and condition code and condition code

                                                   NU                  Not used
8702Y   THSteps adolescent preventive                                                                           Discontinued
        visit, referred to Family Planning
8704Y   THSteps exception to                 $70.00 99381,             Initial comprehensive             $70.00 Refer to the THSteps
        periodicity, referred to Family                                preventive medicine                      Medical section,
        Planning                                                       evaluation and management                beginning on page 53, in
                                                                       of an individual including an            the bulletin.
                                                                       age and gender appropriate
                                                                       history, examination,
                                                                       counseling/anticipatory
                                                                       guidance, risk factor reduction
                                                                       interventions, and the
                                                                       ordering of appropriate
                                                                       immunization(s), laboratory,
                                                                       diagnostic procedures, new
                                                                       patient; infant (younger than 1
                                                                       year),
99382,        ...Early childhood (age 1
              through 4 years),
99383,        ...Late childhood (age 5
              through 11 years),
99384,        ...Adolescent (age 12 through
              17 years),
99385         ...18 through 39 years
or            or
99391,        Periodic comprehensive
              preventive medicine re-
              evaluation and management
              of an individual including an
              age and gender appropriate
              history, examination,
              counseling/anticipatory
              guidance, risk factor reduction
              interventions, and the
              ordering of appropriate
              immunization(s), laboratory,
              diagnostic procedures,
              established patient; infant
              (younger than 1 year),
99392,        ...Early childhood (age 1
              through 4 years),
99393,        ...Late childhood (age 5
              through 11 years),
99394,        ...Adolescent (age 12 through
              17 years),
99395         ...18 through 39 years
and           and
modifier 23   Unusual anesthesia:
              occasionally, a procedure,
              which usually requires either
              no anesthesia or local
              anesthesia, because of
              unusual circumstances; must
              be done under general
              anesthesia
or            or
32            Mandated services: services
              related to mandated
              consultation and/or related
              services (i.e., PRO, third party
              payer, governmental,
              legislative, or regulatory
              requirement)
                                                or                 or
                                                SC                 Medically necessary service
                                                                   or supply
                                                with certification  with certification condition
                                                condition indicator indicator
                                                N                   No - EPSDT referral was not
                                                                    given to the patient
                                                and condition code and condition code

                                                NU                 Not used
8823X   DNA/RNA testing (studies)                                                                             Discontinued
8999Y   Pathology and laboratory                                                                              Discontinued
9000X   Provision and insertion of six                                                                        Discontinued
        subdermal contraceptive
        capsules (Norplant)
9001Z   Initial examination of the        $35.53 99431             History and examination of        $35.53
        newborn infant, brief                                      the normal newborn infant,
                                                                   initiation of diagnostic and
                                                                   treatment programs and
                                                                   preparation of hospital
                                                                   records; this code should also
                                                                   be used for birthing room
                                                                   deliveries
                                                or                 or
                                                99432              Normal newborn care in other
                                                                   than hospital or birthing room
                                                                   setting, including physical
                                                                   examination of baby and
                                                                   conference(s) with parent(s)

                                                with               with
                                                modifier 52        Reduced services, under
                                                                   certain circumstances a
                                                                   service or procedure is
                                                                   partially reduced or eliminated
                                                                   at the physician's discretion
9003X   Provision of Norplant                                                                                 Discontinued
9006X   Insertion of Norplant by                                                                              Discontinued
        physician or nurse practitioner
9008X   Insertion and provision of                                                                            Discontinued; TOS 2, 8,
        vitrasert implant                                                                                     and F
9009X   Removal of vitrasert implant     TOS F: Group 2 67121          Removal of implanted            TOS F: Group 2
                                                                       material, posterior segment;
                                                                       intraocular
9020X   Initial antepartum visit                $70.64 99201, 99202,   CPT codes for office or other   $22.64; $35.73; Use modifier TH to
                                                       99203, 99204,   outpatient visit for the        $48.28; $70.64, specify antepartum care;
                                                       99205           evaluation and management                $87.83 providers should be
                                                                       of a new patient (varying                       prepared to provide
                                                                       levels of service)                              documentation to support

                                                       with            with                                              level of service -
                                                       modifier TH     Obstetrical                                       higher level of service
                                                                       treatment/services, prenatal                      evaluation and
                                                                       or postpartum                                     management codes are
                                                                                                                         only appropriate for high-
                                                                                                                         risk care.
9030X   Labor, birthing center,                 $82.43 S4005           Interim labor facility global          $152.03    Refer to the Birthing
        antepartum care only                                           (labor occurring but not                          Centers section,
                                                                       resulting in delivery)                            beginning on page 18, in
                                                                                                                         the bulletin.
9030X   Antepartum care only                    $27.00 99211, 99212,   CPT codes for office or other   $11.73, $19.64,   Use modifier TH to
                                                       99213, 99214,   outpatient visit for the        $29.52, $41.46,   specify
                                                       99215           evaluation and management                $63.83   antepartum/postpartum
                                                                       of an established patient                         care; providers should be
                                                                       (varying levels of service)                       prepared to provide
                                                       with            with                                              documentation to support
                                                       modifier TH     Obstetrical treatment,                            level of service, higher
                                                                       services, prenatal or                             level of service evaluation
                                                                       postpartum                                        and management codes
                                                                                                                         are only appropriate for
                                                                                                                         high-risk care.
9099Y   Office, injections, DME,                                                                                         Discontinued; supplies
        supplies, services, outpatient                                                                                   covered under Home
        services                                                                                                         Health benefit.
9099Z   Facility charges for the              $1,487.79 845            CAPD (outpatient/home),         Composite rate
        treatment of monthly in-home                                   support services
        maintenance dialysis
                                                       or              or
                                                       855             CAPD (outpatient/home),
                                                                       support services
9100X   Comprehensive visit, (face-to-          $54.58 G9012           Other specified case                    $54.58 Refer to the THSteps
        face)                                                          management service not                         Medical section,
                                                                       elsewhere classified                           beginning on page 53, in
                                                                                                                      the bulletin.
                                                       with            with
                                                modifiers U2   Medicaid level of care 2, as
                                                               defined by each state
                                                               (comprehensive needs
                                                               assessment)
                                                and            and
                                                U5             Medicaid level of care 5, as
                                                               defined by each state (face-to-
                                                               face)
                                                and (if FQHC   and (if FQHC provider)                 If FQHC
                                                provider)                                            provider,
                                                                                                       specific
                                                EP             Service provided as part of       encounter rate
                                                               Medicaid EPSDT program
9101X   Follow-up visit, (face-to-face)   $54.58 G9012         Other specified case                     $54.58 Refer to the THSteps
                                                               management service not                          Medical section,
                                                               elsewhere classified                            beginning on page 53, in
                                                                                                               the bulletin.
                                                with           with
                                                modifiers TS   Follow-up service
                                                and            and
                                                U5             Medicaid level of care 5, as
                                                               defined by each state (face-to-
                                                               face)
                                                and (if FQHC   and (if FQHC provider)                 If FQHC
                                                provider)                                            provider,
                                                                                                       specific
                                                                                                 encounter rate
                                                EP             Service provided as part of
                                                               Medicaid EPSDT program
9102X   Follow-up visit, (telephone)      $18.00 G9012         Other specified case                     $18.00 Refer to the THSteps
                                                               management service not                          Medical section,
                                                               elsewhere classified                            beginning on page 53, in
                                                                                                               the bulletin.
                                                with           with
                                                modifier TS    Follow-up service
                                                and (if FQHC   and (if FQHC provider)                 If FQHC
                                                provider)                                            provider,
                                                                                                       specific
                                                                                                 encounter rate
                                                EP             Service provided as part of
                                                               Medicaid EPSDT program
9200X   THSteps Dental for Indian               T1015          Clinic visit/encounter, all-            $172.00
        Health Service                                         inclusive
9201X   Optometry for Indian Health             T1015          Clinic visit/encounter, all-            $172.00
        Service                                                inclusive
9202X   Ophthalmology for Indian Health                     T1015         Clinic visit/encounter, all-            $172.00
        Service                                                           inclusive
9248X   Computer-assisted corneal           TOS 1: $85.22    S0820        Computerized corneal           TOS 1: $85.22       Prior authorization is no
        topography (unilateral),                       TOS                topography, unilateral                             longer required for
        optometrist only                   I: $40.35                                                     TOS I: $40.35       optometrists.
                                                     TOS T:
                                                      $44.88                                               TOS T: $44.88
and     and
9249X   Computer-assisted corneal
        topography (unilateral),
        ophthalmologist only
9250X   Re-evaluation of speech,                    $16.59 92506          Evaluation of speech,                    $16.59
        language, voice,                                                  language, voice,
        communication, auditory                                           communication, auditory
        process and/or aural rehab                                        processing, and/or aural
        status                                                            rehabilitation status
                                                            with          with
                                                            modifier U4   Medicaid level of care 4, as
                                                                          defined by each state
                                                                          (reassessment)
9203Z   Rural health encounter             Provider-specific T1015        Clinic visit/encounter, all-   Provider-specific
                                             encounter rate               inclusive                        encounter rate
9401Z   Certified respiratory care                   $66.68 99503         Home visit for respiratory               $66.68
        practitioner treatment and                                        therapy care (e.g.,
        services                                                          bronchodilator, oxygen
                                                                          therapy, respiratory
                                                                          assessment, apnea
                                                                          evaluation)
9404Z   Disposable supplies provided by                                                                                      Discontinued
        certified respiratory care
        practitioner
9725X   Myofascial release/soft tissue     $22.91; Provider- 97140        Manual therapy techniques       $5.72; Provider- Provider interim rate for
        mobilization, one or more           specific interim              (e.g., mobilization/            specific interim Home Health agencies
        regions                                          rate             manipulation, manual                         rate
                                                                          lymphatic drainage, manual
                                                                          traction), one or more
                                                                          regions, each 15 minutes
9900W   Partial hospitalization, more                                                                                        Discontinued
        than five hours and less than 24
        hours duration
9901W   Intensive outpatient, more than                                                                                      Discontinued
        1½ hours and less than five
        hours duration
9902W   Off-site service                                                                                                     Discontinued
9903W   Residential service, in facility,   Discontinued
        less than 24 hours, not inpatient
9904W   Forensic services, involvement      Discontinued
        with legal system
9905W   Individual psychotherapy by         Discontinued
        MSN
9906W   Individual psychotherapy by         Discontinued
        LMSW
9907W   Group psychotherapy by MSN          Discontinued
9908W   Group psychotherapy by LMSW         Discontinued
9909W   Family psychotherapy by LMSW        Discontinued

9910W   Family psychotherapy by LPC         Discontinued
9911W   Family psychotherapy by MSN         Discontinued
9912W   Family psychotherapy by LMSW-       Discontinued
        ACP
9913W   Multiple family psychotherapy by    Discontinued
        psychiatrist
9914W   Multiple family psychotherapy by    Discontinued
        psychologist
9915W   Multiple family psychotherapy by    Discontinued
        LMSW
9916W   Multiple family psychotherapy by    Discontinued
        LPC
9917W   Multiple family psychotherapy by    Discontinued
        MSN
9918W   Multiple family psychotherapy by    Discontinued
        LMSW-ACP
9919W   Marriage/couple counseling by       Discontinued
        psychiatrist
9920W   Marriage/couple counseling by       Discontinued
        psychologist

9921W   Marriage/couple counseling by       Discontinued
        LMSW-ACP
9922W   Marriage/couple counseling by       Discontinued
        MSN

9923W   Marriage/couple counseling by       Discontinued
        LMSW
9924W   Marriage/couple counseling by         Discontinued
        LPC
9925W   Multiple psychotherapy                Discontinued
        group/psycho-educational group
        by LMSW
9926W   Multiple psychotherapy                Discontinued
        group/psycho-educational group
        by LPC
9927W   Multiple psychotherapy                Discontinued
        group/psycho-educational group
        by MSN
9928W   Multiple psychotherapy                Discontinued
        group/psycho-educational group
        by LMSW-ACP
9929W   Multiple psychotherapy                Discontinued
        group/psycho-educational group
        by psychiatrist
9930W   Multiple psychotherapy                Discontinued
        group/psycho-educational group
        by psychologist
9931W   Biofeedback                           Discontinued
9932W   Acupuncture for substance             Discontinued
        abuse treatment
9936X   Physician evaluation of clients       Discontinued
        to determine enrollment into pilot

9944X   RPH diabetes pilot, evaluation        Discontinued
        and management of new patient
        for self-limited or minor condition
9945X   RPH diabetes pilot, evaluation        Discontinued
        and management of a new
        patient for presenting problems
        of low/moderate severity
9946X   RPH diabetes pilot, evaluation        Discontinued
        and management of new patient
        for presenting problems of
        moderate severity

9947X   RPH diabetes pilot, evaluation        Discontinued
        and management for an
        established patient that may not
        require presence of physician
9948X   RPH diabetes pilot, evaluation               Discontinued
        and management of an
        established patient for a self-
        limited or minor condition
9949X   RPH diabetes pilot, evaluation               Discontinued
        and management of an
        established patient for
        low/moderate severity
9950X   RPH diabetes pilot, preventive               Discontinued
        medical counseling and/or risk
        fact red intervention,
        approximately 15 minutes
9951X   RPH diabetes pilot, previous                 Discontinued
        medical counseling and/or risk
        fact red intervention(s),
        approximately 30 minutes
9952X   RPH diabetes pilot, previous                 Discontinued
        medical counseling and/or risk
        fact red interventions,
        approximately 45 minutes
9953X   RPH diabetes pilot, previous       $101.04   Discontinued
        medical counseling and/or risk
        fact red interventions,
        approximately 60 minutes
9954X   RPH diabetes pilot, previous                 Discontinued
        medical counseling and/or risk
        fact red intervent (group),
        approximately 30 minutes
9955X   RPH diabetes pilot, previous                 Discontinued
        medical counseling and/or risk
        fact red intervent (group),
        approximately 60 minutes
9956X   RPH diabetes pilot, cholesterol,             Discontinued
        serum, total
9957X   RPH diabetes pilot, quantitative             Discontinued
9958X   RPH diabetes pilot, glycated                 Discontinued
        hemoglobin lipoprotein, direct
        measure
9959X   RPH diabetes pilot, HDL (high                Discontinued
        density cholesterol)
9960X   RPH diabetes pilot, LDL                      Discontinued
        cholesterol
9961X   RPH diabetes pilot, VLDL                                                                                            Discontinued
        cholesterol
9962X   RPH diabetes pilot, test panel                                                                                      Discontinued
        blood glucose, total cholesterol,
        HDL, LDL, and TG
9963X   RPH diabetes pilot, phlebotomy                                                                                      Discontinued
999VV   Unlisted service                                                                                                    Discontinued

9999A   Unlisted ambulance service              Not a benefit                                                               Discontinued; use the
                                                                                                                            appropriate national code.
9999Y   Office, injections, DME, supplies                                                                                   Discontinued
        services, outpatient services


A0010   Ambulance service, BLS base         Provider-specific A0429   Ambulance service, basic life     Provider-specific Must be billed with
        rate, emergency transport, one                   rate         support, emergency transport                   rate procedure code A0425
        way                                                           (BLS emergency)                                     with modifier ET.

A0020   Ambulance service, BLS per          Provider-specific A0425   Ground mileage, per statute            Emergency Must be billed with
        mile, transport, one way                         rate         mile                                     mileage = procedure codes A0429
                                                                                                        provider-specific or A0428.
                                                                                                          rate; nonemer-
                                                                                                        gency mileage =
                                                                                                                    $3.30
A0030   Ambulance service,                        $1,140.08 A0430     Ambulance service,                       $1,140.08 Must be billed with
        conventional air service,                                     conventional air services,                         procedure code A0435.
        transport, one way                                            transport, one way (fixed wing)

A0040   Ambulance service, air,                     $609.00 A0431     Ambulance service,                         $609.00 Must be billed with
        helicopter service, transport                                 conventional air services,                         procedure code A0436.
                                                                      transport, one way (rotary
                                                                      wing)
A0050   Ambulance service, emergency,              Manually A0999     Unlisted ambulance service               Manually Refer to the Ambulance
        water, special transportation              reviewed                                                    reviewed section, beginning on
        services                                                                                                        page 17, in the bulletin.
A0060   Ambulance service, waiting          Provider-specific A0420   Ambulance waiting time (ALS       Provider-specific
        time, ½-hour increments                          rate         or BLS), ½-hour increments                     rate

A0070   Ambulance service, oxygen,          Provider-specific A0422   Ambulance (ALS or BLS)            Provider-specific
        administration and supplies                      rate         oxygen and oxygen supplies,                    rate
                                                                      life sustaining situation
A0150   Nonemergency transportation;        Provider-specific A0428   Ambulance service, basic life     Provider-specific Must be billed with
        ambulance, base rate, one way                    rate         support, nonemergency                          rate procedure code A0425.
                                                                      transport, BLS
BTL99   Treatment of tubal ligation                                                                                       Discontinued
        complications
CP001   Private HMO copay, professional               $10.00                                                              Retained/atypical


CP002   Private PPO copay, professional               $10.00                                                              Retained/atypical
CP003   Medicare HMO copay,                           $10.00                                                              Retained/atypical
        professional
CP004   Medicare PPO copay,                           $10.00                                                              Retained/atypical
        professional
CP005   Private HMO copay, outpatient                 $50.00                                                              Retained/atypical
CP006   Private PPO copay, outpatient                 $50.00                                                              Retained/atypical
CP007   Medicare HMO copay, outpatient                $50.00                                                              Retained/atypical

CP008   Medicare PPO copay, outpatient                 $5.00                                                              Retained/atypical

D924X   Intravenous sedation                          $81.25 D9241   Intravenous conscious                     $81.25
                                                                     sedation/analgesia, first 30
                                                                     minutes
D999X   Informational code to indicate                                                                                    Discontinued
        dental procedure(s) performed
        under general anesthesia
IUD99   Treatment of IUD complications                                                                                    Discontinued
J105X   Injection, depot-                             $25.00 J1055   Injection,                                $48.10
        medroxyprogesterone acetate,                                 medroxyprogesterone acetate
        up to 150 mg                                                 for contraceptive use, 150 mg
NOR99   Treatment of contraceptive                                                                                        Discontinued
        implant complications
S4627   Waiver case management,                     $231.87 G9012    Other specified case                     $231.87
        comprehensive, all inclusive, per                            management service not
        monthly                                                      elsewhere classified
TGC99   Teen group counseling                        5 to 49 99411   Preventive medicine                      5 to 49 Title XX, Program 300
                                               individuals =         counseling and/or risk factor      individuals = only
                                             $1.50; 50 to 99         reduction intervention(s)        $1.50; 50 to 99
                                               individuals =         provided to individuals in a       individuals =
                                                      $75.00         group setting (separate                   $75.00
                                                                     procedure), approximately 30
                                                                     minutes
VAS99   Treatment of vasectomy                                                                                            Discontinued
        complications
W0001   Operating room (charge for the      Provider-specific 360    Operating room services         Provider-specific
        room)                                     interim rate                                             interim rate
                                                          or     or
                                                          361    Operating room services,
                                                                 minor surgery
                                                          or     or
                                                          369    Operating room services,
                                                                 other
W0002   Recovery room (charge for the   Provider-specific 710    Recovery room                   Provider-specific
        room)                                 interim rate                                             interim rate

                                                          or     or
                                                          719    Recovery room, other
W0003   Anesthesia (fee for supplies)   Provider-specific 370    Anesthesia                      Provider-specific
                                              interim rate                                             interim rate

                                                          or     or
                                                          371    Anesthesia, incident to
                                                                 radiology
                                                          or     or
                                                          372    Anesthesia, incident to other
                                                                 diagnostic services
                                                          or     or
                                                          379    Anesthesia, other
W0004   Emergency room (charge for      Provider-specific 450    Emergency room                  Provider-specific
        room)                                 interim rate                                             interim rate
                                                           or    or
                                                           456   Emergency room, urgent care

                                                           or    or
                                                           459   Emergency room, other
W0005   Oral and topical medications    Provider-specific 250    Pharmacy                        Provider-specific
        used in the emergency room            interim rate                                             interim rate

                                                          or     or
                                                          251    Pharmacy, generic drugs
                                                          or     or
                                                          252    Pharmacy, nongeneric drugs
                                                          or     or
                                                          254    Pharmacy, drugs incident to
                                                                 other diagnostic services
                                                          or     or
                                                          255    Pharmacy, drugs incident to
                                                                 radiology
                                                          or     or
                                                            257     Pharmacy, nonprescription

                                                            or      or
                                                            259     Pharmacy, other
W0006   Inhalation therapy, aerosol        Provider-specific 412    Respiratory services,                Provider-specific
        therapy                                  interim rate       inhalation services                        interim rate
W0007   Inhalers                           Provider-specific 250    Pharmacy                             Provider-specific
                                                 interim rate                                                  interim rate

                                                            or      or
                                                            251     Pharmacy, generic drugs
                                                            or      or
                                                            252     Pharmacy, nongeneric drugs
                                                            or      or
                                                            257     Pharmacy, nonprescription
                                                            or      or
                                                            259     Pharmacy, other
W0008   Intermittent positive pressure                                                                                        Discontinued
        breathing (IPPB)
W0009   Oxygen and related equipment       Provider-specific 410    Respiratory services                 Provider-specific
                                                 interim rate                                                  interim rate
                                                            or      or
                                                            412     Respiratory services,
                                                                    inhalation services
W7026   Ophthalmic ultrasound                                                                                                 Discontinued
        echography, tomography, with
        or without A or M-mode
W7259   Hand and wrist                                                                                                        Discontinued
W7310   Ankle and foot                                                                                                        Discontinued
W7451   Transport portable X-ray                     $41.92 R0075   Transportation of portable X-                  $26.37
        equipment and personnel to                                  ray equipment and personnel
        home/nursing home, per trip to                              to home or nursing home, per
        facility/location, two patients                             trip to facility or location, more
        seen                                                        than one patient seen, per
                                                                    patient
W7453   Transport portable X-ray                     $20.97 R0075   Transportation of portable X-                  $26.37
        equipment and personnel to                                  ray equipment and personnel
        home/nursing home, per trip to                              to home or nursing home, per
        facility/location, four patients                            trip to facility or location, more
        seen                                                        than one patient seen, per
                                                                    patient
W7460    Transport portable X-ray                     $20.97 R0075     Transportation of portable X-                  $26.37
         equipment and personnel to                                    ray equipment and personnel
         home/nursing home, per trip to                                to home or nursing home, per
         facility/location, five patients                              trip to facility or location, more
         seen                                                          than one patient seen, per
                                                                       patient
W8035    Economy wheelchair, fixed full                                                                                          Discontinued
         length arms, fixed footrest
W8042    Mask replacement (nasal CPAP                                                                                            Discontinued; not payable
         system)                                                                                                                 separately
W8044    Valve replacement (nasal CPAP                                                                                           Discontinued; not payable
         system)                                                                                                                 separately
W8046    Hose assembly replacement                                                                                               Discontinued; not payable
         (nasal CPAP system)                                                                                                     separately
W8097    Maxi-mist                                                                                                               Discontinued; not payable
                                                                                                                                 separately
W8999    Dump code home health, not                                                                                              Discontinued
         otherwise classified time (DME)
W9094    Skilled nursing visit to include    Provider-specific G0154   Services of skilled nurse in         Provider-specific
         “incidental supplies” used during         interim rate        home health setting, each 15               interim rate
         visit, per visit                                              minutes
W9095    Home health aide visit to           Provider-specific G0156   Services of home health aide         Provider-specific
         include, incidental supplies used         interim rate        in home health setting, each               interim rate
         during visit, per visit                                       15 minutes
W9999    Not otherwise classified,                  Manually 76499     Unlisted diagnostic radiologic               Manually
         radiology                                  reviewed           procedure                                    reviewed
X0004    Crossover, emergency room                                                                                               Discontinued
X0150,   MOHS surgery local codes                ASC Group: 17304      Chemosurgery (MOHS                    TOS F: Group 2 Use the appropriate .
X0151,                                              Group 2            micrographic technique)                              national codes
X0152,                                                                 national CPT codes
X0153,
X0154,
X0155,
X0156,
X0157,
X0158,
X0159
X0150,   MOHS surgery local codes                     $39.53   17304   Chemosurgery (MOHS                            $283.40 Use the appropriate
X0151,                                                $53.29   or      micrographic technique)                               national codes.
X0152,                                               $100.20   17305   national CPT codes                            $122.20
X0153,                                                $53.03   or
X0154,                                                $65.98   17306                                                  $95.47
X0155,                                               $76.13    or
X0156,                                               $77.14    17307                                           $97.65
X0157,                                              $106.07    or
X0158,                                              $166.17    17310                                           $14.18
X0159,                                              $177.63
X0160,                                              $390.61
X0161                                               $461.05
                                              TOS 8: Not a                                               TOS 8: Not a
                                                     benefit                                                   benefit
X0347    Routine foot care                 TOS 2: $21.63       11055   Paring or cutting of benign             $15.00
                                              TOS 8: Not a             hyperkeratotic lesion (e.g.,
                                                     benefit           corn or callus); single lesion
                                                               or      or                                          or
                                                               11056   Paring or cutting of benign             $21.00
                                                                       hyperkeratotic lesion (e.g.,
                                                                       corn or callus); two to four
                                                                       lesions
                                                               or      or                                          or
                                                               11057   Paring or cutting of benign             $22.09
                                                                       hyperkeratotic lesion (e.g.,
                                                                       corn or callus); more than four
                                                                       lesions
                                                               or      or                                          or
                                                               11719   Trimming of nondystrophic               $10.09
                                                                       nails, any number
                                                               or      or                                          or
                                                               G0127   Trimming of dystrophic nails,           $11.73
                                                                       any number
X0348    Routine foot care rendered in a   TOS 2: $20.13     11055     Paring or cutting of benign             $15.00 Modifier TT is to be used
         nursing home, multiple patients      TOS 8: Not a             hyperkeratotic lesion (e.g.,                   in POS 4 or 8 with any of
         seen                                        benefit           corn or callus); single lesion                 the national codes listed.

                                                               or      or                                          or When used, the
                                                               11056   Paring or cutting of benign             $21.00 reimbursement will be
                                                                       hyperkeratotic lesion (e.g.,                   reduced by $1.50.
                                                                       corn or callus); two to four
                                                                       lesions
                                                               or      or                                          or
                                                               11057   Paring or cutting of benign             $22.09
                                                                       hyperkeratotic lesion (e.g.,
                                                                       corn or callus); more than four
                                                                       lesions
                                                               or      or                                          or
                                                               11719   Trimming of nondystrophic               $10.09
                                                                       nails, any number
                                                               or      or                                           or
                                                           G0127         Trimming of dystrophic nails,             $11.73
                                                                         any number
                                                           with          with
                                                           modifier TT   Individualized service             TOS 8: Not a
                                                                         provided to more than one                benefit
                                                                         patient in same setting
X08     Crossover, outpatient                                                                                                Discontinued
X09     Crossover, inpatient                                                                                                 Discontinued
X1000   Crossover, injection                                                                                                 Discontinued
X1100   Crossover, pharmacy                                                                                                  Discontinued
X2051   Temporary closure of lacrimal     TOS 2: $62.68     68761        Closure of the lacrimal         TOS 2: $63.28
        punctum (collagen material or              TOS 8:                punctum, by plug, each                     TOS
        plug)                                 Not a benefit                                               8: Not a benefit
X2051   Temporary closure of lacrimal        ASC: Group 2 68761          Closure of the lacrimal            ASC: Group 2
        punctum (collagen material or                                    punctum; by plug, each
        plug)
X2594   Tissue plasminogen activator                                                                                         Discontinued
        (activase), infusion therapy

X2990   THSteps dental, anesthesia only         5.00 RVUs 170            Anesthesia for intraoral              5.00 RVUs TOS 7: Use modifier EP
                                                                         procedures, including biopsy;                   to identify THSteps dental
                                                                         not otherwise specified                         anesthesia.
                                                           with          with
                                                           modifier EP   Service provided as part of
                                                                         Medicaid EPSDT program
X2990   THSteps dental services              ASC: Group 4 41899          Unlisted procedure,                ASC: Group 4 ASC: Use modifier EP to
                                                                         dentoalveolar structures                        identify THSteps dental
                                                                                                                         ASC/HASC service.

                                                           with          with
                                                           modifier EP   Service provided as part of
                                                                         Medicaid EPSDT program
X2998   Adenoidectomy and bilateral        TOS 2: $310.59 42830          Adenoidectomy, primary;         TOS 2:
        myringotomy with insertion of                                    younger than 12 years                    $132.29
        tubes
                                                           or            or                                            or
                                                           42831         Age 12 years or older                    $150.02
                                                           or            or                                            or
                                                           42835         Adenoidectomy, secondary;                $119.74
                                                                         younger than 12 years
                                                           or            or                                            or
                                                           42836         Age 12 years or older                    $177.84
                                                           and           and                                           or
                                                         69433         Tympanostomy (requiring                    $58.92
                                                                       insertion of ventilating tube),
                                                                       local or topical anesthesia
                                                         or            or                                             or
                                                         69436         Tympanostomy (requiring                    $84.56
                                                                       insertion of ventilating tube),
                                                                       general anesthesia
X2999   Surgery, not otherwise                                                                                              Discontinued
        classified, six months of
        postcare included
X3622   Removal of tenckhoff catheter             $219.17 49422        Removal of permanent              TOS 2: $294.85;
                                                                       intraperitoneal cannula or          TOS 8: Not a
                                                                       catheter                                   benefit
X4060   Heart-bilateral lung                       TOS 2: 33935        Heart, lung transplant with                TOS 2: Prior authorization is
        transplantation                    $6,597.50; TOS              client cardiectomy-               $6,597.50; TOS required.
                                                8: $974.40             pneumonectomy                         8: $1,055.60
X4100   Crossover, radiology                                                                                              Discontinued
X4562   Insertion or replacement of                                                                                         Discontinued
        progestasert IUD, including
        device
X4563   Insertion or replacement of                                                                                         Discontinued
        copper T 380A IUD, including
        device
X4572   Furnish and insert or replace             $374.00 58300        Insertion of IUD                           $69.00 Provider receiving PHS
        copper T 380-A IUD                                                                                               pricing must bill actual
                                                                                                                         cost of device; subject to
                                                                                                                         retrospective review.
                                                         and           and                                           and
                                                         J7300         Intrauterine copper                       $321.13
                                                                       contraceptive
X4822   Antepartum care only, high-risk            $35.00 99211,       CPT codes for office or other              $11.73 Use modifier TH to specify
        pregnancy                                                      outpatient visit for the
                                                         99212,        evaluation and management                  $19.64    antepartum/postpartum
                                                         99213,        of an established patient                  $29.52    care. Providers should be
                                                         99214,        (varying levels of service)                $41.46    prepared to provide
                                                         99215                                                    $63.83    documentation to support

                                                         with          with                                                 level of service - higher
                                                         modifier TH   Obstetrical                                          level of service evaluation
                                                                       treatment/services, prenatal                         and management codes
                                                                       or postpartum                                        are only appropriate for
                                                                                                                            high-risk care.

X5000   Total crossover, billed and paid                                                                                    Discontinued
        for this claim
X5100   Crossover laboratory                                                                                         Discontinued
X5642   Muscle surgery, two or more        TOS 2: $887.21; 67312   Strabismus surgery,           TOS 2: $786.63,
        muscles, two eyes, initial           TOS 8: Not a          recession, or resection       $837.38; TOS 8:
                                                    benefit        procedure; two horizontal         Not a benefit
                                                                   muscles
                                                          and/or   and/or
                                                          67316    Strabismus surgery,
                                                                   recession, or resection
                                                                   procedure; two or more
                                                                   vertical muscles (excluding
                                                                   superior oblique)
X6000   Crossover ambulance                                                                                          Discontinued
X7010   Induction of anesthesia only (to                                                                             Discontinued
        be used by anesthesiologist
        only)
X7036   SMAC with CBC                                                                                                Discontinued
X7107   Dialysis supplies, crossover                                                                                 Discontinued
X7619   Any two, same-day;                                                                                           Discontinued
        RBC/WBC/HGB/HCT/Indices/C
        OMP WBC DIFF/PART WBC
        DIFF/RBC MORPH/PLT EST
X8000   Crossover, other                                                                                             Discontinued; TOS 5:
                                                                                                                     A9270 may be used to
                                                                                                                     indicate noncovered
                                                                                                                     laboratory services, which
                                                                                                                     is not a benefit.
                                                                                                                     Noncovered services are
                                                                                                                     not a benefit of the Texas
                                                                                                                     Medicaid Program.
X8006   Arterial group (includes                                                                                     Discontinued
        cholesterol glucose total lipids
        lipo-protein)
X8414   Spontaneous blastogenesis                                                                                    Discontinued
        assays
X8428   Active T-cells                                                                                               Discontinued
X8445   CA-125 (cancer antigen-125)                                                                                  Discontinued
X8888   Noncovered laboratory service                                                                                Discontinued
X8888   Noncovered service                                                                                           Discontinued; noncovered
                                                                                                                     services are not a benefit
                                                                                                                     of the Texas Medicaid
                                                                                                                     Program.
X9000   CHC crossover encounter                                                                                      Discontinued
X9004   Crossover physician                                                                                Discontinued
X9079   Crossover outpatient                                                                               Discontinued
X9094   Crossover home health                                                                              Discontinued
X9100   Crossover clinic visit                                                                             Discontinued
X9201   Crossover rural health encounter                                                                   Discontinued
X9203   Comprehensive health center                                                                        Discontinued
X9223   encounter blood
        Peripheral code smear                                                                              Discontinued
X9440   Crossover physical therapy                                                                         Discontinued

X9441   Crossover PT                                                                                       Discontinued

X9550   Crossover blood                                                                                    Discontinued; TOS 1
X9591   Lab handling fee for obtaining        $3.55 99000        Handling and/or conveyance         $3.55 Use modifier FP if the
        specimens by venipuncture or                             of specimen for transfer from            service was for Family
        catheter for Family Planning                             the physicians office to a               Planning.
        services                                                 laboratory
                                                   with          with
                                                   modifier FP   Service provided as part of
                                                                 Medicaid Family Planning
                                                                 Program
X9989   Unlisted clinical lab, genetic     Manually 81099        Unlisted urinalysis procedure   Manually Bill the appropriate code.
        provider                           reviewed                                              reviewed
                                                    or           or
                                                    84999        Unlisted chemistry procedure
                                                   or            or
                                                   85999         Unlisted hematology
                                                                 procedure
                                                   or            or
                                                   86849         Unlisted immunology
                                                                 procedure
                                                   or            or
                                                   87999         Unlisted microbiology
                                                                 procedure
                                                   or            or
                                                   88199         Unlisted cytopathology
                                                                 procedure
X9999   Noncovered take-home drug or                                                                                  Discontinued; TOS 2:
        supply                                                                                                        providers may indicate
                                                                                                                      the appropriate revenue
                                                                                                                      code; however, take-
                                                                                                                      home drugs or supplies
                                                                                                                      are not a benefit of the
                                                                                                                      Texas Medicaid Program.
X9999   Surgery, not otherwise                                                                                        Discontinued; TOS 5
        classified, six months of
        postcare included
X9999   NOC, laboratory and pathology                                                                                 Discontinued; TOS X
X9999   Crossover lump code                                                                                           Discontinued
XC1     Laboratory/blood administration                                                                               Discontinued
XR1     Radiology                                                                                                     Discontinued
Y0010   Occupational therapy                                                                                          Discontinued
Y0011   Treatment room in ER                 Provider-specific 761   Treatment or observation    Provider-specific
                                                   interim rate      room, treatment room              interim rate
Y0012   Day surgery room                     Provider-specific 490   Ambulatory surgical care    Provider-specific
                                                   interim rate                                        interim rate

                                                              or     or
                                                              499    Ambulatory surgical care,
                                                                     other
Y0013   Observation room                     Provider-specific 762   Treatment or observation    Provider-specific
                                                   interim rate      room, observation room            interim rate
Y1000   Sodium iodide I123, 0.1 mci                                                                                   Discontinued; bill the
                                                                                                                      appropriate national code.
Y1002   Technetium TC 99M,                                                                                            Discontinued; bill the
        pyrophosphate kit, each                                                                                       appropriate national code.
Y1006   Sodium iodide I131; capsules,                                                                                 Discontinued; bill the
        15, 25, 50, or 100 UCI, 5 cap vial                                                                            appropriate national code.

Y1014   Technetium TC 99M, sulfur                                                                                     Discontinued; bill the
        colloid injection, unit dose                                                                                  appropriate national code.
Y1016   Technetium TC 99M, albumin                                                                                    Discontinued; bill the
        aggregated injection, unit dose                                                                               appropriate national code.
Y1017   Technetium TC 99M, medronate                                                                                  Discontinued; bill the
        injection, unit dose                                                                                          appropriate national code.
Y1018   Technetium TC 99M,                                                                                            Discontinued; bill the
        pyrophosphate injection, unit                                                                                 appropriate national code.
        dose
Y1020   Technetium TC 99M,                   Discontinued; bill the
        penetetrate injection, unit dose     appropriate national code.
Y1022   Indium IN III DTPA, 0.5 mci          Discontinued; bill the
                                             appropriate national code.
Y1024   Technetium TC 99M, sodium            Discontinued; bill the
        pertechnetate injection, unit dose   appropriate national code.

Y1030   Thallium TL201, thallous             Discontinued; bill the
        chloride, unit dose, 2.0 mci         appropriate national code.
Y1031   Thallium TL201, thallous             Discontinued; bill the
        chloride, unit dose, 4.0 mci         appropriate national code.
Y1032   Thallium TL201, thallous             Discontinued; bill the
        chloride, unit dose, 8.0 mci         appropriate national code.
Y1037   Sodium iodide I131; 15, 25, 50,      Discontinued; bill the
        or 100 UCI, capsules                 appropriate national code.
Y1038   Sodium iodide I123; 15, 25, 50,      Discontinued; bill the
        or 100 UCI, capsules                 appropriate national code.
Y1039   Sodium iodide I131; solution 1-5     Discontinued; bill the
        mci                                  appropriate national code.
Y1040   Sodium iodide I131; solution 6-      Discontinued; bill the
        10 mci                               appropriate national code.
Y1041   99M TC sodium pertechnetate,         Discontinued; bill the
        1-20 mci                             appropriate national code.
Y1042   99M TC sulfur colloid, 1-6 mci       Discontinued; bill the
                                             appropriate national code.
Y1043   99M TC sulfur colloid, 7-12 mci      Discontinued; bill the
                                             appropriate national code.

Y1044   99M TC MAA, 1-4 mci                  Discontinued; bill the
                                             appropriate national code.
Y1045   99M TC DTPA, 1-20 mci                Discontinued; bill the
                                             appropriate national code.

Y1047   99M TC MDP, 1-20 mci                 Discontinued; bill the
                                             appropriate national code.

Y1048   99M TC HDP 1-20 mci                  Discontinued; bill the
                                             appropriate national code.

Y1049   99M TC DISIDA, 1-8 mci               Discontinued; bill the
                                             appropriate national code.
Y1050   99M TC PYP, 1-20 mci                                                                          Discontinued; bill the
                                                                                                      appropriate national code.
Y1051   99M TC PYP-MUGA, 1-20 mci                                                                     Discontinued; bill the
                                                                                                      appropriate national code.
Y1056   Sodium iodide I131, solution 10-                                                              Discontinued; bill the
        20 mci                                                                                        appropriate national code.
Y1057   Sodium iodide I131, solution 20-                                                              Discontinued; bill the
        30 mci                                                                                        appropriate national code.
Y1075   Iodine-125 radioactive seed and                                                               Discontinued; bill the
        plaque assembly                                                                               appropriate national code.
Y1076   CB-51 NA CR solution, 50 UCI                                                                  Discontinued; bill the
                                                                                                      appropriate national code.

Y2010   Zylonite single vision             $33.15 V2020    Frames, purchase                  $14.45
                                                  and      and                                  and
                                                  V2100,   Sphere, single vision, plano to    $9.35
                                                           plus or minus 4.00D, per lens,
                                                 V2101,    ...4.12D to 7.00D, per lens,       $9.35
                                                 V2103,    ...4.00D sphere, 0.12D to          $9.35
                                                           2.00D cylinder, per lens,
                                                 V2104,    ...4.00D sphere, 2.12D to          $9.35
                                                           4.00D cylinder, per lens,
                                                 V2107     ...4.25D to 7.00D sphere,          $9.35
                                                           0.12D to 2.00D cylinder, per
                                                           lens
                                                 or        or                                    or
                                                 V2108     4.25D to 7.00D sphere, 2.12D       $9.35
                                                           to 4.00D cylinder, per lens

Y2020   Zylonite bifocal                   $39.95 V2020    Frames, purchase                  $14.45
                                                  and      and                                  and
                                                  V2200,   Sphere, bifocal, plano to plus    $12.75
                                                           or minus 4.00D, per lens,

                                                 V2201,    ...4.12D to 7.00D, per lens,      $12.75
                                                 V2203,    ...4.00D sphere, 0.12D to         $12.75
                                                           2.00D cylinder, per lens,
                                                 V2204,    ...4.00D sphere, 2.12D to         $12.75
                                                           4.00D cylinder, per lens,
                                                 V2207     ...4.25D to 7.00D sphere,         $12.75
                                                           0.12D to 2.00D cylinder, per
                                                           lens
                                                 or        or                                    or
                                             V2208     4.25D to 7.00D sphere, 2.12D      $12.75
                                                       to 4.00D cylinder, per lens

Y2030   Zylonite trifocal              $48.45 V2020    Frames, purchase                  $14.45
                                              and      and                                  and
                                              V2300,   Sphere, trifocal; plano to plus   $17.00
                                                       or minus 4.00D, per lens,

                                             V2301,    ...4.12D to 7.00D, per lens,      $17.00
                                             V2303,    ...4.00D sphere, 0.12D to         $17.00
                                                       2.00D cylinder, per lens,
                                             V2304,    ...4.00D sphere, 2.12D to         $17.00
                                                       4.00D cylinder, per lens,
                                             V2307,    ...4.25D to 7.00D sphere,         $17.00
                                                       0.12D to 2.00D cylinder, per
                                                       lens,
                                             V2308     ...4.25D to 7.00D sphere,         $17.00
                                                       2.12D to 4.00D cylinder, per
                                                       lens
Y2040   Zylonite/metal single vision   $33.15 V2025    Deluxe frame                      $14.45 V2107 and V2108 are not

                                             and       and                                  and classified as high
                                             V2100,    Sphere, single vision; plano to    $9.35 powered; refer to the
                                                       plus or minus 4.00D, per lens,           Vision section, beginning
                                             V2101,    ...4.12D to 7.00D, per lens,       $9.35 on page 62 in the bulletin,

                                             V2103,    ...4.00D sphere, 0.12D to          $9.35 for more information.
                                                       2.00D cylinder, per lens,
                                             V2104,    ...4.00D sphere, 2.12D to          $9.35
                                                       4.00D cylinder, per lens,
                                             V2107     ...4.25D to 7.00D sphere,          $9.35
                                                       0.12D to 2.00D cylinder, per
                                                       lens
                                             or        or                                    or
                                             V2108     ...4.25D to 7.00D sphere,          $9.35
                                                       2.12D to 4.00D cylinder, per
                                                       lens
Y2050   Zylonite/metal bifocal         $39.95 V2025    Deluxe frame                      $14.45
                                              and      and                                  and
                                              V2200,   Sphere, bifocal; plano to plus    $12.75
                                                       or minus 4.00D, per lens,

                                             V2201,    ...4.12D to 7.00D, per lens,      $12.75
                                             V2203,    ...4.00D sphere, 0.12D to         $12.75
                                                       2.00D cylinder, per lens,
                                             V2204,    ...4.00D sphere, 2.12D to         $12.75
                                                       4.00D cylinder, per lens,
                                          V2207     ...4.25D to 7.00D sphere,         $12.75
                                                    0.12D to 2.00D cylinder, per
                                                    lens
                                          or        or                                    or
                                          V2208     4.25D to 7.00D sphere, 2.12D      $12.75
                                                    to 4.00D cylinder, per lens

Y2060   Zylonite/metal trifocal     $48.45 V2025    Deluxe frame                      $14.45
                                           and      and                                  and
                                           V2300,   Sphere, trifocal; plano to plus   $17.00
                                                    or minus 4.00D, per lens,

                                          V2301     ...4.12D to 7.00D, per lens,      $17.00
                                          V2303,    ...4.00D sphere, 0.12D to         $17.00
                                                    2.00D cylinder, per lens,
                                          V2304,    ...4.00D sphere, 2.12D to         $17.00
                                                    4.00D cylinder, per lens,
                                          V2307     ...4.25D to 7.00D sphere,         $17.00
                                                    0.12D to 2.00D cylinder, per
                                                    lens
                                          or        or                                    or
                                          V2308     4.25D to 7.00D sphere, 2.12D      $17.00
                                                    to 4.00D cylinder, per lens

Y2607   Zylonite frame              $14.45 V2020    Frames, purchase                  $14.45
Y2608   Zylonite/metal frame        $14.45 V2020    Frames, purchase                  $14.45
                                           or       or
                                           V2025    Deluxe frame
Y2609   Single vision/single lens   $10.35 V2100,   Sphere, single vision; plano to    $9.35
                                                    plus or minus 4.00D, per lens,
                                          V2101,    ...4.12D to 7.00D, per lens,
                                          V2103,    ...4.00D sphere, 0.12D to
                                                    2.00D cylinder, per lens,
                                          V2104,    ...4.00D sphere, 2.12D to
                                                    4.00D cylinder, per lens,
                                          V2107     ...4.25D to 7.00D sphere,
                                                    0.12D to 2.00D cylinder, per
                                                    lens
                                          or        or
                                          V2108     4.25D to 7.00D sphere, 2.12D
                                                    to 4.00D cylinder, per lens

Y2610   Single vision pair          $18.70 V2100,   Sphere, single vision; plano to    $9.35
                                                    plus or minus 4.00D, per lens,

                                          V2101,    ...4.12D to 7.00D, per lens,
                                     V2103,    ...4.00D sphere, 0.12D to
                                               2.00D cylinder, per lens,
                                     V2104,    ...4.00D sphere, 2.12D to
                                               4.00D cylinder, per lens,
                                     V2107     ...4.25D to 7.00D sphere,
                                               0.12D to 2.00D cylinder, per
                                               lens
                                     or        or
                                     V2108     4.25D to 7.00D sphere, 2.12D
                                               to 4.00D cylinder, per lens

Y2611   Bifocal single         $13.50 V2200,   Sphere, single vision; plano to   $12.75
                                               plus or minus 4.00D, per lens,
                                     V2201,    ...4.12D to 7.00D, per lens,
                                     V2203,    ...4.00D sphere, 0.12D to
                                               2.00D cylinder, per lens,
                                     V2204,    ...4.00D sphere, 2.12D to
                                               4.00D cylinder, per lens,
                                     V2207     ...4.25D to 7.00D sphere,
                                               0.12D to 2.00D cylinder, per
                                               lens
                                     or        or
                                     V2208     4.25D to 7.00D sphere, 2.12D
                                               to 4.00D cylinder, per lens

Y2612   Bifocal pair           $25.50 V2200,   Sphere, single vision; plano to   $12.75
                                               plus or minus 4.00D, per lens,
                                     V2201,    ...4.12D to 7.00D, per lens,
                                     V2203,    ...4.00D sphere, 0.12D to
                                               2.00D cylinder, per lens,
                                     V2204,    ...4.00D sphere, 2.12D to
                                               4.00D cylinder, per lens,
                                     V2207     ...4.25D to 7.00D sphere,
                                               0.12D to 2.00D cylinder, per
                                               lens
                                     or        or
                                     V2208     4.25D to 7.00D sphere, 2.12D
                                               to 4.00D cylinder, per lens

Y2613   Trifocal single lens   $20.00 V2300,   Sphere, trifocal; plano to plus   $17.00
                                               or minus 4.00D, per lens,

                                     V2301,    ...4.12D to 7.00D, per lens,
                                     V2303,    ...4.00D sphere, 0.12D to
                                               2.00D cylinder, per lens,
                                                  V2304,    ...4.00D sphere, 2.12D to
                                                            4.00D cylinder, per lens,
                                                  V2307     ...4.25D to 7.00D sphere,
                                                            0.12D to 2.00D cylinder, per
                                                            lens
                                                  or        or
                                                  V2308     4.25D to 7.00D sphere, 2.12D
                                                            to 4.00D cylinder, per lens

Y2614   Trifocal pair of lenses             $34.00 V2300,   Sphere, trifocal; plano to plus    $17.00
                                                            or minus 4.00D, per lens,

                                                  V2301,    ...4.12D to 7.00D, per lens,
                                                  V2303,    ...4.00D sphere, 0.12D to
                                                            2.00D cylinder, per lens,
                                                  V2304,    ...4.00D sphere, 2.12D to
                                                            4.00D cylinder, per lens,
                                                  V2307     ...4.25D to 7.00D sphere,
                                                            0.12D to 2.00D cylinder, per
                                                            lens
                                                  or        or
                                                  V2308     4.25D to 7.00D sphere, 2.12D
                                                            to 4.00D cylinder, per lens

Y3048   Shoes attached to brace                                                                         Discontinued
Y4100   Denture obturators                                                                              Discontinued
        hemimaxillectomy
Y4110   Trifocal lenses to be worn in      $155.46 V2300,   Sphere, trifocal; plano to plus    $17.00
        conjunction with cataract lenses                    or minus 4.00D, per lens,
        or intraocular lenses
                                                  V2301,    ...4.12D to 7.00D, per lens,       $17.00
                                                  V2303,    ...4.00D sphere, 0.12D to          $17.00
                                                            2.00D cylinder, per lens,
                                                  V2304,    ...4.00D sphere, 2.12D to          $17.00
                                                            4.00D cylinder, per lens,
                                                  V2307,    ...4.25D to 7.00D sphere,          $17.00
                                                            0.12D to 2.00D cylinder, per
                                                            lens,
                                                  V2308     ...4.25D to 7.00D sphere,          $17.00
                                                            2.12D to 4.00D cylinder, per
                                                            lens
                                                  or        or                                     or
                                                  V2302,    4.00D sphere, 4.25D to 6.00D      $155.46
                                                            cylinder, per lens,
                                                  V2305,    ...4.00D sphere, over 6.00D       $155.46
                                                            cylinder, per lens,
                                                 V2306,        ...4.25D to 7.00D sphere,         $155.46
                                                               4.25D to 6.00D cylinder, per
                                                               lens,
                                                 V2309,        ...4.25D to 7.00D sphere,         $155.46
                                                               over 6.00D cylinder, per lens,
                                                 V2310,        ...7.25D to 12.00D sphere,        $155.46
                                                               0.25D to 2.25D cylinder, per
                                                               lens,
                                                 V2311,        ...7.25D to 12.00D sphere,        $155.46
                                                               2.25D to 4.00D cylinder, per
                                                               lens,
                                                 V2312,        ...7.25D to 12.00D sphere,        $155.46
                                                               2.25D to 4.00D cylinder, per
                                                               lens,
                                                 V2313,        ...7.25D to 12.00D sphere,        $155.46
                                                               4.25D to 6.00D cylinder, per
                                                               lens,
                                                 V2314         ...12.00D, per lens               $155.46
                                                 with          with
                                                 modifier VP   Aphakic patient
Y4170   Single vision lenses to be worn   $22.33 V2100,        Sphere, single vision; plano to     $9.35
        in conjunction with cataract                           plus or minus 4.00D, per lens,
        contact lenses or intraocular
        lenses
                                                 V2101,        ...4.12D to 7.00D, per lens,        $9.35
                                                 V2103,        ...4.00D sphere, 0.12D to           $9.35
                                                               2.00D cylinder, per lens,
                                                 V2104,        ...4.00D sphere, 2.12D to           $9.35
                                                               4.00D cylinder, per lens,
                                                 V2107,        ...4.25D to 7.00D sphere,           $9.35
                                                               0.12D to 2.00D cylinder, per
                                                               lens
                                                 V2108         ...4.25D to 7.00D sphere,           $9.35
                                                               2.12D to 4.00D cylinder, per
                                                               lens
                                                 or            or                                     or
                                                 V2102,        Sphere, single vision; plano to    $22.33
                                                               plus or minus 7.12 to plus or
                                                               minus 20.00D, per lens,

                                                 V2105,        ...4.00D sphere, 4.25D to          $22.33
                                                               6.00D cylinder, per lens,
                                                 V2106,        ...4.00D sphere, over 6.00D        $22.33
                                                               cylinder, per lens,
                                                 V2109,        ...4.25D to 7.00D sphere,          $22.33
                                                               4.25D to 6.00D cylinder, per
                                                               lens,
                                               V2110,        ...4.25D to 7.00D sphere,        $22.33
                                                             over 6.00D cylinder, per lens,
                                               V2111,        ...7.25D to 12.00D sphere,       $22.33
                                                             0.25D to 2.25D cylinder, per
                                                             lens,
                                               V2112,        ...7.25D to 12.00D sphere,       $22.33
                                                             2.25D to 4.00D cylinder, per
                                                             lens,
                                               V2113,        ...7.25D to 12.00D sphere,       $22.33
                                                             4.25D to 6.00D cylinder, per
                                                             lens,
                                               V2114         ...12.00D, per lens              $22.33
                                               with          with
                                               modifier VP   Aphakic patient
Y4171   Bifocal lenses to be worn in    $30.45 V2200,        Sphere, bifocal; plano to plus   $12.75
        conjunction with cataract                            or minus 4.00D, per lens,
        contact lenses or intraocular
        lenses
                                               V2201,        ...4.12D to 7.00D, per lens,     $12.75
                                               V2203,        ...4.00D sphere, 0.12D to        $12.75
                                                             2.00D cylinder, per lens,
                                               V2204,        ...4.00D sphere, 2.12D to        $12.75
                                                             4.00D cylinder, per lens,
                                               V2207,        ...4.25D to 7.00D sphere,        $12.75
                                                             0.12D to 2.00D cylinder, per
                                                             lens,
                                               V2208         ...4.25D to 7.00D sphere,        $12.75
                                                             2.12D to 4.00D cylinder, per
                                                             lens
                                               or            or                                   or
                                               V2202,        4.00D sphere, 4.25D to 6.00D     $30.45
                                                             cylinder, per lens,
                                               V2205,        ...4.00D sphere, over 6.00D      $30.45
                                                             cylinder, per lens,
                                               V2206,        ...4.25D to 7.00D sphere,        $30.45
                                                             4.25D to 6.00D cylinder, per
                                                             lens,
                                               V2209,        ...4.25D to 7.00D sphere,        $30.45
                                                             over 6.00D cylinder, per lens,
                                               V2210,        ...7.25D to 12.00D sphere,       $30.45
                                                             0.25D to 2.25D cylinder, per
                                                             lens,
                                               V2211,        ...7.25D to 12.00D sphere,       $30.45
                                                             2.25D to 4.00D cylinder, per
                                                             lens,
                                                   V2212,        ...7.25D to 12.00D sphere,        $30.45
                                                                 2.25D to 4.00D cylinder, per
                                                                 lens,
                                                   V2213,        ...7.25D to 12.00D sphere,        $30.45
                                                                 4.25D to 6.00D cylinder, per
                                                                 lens,
                                                   V2214         ...12.00D, per lens               $30.45
                                                   with          with
                                                   modifier VP   Aphakic patient
Y4172   Ultraviolet absorbing or            $53.20 V2755         UV lens, per lens                 $53.20
        reflecting prosthetic lens,
        permanent, unilateral
Y4175   Soft contact lens for corneal      $167.81 92070         Fitting of contact lens for       $49.92
        bandage                                                  treatment of disease,
                                                                 including supply of lens
Y4176   Continuous or extended wear        $318.71 V2523         Contact lens hydrophilic;        $145.98
        contact lens (soft) for aphakia,                         extended wear, per lens
        permanent, unilateral
Y4178   Balance lens for unilateral         $45.68 V2700         Balance lens, per lens            $11.00
        cataract glasses
Y4179   Soft contact lens for aphakia,     $265.68 V2520,        Contact lens hydrophilic;         $41.92
        permanent including six months                           spherical, per lens,
        follow-up care
                                                   V2521,        ...Toric or prism ballast, per    $77.17
                                                                 lens,
                                                   V2522,        ...Bifocal, per lens,             $51.92
                                                   V2523,        ...Extended wear, per lens        $51.92
                                                   with          with
                                                   modifier VP   Aphakic patient
Y4180   Hard contact lens for aphakia,     $132.84 V2500,        Contact lens, PMMA;               $50.67
        permanent, unilateral                                    spherical, per lens,
                                                   V2501,        ...Toric or prism ballast, per    $88.58
                                                                 lens,
                                                   V2502,        ...Bifocal, per lens             $120.00
                                                   with          with
                                                   modifier VP   Aphakic patient
Y4183   Contact lens, temporary,                                                                            Discontinued
        unilateral
Y4185   Hyperaspheric cataract lens,        $74.44 V2430         Variable asphericity lens;        $82.13
        permanent, bifocal, unilateral                           bifocal, full field, glass or
                                                                 plastic, per lens
Y4186   Frames for cataract glasses                                                                         Discontinued
Y4187   Cataract glasses, temporary,                                                                        Discontinued
        unilateral
Y4188   Hyperaspheric cataract lens,      $86.28 V2410         Variable asphericity lens;            $63.22
        permanent, single vision,                              single vision, full field, glass
        unilateral                                             or plastic, per lens
Y4189   Aspheric cataract lens,           $56.27 V2410         Variable asphericity lens;            $63.22
        permanent, single vision                               single vision, full field, glass
                                                               or plastic, per lens
Y4190   Punctum plug kit                                                                                       Discontinued; not payable
                                                                                                               separately
Y4193   Cataract glasses, temporary,
        bifocals, unilateral
Y4194   Cornea contact, permanent,       $208.08 V2500,        Contact lens, PMMA,                   $50.67
        unilateral                                             spherical, per lens,
                                                 V2501,        ...Toric or prism ballast, per        $88.55
                                                               lens,
                                                 V2502,        ...Bifocal, per lens,                $120.00
                                                 V2510,        ...Contact lens, gas                  $61.50
                                                               permeable, spherical, per
                                                               lens,
                                                 V2511,        ...Toric, prism ballast, per         $180.17
                                                               lens,
                                                 V2512,        ...Bifocal, per lens bifocal, per    $152.25
                                                               lens,
                                                 V2513,        ...Extended wear, per lens,           $61.50
                                                 V2520,        ...Contact lens hydrophilic;          $41.92
                                                               spherical, per lens,
                                                 V2521,        ...Toric or prism ballast, per        $77.17
                                                               lens,
                                                 V2522,        ...Bifocal, per lens,                 $51.92
                                                 V2523,        ...Extended wear, per lens,           $51.92
                                                 V2530,        ...Contact lens, scleral, gas           TBD
                                                               impermeable, per lens,
                                                 V2531         ...Gas permeable, per lens               TBD
                                                 or            or                                         or
                                                 V2599         Contact lens, other type            Manually
                                                                                                   reviewed
                                                 with          with
                                                 modifier VP   Aphakic patient
Y4196   Aspheric cataract lens,          $116.73 V2430         Variable asphericity lens,            $82.13
        permanent, bifocal, unilateral                         bifocal, full field, glass or
                                                               plastic, per lens
Y4200   Catheter for control of nasal                                                                          Discontinued; not payable
        bleeding                                                                                               separately
Y4245   Prosthesis, leather-molded,       Discontinued
        ischial-bearing socket (KB/KD
        substitute)
Y4249   Prosthesis, dupaco hydraulic      Discontinued
        knee control (KB/KD substitute)
Y4307   Home glucose monitor supply kit   Discontinued

Y4400   Bone marrow surgical tray         Discontinued; not payable
                                          separately
Y5040   Aminophylline, 250 mg/10 mL       Discontinued
        (in ambulance)
Y5041   Aminophylline, 500 mg/20 mL       Discontinued
        (in ambulance)
Y5042   Aminophylline, 500 mg/250 cc      Discontinued
        (in ambulance)

Y5043   Atropine, 0.5 mg/5 mL (in         Discontinued
        ambulance)
Y5046   Bretylium, 500 mg (in             Discontinued
        ambulance)
Y5048   Calcium chloride, 1,000 mg/10     Discontinued
        mL (in ambulance)
Y5049   D5W, 100 cc (in ambulance)        Discontinued
Y5053   Sodium bicarbonate, 5 percent     Discontinued
        IN dextrose/water, 500 cc,
        ambulance
Y5056   Decadron, 10 mg (in ambulance)    Discontinued
Y5057   Diphenhydramine HCL, 50 mg/1      Discontinued
        mL (in ambulance)

Y5059   Dopamine HCL, 400 mcg/10 mL       Discontinued
        (in ambulance)
Y5063   Furosemide, 40 mg/4 mL (in        Discontinued
        ambulance)
Y5064   Glucagon, 1 mg vial (in           Discontinued
        ambulance)
Y5065   Hexadrol, 100 mg/10 mL (in        Discontinued
        ambulance)
Y5066   Inderal, 3 mg (in ambulance)      Discontinued
Y5067   Isoproterenol HCL, 1 mg/5 mL      Discontinued
        (in ambulance)
Y5068   Lidocaine, 50 mg/5 mL (in           Discontinued
        ambulance)
Y5070   Lidocaine, 2 g/50 mL (in            Discontinued
        ambulance)
Y5071   Magnesium sulphate, 2 mL (in        Discontinued
        ambulance)
Y5073   Mannitol, 12.58/50 mL (in           Discontinued
        ambulance)
Y5074   Morphine sulphate, 10 mg/10         Discontinued
        mL (in ambulance)
Y5076   Nitrostat (nitroglycerine tablet)   Discontinued
        (in ambulance)
Y5079   Nubain, 10 mg (in ambulance)        Discontinued
Y5080   Phenergan, 25 mg (in                Discontinued
        ambulance)
Y5081   Phenergan, 50 mg (in                Discontinued
        ambulance)
Y5082   Pitocin, 1 mL (in ambulance)        Discontinued
Y5083   Procainamide, 20 mg (in             Discontinued
        ambulance)
Y5084   Procainamide, 100 mg/1 mL (in       Discontinued
        ambulance)
Y5088   Valium, 10 mg (in ambulance)        Discontinued
Y5089   Verapamil, 5 mg/2 mL (in            Discontinued
        ambulance)
Y5090   Verapamil, 10 mg/4 mL (in           Discontinued
        ambulance)
Y5106   Alupent inhalant solution, 10 mL    Discontinued
Y5107   Alupent inhalant solution, 30 mL    Discontinued
Y5108   Proventil (albuterol sulfate)       Discontinued
        solution for inhalation
Y5900   Outlet port clamp (dialysis)        Discontinued; part of
                                            dialysis global fee
Y5901   Spike covers or protectors          Discontinued; part of
        (dialysis)                          dialysis global fee
Y5902   Cycler drainage set (dialysis)      Discontinued; part of
                                            dialysis global fee
Y5903   Thermometer, oral (dialysis)        Discontinued; part of
                                            dialysis global fee
Y5905   9-in. cycler administration set                                                                              Discontinued; part of
        (dialysis)                                                                                                   dialysis global fee
Y5906   Solution transfer set (dialysis)                                                                             Discontinued; part of
                                                                                                                     dialysis global fee

Y5907   Cycler tubing set with universal           $21.98                                                            Discontinued; part of
        connector (dialysis)                                                                                         dialysis global fee
Y5908   3-prong manifold set (dialysis)             $7.36                                                            Discontinued; part of
                                                                                                                     dialysis global fee
Y5909   5-prong manifold set (dialysis)                                                                              Discontinued; part of
                                                                                                                     dialysis global fee
Y5910   10-prong manifold set (dialysis)                                                                             Discontinued; part of
                                                                                                                     dialysis global fee
Y5912   Gauze sponges, 4 X 4 (dialysis)                                                                              Discontinued; part of
                                                                                                                     dialysis global fee
Y6002   Ambulance service, flat rate,                                                                                Discontinued
        when no mileage is billed on the
        claim
Y6005   Nonemergency ambulance, flat                                                                                 Discontinued
        rate
Y6007   Nonemergency ambulance,                     $3.30 A0425     Ground mileage, per statute    Provider profiles Use modifier ET to
        mileage                                                     mile                              = emergency identify the service as an
                                                                                                   mileage;          emergency. Services
                                                                                                                     billed without a modifier
                                                                                                       $3.30 = non- will be identified as a
                                                                                                        emergency nonemergency.
                                                                                                            mileage
Y6102   Extra charge for night calls - 8                                                                             Discontinued; not payable
        p.m. to 8 a.m.                                                                                               separately
Y6103   (weekends/holidays)
        Extra charge additional attendant Provider-specific A0424   Extra ambulance attendant,   Provider-specific
                                                       rate         ALS or BLS (requires medical              rate
                                                                    review)
Y6104   Air ambulance mileage                      $16.24 A0435     Fixed wing air mileage, per             $16.24
                                                                    statute mile
                                                            or      or
                                                            A0436   Rotary wing air mileage, per
                                                                    statute mile
Y6107   Blue top collection tube (in                                                                                 Discontinued
        ambulance)
Y6109   Green top collection tube (in                                                                                Discontinued
        ambulance)
Y6110   Gray top collection tube (in                                                                                 Discontinued
        ambulance)
Y6112   Endotracheal tubes (in                                                                                             Discontinued
        ambulance)
Y6115   Defibrillator pads (in ambulance)                                                                                  Discontinued
Y6116   Burn sheets (in ambulance)                                                                                         Discontinued
Y6117   Butterfly needles (in ambulance)                                                                                   Discontinued
Y6120   Sterile saline or water, 30 cc vial                                                                                Discontinued
        (in ambulance)
Y6122   Betadine ointment (in                                                                                              Discontinued
        ambulance)
Y6126   Dextrostix (in ambulance)                                                                                          Discontinued
Y7026   Skull X-ray complete study,                                                                                        Discontinued
        three or more views
Y7102   Unna boot                                                                                                          Discontinued
Y7103   Dressings, billed by physician                                                                                     Discontinued
Y7107   Miscellaneous supplies                                                                                             Discontinued; TOS 2:
                                                                                                                           providers should bill the
                                                                                                                           appropriate revenue code.
Y7110   Surgical trays (outpatient)                                                                                        Discontinued
Y7112   IV equipment (outpatient) (to         Provider-specific 264   IV therapy, IV therapy/supplies Provider-specific
        include trays)                              interim rate                                            interim rate
Y7114   Continuous ambulatory                                                                                              Discontinued
        peritoneal dialysis supply kit, per
        month

Y7669   Electrophoresis pattern                      Manually 83020   Hemoglobin fractionation and              $17.80
        hemoglobin                                   reviewed         quantitation; electrophoresis
                                                                      (e.g., A2, S, C, and/or F)

Y7680   Hemoglobin, routine-any                      Manually 83036   Hemoglobin; glycated                         TBD
        method, genetics                             reviewed
Y7744   Resin uptake T-3 or T-4 with                 Manually 84479   Thyroid hormone (T3 or T4)                  $8.95
        total thyroxine                              reviewed         uptake or thyroid hormone
                                                                      binding ratio (THBR)
Y7746   Uric acid                                    Manually 84550   Uric acid; blood                            $6.41
                                                     reviewed
Y7747   Transaminase SGOT or SGPT                    Manually 84450   Transferase, aspartate amino                $7.14 Bill the appropriate code.
                                                     reviewed         (AST) (SGOT)
                                                              or      or                                             or
                                                              84460   Transferase; alanine amino                  $7.32
                                                                      (ALT) (SGPT)
Y7772   T7 genetics                                  Manually 84437   Thyroxine; requiring elution                $8.95
                                                     reviewed         (e.g., neonatal)
Y8069   Oxygen mask or nasal cannula                                                              Discontinued

Y8102   Two chemistry tests                                                                       Discontinued

Y8103   Panel of three tests                                                                      Discontinued

Y8106   Six tests                                                                                 Discontinued

Y8112   Genetics, blood panel or SMA,                                                             Discontinued
        12 tests/chemistry profile
Y8150   Alpha-N acetylglucosaminidase-   $73.83 84999   Unlisted chemistry procedure   Manually Enter the local code in
        FI                                                                             reviewed the Comments field.
Y8151   Alpha-N acetylglucosaminidase-   $73.83 84999   Unlisted chemistry procedure   Manually Enter the local code in
        AF                                                                             reviewed the Comments field.

Y8152   Acid lipase-WBC                  $41.09 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                       reviewed the Comments field.
Y8153   Acid lipase-FI                   $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                       reviewed the Comments field.
Y8154   Acid lipase-AF                   $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                       reviewed the Comments field.

Y8155   Acid phosphatase-BC              $41.09 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                       reviewed the Comments field.
Y8156   Acid phosphatase-FI              $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                       reviewed the Comments field.

Y8157   Acid phosphatase-AF              $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                       reviewed the Comments field.

Y8158   Adenosine deaminase--RBC         $41.09 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                       reviewed the Comments field.

Y8159   Adenosine deaminase-I            $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                       reviewed the Comments field.

Y8160   Adenosine deaminase-AF           $83.74 84999   Unlisted chemistry procedure   Manually   Enter the local code in
                                                                                       reviewed   the Comments field.
Y8161   Aldolase-WBC                     $41.09 84999   Unlisted chemistry procedure   Manually   Enter the local code in
                                                                                       reviewed   the Comments field.

Y8162   Aldolase-FI                      $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                       reviewed the Comments field.
Y8163   Aldolase-AF                         $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8164   Arginase-RBC                        $41.09 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8165   Argininosuccinic acid sythetase,    $35.53 84999   Unlisted chemistry procedure   Manually Enter the local code in
        liver                                                                             reviewed the Comments field.

Y8166   Amino acid qualitative screen-U      $8.13 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8167   Amino acid qualitative screen-P      $8.13 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8168   Amino acid quantitative screen-U   $128.91 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8169   Amino acid quantitative screen-S   $128.91 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8170   Aryl sulfatase A-WBC                $41.09 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.

Y8171   Aryl sulfatase A-FI                 $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.

Y8172   Aryl sulfatase-AF                   $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.

Y8173   Aryl sulfatase B-WBC                $41.09 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8174   Aryl sulfatase B-FI                 $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8175   Aryl sulfatase B-AF                 $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.

Y8176   Beta-aspartylglucosamin-idase-      $35.53 84999   Unlisted chemistry procedure   Manually Enter the local code in
        SB                                                                                reviewed the Comments field.

Y8177   Cholinesterase-pseudo-S             $19.26 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8178   Cholinesterase-true-WB              $23.11 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.

Y8179   Cystathionase-WB                   $103.37 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8180   Cystathionase-WBC                  $105.38 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8181   Cystathionine synthase-SB        $105.94 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.
Y8182   Enzyme screen-P                  $186.18 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.
Y8183   Erythrocyte galacto kinase       $128.40 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.
Y8184   Alpha-fetoprotein-S               $40.60 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8185   Alpha-fetoprotein-AF              $40.60 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.
Y8186   Alpha-L-fucosidase-WBC            $41.09 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.
Y8187   Alpha-L-fucosidase-FI             $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8188   Alpha-L-fucosidase-AF             $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8189   Beta-galactocerebrosidase-WBC     $35.53 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8190   Beta-galactocerebrosidase-S       $20.30 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.
Y8191   Beta-galactocerebrosidase-SB    Manually 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                        reviewed                                        reviewed the Comments field.

Y8192   Beta-galactocerebrosidase-P     Manually 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                        reviewed                                        reviewed the Comments field.
Y8193   Galactose transferase-WB          $32.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8194   Alpha-galactosidase-WBC           $41.09 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8195   Alpha-galactosidase-FI            $88.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8196   Alpha-galactosidase-AF            $88.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.
Y8197   Beta-galactosidase-WBC            $41.09 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.
Y8198   Beta-galactosidase-FI               $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.

Y8199   Beta-galactosidase-AF               $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8200   Glucose-6-phosphate                 $25.68 84999   Unlisted chemistry procedure   Manually Enter the local code in
        dehydrogenase-WB                                                                  reviewed the Comments field.

Y8201   Alpha-gludosidase-WBC               $41.09 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.

Y8202   Alpha-glucosidase-FI                $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.

Y8203   Alpha-glucosidase-AF                $83.74 84999   Unlisted chemistry procedure   Manually   Enter the local code in
                                                                                          reviewed   the Comments field.
Y8204   Beta-glucosidase-WBC                $41.09 84999   Unlisted chemistry procedure   Manually   Enter the local code in
                                                                                          reviewed   the Comments field.
Y8205   Beta-glucosidase-FI                 $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8206   Beta-glucosidase-AF                 $83.74 84999   Unlisted chemistry procedure   Manually   Enter the local code in
                                                                                          reviewed   the Comments field.
Y8207   Beta-glucuronidase-S                $25.68 84999   Unlisted chemistry procedure   Manually   Enter the local code in
                                                                                          reviewed   the Comments field.
Y8208   Beta-glucuronidase-WBC              $41.09 84999   Unlisted chemistry procedure   Manually   Enter the local code in
                                                                                          reviewed   the Comments field.
Y8209   Beta-glucuronidase-FI               $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8210   Beta-glucuronidase-AF               $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.

Y8211   Glycogen storage disease           $449.39 84999   Unlisted chemistry procedure   Manually Enter the local code in
        enzyme assay series                                                               reviewed the Comments field.
Y8212   Glycogen debrancher enzyme         $329.88 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8213   GM2 type 2, WBC                     $19.90 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.
Y8214   GM2 type 2, SB                     $105.94 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.

Y8215   Heparin sulfate N-sulfamidase-FI    $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                          reviewed the Comments field.

Y8216   Heparin sulfate N-sulfamidase-      $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
        AF                                                                                reviewed the Comments field.
Y8217   Hexosamidase A-S                  $20.30 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8218   Hexosamidase A-WBC               $126.88 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8219   Hexosamidase A-SB                 $36.54 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8220   Hexosamidase A and B-S            $25.68 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8221   Hexosamidase A and B-WBC          $41.09 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8222   Hexosamidase A and B-FI           $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.
Y8223   Hexosamidase A and B-AF           $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8224   Hypoxanthine-guanine-             $38.52 84999   Unlisted chemistry procedure   Manually Enter the local code in
        phosphoribosyl-transferase-RBC                                                  reviewed the Comments field.

Y8225   Hypoxanthine-guanine-             $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
        phosphoribosyl-transferase-FI                                                   reviewed the Comments field.

Y8226   Hypoxanthine-guanine-             $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
        phosphoribosyl-transferase-AF                                                   reviewed the Comments field.

Y8227   Alpha-L-iduronidase (Scheie's     $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
        S)-WBC                                                                          reviewed the Comments field.
Y8228   Alpha-L-iduronidase (Scheie's     $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
        S)-FI                                                                           reviewed the Comments field.
Y8229   Alpha-L-iduronidase (Scheie's     $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
        S)-AF,                                                                          reviewed the Comments field.

Y8230   Alpha-L-iduronidate Sulfatiase    $68.06 84999   Unlisted chemistry procedure   Manually Enter the local code in
        (Hunter's S)-S                                                                  reviewed the Comments field.

Y8231   Alpha-mannosidase-WBC             $32.10 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8232   Alpha-mannosidase-FI              $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.

Y8233   Alpha-mannosidase-AF              $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                        reviewed the Comments field.
Y8234   Mucolipidosis II (I-cell disease)-     $21.83 84999   Unlisted chemistry procedure   Manually Enter the local code in
        WBC                                                                                  reviewed the Comments field.
Y8235   Mucolipidosis II (beta-               $105.94 84999   Unlisted chemistry procedure   Manually Enter the local code in
        galactosidase)-SB                                                                    reviewed the Comments field.
Y8236   Mucolipidosis III (pseudo-hurler)-     $93.10 84999   Unlisted chemistry procedure   Manually Enter the local code in
        SB                                                                                   reviewed the Comments field.
Y8237   Neuraminidase-WB                       $68.70 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                             reviewed the Comments field.
Y8238   Nucleoside phosphorylase-RBC           $38.52 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                             reviewed the Comments field.
Y8239   Nucleoside phosphorylase-FI            $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                             reviewed the Comments field.
Y8240   Nucleoside phosphorylase-AF            $83.74 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                             reviewed the Comments field.
Y8241   Organic acid screen-U                 $126.88 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                             reviewed the Comments field.
Y8242   Ornithine transcarbamylase, liver      $24.29 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                             reviewed the Comments field.

Y8243   Orotate phosphoribosyl               Manually 84999   Unlisted chemistry procedure   Manually Enter the local code in
        transferase                          reviewed                                        reviewed the Comments field.
Y8244   Ortidylic-decarboxylase              Manually 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                             reviewed                                        reviewed the Comments field.

Y8245   Feroxidase-WB                          $64.20 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                             reviewed the Comments field.

Y8246   Phenylalanine (serum levels)           $12.84 84999   Unlisted chemistry procedure   Manually   Enter the local code in
                                                                                             reviewed   the Comments field.
Y8247   Phosphorylase-B-kinase                $329.88 84999   Unlisted chemistry procedure   Manually   Enter the local code in
                                                                                             reviewed   the Comments field.
Y8248   PP-Ribose-P-amidotransferase         Manually 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                             reviewed                                        reviewed the Comments field.
Y8249   PP-Ribose-P-synthetase               Manually 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                             reviewed                                        reviewed the Comments field.
Y8250   Pyruvate kinase-WB                     $23.11 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                             reviewed the Comments field.

Y8251   Sphingomyelinase-WBC                   $41.09 84999   Unlisted chemistry procedure   Manually Enter the local code in
                                                                                             reviewed the Comments field.
Y8252   Sphingomyelinase-FI                   $83.74 84999         Unlisted chemistry procedure    Manually Enter the local code in
                                                                                                   reviewed the Comments field.

Y8253   Sphingomyelinase-AF                   $83.74 84999         Unlisted chemistry procedure    Manually Enter the local code in
                                                                                                   reviewed the Comments field.
Y8254   UDPG transferase-RBC                  $38.52 84999         Unlisted chemistry procedure    Manually Enter the local code in
                                                                                                   reviewed the Comments field.

Y8255   UDPG transferase-FI                   $83.74 84999         Unlisted chemistry procedure    Manually Enter the local code in
                                                                                                   reviewed the Comments field.

Y8256   UDPG transferase-AF                   $83.74 84999         Unlisted chemistry procedure    Manually Enter the local code in
                                                                                                   reviewed the Comments field.

Y8257   Urine mucopolysaccharides             $38.52 84999         Unlisted chemistry procedure    Manually   Enter the local code in
        screen (thin-layer                                                                         reviewed   the Comments field.
Y8258   chromatography)-U
        Urine mucopolysaccharides            $148.94 84999         Unlisted chemistry procedure    Manually   Enter the local code in
        screen (quantitative study)                                                                reviewed   the Comments field.
Y8259   Xanthine oxidase                    Manually 84999         Unlisted chemistry procedure    Manually Enter the local code in
                                            reviewed                                               reviewed the Comments field.
Y8260   Lactate/pyruvate kinese-S             $38.06 84999         Unlisted chemistry procedure    Manually Enter the local code in
                                                                                                   reviewed the Comments field.
Y8261   Lactate/pyruvate tolerance tests-    $203.00 84999         Unlisted chemistry procedure    Manually Enter the local code in
        T                                                                                          reviewed the Comments field.
Y8275   Genetic health history/detailed      $101.50 99244         Office consultation for a new    $248.68 A modifier is required for
                                                                   or established patient, which            payment consideration.
                                                                   requires these three key
                                                                   components: a
                                                                   comprehensive history; a
                                                                   comprehensive examination;
                                                                   and medical decision making
                                                                   of moderate complexity
and     and                                      and with          with
Y8277   Genetic physical                     $101.50 modifier TG   Complex/high level of care
        examination/complex
and     and                                      and
Y8280   Psycho-social genetic                 $45.68
        assessment/standard
Y8275   Genetic health history/detailed   $101.50 99245           Office consultation for a new      $370.48 A modifier is required for
                                                                  or established patient, which              payment consideration.
                                                                  requires these three key
                                                                  components: a
                                                                  comprehensive history; a
                                                                  comprehensive examination;
                                                                  and medical decision making
                                                                  of high complexity
and     and                                   and with            with
Y8278   Genetic physical                  $177.63 modifier TG     Complex/high level of care
        examination/comprehensive
and     and                                   and
Y8281   Psycho-social genetic              $91.35
        assessment/complex or
        extensive
Y8275   Genetic health history/detailed   $101.50 99404           Preventive medicine                $152.25 A modifier is required for
                                                                  counseling and/or risk factor              payment consideration.
                                                                  reduction intervention(s)
                                                                  provided to an individual
                                                                  (separate procedure);
                                                                  approximately 60 minutes
and     and                                   and with            with
Y8283   Prenatal diagnostic procedure      $50.75 modifier TG     Complex/high level of care
        counseling
Y8276   Genetic physical examination       $50.75 99214           Office or other outpatient visit    $81.20 A modifier is required for
                                                                  for the evaluation and                     payment consideration.
                                                                  management of an
                                                                  established patient, which
                                                                  requires at least two of these
                                                                  three key components: a
                                                                  detailed history; a detailed
                                                                  examination; medical decision
                                                                  making of moderate
                                                                  complexity

and     and                                   and with            with
Y8282   Genetic health history/update      $30.45 modifier TG     Complex/high level of care
Y8283   Prenatal diagnostic procedure      $50.75 99402           Preventive medicine                 $50.75 A modifier is required for
        counseling                                                counseling and/or risk factor              payment consideration.
                                                                  reduction intervention(s)
                                                                  provided to an individual
                                                                  (separate procedure);
                                                                  approximately 30 minutes
                                                    with          with
                                                    modifier TG   Complex/high level of care
Y8284   Medical genetics counseling,     $101.50 99215                 Office or other outpatient visit          $147.18 A modifier is required for
        other than that related to a                                   for the evaluation and                            payment consideration.
        prenatal diagnostic procedure                                  management of an
                                                                       established patient, which
                                                                       requires at least two of these
                                                                       three key components: a
                                                                       comprehensive history; a
                                                                       comprehensive examination;
                                                                       medical decision making of
                                                                       high complexity

and     and                                  and with                  with
Y8285   Psycho-social genetic             $45.68 modifier TG           Complex/high level of care
        counseling/initial
Y8286   Follow-up genetics counseling     $25.38 99213                 Office or other outpatient visit           $50.76 A modifier is required for
                                                                       for the evaluation and                            payment consideration.
                                                                       management of an
                                                                       established patient, which
                                                                       requires at least two of these
                                                                       three key components: an
                                                                       expanded problem-focused
                                                                       history; an expanded problem-
                                                                       focused examination; medical
                                                                       decision making of low
                                                                       complexity

and     and                                        with                with
Y8279   Psycho-social genetic                      modifier TG         Complex/high level of care
        counseling, follow-up
Y8287   Amniocentesis                     $86.28                 59000 Amniocentesis; diagnostic                  $70.37
Y8288   Lymphocytes (Q-R or G            $253.75 88261, 88262,         National CPT codes for                   $244.24;
        banded) genetics                         88263, 88264,         cytogenetic studies                      $172.25;
                                                 88267, 88269,                                                  $207.67;
                                                 88283                                                          $172.25;
                                                                                                                $212.17;
                                                                                                          $229.85; $94.79

Y8289   Lymphocytes (other banding or    $152.25 88261, 88262,         National CPT codes for                   $244.24;
        analytical procedure) genetics           88263, 88264,         cytogenetic studies                      $172.25;
                                                 88267, 88269,                                                  $207.67;
                                                 88283                                                          $172.25;
                                                                                                                $212.17;
                                                                                                          $229.85; $94.79
Y8290   Lymphocytes (full analytical with    $294.35 88261, 88262,   National CPT codes for         $244.24;
        2 band/Q-R-G) genetics                       88263, 88264,   cytogenetic studies            $172.25;
                                                     88267, 88269,                                  $207.67;
                                                     88283                                          $172.25;
                                                                                                    $212.17;
                                                                                              $229.85; $94.79
Y8291   Fibroblast (Q-R or G banded)         $263.90 88261, 88262,   National CPT codes for         $244.24;
        genetics                                     88263, 88264,   cytogenetic studies            $172.25;
                                                     88267, 88269,                                  $207.67;
                                                     88283                                          $172.25;
                                                                                                    $212.17;
                                                                                              $229.85; $94.79
Y8292   Fibroblast (other banding or         $253.75 88261, 88262,   National CPT codes for         $244.24;
        analytical procedures) genetics              88263, 88264,   cytogenetic studies            $172.25;
                                                     88267, 88269,                                  $207.67;
                                                     88283                                          $172.25;
                                                                                                    $212.17;
                                                                                              $229.85; $94.79
Y8293   Fibroblast (full analytical with 2   $304.50 88261, 88262,   National CPT codes for         $244.24;
        band/Q-R-G) genetics                         88263, 88264,   cytogenetic studies            $172.25;
                                                     88267, 88269,                                  $207.67;
                                                     88283                                          $172.25;
                                                                                                    $212.17;
                                                                                              $229.85; $94.79
Y8294   Cell                                  $20.30 88261, 88262,   National CPT codes for         $244.24;
        culture/fibroblast/nonbanded                 88263, 88264,   cytogenetic studies            $172.25;
        genetics                                     88267, 88269,                                  $207.67;
                                                     88283                                          $172.25;
                                                                                                    $212.17;
                                                                                              $229.85; $94.79
Y8295   Cell culture/amniotic genetics       $203.00 88261, 88262,   National CPT codes for         $244.24;
                                                     88263, 88264,   cytogenetic studies            $172.25;
                                                     88267, 88269,                                  $207.67;
                                                     88283                                          $172.25;
                                                                                                    $212.17;
                                                                                              $229.85; $94.79
Y8296   Y body study-genetics                 $30.45 88261, 88262,   National CPT codes for         $244.24;
                                                     88263, 88264,   cytogenetic studies            $172.25;
                                                     88267, 88269,                                  $207.67;
                                                     88283                                          $172.25;
                                                                                                    $212.17;
                                                                                              $229.85; $94.79
Y8297   X body study-genetics                       $30.45 88261, 88262,   National CPT codes for                  $244.24;
                                                           88263, 88264,   cytogenetic studies                     $172.25;
                                                           88267, 88269,                                           $207.67;
                                                           88283                                                   $172.25;
                                                                                                                   $212.17;
                                                                                                             $229.85; $94.79
Y8298   Combined x and y body study-                $50.75 88261, 88262,   National CPT codes for                  $244.24;
        genetics                                           88263, 88264,   cytogenetic studies                     $172.25;
                                                           88267, 88269,                                           $207.67;
                                                           88283                                                   $172.25;
                                                                                                                   $212.17;
                                                                                                             $229.85; $94.79
Y8381   Supplies for CPM device (i.e.,                                                                                         Discontinued
        pads)
Y8670   Infusion pump administration set                                                                                       Discontinued
Y8671   Infusion pump cassette                                                                                                 Discontinued
Y9311   P 32 (Phosphorus)                                                                                                      Discontinued; TOS 9: bill
                                                                                                                               the appropriate national
                                                                                                                               codes.
Y9312   RA-RN (Radium-Radon)                                                                                                   Discontinued; TOS 6, 9:
                                                                                                                               bill the appropriate
                                                                                                                               national codes.
Y9313   CS (Cesium)                                                                                                            Discontinued; TOS 6, 9:
                                                                                                                               bill the appropriate
                                                                                                                               national codes.
Y9314   I 131 (Iodine)                                                                                                         Discontinued; TOS 9: bill
                                                                                                                               the appropriate national
                                                                                                                               codes.
Y9315   Radioisotope, other                                                                                                    Discontinued; TOS 9: bill
                                                                                                                               the appropriate national
                                                                                                                               codes
Y9550   Whole blood                        Provider-specific P9010         Blood (whole), for transfusion,           $45.00
                                                 interim rate              per unit
Y9551   Whole blood, replaced, per pint        Not a benefit P9010         Blood (whole), for transfusion,           $45.00
                                                                           per unit
Y9552   Living related donor specified         Not a benefit P9010         Blood (whole), for transfusion,           $45.00
        transfusions for (DST) kidney                                      per unit
        transplantation, per pint
Y9555   Packed cells, not replaced, per        Not a benefit P9021         Red blood cells, each unit                $66.19 Bill the appropriate code.
        pint
                                                           or              or                                             or
                                                        P9022         Red blood cells, washed,             $104.15
                                                                      each unit
Y9556   Packed cells                      Not a benefit P9021         Red blood cells, each unit            $66.19 Bill the appropriate code.
                                                        or            or                                        or
                                                        P9022         Red blood cells, washed,             $104.15
                                                                      each unit
Y9565   Plasma                            Not a benefit P9017         Fresh frozen plasma (single           $77.33 Bill the appropriate code.
                                                                      donor), each unit
                                                        or            or                                         or
                                                        P9023         Plasma, pooled multiple             Manually
                                                                      donor, solvent/detergent            reviewed
                                                                      treated, frozen, each unit
                                                        or            or                                        or
                                                        P9044         Plasma, cryoprecipitate               $77.33
                                                                      reduced, each unit
Y9600   Handling fee, for major repairs                                                                               Discontinued; Clients age
        only                                                                                                          21 and older are
                                                                                                                      responsible for repairs.
Y9603   Over $1.75 cost of materials           $10.00                                                                 Discontinued; vision
                                                                                                                      providers
Y9607   Zylonite frames                        $14.45 V2020, V2025,   National codes for frames and V2020 or V2025    Use modifier RP to
                                                      V2100, V2101,   lenses                        = $14.45;         indicate replacement (see
                                                      V2103, V2104,                                 V2100–V2108 =     local code elimination
                                                      V2107, V2108,                                 $9.35;            decisions for
                                                      V2200, V2201,                                 V2200–V2208 =     Y2607–Y2614); bill the
                                                      V2203, V2204,                                 $12.75;           appropriate quantity of
                                                      V2207, V2208,                                 V2300–V2308 =     lenses.
                                                      V2300, V2301,                                 $17.00
                                                      V2303, V2304,
                                                      V2307
                                                      or
                                                      V2308
                                                      with            with
                                                      modifier RP     Replacement and repair
Y9608   Zylonite and metal frames              $14.45 V2020, V2025,   National codes for frames and V2020 or V2025    Use modifier RP to
                                                      V2100, V2101,   lenses                        = $14.45;         indicate replacement (see
                                                      V2103, V2104,                                 V2100–V2108 =     local code elimination
                                                      V2107, V2108,                                 $9.35;            decisions for
                                                      V2200, V2201,                                 V2200–V2208 =     Y2607–Y2614); bill the
                                                      V2203, V2204,                                 $12.75;           appropriate quantity of
                                                      V2207, V2208,                                 V2300–V2308 =     lenses.
                                                      V2300, V2301,                                 $17.00
                                                      V2303, V2304,
                                                      V2307
                                                      or
                                                      V2308
                                               with            with
                                               modifier RP     Replacement and repair
Y9609   Single vision, one lens         $10.35 V2020, V2025,   National codes for frames and V2020 or V2025   Use modifier RP to
                                               V2100, V2101,   lenses                        = $14.45;        indicate replacement (see
                                               V2103, V2104,                                 V2100–V2108 =    local code elimination
                                               V2107, V2108,                                 $9.35;           decisions for
                                               V2200, V2201,                                 V2200–V2208 =    Y2607–Y2614); bill the
                                               V2203, V2204,                                 $12.75;          appropriate quantity of
                                               V2207, V2208,                                 V2300–V2308 =    lenses.
                                               V2300, V2301,                                 $17.00
                                               V2303, V2304,
                                               V2307
                                               or
                                               V2308
                                               with            with
                                               modifier RP     Replacement and repair
Y9610   Single vision, pair of lenses   $18.70 V2020, V2025,   National codes for frames and V2020 or V2025   Use modifier RP to
                                               V2100, V2101,   lenses                        = $14.45;        indicate replacement (see
                                               V2103, V2104,                                 V2100–V2108 =    local code elimination
                                               V2107, V2108,                                 $9.35;           decisions for
                                               V2200, V2201,                                 V2200–V2208 =    Y2607–Y2614); bill the
                                               V2203, V2204,                                 $12.75;          appropriate quantity of
                                               V2207, V2208,                                 V2300–V2308 =    lenses.
                                               V2300, V2301,                                 $17.00
                                               V2303, V2304,
                                               V2307
                                               or
                                               V2308
                                               with            with
                                               modifier RP     Replacement and repair
Y9611   Bifocal, one lens               $13.50 V2020, V2025,   National codes for frames and V2020 or V2025   Use modifier RP to
                                               V2100, V2101,   lenses                        = $14.45;        indicate replacement (see
                                               V2103, V2104,                                 V2100–V2108 =    local code elimination
                                               V2107, V2108,                                 $9.35;           decisions for
                                               V2200, V2201,                                 V2200–V2208 =    Y2607–Y2614); bill the
                                               V2203, V2204,                                 $12.75;          appropriate quantity of
                                               V2207, V2208,                                 V2300–V2308 =    lenses.
                                               V2300, V2301,                                 $17.00
                                               V2303, V2304,
                                               V2307
                                               or
                                               V2308
                                               with            with
                                               modifier RP     Replacement and repair
Y9612   Bifocal, pair of lenses         $25.50 V2020, V2025,   National codes for frames and V2020 or V2025   Use modifier RP to
                                               V2100, V2101,   lenses                        = $14.45;        indicate replacement (see
                                               V2103, V2104,                                 V2100–V2108 =    local code elimination
                                               V2107, V2108,                                 $9.35;           decisions for
                                               V2200, V2201,                                 V2200–V2208 =    Y2607–Y2614); bill the
                                               V2203, V2204,                                 $12.75;          appropriate quantity of
                                               V2207, V2208,                                 V2300–V2308 =    lenses.
                                               V2300, V2301,                                 $17.00
                                               V2303, V2304,
                                               V2307
                                               or
                                               V2308
                                               with            with
                                               modifier RP     Replacement and repair
Y9613   Trifocal, one lens              $18.00 V2020, V2025,   National codes for frames and V2020 or V2025   Use modifier RP to
                                               V2100, V2101,   lenses                        = $14.45;        indicate replacement (see
                                               V2103, V2104,                                 V2100–V2108 =    local code elimination
                                               V2107, V2108,                                 $9.35;           decisions for
                                               V2200, V2201,                                 V2200–V2208 =    Y2607–Y2614); bill the
                                               V2203, V2204,                                 $12.75;          appropriate quantity of
                                               V2207, V2208,                                 V2300–V2308 =    lenses.
                                               V2300, V2301,                                 $17.00
                                               V2303, V2304,
                                               V2307
                                               or
                                               V2308
                                               with            with
                                               modifier RP     Replacement and repair
Y9614   Trifocal, pair of lenses        $34.00 V2020, V2025,   National codes for frames and V2020 or V2025   Use modifier RP to
                                               V2100, V2101,   lenses                        = $14.45;        indicate replacement (see
                                               V2103, V2104,                                 V2100–V2108 =    local code elimination
                                               V2107, V2108,                                 $9.35;           decisions for
                                               V2200, V2201,                                 V2200–V2208 =    Y2607–Y2614); bill the
                                               V2203, V2204,                                 $12.75;          appropriate quantity of
                                               V2207, V2208,                                 V2300–V2308 =    lenses.
                                               V2300, V2301,                                 $17.00
                                               V2303, V2304,
                                               V2307
                                               or
                                               V2308
                                               with            with
                                               modifier RP     Replacement and repair
Y9999   Unlisted radiology procedure,                                                                         Discontinued; TOS 4
        included in another service
Y9999   Not otherwise classified,                                                                             Discontinued; TOS 6
        radiation therapy service
Y9999   Surgery, not otherwise                                                                                            Discontinued; TOS 9
        classified, minor/diagnostic
Y9999   NOC, supply                                                                                                       Discontinued
Y9999   Noncovered professional fees       Provider-specific 960    Professional fees                Provider-specific
        billed by facility                       interim rate                                              interim rate
Y9999   Unlisted procedure; ASC                   Manually                                                             Discontinued; use
                                                  reviewed                                                             appropriate national
                                                                                                                       codes.
Z0034   Vaginal contraceptive film                    $3.60 A4269   Contraceptive supply,                        $4.00 Package of 6 is billed as
        (quantity of 6)                                             spermicide (e.g., foam, gel),                      quantity of 1.
                                                                    each
Z0035   Spermicidal cream                             $4.10 A4269   Contraceptive supply,                        $4.00 Bill the appropriate
                                                                    spermicide (e.g., foam, gel),                      quantity.
                                                                    each
Z0036   Spermicidal jelly                             $3.60 A4269   Contraceptive supply,                        $4.00 Bill the appropriate
                                                                    spermicide (e.g., foam, gel),                      quantity.
                                                                    each
Z0037   Contraceptive suppository each                $0.70 A4269   Contraceptive supply,                        $4.00 Package of 6 is billed as
                                                                    spermicide (e.g., foam, gel),                      quantity of 1.
                                                                    each
Z0038   Spermicidal foam                              $4.50 A4269   Contraceptive supply,                        $4.00 Bill the appropriate
                                                                    spermicide (e.g., foam, gel),                      quantity.
                                                                    each
Z0039   Other medication for genital                  $5.90 J3490   Unclassified drugs                           $5.90 Titles V, X, and XX,
        infection                                                                                                      Program 300 only

Z0040   Oral contraceptive (1 cycle)                  $2.80 S4993   Contraceptive pills for birth                $2.80
                                                                    control
Z0041   Cervical cap, for supply only                 $2.40 A4261   Cervical cap for contraceptive             $24.22
                                                                    use

Z0042   Condoms, package of 12                        $2.70 A4267   Contraceptive supply,                        $0.22 Bill the appropriate
                                                                    condom, male, each                                 quantity to reflect the
                                                                                                                       number of condoms
                                                                                                                       administered.
Z0043   Natural family planning supplies                                                                                  Discontinued


Z0044   Contraceptive sponge, each                                                                                        Discontinued
Z0050   Initial patient education            $11.67 99429        Unlisted preventive medicine             $11.67 Modifier FP is necessary
                                                                 service                                         for consideration of
                                                                                                                 payment.

                                                   with          with
                                                   modifier FP   Service provided as part of
                                                                 Medicaid Family Planning
                                                                 Program
Z0051   Method-specific                       $8.42 99401        Preventive medicine                        $8.42 Modifier FP is necessary
        education/counseling                                     counseling and/or risk factor                    for consideration of
                                                                 reduction intervention(s)                        payment.
                                                                 provided to an individual
                                                                 (separate procedure);
                                                                 approximately 15 minutes
                                                   with          with
                                                   modifier FP   Service provided as part of
                                                                 Medicaid Family Planning
                                                                 Program
Z0052   Problem counseling                   $10.45 99402        Preventive medicine                      $10.45 Modifier FP is necessary
                                                                 counseling and/or risk factor                   for consideration of
                                                                 reduction intervention(s)                       payment.
                                                                 provided to an individual
                                                                 (separate procedure);
                                                                 approximately 30 minutes
                                                   with          with
                                                   modifier FP   Service provided as part of
                                                                 Medicaid Family Panning
                                                                 Program
Z0053   Introduction to family planning in    $7.00 S9445        Patient education, not                     $7.00 Modifier FP is necessary
        a hospital setting/auspices                              otherwise classified,                            for consideration of
                                                                 nonphysician provider,                           payment.
                                                                 individual, per session
                                                   with          with
                                                   modifier FP   Service provided as part of
                                                                 Medicaid Family Panning
                                                                 Program
Z0054   Instruction in natural family         $7.61 H1010        Nonmedical family planning                 $7.61
        planning methods                                         education, per session
Z0055   Antimonilia medication for           $14.00 A9150        Nonprescription drugs              With modifier Modifier FP is necessary
        genital infection                                                                           FP = $14.00; for consideration of
                                                                                                 Without modifier payment.
                                                                                                  FP = manually
                                                                                                         reviewed

                                                   with          with
                                                    modifier FP   Service provided as part of
                                                                  Medicaid Family Planning
                                                                  Program
Z0056   Diaphragm                             $10.00 A4266        Diaphragm for contraceptive       $10.01
                                                                  use
Z1006   Injection, corticotropin, acthar      $20.08 J0800        Injection, corticotropin, up to   $87.55
        gel, 80 units                                             40 units

Z1015   Injection, triamcinolone              $34.75 J3302        Injection, triamcinolone           $0.77
        diacetate, aristocort forte, 200                          diacetate, per 5 mg
        mg
Z1016   Injection, triamcinolone               $3.25 J3302        Injection, triamcinolone           $0.77
        diacetate, 25 mg/cc, 1 cc                                 diacetate, per 5 mg
        (intralesional)
Z1025   Injection, adrenacorticotropin         $5.13 J0800        Injection, corticotropin, up to   $87.55
        hormone, ACTH, 60 units                                   40 units
Z1029   Injection, adrenacorticotropin         $5.69 J0800        Injection, corticotropin, up to   $87.55
        hormone, ACTH, 80 units                                   40 units
Z1044   Injection, triamcinolone              $15.19 J3302        Injection, triamcinolone           $0.77
        diacetate, aristocort forte, 80 mg                        diacetate, per 5 mg

Z1048   Injection, gamimune, 50 cc           $119.00 J1561        Injection, immune globulin,       $38.26
                                                                  intravenous, 500 mg

Z1141   Injection, dexamethasone              $10.38 J1095        Injection, dexamethasone           $2.06
        acetate, decadron LA, 1 cc                                acetate, per 8 mg
Z1144   Injection, depo-medrol, 60 mg          $9.96 J1020        Injection, methylprednisolone      $2.12
                                                                  acetate, 20 mg

                                                    or            or                                    or
                                                    J1030         Injection, methylprednisolone      $1.42
                                                                  acetate, 40 mg

                                                    or            or                                    or
                                                    J1040         Injection, methylprednisolone      $2.55
                                                                  acetate, 80 mg

Z1145   Injection, dexamethasone               $5.80 J1100        Injection, dexamethasone           $0.10
        sodium phosphate - decadron, 4                            sodium phosphate, 1 mg
        mg/cc, 2 cc (8 mg)

Z1194   Injection, depo-medrol, 120 mg        $15.19 J1020        Injection, methylprednisolone      $2.12
                                                                  acetate, 20 mg

                                                    or            or                                    or
                                                    J1030    Injection, methylprednisolone     $1.42
                                                             acetate, 40 mg

                                                    or       or                                   or
                                                    J1040    Injection, methylprednisolone     $2.55
                                                             acetate, 80 mg

Z1210   Eucomol, 1 or 2 cc                                                                             Discontinued
Z1266   Injection, halperidol decanoate,     $134.38 J1631   Injection, haloperidol           $20.85
        haldol decanoate, 50 mg/mL, 10                       decanoate, per 50 mg
        mL
Z1299   Injection, heparin, 50 mg or           $3.98 J1644   Injection, heparin sodium, per    $0.71
        5,000 units, 1 cc                                    1,000 units

Z1301   Injection, heparin, 100 mg or          $4.94 J1644   Injection, heparin sodium, per    $0.71
        10,000 units, 1 cc                                   1,000 units
Z1302   Injection, heparin, 200 mg or          $8.24 J1644   Injection, heparin sodium, per    $0.71
        20,000 units, 1 cc                                   1,000 units
Z1303   Injection, heparin repos, 200 mg       $7.43 J1644   Injection, heparin sodium, per    $0.71
        or 20,000 units, 1 cc                                1,000 units
Z1304   Injection, heparin, sodium,            $4.76 J1644   Injection, heparin sodium, per    $0.71
        5,000 U, 2 cc (10,000 units)                         1,000 units
Z1317   Injection, dexamethasone               $4.02 J1100   Injection, dexamethasone          $0.10
        sodium phosphate, hexadrol, 4                        sodium phosphate, 1 mg
        mg/cc, 2 cc (8 mg)
Z1400   Injection, kanamycin sulfate, 1       $23.76 J1840   Injection, kanamycin sulfate,     $2.82
        g/3 cc, 3 cc                                         up to 500 mg
Z1411   Injection, triamcinolone              $14.45 J3301   Injection, triamcinolone          $1.42
        acetonide, kenalog, 40 mg/cc, 2                      acetonide, per 10 mg
        cc (80 mg)
Z1413   Injection, cefazolin sodium,           $8.70 J0690   Injection, cefazolin sodium,      $2.01
        kefzol, 1 g, 10 cc                                   500 mg
Z1414   Injection, triamcinolone               $2.15 J3301   Injection, triamcinolone          $1.42
        acetonide, kenalog, 10 mg/cc, 2                      acetonide, per 10 mg
        cc (20 mg)
Z1415   Kenalog, 60 mg                        $11.28 J3302   Injection, triamcinolone          $0.77
                                                             diacetate, per 5 mg
Z1452   Injection, lincocin, 2 cc (600 mg)     $7.06 J2010   Injection, lincomycin HCL, up     $1.05
                                                             to 300 mg
Z1454   Injection, furosemide, 10 mg/cc,       $3.25 J1940   Injection, furosemide, up to      $0.83
        4 cc (40 mg)                                         20 mg
Z1456   Loridine, 250 mg/5 cc                                                                          Discontinued

Z1463   Injection, lincocin, 3 cc (900 mg)     $8.51 J2010   Injection, lincomycin HCL, up     $1.05
                                                             to 300 mg
Z1603   Injection, penicillin, 800,000                                                                 Discontinued
        units through 1,200,000 units
Z1604   Injection, penicillin, 5 million                                                               Discontinued
        units
Z1605   Injection, penicillin, 20 million                                                              Discontinued
        units
Z1606   Injection, penicillin g, 100,000                                                               Discontinued
        units through 1 million units
Z1607   Injection, penicillin g, 3 million                                                             Discontinued
        units through 5 million units
Z1610   Nebupent (pentamidine) for           $124.31 J2545   Pentamidine isethionate,         $77.88
        inhalent solution                                    inhalation solution, per 300
                                                             mg, administered through a
                                                             DME
Z1611   Injection, penicillin g procaine,                                                              Discontinued
        1,200,000 units

Z1634   Injection, prednisolone, 25            $3.25 J2650   Injection, prednisolone           $0.32
        mg/cc, 2 cc (50 mg)                                  acetate, up to 1 mL
Z1653   Injection, prednisolone, 59 mg,        $3.00 J2650   Injection, prednisolone           $0.32
        1 cc                                                 acetate, up to 1 mL
Z1654   Injection, potassium chloride, 2       $3.00 J3480   Injection, potassium chloride,    $0.09
        mEq/mL, 30 mL                                        per 2 mEq
Z1681   Rogenic, 5 cc                                                                                  Discontinued

Z1688   Injection, glycopyrrolate-robinul,                                                             Discontinued
        1 cc
Z1689   Injection, glycopyrrolate-robinul,                                                             Discontinued
        2 cc

Z1704   Injection, sodium morrhuate, 5                                                                 Discontinued
        percent, 5 cc

Z1705   Injection, solu cortef mix-vials,      $9.71 J1710   Injection, hydrocortisone         $4.75
        250 mg/2 cc                                          sodium phosphate, up to 50
                                                             mg
Z1712   Susphrine, 1 cc                        $8.08 J0170   Injection, adrenalin,             $0.27
                                                             epinephrine, up to 1 mL
                                                             ampule
Z1727   Injection, solu-medrol, 1,000 mg       $32.15 J2920   Injection, methylprednisolone      $1.56
                                                              sodium succinate, up to 40 mg

                                                     or       or                                    or
                                                     J2930    Injection, methylprednisolone      $1.71
                                                              sodium succinate, up to 125
                                                              mg
Z1761   Injection, theelin, 20,000 units or                                                              Discontinued
        2 mg/cc, 1 cc
Z1806   Injection, vistaril, 25 mg/cc, 2 cc     $1.11 J3410   Injection, hydroxyzine HCL,        $0.75
        (50 mg)                                               up to 25 mg
Z2008   Initial orthodontic visit              $15.00 D8660   Preorthodontic treatment visit    $15.00
Z2009   Diagnostic workup, approved           $175.00 D8080   Comprehensive orthodontic        $775.00 Bill the appropriate code
                                                              treatment of the adolescent              based on dentition.
                                                              dentition
and     and                                       and
Z2011   Orthodontic appliance, upper          $300.00
and     and                                       and
Z2012   Orthodontic appliance, lower          $300.00
Z2010   Diagnostic workup, not approved       $100.00 D0330   Panoramic film                    $32.54

                                                     and      and                                  and
                                                     D0340    Cephalometric film                $33.75
                                                     and      and                                  and
                                                     D0350    Oral/facial images (includes      $18.75
                                                              intra and extraoral images)
                                                      and     and                                  and
                                                      D0470   Diagnostic casts                  $22.50
Z2013   Orthodontic adjustments, per           $68.10 D8670   Periodic orthodontic treatment    $68.10
        month                                                 visit (as part of contract)
Z2014   Orthodontic retainer, upper           $100.00 D8680   Orthodontic retention            $100.00
                                                              (removal of appliances,
                                                              construction and placement of
and     and                                       and         retainer[s])
Z2015   Orthodontic retainer, lower           $100.00
and     and                                       and
1033D   Mandibular fixed 2 x 4 retainer       $125.00
and     and                                       and
1034D   Mandibular fixed 3 x 3 retainer       $125.00
and     and                                       and
1035D   Mandibular fixed 4 x 4 retainer       $125.00
Z2016   Premature appliance removal,           $50.00 D7997   Appliance removal (not by         $50.00
        per arch                                              dentist who placed
                                                              appliance), includes removal
                                                              of archbar
Z2098   Fluorouracil, 50 mg/cc, 1 cc     $0.85 J9190   Fluorouracil, 500 mg                $2.21

Z3005   Leucovorin, 50 mg, vial         $90.89 J0640   Injection, leucovorin calcium,     $15.67
                                                       per 50 mg
Z5007   Hearing aid                    $300.00 V5140   Binaural, behind the ear          $300.00

Z5007   Hearing aid                    $300.00 V5120   Binaural, body                    $300.00

Z5007   Hearing aid                    $300.00 V5130   Binaural, in the ear              $300.00

Z5007   Hearing aid                    $300.00 V5248   Hearing aid, analog, binaural,    $300.00
                                                       CIC

Z5007   Hearing aid                    $300.00 V5249   Hearing aid, analog, binaural,    $300.00
                                                       ITC

Z5007   Hearing aid                    $300.00 V5242   Hearing aid, analog,              $300.00
                                                       monaural, CIC, completely in
                                                       the ear canal

Z5007   Hearing aid                    $300.00 V5243   Hearing aid, analog,              $300.00
                                                       monaural, ITC, in the canal

Z5007   Hearing aid                    $300.00 V5220   Hearing aid, bicros, behind       $300.00
                                                       the ear

Z5007   Hearing aid                    $300.00 V5210   Hearing aid, bicros, in the ear   $300.00

Z5007   Hearing aid                    $300.00 V5100   Hearing aid, bilateral, body      $300.00
                                                       worn
Z5007   Hearing aid                    $300.00 V5180   Hearing aid, cros, behind the     $300.00
                                                       ear
Z5007   Hearing aid                    $300.00 V5170   Hearing aid, cros, in the ear     $300.00
Z5007   Hearing aid                    $300.00 V5261   Hearing aid, digital, binaural,   $300.00
                                                       BTE
Z5007   Hearing aid                    $300.00 V5258   Hearing aid, digital, binaural,   $300.00
                                                       CIC
Z5007   Hearing aid                    $300.00 V5259   Hearing aid, digital, binaural,   $300.00
                                                       ITC
Z5007   Hearing aid                    $300.00 V5260   Hearing aid, digital, binaural,   $300.00
                                                       ITE
Z5007   Hearing aid                    $300.00 V5257   Hearing aid, digital, monaural,   $300.00
                                                       BTE
Z5007   Hearing aid                       $300.00 V5254   Hearing aid, digital, monaural,   $300.00
                                                          CIC

Z5007   Hearing aid                       $300.00 V5255   Hearing aid, digital, monaural,   $300.00
                                                          ITC

Z5007   Hearing aid                       $300.00 V5256   Hearing aid, digital, monaural,   $300.00
                                                          ITE
Z5007   Hearing aid                       $300.00 V5250   Hearing aid, digitally            $300.00
                                                          programmable analog,
                                                          binaural, CIC
Z5007   Hearing aid                       $300.00 V5251   Hearing aid, digitally            $300.00
                                                          programmable analog,
                                                          binaural, ITC
Z5007   Hearing aid                       $300.00 V5253   Hearing aid, digitally            $300.00
                                                          programmable, binaural, BTE
Z5007   Hearing aid                       $300.00 V5252   Hearing aid, digitally            $300.00
                                                          programmable, binaural, ITE
Z5007   Hearing aid                       $300.00 V5060   Hearing aid, monaural, behind     $300.00
                                                          the ear
Z5007   Hearing aid                       $300.00 V5030   Hearing aid, monaural, body       $300.00
                                                          worn, air conduction
Z5007   Hearing aid                       $300.00 V5040   Hearing aid, monaural, body       $300.00
                                                          worn, bone conduction
Z5007   Hearing aid                       $300.00 V5050   Hearing aid, monaural, in the     $300.00
                                                          ear
Z5008   Ear mold                           $18.90 V5264   Ear mold/insert, not               $18.90
                                                          disposable, any type
Z5009   Hearing aid repairs                                                                         Discontinued
Z6005   Injection, cefoperazone sodium,    $31.45 S0021   Injection, cefoperazone            $15.13 Bill the appropriate
        cefobid, 2 g                                      sodium, 1 g                               quantity based on the
                                                                                                    dosage administered.
Z6006   Injection, cefoperazone sodium,    $15.97 S0021   Injection, cefoperazone            $15.13
        cefobid, 1 g                                      sodium, 1 g
Z6090   Injection, ceftriaxone sodium-                                                                Discontinued; TOS 1
        rocephin, 10 mg
Z6092   Injection, ceftriaxone sodium,     $24.46 J0696   Injection, ceftriaxone sodium,     $12.58
        rocephin, 500 mg                                  per 250 mg

Z8006   Hearing aid evaluation             $62.12 V5010   Assessment for hearing aid         $62.12
Z8007   Hearing aid fitting and            $63.03 V5011   Fitting/orientation/checking of    $48.03
        dispensing                                        hearing aid
                                                           and           and                                          and
                                                           V5090         Dispensing fee, unspecified               $15.00
                                                                         hearing aid
                                                           or            or                                            or
                                                           V5110         Dispensing fee, bilateral                 $15.00
                                                           or            or                                            or
                                                           V5160         Dispensing fee, binaural                  $15.00
                                                           or            or                                            or
                                                           V5200         Dispensing fee, cros                      $15.00
                                                           or            or                                            or
                                                           V5240         Dispensing fee, bicros                    $15.00
                                                           or            or                                            or
                                                           V5241         Dispensing fee, monaural                  $15.00
                                                                         hearing aid, any type
Z8008   Hearing aid, first revisit                $12.79 92592           Hearing aid check; monaural               $12.79
                                                           or            or
                                                           92593         Hearing aid check; binaural
Z8009   Hearing aid, second revisit               $25.35 92592           Hearing aid check; monaural               $25.35
                                                           or            or
                                                           92593         Hearing aid check; binaural
                                                           with          with
                                                           modifier TG   Complex/high level of care
Z8263   Intermittent peritoneal dialysis,   Composite rate 829           Hemodialysis (outpatient,          Composite rate
        continuous cycling dialysis and                                  home), other
        hemodialysis training
                                                           or            or
                                                           839           Peritoneal dialysis (outpatient,
                                                                         home), other
                                                           or            or
                                                           859           CCPD (outpatient, home),
                                                                         other
Z8265   Continuous ambulatory               Composite rate 849           CAPD (outpatient, home),           Composite rate
        peritoneal dialysis (CAPD)                                       other
        training
Z8888   Noncovered by provider                                                                                               Discontinued
Z9008   Family Planning annual exam                 $48.28 99203          Office or other outpatient visit             $48.27 Bill the appropriate code
                                                                          for the evaluation and                              with modifier FP, and
                                                                          management of a new                                 reference the appropriate
                                                                          patient, which requires these                       Family Planning
                                                                          three key components: a                             diagnosis.
                                                                          detailed history; a detailed
                                                                          examination; and medical
                                                                          decision making of low
                                                                          complexity. Counseling and/or
                                                                          coordination of care with other
                                                                          providers or agencies are
                                                                          provided.

                                                           or             or                                               or
                                                           99214          Office or other outpatient visit             $41.46
                                                                          for the evaluation and
                                                                          management of an
                                                                          established patient, which
                                                                          requires at least two of these
                                                                          three key components: a
                                                                          detailed history; a detailed
                                                                          examination; medical decision
                                                                          making of moderate
                                                                          complexity.

                                                           with           with                                         $41.46
                                                           modifier FP    Service provided as part of
                                                                          Medicaid Family Planning
                                                                          Program
                                                           or             or
                                                           FP diagnosis   Diagnosis (diagnosis grouping
                                                                          SFPD)
Z9070   Mileage, hearing aid program                                                                                              Discontinued
Z9084   Intravenous therapy, IV therapy             $34.68 90780          Intravenous infusion for                     $30.55
        (not including chemotherapy                                       therapy/diagnosis,
                                                                          administered by physician or
                                                                          under direct supervision of
                                                                          physician; up to one hour
Z9100   Clinic visit fee, outpatient      Provider-specific 510           Clinic                             Provider-specific
                                                interim rate                                                       interim rate

                                                           or             or
                                                           511            Clinic, chronic pain center
                                                           or             or
                                                           512            Clinic, dental
                                                           or             or
                                                               514    Clinic, OB/GYN
                                                               or     or
                                                               515    Clinic, pediatric
                                                               or     or
                                                               516    Clinic, urgent care clinic
                                                               or     or
                                                               517    Clinic, family practice clinic
                                                               or     or
                                                               519    Clinic, other
Z9101   Psychiatric outpatient services,    Provider-specific 513     Clinic; psychiatric                Provider-specific
        hospital charges only                     interim rate                                                 interim rate

Z9112   Initial hour of hyperbaric oxygen   Provider-specific 413     Respiratory services,              Provider-specific
        therapy (technical component)             interim rate        hyperbaric oxygen therapy                interim rate
Z9113   Hyperbaric oxygen therapy;          Provider-specific 413     Respiratory services,              Provider-specific
        each additional ½-hour                    interim rate        hyperbaric oxygen therapy                interim rate
        (technical component)
Z9130   Gold injection package #1,                                                                                            Discontinued
        includes myochrisine, urinalysis
Z9131   Gold injection package #2,                                                                                            Discontinued
        includes myochrisine, urinalysis,
        CBC
Z9202   Rural health encounter              Provider-specific T1015   Clinic visit, encounter, all-      Provider-specific
                                              encounter rate          inclusive                            encounter rate
Z9214   Interferon, 5 million units/2 cc              $48.95 J1825    Injection, interferon beta-1a,              $201.56
                                                                      33 mcg
                                                              or      or                                                or
                                                              J9212   Injection, interferon alfacon-1,               $3.66
                                                                      recombinant, 1 mcg
                                                              or      or                                               or
                                                              J9213   Interferon, alfa-2A,                         $31.22
                                                                      recombinant, 3 million units
                                                              or      or                                               or
                                                              J9214   Interferon, alfa-2B,                         $12.08
                                                                      recombinant, 1 million units
                                                              or      or                                                or
                                                              J9215   Interferon, alfa-N3, (human                    $7.03
                                                                      leukocyte derived), 250,000 IU
                                                              or      or                                               or
                                                              J9216   Interferon, gamma 1-B, 3                    $170.37
                                                                      million units
Z9216   Interferon, 10 million units/2 cc             $89.35 J1825    Injection, interferon beta-1A,              $201.56
                                                                      33 mcg
                                                              or      or                                                or
                                                       J9212   Injection, interferon alfacon-1,           $3.66
                                                               recombinant, 1 mcg
                                                       or      or                                            or
                                                       J9213   Interferon, alfa-2A,                      $31.22
                                                               recombinant, 3 million units
                                                       or      or                                            or
                                                       J9214   Interferon, alfa-2B,                      $12.08
                                                               recombinant, 1 million units
                                                       or      or                                            or
                                                       J9215   Interferon, alfa-n3, human                 $7.03
                                                               leukocyte derived, 250,000 IU

                                                       or      or                                            or
                                                       J9216   Interferon, gamma 1-B, 3                 $170.37
                                                               million units
Z9408   Maintenance hemodialysis, per    Composite rate 821    Hemodialysis, outpatient,          Composite rate
        day, in facility                                       home, composite
                                                       or      or
                                                       831     Peritoneal dialysis
                                                               (outpatient/home), composite

                                                       or      or
                                                       841     CAPD (outpatient/home),
                                                               composite
                                                       or      or
                                                       851     CCPD (outpatient/home),
                                                               composite
Z9425   Deferoxamine (2 g) therapy               $8.30 J0895   Injection, deferoxamine                   $11.33
        (reconstituted)                                        mesylate, 500 mg
Z9503   Eye exam with refraction for            $43.65 S0620   Routine ophthalmological                  $43.65 Reimbursement is not
        prescription of eyeglasses (by                         examination including                            different for a physician
        physician)                                             refraction; new patient                          (ophthalmologist) or an
                                                                                                                optometrist.
                                                       or      or                                            or
                                                       S0621   Routine ophthalmological                  $39.29
                                                               examination including
                                                               refraction; established patient

Z9513   Optometry exam                          $40.60 S0620   Routine ophthalmological                  $43.65 Reimbursement is not
                                                               examination including                            different for a physician
                                                               refraction; new patient                          (ophthalmologist) or an
                                                                                                                optometrist.
                                                       or      or                                            or
                                                       S0621   Routine ophthalmological                  $39.29
                                                               examination including
                                                               refraction; established patient
Z9539   Schirmer’s test                                                                                                    Discontinued; Not
                                                                                                                           payable separately
Z9615   Chemotherapy planning program                                                                                      Discontinued

Z9617   Fetal monitoring, external         Provider-specific 729       Labor room/delivery, other     Provider-specific
                                                 interim rate                                               interim rate
Z9627   Fetal stress testing               Provider-specific 729       Labor room/delivery, other     Provider-specific
                                                 interim rate                                               interim rate

Z9800   Comprehensive (initial hospital                                                                                    Discontinued; TOS 1
        care), state hospital physician
Z9800   Maintenance IPD session, less        Composite rate 821        Hemodialysis                     Composite rate
        than 20 hours                                                  (outpatient/home), composite
                                                            or         or
                                                            831        Peritoneal dialysis
                                                                       (outpatient/home), composite

                                                            or         or
                                                            841        CAPD (outpatient/home),
                                                                       composite
                                                            or         or
                                                            851        CCPD (outpatient/home),
                                                                       composite
Z9801   Maintenance IPD session, 20 to                                                                                     Discontinued; TOS 9
        29 hours
Z9801   Intensive (psychiatric/medical)                                                                                    Discontinued; TOS 1
        follow-up care, state hospital
        physician
Z9802   Maintenance IPD session, 30 or                                                                                     Discontinued; TOS 9
        more hours
Z9802   Systematic (psychiatric/medical)                                                                                   Discontinued;
        follow-up care, state hospital
        physician
Z9803   Maintenance                                                                                                        Discontinued
        (psychiatric/medical) follow-up
        care, state hospital physician
Z9803   Cont ambulatory peritoneal         Composite rate          845 CAPD (outpatient/home),        Composite rate
        dialysis (CAPD)/continuous                                     support services
        cycling peritoneal dialysis                         or         or
                                                                   855 CCPD (outpatient/home),
                                                                       support services
Z9804   Individual medical                                                                          Discontinued
        psychotherapy, state hospital
        physician
Z9805   Group medical psychotherapy,                                                                Discontinued; TOS 1
        state hospital physician
Z9812   Hyperalimentation               $145.00 S9364   Home infusion therapy, total      $145.00
                                                        parenteral nutrition (TPN);
                                                        administrative services,
                                                        professional pharmacy
                                                        services, care coordination,
                                                        and all necessary supplies
                                                        and equipment (includes
                                                        standard TPN formula, lipids,
                                                        specialty amino acid
                                                        formulas, drugs, and nursing
                                                        visits coded separately), per
                                                        diem (do not use with home
                                                        infusion codes S9365–S9368
                                                        using daily volume scales)
Z9812   Hyperalimentation               $145.00 S9366   Home infusion therapy, TPN;       $145.00
                                                        more than one liter but no
                                                        more than two liters per day,
                                                        administrative services,
                                                        professional pharmacy
                                                        services, care coordination,
                                                        and all necessary supplies
                                                        and equipment (includes
                                                        standard TPN formula, lipids,
                                                        specialty amino acid
                                                        formulas, drugs, and nursing
                                                        visits coded separately), per
                                                        diem
Z9812   Hyperalimentation               $145.00 S9368   Home infusion therapy, TPN;       $145.00
                                                        more than three liters per day,
                                                        administrative services,
                                                        professional pharmacy
                                                        services, care coordination,
                                                        and all necessary supplies
                                                        and equipment (includes
                                                        standard TPN formula, lipids,
                                                        specialty amino acid
                                                        formulas, drugs, and nursing
                                                        visits coded separately), per
                                                        diem
Z9812   Hyperalimentation                     $145.00 S9367     Home infusion therapy, TPN;                $145.00
                                                                more than two liters but no
                                                                more than three liters per day,
                                                                administrative services,
                                                                professional pharmacy
                                                                services, care coordination,
                                                                and all necessary supplies
                                                                and equipment (includes
                                                                standard TPN formula; lipids,
                                                                specialty amino acids, drugs,
                                                                and nursing visits coded
                                                                separately), per diem
Z9812   Hyperalimentation                     $145.00 S9365     Home infusion therapy, TPN;                $145.00
                                                                one liter per day,
                                                                administrative services,
                                                                professional pharmacy
                                                                services, care coordination,
                                                                and all necessary supplies
                                                                and equipment (includes
                                                                standard TPN formula; lipids,
                                                                specialty amino acid
                                                                formulas, drugs, and nursing
                                                                visits coded separately), per
                                                                diem
Z9813   FQHC encounter                Provider-specific T1015   Clinic visit/encounter, all-      Provider-specific
                                        encounter rate          inclusive                           encounter rate
Z9999   NOC, medical services                                                                                         Discontinued; TOS 2

Z9999   Unlisted surgical procedure                                                                                   Discontinued
        including 6 weeks of post-
        operative care
Z9999   Hearing aid, other                   Manually V5299     Hearing service,                         Manually
                                             reviewed           miscellaneous                            reviewed

				
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