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Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
CPT CODE MOD MAX ALLOW Surgery
Effective January 1, 2010
04000 $ 43.00
10021 $ 83.46
10022 $ 86.07
10040 $ 69.03
10060 $ 66.72
10061 $ 121.55
10080 $ 79.19
10081 $ 145.09
10120 $ 76.56
10121 $ 150.87
10140 $ 80.43
10160 $ 70.19
10180 $ 116.67
11000 $ 35.26
11001 $ 19.24
11004 $ 488.50
11005 $ 665.92
11006 $ 614.50
11008 $ 250.17
11010 $ 249.23
11011 $ 309.16
11012 $ 427.06
11040 $ 30.58
11041 $ 46.89
11042 $ 62.57
11043 $ 150.54
11044 $ 202.94
11055 $ 18.95
11056 $ 25.23
11057 $ 28.01
11100 $ 59.76
11101 $ 29.40
11200 $ 49.54
11201 $ 19.25
11300 $ 42.10
11301 $ 57.16
11302 $ 69.14
11303 $ 85.28
11305 $ 43.86
11306 $ 61.50
11307 $ 71.95
11308 $ 89.93
11310 $ 53.74
11311 $ 68.50
11312 $ 78.94
11313 $ 103.17
11400 $ 77.86
11401 $ 94.09
11402 $ 108.88
11403 $ 127.73
11404 $ 143.44
Rev 1/1/2010
1 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
11406 $ 176.42 Effective January 1, 2010
11420 $ 75.78
11421 $ 99.98
11422 $ 114.17
11423 $ 139.63
11424 $ 158.40
11426 $ 216.37
11440 $ 90.44
11441 $ 110.16
11442 $ 124.63
11443 $ 158.57
11444 $ 197.32
11446 $ 245.55
11450 $ 202.10
11451 $ 262.24
11462 $ 189.50
11463 $ 252.89
11470 $ 229.68
11471 $ 279.98
11600 $ 106.86
11601 $ 129.43
11602 $ 143.04
11603 $ 161.98
11604 $ 178.67
11606 $ 225.75
11620 $ 107.55
11621 $ 137.41
11622 $ 160.08
11623 $ 185.70
11624 $ 218.45
11626 $ 266.82
11640 $ 120.51
11641 $ 163.20
11642 $ 186.38
11643 $ 218.74
11644 $ 272.10
11646 $ 353.21
11719 $ 15.58
11720 $ 22.74
11721 $ 35.64
11730 $ 56.51
11732 $ 27.92
11740 $ 29.41
11750 $ 121.76
11752 $ 167.33
11755 $ 75.89
11760 $ 93.48
11762 $ 171.62
11765 $ 46.70
11770 $ 181.38
11771 $ 355.08
11772 $ 418.36
Rev 1/1/2010
2 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
11900 $ 32.50 Effective January 1, 2010
11901 $ 46.34
11921 $ 122.79
11960 $ 593.24
11970 $ 452.12
11971 $ 201.72
11975 $ 78.21
11976 $ 106.11
11977 $ 132.88
11980 $ 96.81
12001 $ 103.88
12002 $ 114.30
12004 $ 136.30
12005 $ 169.25
12006 $ 221.54
12007 $ 242.20
12011 $ 110.54
12013 $ 125.35
12014 $ 148.56
12015 $ 187.79
12016 $ 227.66
12017 $ 301.78
12018 $ 369.27
12020 $ 150.96
12021 $ 104.73
12031 $ 126.59
12032 $ 144.23
12034 $ 171.81
12035 $ 197.77
12036 $ 256.62
12037 $ 294.12
12041 $ 141.06
12042 $ 158.67
12044 $ 182.14
12045 $ 213.61
12046 $ 271.27
12047 $ 309.52
12051 $ 146.11
12052 $ 163.79
12053 $ 183.21
12054 $ 215.13
12055 $ 271.70
12056 $ 348.78
12057 $ 385.80
13100 $ 174.90
13101 $ 221.61
13102 $ 63.78
13120 $ 187.17
13121 $ 249.35
13122 $ 74.15
13131 $ 217.80
13132 $ 346.78
Rev 1/1/2010
3 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
13133 $ 109.63 Effective January 1, 2010
13150 $ 234.69
13151 $ 268.39
13152 $ 388.28
13153 $ 120.60
13160 $ 516.23
14000 $ 366.39
14001 $ 496.92
14020 $ 422.38
14021 $ 585.12
14040 $ 502.61
14041 $ 669.87
14060 $ 548.99
14061 $ 757.13
14301 $ 686.88
14302 $ 150.16
14350 $ 524.18
15002 $ 252.08
+15003 $ 55.89
15004 $ 303.18
+15005 $ 93.17
15040 $ 221.36
15050 $ 252.21
15100 $ 484.50
15101 $ 104.44
15110 $ 689.38
15111 $ 107.92
15115 $ 645.88
15116 $ 139.77
15120 $ 563.03
15121 $ 167.82
15130 $ 574.99
15131 $ 88.28
15135 $ 691.27
15136 $ 81.99
15150 $ 571.67
15151 $ 113.82
15152 $ 139.70
15155 $ 570.85
15156 $ 147.72
15157 $ 163.68
15170 $ 298.97
15171 $ 76.23
15175 $ 422.17
15176 $ 121.37
15200 $ 481.79
15201 $ 90.50
15220 $ 491.65
15221 $ 81.69
15240 $ 546.17
15241 $ 126.13
15260 $ 601.98
Rev 1/1/2010
4 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
15261 $ 148.24 Effective January 1, 2010
15300 $ 244.95
15301 $ 50.74
15320 $ 283.57
15321 $ 75.61
15330 $ 244.61
15331 $ 50.41
15335 $ 271.50
15336 $ 73.15
15340 $ 260.90
15341 $ 37.58
15360 $ 281.81
15361 $ 59.05
15365 $ 294.02
15366 $ 73.22
15400 $ 220.30
15401 $ 47.29
15420 $ 314.30
15421 $ 96.62
15430 $ 428.13
15570 $ 536.69
15572 $ 525.84
15574 $ 553.54
15576 $ 477.08
15600 $ 186.61
15610 $ 172.86
15620 $ 249.92
15630 $ 260.15
15650 $ 306.55
15731 $ 830.82
15732 $ 1,047.53
15734 $ 1,113.49
15736 $ 1,001.78
15738 $ 1,010.43
15740 $ 654.40
15750 $ 725.74
15756 $ 2,066.14
15757 $ 2,067.10
15758 $ 2,061.05
15760 $ 548.80
15770 $ 482.01
15780 $ 376.19
15781 $ 300.76
15782 $ 227.89
15786 $ 104.35
15787 $ 19.21
15819 $ 557.88
15820 $ 399.48
15821 $ 436.16
15822 $ 358.62
15823 $ 515.70
15830 $ 889.69
Rev 1/1/2010
5 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
15832 $ 661.41 Effective January 1, 2010
15833 $ 594.34
15834 $ 597.25
15835 $ 616.07
15836 $ 514.68
15837 $ 497.21
15838 $ 429.22
15839 $ 457.98
15840 $ 850.36
15841 $ 1,327.29
15842 $ 2,209.79
15845 $ 799.85
15851 $ 58.37
15852 $ 63.16
15860 $ 107.74
15920 $ 406.81
15922 $ 550.52
15931 $ 454.51
15933 $ 614.17
15934 $ 691.82
15935 $ 846.08
15936 $ 737.38
15937 $ 874.37
15940 $ 472.36
15941 $ 656.10
15944 $ 681.74
15945 $ 770.99
15946 $ 1,240.91
15950 $ 391.40
15951 $ 622.66
15952 $ 625.40
15953 $ 723.67
15956 $ 989.26
15958 $ 986.78
16000 $ 50.96
16020 $ 48.82
16025 $ 95.72
16030 $ 120.12
16035 $ 242.93
16036 $ 84.50
17000 $ 43.30
17003 $ 11.38
17004 $ 167.14
17106 $ 243.67
17107 $ 462.78
17110 $ 43.88
17111 $ 59.31
17250 $ 33.12
17260 $ 69.28
17261 $ 84.10
17262 $ 107.75
17263 $ 123.56
Rev 1/1/2010
6 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
17264 $ 135.90 Effective January 1, 2010
17266 $ 161.44
17270 $ 89.39
17271 $ 103.03
17272 $ 121.98
17273 $ 139.98
17274 $ 172.45
17276 $ 201.29
17280 $ 88.58
17281 $ 118.18
17282 $ 139.34
17283 $ 171.43
17284 $ 202.62
17286 $ 267.35
17311 $ 537.06
17312 $ 325.03
17314 $ 301.15
17315 $ 63.08
17340 $ 51.77
17360 $ 75.20
19000 $ 53.25
19001 $ 30.64
19020 $ 246.30
19030 $ 208.41
19100 $ 101.86
19101 $ 282.17
19102 $ 247.49
19103 $ 496.11
19110 $ 306.99
19112 $ 272.46
19120 $ 306.21
19125 $ 334.16
19126 $ 143.13
19260 $ 784.38
19271 $ 1,114.76
19272 $ 1,194.14
19290 $ 119.26
19291 $ 49.05
19295 $ 98.57
19296 $ 4,448.48
19297 $ 82.93
19298 $ 1,659.84
19300 $ 407.76
19301 $ 305.02
19302 $ 645.16
19303 $ 651.16
19304 $ 405.70
19305 $ 798.77
19306 $ 830.89
19307 $ 835.45
19316 $ 682.88
19318 $ 938.11
Rev 1/1/2010
7 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
19324 $ 313.80 Effective January 1, 2010
19325 $ 468.14
19328 $ 326.48
19330 $ 406.02
19340 $ 389.83
19342 $ 688.70
19350 $ 610.85
19357 $ 1,034.56
19361 $ 1,191.93
19364 $ 2,074.65
19366 $ 1,196.93
19367 $ 1,468.16
19368 $ 1,743.08
19369 $ 1,653.17
19370 $ 472.77
19371 $ 562.94
19380 $ 557.42
20000 $ 116.35
20005 $ 190.75
20100 $ 518.55
20101 $ 186.78
20102 $ 224.07
20103 $ 289.17
20150 $ 816.41
20200 $ 95.71
20205 $ 174.45
20206 $ 93.20
20220 $ 121.17
20225 $ 113.16
20240 $ 199.99
20245 $ 260.99
20250 $ 319.72
20251 $ 365.50
20500 $ 123.36
20501 $ 218.45
20520 $ 146.70
20525 $ 242.84
20550 $ 62.87
20551 $ 59.49
20552 $ 59.49
20553 $ 59.49
20555 $ 230.78
20600 $ 48.97
20605 $ 54.08
20610 $ 63.25
20612 $ 49.05
20615 $ 144.05
20650 $ 152.41
20660 $ 139.59
20661 $ 340.35
20662 $ 400.07
20663 $ 332.28
Rev 1/1/2010
8 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
20664 $ 482.32 Effective January 1, 2010
20665 $ 88.16
20670 $ 148.66
20680 $ 238.19
20690 $ 213.36
20692 $ 368.68
20693 $ 405.00
20694 $ 301.95
20696 $ 852.92
20697 $ 1,024.28
20802 $ 2,404.82
20805 $ 3,091.43
20808 $ 3,810.27
20816 $ 2,193.67
20822 $ 1,799.51
20824 $ 2,169.16
20827 $ 1,893.46
20838 $ 2,488.90
20900 $ 324.45
20902 $ 470.52
20910 $ 300.29
20912 $ 392.99
20920 $ 328.96
20922 $ 453.87
20924 $ 417.24
20926 $ 327.56
20931 $ 111.07
20937 $ 167.18
20938 $ 183.07
20950 $ 88.30
20955 $ 2,382.80
20956 $ 2,260.51
20957 $ 2,190.97
20962 $ 2,228.85
20969 $ 2,657.53
20970 $ 2,609.56
20972 $ 2,443.58
20973 $ 2,731.26
20975 $ 161.98
20982 $ 3,777.82
20985 $ 106.34
21011 $ 205.15
21012 $ 218.73
21013 $ 318.22
21014 $ 337.74
21015 $ 372.85
21016 $ 677.19
21025 $ 580.48
21026 $ 295.40
21029 $ 501.23
21030 $ 354.65
21032 $ 225.68
Rev 1/1/2010
9 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
21034 $ 813.20 Effective January 1, 2010
21040 $ 163.43
21044 $ 684.08
21045 $ 939.31
21046 $ 780.21
21047 $ 957.32
21048 $ 802.80
21049 $ 908.14
21070 $ 485.52
21100 $ 230.29
21121 $ 465.78
21122 $ 500.60
21123 $ 645.57
21125 $ 561.03
21127 $ 650.03
21137 $ 569.56
21138 $ 685.60
21139 $ 834.86
21141 $ 1,027.89
21142 $ 1,091.11
21143 $ 1,080.02
21145 $ 1,080.98
21146 $ 1,121.60
21147 $ 1,171.18
21150 $ 1,366.99
21151 $ 1,615.82
21154 $ 1,686.92
21155 $ 1,883.40
21159 $ 2,358.21
21160 $ 2,499.56
21172 $ 1,508.48
21175 $ 1,858.01
21179 $ 1,304.09
21180 $ 1,454.88
21181 $ 580.94
21182 $ 1,836.71
21183 $ 1,978.54
21184 $ 2,244.18
21188 $ 1,276.75
21193 $ 950.84
21194 $ 1,099.84
21195 $ 972.44
21196 $ 1,067.68
21198 $ 908.62
21199 $ 1,009.41
21206 $ 794.93
21210 $ 666.63
21230 $ 684.21
21235 $ 507.45
21240 $ 917.85
21245 $ 743.32
21247 $ 1,435.22
Rev 1/1/2010
10 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
21255 $ 1,043.54 Effective January 1, 2010
21256 $ 1,052.71
21260 $ 983.44
21261 $ 1,676.18
21263 $ 1,692.01
21267 $ 1,101.35
21268 $ 1,385.80
21270 $ 637.12
21275 $ 688.70
21280 $ 409.64
21282 $ 258.91
21300 $ 80.25
21310 $ 70.16
21315 $ 129.77
21320 $ 168.83
21325 $ 249.73
21330 $ 361.37
21335 $ 559.35
21336 $ 342.16
21337 $ 215.30
21338 $ 393.60
21339 $ 493.45
21343 $ 745.47
21344 $ 1,034.21
21347 $ 749.21
21348 $ 918.50
21355 $ 210.92
21356 $ 266.31
21360 $ 422.79
21365 $ 885.82
21366 $ 990.42
21385 $ 580.61
21386 $ 581.68
21387 $ 577.61
21390 $ 659.70
21395 $ 741.32
21407 $ 526.85
21408 $ 719.35
21422 $ 545.40
21423 $ 636.83
21435 $ 1,004.11
21436 $ 1,459.99
21440 $ 221.14
21450 $ 233.65
21451 $ 357.58
21452 $ 206.19
21453 $ 404.56
21454 $ 418.08
21461 $ 551.47
21462 $ 654.82
21465 $ 659.53
21470 $ 952.96
Rev 1/1/2010
11 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
21501 $ 224.86 Effective January 1, 2010
21502 $ 437.57
21510 $ 383.71
21550 $ 118.07
21552 $ 291.14
21554 $ 478.12
21555 $ 241.01
21556 $ 307.88
21557 $ 568.30
21558 $ 896.92
21600 $ 451.21
21610 $ 769.56
21615 $ 670.98
21616 $ 744.98
21620 $ 493.93
21627 $ 568.75
21630 $ 1,039.32
21632 $ 1,080.78
21685 $ 796.07
21700 $ 411.89
21705 $ 531.89
21720 $ 373.98
21725 $ 420.64
21740 $ 981.44
21742 $ 981.44
21743 $ 981.44
21750 $ 721.98
21800 $ 75.85
21805 $ 220.22
21810 $ 478.41
21820 $ 103.05
21825 $ 581.08
21920 $ 118.45
21925 $ 357.76
21930 $ 288.32
21931 $ 304.55
21932 $ 437.58
21933 $ 482.34
21935 $ 911.69
21936 $ 933.24
22010 $ 690.06
22015 $ 684.06
22100 $ 607.23
22101 $ 616.09
22102 $ 557.10
22103 $ 141.00
22110 $ 788.13
22112 $ 778.61
22114 $ 758.62
22116 $ 139.44
22210 $ 1,348.37
22212 $ 1,193.19
Rev 1/1/2010
12 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
22214 $ 1,176.22 Effective January 1, 2010
22216 $ 351.26
22220 $ 1,285.30
22222 $ 1,147.10
22224 $ 1,235.42
22226 $ 348.59
22305 $ 152.47
22310 $ 195.40
22315 $ 538.02
22318 $ 1,249.63
22319 $ 1,411.97
22325 $ 1,002.72
22326 $ 1,220.11
22327 $ 1,185.63
22328 $ 279.13
22505 $ 149.61
22520 $ 501.38
22521 $ 470.40
22522 $ 163.94
22523 $ 516.22
22524 $ 494.77
22525 $ 235.58
22532 $ 1,394.84
22533 $ 1,300.70
22534 $ 327.65
22548 $ 1,619.79
22554 $ 1,233.87
22556 $ 1,467.61
22558 $ 1,362.46
22585 $ 337.83
22590 $ 1,353.70
22595 $ 1,294.82
22600 $ 1,084.09
22610 $ 1,068.33
22612 $ 1,330.57
22614 $ 378.13
22630 $ 1,309.41
22632 $ 315.35
22800 $ 1,189.47
22802 $ 1,881.79
22804 $ 2,107.66
22808 $ 1,538.32
22810 $ 1,680.42
22812 $ 1,910.73
22818 $ 1,928.24
22819 $ 2,117.16
22830 $ 734.20
22840 $ 671.71
22842 $ 666.49
22843 $ 732.68
22844 $ 911.49
22845 $ 654.68
Rev 1/1/2010
13 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
22846 $ 713.11 Effective January 1, 2010
22847 $ 767.98
22848 $ 378.32
22849 $ 1,060.65
22850 $ 623.81
22851 $ 428.56
22852 $ 611.69
22855 $ 849.57
22856 $ 1,301.56
22861 $ 1,582.24
22864 $ 1,458.95
22900 $ 318.44
22901 $ 430.44
22902 $ 273.61
22903 $ 285.03
22904 $ 673.21
22905 $ 872.67
23000 $ 320.45
23020 $ 577.57
23030 $ 235.87
23031 $ 183.14
23035 $ 626.69
23040 $ 643.94
23044 $ 507.84
23065 $ 126.57
23066 $ 264.20
23071 $ 270.71
23073 $ 448.59
23075 $ 181.60
23076 $ 438.08
23077 $ 876.03
23078 $ 907.98
23100 $ 441.54
23101 $ 417.97
23105 $ 583.51
23106 $ 416.18
23107 $ 610.34
23120 $ 462.06
23125 $ 619.37
23130 $ 517.33
23140 $ 426.81
23145 $ 637.60
23146 $ 503.83
23150 $ 540.36
23155 $ 676.57
23156 $ 568.59
23170 $ 461.98
23172 $ 457.14
23174 $ 631.51
23180 $ 580.62
23182 $ 634.89
23184 $ 690.24
Rev 1/1/2010
14 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
23190 $ 469.93 Effective January 1, 2010
23195 $ 645.48
23200 $ 783.99
23210 $ 783.56
23220 $ 935.34
23330 $ 143.74
23331 $ 424.89
23332 $ 736.39
23350 $ 180.72
23395 $ 975.92
23397 $ 1,003.28
23400 $ 855.91
23405 $ 572.47
23406 $ 699.13
23410 $ 800.85
23412 $ 880.30
23415 $ 576.12
23420 $ 913.96
23430 $ 632.83
23440 $ 648.26
23450 $ 866.42
23455 $ 959.84
23460 $ 976.39
23462 $ 990.05
23465 $ 1,000.13
23466 $ 954.21
23470 $ 1,102.18
23472 $ 1,124.55
23480 $ 661.88
23485 $ 845.24
23490 $ 742.15
23491 $ 895.23
23500 $ 150.51
23505 $ 248.37
23515 $ 492.49
23520 $ 149.80
23525 $ 228.90
23530 $ 471.47
23532 $ 510.35
23540 $ 160.31
23545 $ 212.33
23550 $ 502.33
23552 $ 539.13
23570 $ 156.74
23575 $ 268.13
23585 $ 579.18
23600 $ 228.05
23605 $ 366.83
23615 $ 644.74
23616 $ 1,355.78
23620 $ 205.25
23625 $ 302.85
Rev 1/1/2010
15 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
23630 $ 510.19 Effective January 1, 2010
23650 $ 224.40
23655 $ 266.92
23660 $ 510.55
23665 $ 315.70
23670 $ 543.53
23675 $ 393.74
23680 $ 676.64
23700 $ 169.55
23800 $ 964.03
23802 $ 977.84
23900 $ 1,114.74
23920 $ 930.35
23921 $ 356.06
23930 $ 207.88
23931 $ 147.99
23935 $ 455.21
24000 $ 393.70
24006 $ 567.24
24065 $ 159.43
24066 $ 340.80
24071 $ 262.87
24073 $ 343.24
24075 $ 275.38
24076 $ 378.07
24077 $ 757.15
24100 $ 334.87
24101 $ 423.75
24102 $ 540.80
24105 $ 258.04
24110 $ 518.74
24115 $ 643.51
24116 $ 741.97
24120 $ 425.72
24125 $ 474.13
24126 $ 523.16
24130 $ 426.47
24134 $ 692.53
24136 $ 515.27
24138 $ 498.14
24140 $ 690.76
24145 $ 523.40
24147 $ 521.75
24149 $ 875.43
24150 $ 906.03
24152 $ 592.24
24155 $ 728.95
24160 $ 460.02
24164 $ 403.43
24200 $ 140.72
24201 $ 322.63
24220 $ 214.67
Rev 1/1/2010
16 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
24300 $ 314.09 Effective January 1, 2010
24301 $ 621.37
24305 $ 413.32
24310 $ 365.24
24320 $ 676.01
24330 $ 604.29
24331 $ 663.10
24332 $ 427.58
24340 $ 498.99
24341 $ 502.16
24342 $ 679.49
24343 $ 564.02
24344 $ 860.46
24345 $ 564.02
24346 $ 860.46
24357 $ 314.68
24358 $ 368.82
24359 $ 451.15
24360 $ 805.11
24361 $ 869.12
24362 $ 907.42
24363 $ 1,190.35
24365 $ 534.61
24366 $ 608.74
24400 $ 709.16
24410 $ 944.34
24420 $ 905.83
24430 $ 865.78
24435 $ 902.85
24470 $ 554.05
24495 $ 531.22
24498 $ 770.00
24500 $ 262.04
24505 $ 415.23
24515 $ 728.44
24516 $ 736.35
24530 $ 290.24
24535 $ 481.20
24538 $ 608.46
24545 $ 676.80
24546 $ 909.30
24560 $ 237.82
24565 $ 395.55
24566 $ 504.61
24575 $ 623.06
24576 $ 236.47
24577 $ 418.03
24579 $ 688.67
24582 $ 553.36
24586 $ 939.66
24587 $ 914.01
24600 $ 310.58
Rev 1/1/2010
17 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
24605 $ 295.40 Effective January 1, 2010
24615 $ 598.49
24620 $ 399.76
24635 $ 952.80
24640 $ 141.28
24650 $ 212.91
24655 $ 341.11
24665 $ 536.51
24666 $ 648.09
24670 $ 219.52
24675 $ 363.18
24685 $ 586.72
24800 $ 703.91
24802 $ 844.70
24900 $ 614.30
24920 $ 608.72
24925 $ 473.69
24930 $ 664.08
24931 $ 759.54
24935 $ 949.25
25000 $ 273.36
25001 $ 263.08
25020 $ 426.10
25023 $ 769.78
25024 $ 658.13
25025 $ 1,061.74
25028 $ 352.35
25031 $ 284.21
25035 $ 569.81
25040 $ 468.39
25065 $ 117.23
25066 $ 273.17
25075 $ 265.00
25076 $ 397.88
25077 $ 686.35
25078 $ 731.42
25085 $ 403.30
25100 $ 301.60
25101 $ 352.93
25105 $ 455.80
25107 $ 457.35
25110 $ 291.70
25111 $ 255.43
25112 $ 316.28
25115 $ 642.75
25116 $ 579.32
25118 $ 334.39
25119 $ 468.40
25120 $ 511.56
25125 $ 576.67
25126 $ 560.59
25130 $ 359.37
Rev 1/1/2010
18 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
25135 $ 451.36 Effective January 1, 2010
25136 $ 390.59
25145 $ 511.90
25150 $ 516.26
25151 $ 553.36
25170 $ 777.95
25210 $ 401.82
25215 $ 586.15
25230 $ 380.57
25240 $ 406.90
25246 $ 196.95
25248 $ 356.98
25250 $ 441.48
25251 $ 668.85
25260 $ 559.30
25263 $ 599.04
25265 $ 715.91
25270 $ 461.06
25272 $ 506.64
25274 $ 635.78
25275 $ 597.94
25280 $ 519.62
25290 $ 445.84
25295 $ 473.57
25300 $ 578.17
25301 $ 541.76
25310 $ 621.11
25312 $ 694.50
25315 $ 719.60
25316 $ 862.58
25320 $ 682.22
25332 $ 731.53
25335 $ 834.84
25337 $ 677.11
25350 $ 654.99
25355 $ 727.12
25360 $ 624.54
25365 $ 871.56
25370 $ 869.19
25375 $ 917.94
25390 $ 747.70
25391 $ 967.01
25392 $ 926.27
25393 $ 1,054.62
25394 $ 639.87
25400 $ 797.41
25405 $ 994.43
25415 $ 962.86
25420 $ 1,113.32
25425 $ 1,006.73
25426 $ 1,003.18
25440 $ 666.54
Rev 1/1/2010
19 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
25441 $ 820.44 Effective January 1, 2010
25442 $ 669.28
25443 $ 694.47
25444 $ 738.16
25445 $ 687.29
25446 $ 1,104.14
25447 $ 681.39
25449 $ 848.15
25450 $ 577.93
25455 $ 644.60
25490 $ 684.56
25491 $ 721.56
25492 $ 837.76
25500 $ 218.07
25505 $ 383.79
25515 $ 587.14
25520 $ 462.07
25525 $ 785.30
25526 $ 926.79
25530 $ 208.83
25535 $ 378.45
25545 $ 575.06
25560 $ 217.77
25565 $ 423.37
25574 $ 496.44
25575 $ 697.32
25600 $ 238.97
25605 $ 419.30
25606 $ 540.05
25607 $ 539.32
25608 $ 615.59
25609 $ 784.23
25622 $ 228.08
25624 $ 359.22
25628 $ 547.66
25630 $ 238.06
25635 $ 346.25
25645 $ 487.85
25650 $ 252.28
25660 $ 270.24
25670 $ 523.62
25671 $ 597.94
25675 $ 331.86
25676 $ 530.90
25680 $ 336.33
25685 $ 635.35
25690 $ 370.96
25695 $ 542.34
25800 $ 673.45
25805 $ 772.00
25810 $ 721.89
25820 $ 528.39
Rev 1/1/2010
20 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
25825 $ 641.64 Effective January 1, 2010
25830 $ 710.29
25900 $ 624.24
25905 $ 644.96
25907 $ 573.38
25909 $ 608.23
25915 $ 1,089.88
25920 $ 551.54
25922 $ 479.31
25924 $ 550.29
25927 $ 594.67
25929 $ 461.56
25931 $ 564.16
26010 $ 129.75
26011 $ 194.30
26020 $ 380.84
26025 $ 400.87
26030 $ 470.42
26034 $ 473.31
26035 $ 631.77
26037 $ 523.41
26040 $ 314.45
26045 $ 445.87
26055 $ 246.90
26060 $ 213.42
26070 $ 316.44
26075 $ 345.42
26080 $ 359.25
26100 $ 285.89
26105 $ 357.91
26110 $ 320.63
26111 $ 267.35
26113 $ 351.82
26115 $ 265.80
26116 $ 424.11
26117 $ 577.07
26118 $ 689.34
26121 $ 598.40
26123 $ 688.04
26125 $ 243.74
26130 $ 463.32
26135 $ 535.90
26140 $ 486.50
26145 $ 501.38
26160 $ 245.76
26170 $ 325.53
26180 $ 363.90
26185 $ 366.42
26200 $ 438.58
26205 $ 565.17
26210 $ 419.41
26215 $ 524.74
Rev 1/1/2010
21 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
26230 $ 458.43 Effective January 1, 2010
26235 $ 442.87
26236 $ 403.83
26250 $ 584.35
26260 $ 543.87
26262 $ 457.89
26320 $ 357.29
26350 $ 547.91
26352 $ 647.24
26356 $ 663.13
26357 $ 668.99
26358 $ 702.64
26370 $ 611.69
26372 $ 678.42
26373 $ 648.98
26390 $ 664.13
26390 $ 664.14
26392 $ 823.45
26410 $ 410.38
26412 $ 536.64
26415 $ 606.77
26416 $ 827.39
26418 $ 403.43
26420 $ 581.65
26426 $ 526.58
26428 $ 580.52
26432 $ 354.03
26433 $ 397.30
26434 $ 470.63
26437 $ 445.54
26440 $ 459.90
26442 $ 589.35
26445 $ 426.43
26449 $ 571.73
26450 $ 270.79
26455 $ 261.20
26460 $ 248.27
26471 $ 437.33
26474 $ 435.56
26476 $ 397.30
26477 $ 416.21
26478 $ 453.28
26479 $ 468.70
26480 $ 581.07
26483 $ 708.73
26485 $ 640.53
26489 $ 597.73
26490 $ 622.69
26492 $ 696.13
26494 $ 678.99
26496 $ 680.33
26497 $ 677.88
Rev 1/1/2010
22 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
26498 $ 943.25 Effective January 1, 2010
26499 $ 670.44
26500 $ 447.96
26502 $ 512.72
26508 $ 460.42
26510 $ 431.59
26516 $ 502.37
26517 $ 638.30
26518 $ 628.42
26520 $ 485.25
26525 $ 473.69
26530 $ 576.31
26531 $ 642.51
26535 $ 392.14
26536 $ 553.63
26540 $ 521.46
26541 $ 664.81
26542 $ 513.99
26545 $ 518.30
26546 $ 658.33
26548 $ 581.47
26550 $ 1,331.33
26551 $ 2,787.57
26553 $ 2,763.90
26554 $ 3,252.32
26555 $ 1,122.58
26556 $ 2,863.07
26560 $ 413.77
26561 $ 764.40
26562 $ 729.87
26565 $ 524.31
26567 $ 490.24
26568 $ 720.41
26580 $ 1,134.94
26587 $ 874.67
26590 $ 1,151.39
26591 $ 310.35
26593 $ 421.15
26596 $ 578.99
26600 $ 187.49
26605 $ 256.97
26607 $ 356.69
26608 $ 356.03
26615 $ 373.05
26641 $ 276.99
26645 $ 325.48
26650 $ 381.59
26665 $ 495.79
26670 $ 265.09
26675 $ 359.76
26676 $ 393.99
26685 $ 457.71
Rev 1/1/2010
23 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
26686 $ 507.92 Effective January 1, 2010
26700 $ 208.04
26705 $ 290.76
26706 $ 336.11
26715 $ 376.42
26720 $ 115.75
26725 $ 209.66
26727 $ 335.04
26735 $ 380.99
26740 $ 135.31
26742 $ 298.17
26746 $ 392.68
26750 $ 118.93
26755 $ 190.70
26756 $ 290.47
26765 $ 285.30
26770 $ 180.58
26775 $ 261.17
26776 $ 310.80
26785 $ 292.59
26820 $ 612.94
26841 $ 542.77
26842 $ 646.64
26843 $ 574.03
26844 $ 627.54
26850 $ 504.80
26852 $ 594.45
26860 $ 399.40
26861 $ 107.94
26862 $ 542.51
26863 $ 226.32
26910 $ 535.19
26951 $ 369.07
26952 $ 465.17
26990 $ 516.86
26991 $ 422.90
26992 $ 819.67
27000 $ 327.22
27001 $ 393.05
27003 $ 499.92
27005 $ 532.91
27006 $ 562.94
27025 $ 640.06
27027 $ 679.94
27030 $ 821.33
27033 $ 839.51
27035 $ 1,010.46
27036 $ 841.65
27040 $ 185.51
27041 $ 498.45
27043 $ 304.07
27045 $ 483.41
Rev 1/1/2010
24 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
27047 $ 417.83 Effective January 1, 2010
27048 $ 402.18
27049 $ 831.05
27050 $ 322.27
27052 $ 447.35
27054 $ 604.67
27057 $ 751.31
27059 $ 1,184.06
27060 $ 351.17
27062 $ 356.99
27065 $ 418.26
27066 $ 666.77
27067 $ 883.22
27070 $ 745.42
27071 $ 796.83
27075 $ 1,062.37
27076 $ 1,329.28
27077 $ 1,412.54
27078 $ 832.36
27080 $ 406.44
27086 $ 140.92
27087 $ 480.38
27090 $ 701.67
27091 $ 1,357.65
27093 $ 217.86
27095 $ 227.59
27096 $ 356.13
27097 $ 569.05
27098 $ 571.59
27100 $ 706.65
27105 $ 675.92
27110 $ 840.43
27111 $ 786.69
27120 $ 1,147.37
27122 $ 1,006.89
27125 $ 982.25
27130 $ 1,326.70
27132 $ 1,523.69
27134 $ 1,843.68
27137 $ 1,393.10
27138 $ 1,449.94
27140 $ 781.50
27146 $ 1,023.00
27147 $ 1,247.06
27151 $ 1,235.69
27156 $ 1,440.98
27158 $ 1,134.10
27161 $ 1,031.87
27165 $ 1,124.44
27170 $ 1,040.27
27175 $ 413.68
27176 $ 732.50
Rev 1/1/2010
25 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
27177 $ 898.42 Effective January 1, 2010
27178 $ 729.77
27179 $ 791.52
27181 $ 862.42
27185 $ 482.19
27187 $ 917.23
27193 $ 333.39
27194 $ 528.04
27200 $ 129.01
27202 $ 569.05
27215 $ 683.77
27216 $ 772.73
27217 $ 919.78
27218 $ 1,121.17
27220 $ 392.91
27222 $ 694.11
27226 $ 967.36
27227 $ 1,405.58
27228 $ 1,567.68
27230 $ 351.12
27232 $ 654.73
27235 $ 807.57
27236 $ 1,017.12
27238 $ 360.69
27240 $ 745.28
27244 $ 1,020.88
27245 $ 1,208.82
27246 $ 328.89
27248 $ 702.18
27250 $ 381.57
27252 $ 550.91
27253 $ 831.68
27254 $ 1,055.53
27256 $ 242.49
27257 $ 325.47
27258 $ 969.54
27259 $ 1,288.69
27265 $ 315.99
27266 $ 438.52
27267 $ 294.19
27268 $ 361.23
27269 $ 855.44
27275 $ 157.65
27280 $ 843.65
27282 $ 709.02
27284 $ 1,026.53
27286 $ 1,075.58
27290 $ 1,483.60
27295 $ 1,139.75
27301 $ 478.46
27303 $ 587.96
27305 $ 397.65
Rev 1/1/2010
26 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
27306 $ 296.62 Effective January 1, 2010
27307 $ 360.35
27310 $ 628.18
27323 $ 169.10
27324 $ 310.03
27325 $ 396.53
27326 $ 376.79
27327 $ 307.73
27328 $ 360.00
27329 $ 893.90
27330 $ 352.65
27331 $ 419.23
27332 $ 563.34
27333 $ 502.89
27334 $ 602.20
27335 $ 687.29
27337 $ 271.44
27339 $ 488.53
27340 $ 290.09
27345 $ 405.07
27347 $ 280.28
27350 $ 563.40
27355 $ 547.03
27356 $ 631.47
27357 $ 679.94
27358 $ 281.44
27360 $ 759.74
27364 $ 1,019.61
27365 $ 1,016.41
27370 $ 207.68
27372 $ 342.30
27380 $ 500.45
27381 $ 696.80
27385 $ 539.85
27386 $ 722.86
27390 $ 362.19
27391 $ 462.88
27392 $ 596.88
27393 $ 435.36
27394 $ 535.48
27395 $ 782.40
27396 $ 531.72
27397 $ 707.59
27400 $ 595.78
27403 $ 567.37
27405 $ 603.23
27407 $ 657.24
27409 $ 868.22
27412 $ 1,395.21
27415 $ 1,164.42
27416 $ 672.69
27418 $ 735.64
Rev 1/1/2010
27 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
27420 $ 663.80 Effective January 1, 2010
27422 $ 666.06
27424 $ 664.06
27425 $ 378.01
27427 $ 638.69
27428 $ 906.19
27429 $ 909.91
27430 $ 632.91
27435 $ 584.66
27437 $ 587.15
27438 $ 762.80
27440 $ 703.04
27441 $ 674.06
27442 $ 799.85
27443 $ 742.63
27445 $ 1,158.58
27446 $ 1,057.91
27447 $ 1,403.35
27448 $ 759.13
27450 $ 939.14
27454 $ 1,089.97
27455 $ 828.40
27457 $ 865.09
27465 $ 896.62
27466 $ 1,031.03
27468 $ 1,153.66
27470 $ 1,075.23
27472 $ 1,192.84
27475 $ 560.06
27477 $ 672.20
27479 $ 803.23
27485 $ 570.38
27486 $ 1,267.72
27487 $ 1,638.14
27488 $ 1,029.44
27495 $ 1,058.19
27496 $ 403.18
27497 $ 466.76
27498 $ 501.32
27499 $ 559.24
27500 $ 512.74
27501 $ 524.90
27502 $ 650.04
27503 $ 651.64
27506 $ 1,088.39
27507 $ 928.88
27508 $ 411.91
27509 $ 463.60
27510 $ 539.22
27511 $ 917.72
27513 $ 1,117.68
27514 $ 1,078.61
Rev 1/1/2010
28 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
27516 $ 415.94 Effective January 1, 2010
27517 $ 587.07
27519 $ 937.72
27520 $ 264.01
27524 $ 651.37
27530 $ 309.43
27532 $ 458.30
27535 $ 769.85
27536 $ 915.75
27538 $ 367.47
27540 $ 790.51
27550 $ 381.61
27552 $ 441.60
27556 $ 918.70
27557 $ 1,058.40
27558 $ 1,093.25
27560 $ 275.52
27562 $ 367.75
27566 $ 748.83
27570 $ 131.98
27580 $ 1,175.64
27590 $ 757.54
27591 $ 846.29
27592 $ 652.22
27594 $ 428.85
27596 $ 665.93
27598 $ 698.79
27600 $ 372.21
27601 $ 373.20
27602 $ 443.88
27603 $ 421.27
27604 $ 308.58
27605 $ 231.69
27606 $ 309.05
27607 $ 577.14
27610 $ 556.53
27612 $ 502.37
27613 $ 169.54
27614 $ 378.54
27615 $ 791.48
27616 $ 832.61
27618 $ 369.28
27619 $ 525.50
27620 $ 420.81
27625 $ 570.17
27626 $ 618.42
27630 $ 374.09
27632 $ 268.29
27634 $ 437.27
27635 $ 559.72
27637 $ 659.56
27638 $ 700.47
Rev 1/1/2010
29 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
27640 $ 804.03 Effective January 1, 2010
27641 $ 660.96
27645 $ 932.17
27646 $ 868.68
27647 $ 746.87
27648 $ 169.20
27650 $ 622.36
27652 $ 669.17
27654 $ 671.56
27656 $ 396.11
27658 $ 419.42
27659 $ 520.62
27664 $ 362.10
27665 $ 468.87
27675 $ 469.79
27676 $ 545.82
27680 $ 374.65
27681 $ 453.79
27685 $ 404.71
27686 $ 505.63
27687 $ 421.92
27690 $ 541.68
27691 $ 636.24
27692 $ 113.57
27695 $ 472.13
27696 $ 542.70
27698 $ 631.59
27700 $ 598.10
27702 $ 915.11
27703 $ 956.70
27704 $ 489.33
27705 $ 705.44
27707 $ 347.23
27709 $ 690.54
27712 $ 877.63
27715 $ 919.78
27720 $ 821.77
27722 $ 770.47
27724 $ 1,004.32
27725 $ 938.00
27727 $ 840.15
27730 $ 537.08
27732 $ 474.39
27734 $ 548.59
27740 $ 749.55
27742 $ 749.43
27745 $ 673.14
27750 $ 284.50
27752 $ 440.71
27756 $ 507.92
27758 $ 798.84
27759 $ 903.81
Rev 1/1/2010
30 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
27760 $ 259.05 Effective January 1, 2010
27762 $ 381.20
27766 $ 543.32
27767 $ 181.51
27768 $ 278.70
27769 $ 477.91
27780 $ 199.89
27781 $ 336.63
27784 $ 460.14
27786 $ 252.20
27788 $ 336.88
27792 $ 505.68
27808 $ 270.47
27810 $ 407.26
27814 $ 695.47
27816 $ 277.78
27818 $ 440.50
27822 $ 1,049.95
27823 $ 1,193.47
27824 $ 283.87
27825 $ 480.72
27826 $ 986.93
27827 $ 1,273.60
27828 $ 1,387.46
27829 $ 695.92
27830 $ 305.29
27831 $ 297.05
27832 $ 441.90
27840 $ 269.51
27842 $ 325.28
27846 $ 627.70
27848 $ 959.58
27860 $ 151.19
27870 $ 908.52
27871 $ 603.99
27880 $ 725.74
27881 $ 801.81
27882 $ 611.40
27884 $ 492.74
27886 $ 597.22
27888 $ 652.35
27889 $ 628.45
27892 $ 428.94
27893 $ 413.88
27894 $ 567.72
28001 $ 168.30
28002 $ 281.84
28003 $ 481.31
28005 $ 503.61
28008 $ 291.13
28010 $ 246.37
28011 $ 278.84
Rev 1/1/2010
31 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
28020 $ 365.04 Effective January 1, 2010
28022 $ 302.05
28024 $ 287.64
28035 $ 381.61
28039 $ 310.75
28041 $ 291.47
28043 $ 239.46
28045 $ 327.28
28046 $ 581.90
28047 $ 614.22
28050 $ 297.01
28052 $ 288.66
28054 $ 244.93
28055 $ 313.25
28060 $ 354.67
28062 $ 471.94
28070 $ 341.04
28072 $ 319.27
28080 $ 282.08
28086 $ 351.32
28088 $ 297.63
28090 $ 296.58
28092 $ 264.33
28100 $ 409.78
28102 $ 500.96
28103 $ 529.78
28104 $ 351.89
28106 $ 452.91
28107 $ 370.68
28108 $ 299.78
28110 $ 302.33
28111 $ 385.52
28112 $ 328.15
28113 $ 345.50
28114 $ 637.68
28116 $ 463.54
28118 $ 406.99
28119 $ 375.71
28120 $ 434.09
28122 $ 457.22
28124 $ 344.30
28126 $ 282.82
28130 $ 520.43
28140 $ 437.28
28150 $ 298.78
28153 $ 287.82
28160 $ 296.01
28171 $ 564.64
28173 $ 534.66
28175 $ 409.33
28190 $ 154.98
28192 $ 294.36
Rev 1/1/2010
32 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
28193 $ 340.04 Effective January 1, 2010
28200 $ 343.18
28202 $ 439.42
28208 $ 291.19
28210 $ 436.50
28220 $ 312.23
28222 $ 398.62
28225 $ 253.82
28226 $ 304.46
28230 $ 279.77
28232 $ 239.32
28234 $ 239.36
28238 $ 498.17
28240 $ 276.43
28250 $ 383.14
28260 $ 458.21
28261 $ 639.14
28262 $ 974.90
28264 $ 652.79
28270 $ 307.49
28272 $ 251.17
28280 $ 317.67
28285 $ 332.31
28286 $ 316.62
28288 $ 331.07
28289 $ 326.07
28290 $ 399.92
28292 $ 477.45
28293 $ 606.09
28294 $ 571.50
28296 $ 596.63
28297 $ 600.60
28298 $ 541.61
28299 $ 594.78
28300 $ 623.34
28302 $ 666.82
28304 $ 555.26
28305 $ 739.18
28306 $ 379.59
28307 $ 440.23
28308 $ 370.09
28309 $ 695.84
28310 $ 362.23
28312 $ 336.49
28313 $ 328.40
28315 $ 331.41
28320 $ 596.87
28322 $ 476.99
28340 $ 464.95
28341 $ 539.91
28344 $ 296.56
28345 $ 399.65
Rev 1/1/2010
33 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
28360 $ 856.81 Effective January 1, 2010
28400 $ 229.60
28405 $ 339.38
28406 $ 441.81
28415 $ 1,275.11
28420 $ 1,333.59
28430 $ 219.11
28435 $ 282.75
28436 $ 332.06
28445 $ 626.33
28446 $ 825.40
28450 $ 196.90
28455 $ 230.61
28456 $ 209.15
28465 $ 664.56
28470 $ 191.99
28475 $ 233.58
28476 $ 261.58
28485 $ 605.56
28490 $ 86.92
28495 $ 107.27
28496 $ 221.38
28505 $ 466.56
28510 $ 82.46
28515 $ 101.31
28525 $ 410.38
28530 $ 115.52
28531 $ 323.43
28540 $ 145.89
28545 $ 163.31
28546 $ 232.94
28555 $ 468.57
28570 $ 163.88
28575 $ 220.62
28576 $ 273.48
28585 $ 577.99
28600 $ 163.62
28605 $ 227.71
28606 $ 443.10
28615 $ 737.30
28630 $ 103.60
28635 $ 135.43
28636 $ 228.61
28645 $ 321.12
28660 $ 114.02
28665 $ 131.92
28666 $ 267.49
28675 $ 330.66
28705 $ 968.91
28715 $ 843.84
28725 $ 726.16
28730 $ 676.10
Rev 1/1/2010
34 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
28735 $ 688.31 Effective January 1, 2010
28737 $ 625.20
28740 $ 514.86
28750 $ 494.66
28755 $ 333.95
28760 $ 467.95
28800 $ 523.36
28805 $ 523.02
28810 $ 388.06
28820 $ 330.55
28825 $ 289.19
28890 $ 305.27
29000 $ 270.21
29010 $ 270.90
29015 $ 263.53
29020 $ 243.65
29025 $ 284.35
29035 $ 286.39
29040 $ 247.56
29044 $ 348.79
29046 $ 361.30
29049 $ 132.31
29055 $ 234.49
29058 $ 159.09
29065 $ 113.10
29075 $ 99.11
29085 $ 99.32
29105 $ 84.26
29125 $ 64.71
29126 $ 78.95
29130 $ 32.45
29131 $ 46.82
29200 $ 48.00
29220 $ 45.47
29240 $ 49.84
29260 $ 39.46
29280 $ 38.21
29305 $ 291.88
29325 $ 260.47
29345 $ 152.24
29355 $ 162.04
29358 $ 177.21
29365 $ 129.09
29405 $ 106.05
29425 $ 110.38
29435 $ 159.25
29440 $ 59.92
29445 $ 184.23
29450 $ 86.71
29505 $ 84.46
29515 $ 71.96
29520 $ 42.71
Rev 1/1/2010
35 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
29530 $ 43.28 Effective January 1, 2010
29540 $ 30.24
29550 $ 27.71
29580 $ 48.73
29581 $ 58.15
29590 $ 40.87
29700 $ 36.85
29705 $ 46.24
29710 $ 76.72
29715 $ 120.70
29720 $ 97.30
29730 $ 44.00
29740 $ 92.64
29750 $ 87.39
29805 $ 344.61
29806 $ 964.64
29819 $ 541.93
29820 $ 514.65
29821 $ 546.33
29822 $ 537.02
29823 $ 580.09
29824 $ 587.29
29825 $ 543.20
29826 $ 632.32
29827 $ 916.14
29828 $ 636.88
29830 $ 374.75
29834 $ 415.58
29835 $ 429.45
29836 $ 486.57
29837 $ 448.86
29838 $ 494.04
29840 $ 356.16
29843 $ 415.76
29844 $ 438.18
29845 $ 498.44
29846 $ 513.38
29847 $ 529.03
29848 $ 362.95
29850 $ 538.39
29851 $ 812.83
29855 $ 721.18
29856 $ 880.27
29860 $ 470.11
29861 $ 605.39
29862 $ 649.43
29863 $ 630.19
29866 $ 913.59
29867 $ 1,090.68
29868 $ 1,475.41
29870 $ 329.13
29871 $ 452.01
Rev 1/1/2010
36 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
29873 $ 425.51 Effective January 1, 2010
29874 $ 484.35
29875 $ 441.78
29876 $ 548.02
29877 $ 506.64
29879 $ 549.10
29880 $ 578.37
29881 $ 532.13
29882 $ 586.55
29883 $ 637.23
29884 $ 516.94
29885 $ 595.33
29886 $ 499.05
29887 $ 620.07
29888 $ 928.04
29889 $ 897.11
29891 $ 570.01
29892 $ 598.18
29893 $ 338.05
29894 $ 494.86
29895 $ 486.73
29896 $ 905.23
29897 $ 502.50
29898 $ 561.28
29899 $ 841.35
29900 $ 419.60
29901 $ 462.15
29902 $ 495.76
29904 $ 428.63
29905 $ 462.33
29906 $ 486.97
29907 $ 594.95
30020 $ 94.39
30100 $ 61.50
30110 $ 112.71
30115 $ 257.56
30117 $ 215.54
30118 $ 586.13
30124 $ 173.66
30125 $ 428.69
30130 $ 197.09
30140 $ 229.35
30150 $ 565.30
30160 $ 627.15
30200 $ 48.84
30210 $ 68.40
30220 $ 110.85
30300 $ 77.40
30310 $ 121.64
30320 $ 300.63
30400 $ 631.50
30410 $ 840.46
Rev 1/1/2010
37 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
30420 $ 1,019.99 Effective January 1, 2010
30430 $ 447.82
30435 $ 718.78
30450 $ 1,031.95
30460 $ 613.05
30462 $ 1,167.33
30465 $ 792.41
30520 $ 382.39
30540 $ 460.07
30545 $ 702.48
30560 $ 82.63
30580 $ 405.36
30600 $ 332.93
30620 $ 404.16
30630 $ 447.18
30801 $ 78.96
30802 $ 126.07
30901 $ 80.73
30903 $ 101.87
30905 $ 160.70
30906 $ 169.16
30915 $ 426.31
30920 $ 617.76
30930 $ 82.33
31000 $ 77.63
31002 $ 99.92
31020 $ 201.36
31030 $ 380.55
31032 $ 433.05
31040 $ 552.44
31050 $ 350.44
31051 $ 468.93
31070 $ 293.83
31075 $ 601.53
31080 $ 674.10
31081 $ 777.28
31084 $ 867.19
31085 $ 917.04
31086 $ 773.72
31087 $ 769.11
31090 $ 628.96
31200 $ 332.09
31201 $ 512.60
31205 $ 609.62
31225 $ 1,205.42
31230 $ 1,366.15
31231 $ 87.93
31233 $ 158.59
31235 $ 170.94
31237 $ 202.28
31238 $ 223.14
31239 $ 555.64
Rev 1/1/2010
38 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
31240 $ 160.39 Effective January 1, 2010
31254 $ 287.40
31255 $ 430.73
31256 $ 203.57
31267 $ 324.33
31276 $ 493.49
31287 $ 242.63
31288 $ 283.29
31290 $ 1,046.30
31291 $ 1,109.37
31292 $ 883.75
31293 $ 963.07
31294 $ 1,134.62
31300 $ 928.40
31320 $ 416.79
31360 $ 1,168.95
31365 $ 1,604.64
31367 $ 1,370.28
31368 $ 1,776.20
31370 $ 1,354.32
31375 $ 1,231.81
31380 $ 1,276.92
31382 $ 1,305.63
31390 $ 1,801.11
31395 $ 2,106.27
31400 $ 694.80
31420 $ 694.87
31500 $ 106.50
31502 $ 57.02
31505 $ 51.89
31510 $ 111.73
31511 $ 130.32
31512 $ 140.96
31513 $ 130.14
31515 $ 114.78
31520 $ 135.11
31525 $ 167.42
31526 $ 158.82
31527 $ 187.57
31528 $ 144.89
31529 $ 155.50
31530 $ 203.48
31531 $ 222.46
31535 $ 195.03
31536 $ 220.23
31540 $ 255.53
31541 $ 272.43
31545 $ 334.72
31546 $ 510.02
31560 $ 318.88
31561 $ 364.45
31570 $ 264.75
Rev 1/1/2010
39 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
31571 $ 260.19 Effective January 1, 2010
31575 $ 92.41
31576 $ 133.51
31577 $ 165.00
31578 $ 188.98
31579 $ 156.90
31580 $ 870.17
31582 $ 1,347.54
31584 $ 1,155.71
31587 $ 725.34
31588 $ 864.89
31590 $ 496.17
31595 $ 554.23
31600 $ 218.70
31601 $ 271.13
31603 $ 245.05
31605 $ 212.27
31610 $ 568.69
31611 $ 441.08
31612 $ 70.84
31613 $ 323.21
31614 $ 528.57
31615 $ 152.93
31620 $ 242.99
31622 $ 196.25
31623 $ 200.60
31624 $ 194.19
31625 $ 220.66
31626 $ 284.09
31627 $ 786.09
31628 $ 249.19
31629 $ 189.39
31630 $ 219.81
31631 $ 240.25
31632 $ 63.30
31633 $ 77.53
31635 $ 213.48
31636 $ 209.28
31637 $ 74.41
31638 $ 232.48
31640 $ 285.41
31641 $ 289.73
31643 $ 198.02
31645 $ 178.62
31646 $ 154.03
31656 $ 121.56
31700 $ 97.97
31708 $ 65.92
31710 $ 64.12
31715 $ 48.93
31717 $ 130.95
31720 $ 76.80
Rev 1/1/2010
40 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
31725 $ 98.40 Effective January 1, 2010
31730 $ 174.67
31750 $ 819.62
31755 $ 1,037.38
31760 $ 1,175.33
31766 $ 1,649.91
31770 $ 1,297.37
31775 $ 1,409.60
31780 $ 1,128.44
31781 $ 1,382.31
31785 $ 943.26
31786 $ 1,332.79
31800 $ 449.26
31805 $ 839.80
31820 $ 328.82
31825 $ 472.79
31830 $ 330.04
32035 $ 587.74
32036 $ 649.63
32095 $ 608.05
32100 $ 801.55
32110 $ 874.75
32120 $ 770.73
32124 $ 818.10
32140 $ 919.00
32141 $ 905.96
32150 $ 876.12
32151 $ 879.78
32160 $ 602.21
32200 $ 808.05
32201 $ 277.38
32215 $ 732.66
32220 $ 1,200.90
32225 $ 906.64
32310 $ 873.02
32320 $ 1,277.10
32400 $ 110.13
32402 $ 572.00
32405 $ 135.59
32420 $ 107.46
32421 $ 124.44
32422 $ 151.75
32440 $ 1,312.97
32442 $ 1,492.87
32445 $ 1,494.36
32480 $ 1,159.51
32482 $ 1,224.95
32484 $ 1,265.34
32486 $ 1,408.97
32488 $ 1,494.85
32491 $ 1,273.37
32500 $ 952.04
Rev 1/1/2010
41 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
32501 $ 266.96 Effective January 1, 2010
32503 $ 1,561.00
32504 $ 1,783.84
32540 $ 935.36
32550 $ 647.52
32551 $ 130.58
32552 $ 106.09
32553 $ 389.35
32560 $ 236.79
32561 $ 62.66
32562 $ 55.70
32601 $ 325.51
32602 $ 352.79
32603 $ 417.09
32604 $ 472.24
32605 $ 392.66
32606 $ 453.74
32650 $ 684.41
32651 $ 834.01
32652 $ 1,153.95
32653 $ 818.35
32654 $ 783.33
32655 $ 867.84
32656 $ 874.87
32657 $ 902.34
32658 $ 818.08
32659 $ 817.44
32660 $ 1,210.81
32661 $ 832.82
32662 $ 1,043.46
32663 $ 1,169.64
32664 $ 855.09
32665 $ 972.09
32700 $ 350.61
32800 $ 833.38
32810 $ 774.97
32815 $ 1,368.57
32820 $ 1,321.10
32900 $ 1,092.06
32905 $ 1,185.16
32906 $ 1,497.39
32940 $ 1,109.20
32960 $ 107.98
32997 $ 277.22
32998 $ 2,448.54
33010 $ 118.18
33011 $ 110.51
33015 $ 396.25
33020 $ 843.03
33025 $ 833.76
33030 $ 1,278.29
33031 $ 1,296.47
Rev 1/1/2010
42 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
33050 $ 874.49 Effective January 1, 2010
33120 $ 1,687.48
33130 $ 1,237.80
33140 $ 1,120.41
33141 $ 269.69
33200 $ 837.53
33201 $ 753.93
33202 $ 620.02
33206 $ 459.28
33207 $ 538.99
33208 $ 546.83
33210 $ 194.10
33211 $ 199.41
33212 $ 365.75
33213 $ 400.62
33214 $ 465.64
33215 $ 263.45
33216 $ 363.00
33217 $ 377.92
33218 $ 349.19
33220 $ 352.61
33222 $ 336.99
33223 $ 418.01
33224 $ 423.23
33225 $ 374.28
33226 $ 407.66
33233 $ 229.63
33234 $ 425.69
33235 $ 496.52
33236 $ 694.05
33237 $ 846.22
33238 $ 882.36
33240 $ 462.79
33241 $ 214.94
33243 $ 1,174.27
33244 $ 787.69
33245 $ 1,002.57
33246 $ 1,350.05
33249 $ 908.85
33250 $ 1,202.35
33251 $ 1,478.40
33254 $ 1,079.69
33255 $ 1,298.40
33256 $ 1,549.59
33257 $ 435.47
33258 $ 491.58
33259 $ 644.46
33261 $ 1,422.51
33282 $ 337.59
33284 $ 262.64
33300 $ 1,126.00
33305 $ 1,349.88
Rev 1/1/2010
43 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
33310 $ 1,126.40 Effective January 1, 2010
33315 $ 1,338.32
33320 $ 1,061.13
33321 $ 1,352.75
33322 $ 1,384.20
33330 $ 1,231.04
33332 $ 1,365.37
33335 $ 1,665.30
33400 $ 1,717.82
33401 $ 1,593.82
33403 $ 1,694.47
33404 $ 1,930.47
33405 $ 1,962.22
33406 $ 2,118.52
33410 $ 1,881.80
33411 $ 2,132.07
33412 $ 2,299.01
33413 $ 2,347.56
33414 $ 2,079.01
33415 $ 1,835.46
33416 $ 1,918.14
33417 $ 1,973.00
33420 $ 1,284.01
33422 $ 1,739.73
33425 $ 1,795.20
33426 $ 2,006.56
33427 $ 2,163.45
33430 $ 2,067.58
33460 $ 1,585.29
33463 $ 1,714.36
33464 $ 1,822.21
33465 $ 1,906.62
33468 $ 2,114.00
33470 $ 1,249.64
33471 $ 1,381.06
33472 $ 1,431.61
33474 $ 1,555.99
33475 $ 1,907.70
33476 $ 1,624.41
33478 $ 1,819.88
33496 $ 1,856.74
33500 $ 1,696.15
33501 $ 1,105.27
33502 $ 1,385.98
33503 $ 1,418.12
33504 $ 1,731.13
33505 $ 1,733.32
33506 $ 1,752.27
33507 $ 1,503.85
33508 $ 14.21
33510 $ 1,683.89
33511 $ 1,821.22
Rev 1/1/2010
44 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
33512 $ 1,954.52 Effective January 1, 2010
33513 $ 2,097.85
33514 $ 2,286.82
33516 $ 2,434.28
33517 $ 156.51
33518 $ 295.39
33519 $ 433.35
33521 $ 571.96
33522 $ 709.94
33523 $ 849.19
33530 $ 356.68
33533 $ 1,727.67
33534 $ 1,898.50
33535 $ 2,073.68
33536 $ 2,247.85
33542 $ 1,926.79
33545 $ 2,322.62
33548 $ 1,982.61
33572 $ 242.04
33600 $ 1,893.05
33602 $ 1,829.44
33606 $ 2,024.92
33608 $ 2,103.30
33610 $ 2,055.04
33611 $ 2,134.83
33612 $ 2,255.27
33615 $ 2,184.55
33617 $ 2,341.47
33619 $ 2,633.45
33641 $ 1,417.29
33645 $ 1,682.75
33647 $ 1,954.65
33660 $ 1,749.58
33665 $ 1,931.52
33670 $ 2,016.77
33681 $ 1,901.63
33684 $ 1,960.71
33688 $ 1,858.97
33690 $ 1,349.11
33692 $ 2,013.68
33694 $ 2,043.88
33697 $ 2,190.45
33702 $ 1,824.24
33710 $ 1,952.60
33720 $ 1,794.06
33722 $ 1,934.33
33730 $ 1,990.08
33732 $ 1,875.36
33735 $ 1,458.82
33736 $ 1,638.48
33737 $ 1,418.70
33750 $ 1,341.80
Rev 1/1/2010
45 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
33755 $ 1,310.97 Effective January 1, 2010
33762 $ 1,357.55
33764 $ 1,355.97
33766 $ 1,515.64
33767 $ 1,552.48
33768 $ 371.67
33770 $ 2,115.54
33771 $ 2,092.29
33774 $ 1,922.93
33775 $ 1,898.17
33776 $ 2,034.63
33777 $ 1,948.09
33778 $ 2,291.30
33779 $ 2,229.41
33780 $ 2,308.93
33781 $ 2,186.80
33782 $ 2,164.62
33783 $ 2,339.72
33786 $ 2,125.42
33788 $ 1,637.25
33800 $ 1,106.97
33802 $ 1,254.23
33803 $ 1,248.83
33813 $ 1,383.61
33814 $ 1,762.94
33820 $ 1,159.54
33822 $ 1,115.03
33824 $ 1,348.95
33840 $ 1,452.28
33845 $ 1,523.19
33851 $ 1,524.71
33852 $ 1,654.86
33853 $ 2,188.21
33860 $ 2,175.96
33861 $ 2,193.43
33863 $ 2,274.24
33864 $ 2,319.87
33870 $ 2,601.02
33875 $ 2,055.14
33877 $ 2,692.66
33880 $ 1,552.20
33881 $ 1,334.45
33883 $ 987.82
33884 $ 365.09
33886 $ 853.85
33889 $ 729.64
33891 $ 931.79
33910 $ 1,417.80
33915 $ 1,132.47
33916 $ 1,495.81
33917 $ 1,678.28
33920 $ 2,132.17
Rev 1/1/2010
46 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
33922 $ 1,595.55 Effective January 1, 2010
33924 $ 299.60
33925 $ 1,538.66
33926 $ 2,073.63
33945 $ 2,726.12
33960 $ 868.05
33961 $ 569.62
33967 $ 247.17
33968 $ 35.93
33970 $ 411.59
33971 $ 591.37
33973 $ 538.68
33974 $ 811.84
33975 $ 1,899.79
33976 $ 2,176.58
33977 $ 1,113.32
33978 $ 1,251.36
33979 $ 2,105.59
34001 $ 721.51
34051 $ 808.17
34101 $ 571.03
34111 $ 478.24
34151 $ 918.53
34201 $ 554.95
34203 $ 676.63
34401 $ 679.41
34421 $ 556.42
34451 $ 796.98
34471 $ 487.53
34490 $ 472.13
34501 $ 649.53
34502 $ 1,457.48
34510 $ 791.19
34520 $ 768.34
34530 $ 975.86
34800 $ 1,167.49
34802 $ 1,288.23
34803 $ 1,189.46
34804 $ 1,288.23
34805 $ 1,071.12
34806 $ 75.82
34808 $ 221.45
34812 $ 362.58
34813 $ 257.55
34820 $ 523.46
34825 $ 698.03
34826 $ 221.45
34830 $ 1,816.48
34831 $ 1,963.50
34832 $ 1,963.50
34833 $ 560.49
34834 $ 263.63
Rev 1/1/2010
47 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
34900 $ 828.17 Effective January 1, 2010
35001 $ 1,115.72
35002 $ 1,102.56
35005 $ 903.89
35011 $ 719.91
35013 $ 982.13
35021 $ 1,167.54
35022 $ 1,202.01
35045 $ 711.54
35081 $ 1,551.52
35082 $ 1,895.91
35091 $ 1,876.82
35092 $ 2,047.09
35102 $ 1,672.26
35103 $ 1,845.26
35111 $ 999.15
35112 $ 962.38
35121 $ 1,426.26
35122 $ 1,696.10
35131 $ 1,066.83
35132 $ 1,242.95
35141 $ 879.32
35142 $ 956.45
35151 $ 992.71
35152 $ 875.69
35161 $ 1,082.06
35162 $ 1,166.54
35180 $ 710.71
35182 $ 958.60
35184 $ 696.41
35188 $ 746.24
35189 $ 983.69
35190 $ 726.34
35201 $ 608.89
35206 $ 597.14
35207 $ 669.76
35211 $ 1,308.33
35216 $ 1,066.23
35221 $ 886.38
35226 $ 601.56
35231 $ 752.88
35236 $ 677.63
35241 $ 1,375.59
35246 $ 1,215.44
35251 $ 897.48
35256 $ 727.16
35261 $ 720.84
35266 $ 658.59
35271 $ 1,294.13
35276 $ 1,099.53
35281 $ 997.77
35286 $ 740.48
Rev 1/1/2010
48 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
35301 $ 1,060.06 Effective January 1, 2010
35302 $ 912.02
35303 $ 1,001.66
35304 $ 1,041.97
35305 $ 1,001.66
+35306 $ 373.80
35311 $ 1,427.09
35321 $ 736.84
35331 $ 1,228.04
35341 $ 1,360.12
35351 $ 1,109.04
35355 $ 954.16
35361 $ 1,326.72
35363 $ 1,432.64
35371 $ 718.94
35372 $ 774.06
35390 $ 160.28
35400 $ 159.50
35450 $ 612.51
35452 $ 369.04
35454 $ 371.72
35456 $ 451.23
35458 $ 574.32
35459 $ 525.77
35460 $ 306.20
35470 $ 511.82
35471 $ 597.37
35472 $ 342.21
35473 $ 357.75
35474 $ 435.13
35475 $ 542.91
35476 $ 288.60
35480 $ 668.05
35481 $ 402.73
35482 $ 412.21
35483 $ 497.41
35484 $ 609.44
35485 $ 476.85
35490 $ 658.77
35491 $ 385.26
35492 $ 403.22
35493 $ 498.24
35494 $ 576.74
35495 $ 481.18
35501 $ 1,119.94
35506 $ 1,171.71
35508 $ 1,116.80
35509 $ 1,092.21
35510 $ 1,133.80
35511 $ 894.83
35512 $ 1,112.21
35515 $ 987.74
Rev 1/1/2010
49 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
35516 $ 993.65 Effective January 1, 2010
35518 $ 938.69
35521 $ 995.37
35522 $ 1,079.99
35523 $ 949.31
35525 $ 1,031.00
35526 $ 1,088.24
35531 $ 1,426.74
35533 $ 1,226.45
35535 $ 1,724.39
35536 $ 1,347.23
35537 $ 1,760.02
35538 $ 1,965.54
35539 $ 1,847.34
35540 $ 2,058.72
35548 $ 1,250.35
35549 $ 1,358.13
35551 $ 1,452.27
35556 $ 1,245.10
35558 $ 871.64
35560 $ 1,355.01
35563 $ 794.49
35565 $ 937.55
35566 $ 1,542.11
35570 $ 1,332.06
35571 $ 1,152.31
35572 $ 316.72
35582 $ 1,545.66
35583 $ 1,315.88
35585 $ 1,625.14
35587 $ 1,214.69
35600 $ 272.02
35601 $ 1,068.17
35606 $ 1,098.87
35612 $ 963.95
35616 $ 961.36
35621 $ 903.88
35623 $ 849.19
35626 $ 1,371.25
35631 $ 1,348.25
35632 $ 1,637.26
35633 $ 1,767.95
35634 $ 1,602.38
35636 $ 1,179.44
35637 $ 1,402.23
35638 $ 1,424.41
35642 $ 924.19
35645 $ 929.59
35646 $ 1,502.73
35650 $ 883.62
35651 $ 1,467.57
35654 $ 1,145.60
Rev 1/1/2010
50 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
35656 $ 1,134.38 Effective January 1, 2010
35661 $ 818.73
35663 $ 884.40
35665 $ 952.56
35666 $ 1,205.47
35671 $ 940.49
35681 $ 250.97
35682 $ 448.21
35683 $ 501.47
35691 $ 1,104.25
35693 $ 811.98
35694 $ 962.78
35695 $ 961.93
35697 $ 142.18
35700 $ 188.95
35701 $ 353.10
35721 $ 358.18
35741 $ 357.15
35761 $ 357.49
35800 $ 404.55
35820 $ 676.95
35840 $ 550.50
35860 $ 354.99
35870 $ 1,126.99
35875 $ 590.87
35876 $ 877.58
35879 $ 828.01
35881 $ 907.36
35901 $ 506.65
35903 $ 584.79
35905 $ 957.03
35907 $ 949.99
36000 $ 18.73
36005 $ 282.01
36010 $ 129.83
36011 $ 152.82
36012 $ 176.97
36013 $ 134.10
36014 $ 151.54
36015 $ 177.29
36100 $ 167.37
36120 $ 114.91
36140 $ 101.11
36147 $ 516.54
36148 $ 162.71
36160 $ 140.14
36200 $ 160.71
36215 $ 225.30
36216 $ 254.02
36217 $ 306.05
36218 $ 49.61
36245 $ 236.66
Rev 1/1/2010
51 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
36246 $ 258.30 Effective January 1, 2010
36247 $ 305.43
36248 $ 50.22
36260 $ 534.91
36261 $ 276.24
36262 $ 211.45
36400 $ 17.10
36405 $ 21.30
36406 $ 17.13
36410 $ 16.80
36420 $ 48.54
36425 $ 69.04
36430 $ 34.49
36440 $ 55.90
36450 $ 117.88
36455 $ 134.37
36460 $ 342.03
36470 $ 84.98
36471 $ 110.11
36475 $ 1,999.25
36476 $ 386.36
36478 $ 1,840.08
36479 $ 390.15
36481 $ 355.98
36488 $ 69.04
36489 $ 115.67
36490 $ 88.91
36491 $ 83.34
36493 $ 56.16
36500 $ 134.64
36510 $ 48.22
36511 $ 79.34
36512 $ 79.34
36513 $ 79.34
36514 $ 79.34
36515 $ 79.34
36516 $ 79.34
36522 $ 228.49
36530 $ 351.91
36532 $ 169.01
36533 $ 320.59
36534 $ 168.44
36535 $ 152.54
36536 $ 1,225.43
36537 $ 278.23
36555 $ 292.33
36556 $ 278.29
36557 $ 633.57
36558 $ 620.19
36560 $ 1,193.08
36561 $ 1,182.46
36563 $ 1,492.07
Rev 1/1/2010
52 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
36565 $ 949.49 Effective January 1, 2010
36566 $ 992.18
36568 $ 341.47
36569 $ 310.01
36570 $ 1,534.35
36571 $ 1,378.76
36575 $ 151.16
36576 $ 377.20
36578 $ 481.45
36580 $ 272.71
36581 $ 570.92
36582 $ 1,074.02
36583 $ 623.78
36584 $ 284.94
36585 $ 1,356.83
36589 $ 153.32
36590 $ 331.77
36591 $ 16.64
36592 $ 20.59
36593 $ 27.68
36595 $ 782.23
36596 $ 172.28
36597 $ 147.00
36598 $ 112.74
36600 $ 21.78
36620 $ 53.60
36625 $ 94.19
36640 $ 123.63
36660 $ 61.41
36680 $ 68.87
36800 $ 145.73
36810 $ 246.79
36815 $ 169.11
36818 $ 638.51
36819 $ 695.27
36820 $ 764.71
36821 $ 514.93
36822 $ 452.39
36825 $ 620.24
36830 $ 690.13
36831 $ 345.94
36832 $ 577.54
36833 $ 554.38
36834 $ 542.53
36835 $ 386.22
36838 $ 1,058.09
36860 $ 142.44
36861 $ 158.12
36870 $ 1,354.68
37140 $ 1,190.04
37145 $ 1,244.24
37160 $ 1,199.82
Rev 1/1/2010
53 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
37180 $ 1,260.89 Effective January 1, 2010
37181 $ 1,370.64
37182 $ 785.93
37183 $ 365.99
37184 $ 2,809.33
37185 $ 914.50
37186 $ 1,899.57
37187 $ 2,734.58
37188 $ 2,260.08
37195 $ 274.58
37200 $ 198.25
37201 $ 292.40
37202 $ 322.28
37203 $ 264.81
37204 $ 911.27
37205 $ 420.33
37206 $ 205.49
37207 $ 436.72
37208 $ 213.08
37209 $ 109.58
37215 $ 951.93
37216 $ 917.13
37250 $ 106.19
37251 $ 81.12
37500 $ 643.08
37565 $ 260.03
37600 $ 296.50
37605 $ 372.44
37606 $ 401.88
37607 $ 324.87
37609 $ 216.32
37615 $ 354.37
37616 $ 851.68
37617 $ 806.23
37618 $ 309.75
37620 $ 584.87
37650 $ 307.41
37660 $ 562.30
37700 $ 240.21
37718 $ 348.94
37722 $ 413.77
37735 $ 604.75
37760 $ 580.34
37761 $ 380.55
37765 $ 400.07
37766 $ 485.84
37780 $ 214.43
37785 $ 257.74
37788 $ 1,181.80
37790 $ 493.87
38100 $ 694.53
38101 $ 699.43
Rev 1/1/2010
54 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
38102 $ 236.55 Effective January 1, 2010
38115 $ 726.82
38120 $ 811.59
38200 $ 128.80
38205 $ 68.55
38206 $ 68.55
38220 $ 205.24
38221 $ 219.09
38230 $ 234.52
38240 $ 122.43
38241 $ 122.13
38242 $ 78.10
38300 $ 122.33
38305 $ 309.11
38308 $ 304.48
38380 $ 449.60
38381 $ 776.07
38382 $ 569.83
38500 $ 166.95
38505 $ 103.57
38510 $ 249.56
38520 $ 308.24
38525 $ 263.61
38530 $ 369.20
38542 $ 363.07
38550 $ 364.92
38555 $ 800.20
38562 $ 570.37
38564 $ 593.37
38570 $ 496.21
38571 $ 643.86
38572 $ 749.18
38700 $ 619.96
38720 $ 952.67
38724 $ 979.54
38740 $ 385.28
38745 $ 550.91
38746 $ 221.95
38747 $ 239.75
38760 $ 499.17
38765 $ 916.75
38770 $ 795.80
38780 $ 970.96
38790 $ 456.57
38794 $ 212.65
39000 $ 476.67
39010 $ 821.92
39200 $ 893.72
39220 $ 1,102.20
39400 $ 440.63
39501 $ 773.71
39502 $ 905.16
Rev 1/1/2010
55 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
39503 $ 1,860.71 Effective January 1, 2010
39520 $ 960.97
39530 $ 925.72
39531 $ 886.11
39540 $ 810.36
39541 $ 842.21
39545 $ 787.05
39560 $ 691.77
39561 $ 947.33
40490 $ 77.62
40520 $ 335.22
40525 $ 511.78
40527 $ 610.12
40530 $ 359.16
40650 $ 264.24
40652 $ 315.10
40654 $ 379.35
40700 $ 721.51
40701 $ 1,039.87
40702 $ 736.75
40720 $ 791.14
40761 $ 859.02
40800 $ 78.54
40801 $ 148.92
40804 $ 87.14
40805 $ 175.35
40806 $ 27.54
40808 $ 73.01
40812 $ 144.65
40819 $ 152.25
40830 $ 105.12
40831 $ 152.42
40840 $ 490.96
40842 $ 488.58
40843 $ 677.82
40844 $ 879.68
40845 $ 1,140.22
41000 $ 88.02
41005 $ 81.97
41005 $ 81.97
41006 $ 182.44
41007 $ 202.95
41009 $ 228.84
41010 $ 84.49
41015 $ 206.36
41017 $ 219.65
41018 $ 303.30
41019 $ 340.98
41100 $ 103.74
41108 $ 80.60
41110 $ 114.09
41112 $ 182.66
Rev 1/1/2010
56 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
41113 $ 215.82 Effective January 1, 2010
41114 $ 487.43
41115 $ 126.67
41116 $ 173.36
41120 $ 581.52
41130 $ 670.78
41135 $ 1,336.85
41140 $ 1,433.29
41145 $ 1,720.50
41150 $ 1,357.42
41153 $ 1,497.57
41155 $ 1,753.72
41250 $ 120.34
41252 $ 186.84
41500 $ 239.36
41520 $ 182.66
41530 $ 1,935.92
41800 $ 78.21
41805 $ 82.65
41806 $ 155.14
41820 $ 431.69
41822 $ 170.26
41823 $ 223.76
41825 $ 103.40
41826 $ 151.38
41827 $ 230.96
41828 $ 218.22
41830 $ 221.44
41872 $ 178.97
41874 $ 204.05
42000 $ 84.91
42100 $ 89.61
42104 $ 115.91
42106 $ 146.49
42107 $ 293.02
42120 $ 410.73
42140 $ 125.21
42145 $ 530.87
42160 $ 126.60
42180 $ 159.20
42182 $ 232.10
42200 $ 675.92
42205 $ 617.90
42210 $ 839.44
42215 $ 548.63
42220 $ 419.17
42225 $ 574.81
42226 $ 607.12
42227 $ 544.76
42235 $ 450.87
42260 $ 502.27
42280 $ 106.40
Rev 1/1/2010
57 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
42281 $ 114.32 Effective January 1, 2010
42300 $ 117.81
42305 $ 319.77
42310 $ 103.79
42320 $ 149.11
42330 $ 131.63
42335 $ 205.46
42405 $ 184.32
42408 $ 269.50
42409 $ 190.92
42410 $ 533.39
42415 $ 975.41
42420 $ 1,128.03
42425 $ 785.37
42426 $ 1,348.34
42440 $ 454.37
42450 $ 282.57
42550 $ 225.03
42700 $ 109.19
42720 $ 285.59
42725 $ 565.99
42800 $ 97.24
42804 $ 97.39
42806 $ 119.80
42808 $ 179.93
42809 $ 118.56
42810 $ 242.85
42815 $ 477.17
42820 $ 240.77
42821 $ 271.07
42825 $ 213.01
42826 $ 229.43
42830 $ 153.36
42831 $ 168.29
42835 $ 149.17
42836 $ 205.27
42842 $ 521.77
42844 $ 839.48
42845 $ 1,400.58
42860 $ 148.28
42870 $ 305.51
42890 $ 748.71
42892 $ 902.69
42894 $ 1,304.71
42900 $ 306.89
42950 $ 533.90
42953 $ 538.28
42955 $ 400.33
42960 $ 127.01
42961 $ 292.46
42962 $ 430.85
42970 $ 252.38
Rev 1/1/2010
58 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
42971 $ 336.98 Effective January 1, 2010
42972 $ 401.93
43020 $ 497.67
43030 $ 510.22
43045 $ 1,123.10
43100 $ 531.35
43101 $ 890.20
43107 $ 1,659.51
43108 $ 1,900.61
43112 $ 1,763.56
43113 $ 1,965.00
43116 $ 1,792.72
43117 $ 1,763.13
43118 $ 1,860.83
43121 $ 1,677.15
43122 $ 1,632.20
43123 $ 1,900.08
43124 $ 1,601.77
43130 $ 729.88
43135 $ 951.47
43200 $ 166.90
43201 $ 215.36
43202 $ 176.20
43204 $ 217.87
43205 $ 192.88
43215 $ 153.00
43216 $ 139.76
43217 $ 168.12
43219 $ 163.38
43220 $ 121.85
43226 $ 135.39
43227 $ 208.10
43228 $ 219.09
43231 $ 225.45
43232 $ 262.04
43234 $ 166.13
43235 $ 203.91
43236 $ 250.52
43237 $ 188.54
43238 $ 233.65
43239 $ 210.98
43240 $ 397.56
43241 $ 149.85
43242 $ 285.50
43243 $ 263.54
43244 $ 237.25
43245 $ 196.14
43246 $ 250.87
43247 $ 196.14
43248 $ 181.98
43249 $ 167.18
43250 $ 185.11
Rev 1/1/2010
59 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
43251 $ 213.77 Effective January 1, 2010
43255 $ 253.45
43256 $ 225.00
43257 $ 264.79
43258 $ 262.88
43259 $ 257.76
43260 $ 333.27
43261 $ 345.12
43262 $ 426.30
43263 $ 339.74
43264 $ 497.85
43265 $ 460.99
43267 $ 413.80
43268 $ 425.98
43269 $ 348.23
43271 $ 416.74
43272 $ 381.49
43273 $ 106.52
43279 $ 994.36
43280 $ 937.80
43281 $ 1,020.06
43282 $ 1,147.20
43300 $ 599.62
43305 $ 1,013.91
43310 $ 1,460.18
43312 $ 1,597.55
43313 $ 2,517.22
43314 $ 2,765.58
43320 $ 927.68
43324 $ 913.54
43325 $ 900.11
43326 $ 853.74
43330 $ 882.05
43331 $ 984.84
43340 $ 922.77
43341 $ 966.10
43350 $ 703.72
43351 $ 842.09
43352 $ 734.91
43360 $ 1,626.06
43361 $ 1,853.78
43400 $ 900.33
43401 $ 926.00
43405 $ 950.19
43410 $ 676.89
43415 $ 987.18
43420 $ 610.09
43425 $ 954.34
43450 $ 78.04
43453 $ 84.63
43456 $ 142.20
Rev 1/1/2010
60 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
43458 $ 145.20 Effective January 1, 2010
43460 $ 178.97
43500 $ 463.24
43501 $ 787.75
43502 $ 888.53
43510 $ 577.71
43520 $ 427.25
43600 $ 82.33
43605 $ 489.33
43610 $ 614.28
43611 $ 714.11
43620 $ 1,206.15
43621 $ 1,225.15
43622 $ 1,282.24
43631 $ 1,029.95
43632 $ 1,028.69
43633 $ 1,046.13
43634 $ 1,276.07
43635 $ 101.53
43640 $ 798.28
43641 $ 812.11
43645 $ 1,491.29
43651 $ 509.97
43652 $ 610.08
43653 $ 440.98
43760 $ 69.66
43761 $ 93.50
43770 $ 839.07
43771 $ 965.36
43772 $ 735.47
43773 $ 965.66
43774 $ 737.77
43775 $ 857.04
43800 $ 565.71
43810 $ 603.77
43820 $ 639.28
43825 $ 804.85
43830 $ 423.21
43831 $ 407.36
43832 $ 644.94
43840 $ 637.17
43842 $ 900.86
43843 $ 892.77
43846 $ 1,091.12
43847 $ 1,198.31
43848 $ 1,280.80
43850 $ 1,015.63
43855 $ 1,036.10
43860 $ 1,022.95
43865 $ 1,104.54
43870 $ 421.46
43880 $ 962.33
Rev 1/1/2010
61 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
43886 $ 235.82 Effective January 1, 2010
43887 $ 229.96
43888 $ 325.81
44005 $ 722.16
44010 $ 577.33
44015 $ 154.75
44020 $ 635.92
44021 $ 633.25
44025 $ 645.52
44050 $ 614.97
44055 $ 682.29
44100 $ 102.37
44110 $ 559.49
44111 $ 687.56
44120 $ 768.53
44121 $ 219.00
44125 $ 809.99
44126 $ 1,877.38
44127 $ 2,158.56
44128 $ 230.91
44130 $ 669.03
44139 $ 109.99
44140 $ 962.89
44141 $ 1,061.86
44143 $ 1,096.06
44144 $ 1,028.91
44145 $ 1,195.86
44146 $ 1,312.68
44147 $ 1,036.77
44150 $ 1,186.05
44151 $ 1,069.31
44155 $ 1,350.14
44156 $ 1,218.68
44157 $ 1,616.42
44158 $ 1,657.83
44160 $ 882.63
44180 $ 709.13
44186 $ 499.80
44187 $ 826.82
44188 $ 906.40
44201 $ 460.40
44202 $ 1,143.03
44203 $ 201.98
44204 $ 1,294.37
44205 $ 1,146.38
44206 $ 1,274.52
44207 $ 1,394.10
44208 $ 1,508.93
44210 $ 1,336.07
44211 $ 1,659.45
44212 $ 1,550.75
44213 $ 161.95
Rev 1/1/2010
62 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
44227 $ 1,274.43 Effective January 1, 2010
44300 $ 497.63
44310 $ 678.73
44312 $ 323.59
44314 $ 637.27
44316 $ 878.14
44320 $ 734.70
44322 $ 725.86
44340 $ 286.57
44345 $ 581.74
44346 $ 658.02
44360 $ 168.44
44361 $ 185.78
44363 $ 203.01
44364 $ 243.67
44365 $ 215.33
44366 $ 286.51
44369 $ 293.75
44370 $ 224.27
44372 $ 287.42
44373 $ 226.98
44376 $ 290.21
44377 $ 304.38
44378 $ 389.70
44379 $ 366.03
44380 $ 87.21
44382 $ 104.84
44383 $ 125.07
44385 $ 157.67
44386 $ 173.97
44388 $ 234.12
44389 $ 257.56
44390 $ 272.43
44391 $ 321.72
44392 $ 306.80
44393 $ 352.24
44394 $ 337.26
44397 $ 234.80
44500 $ 24.20
44602 $ 581.56
44603 $ 742.49
44604 $ 731.66
44605 $ 807.34
44615 $ 708.34
44620 $ 561.72
44625 $ 726.47
44626 $ 1,126.37
44640 $ 737.68
44650 $ 766.42
44660 $ 749.05
44661 $ 946.75
44680 $ 748.86
Rev 1/1/2010
63 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
44700 $ 796.05 Effective January 1, 2010
44701 $ 138.50
44800 $ 563.62
44820 $ 538.35
44850 $ 504.54
44900 $ 459.09
44901 $ 222.17
44950 $ 458.73
44955 $ 90.28
44960 $ 563.14
44970 $ 450.09
45000 $ 234.80
45005 $ 157.69
45020 $ 260.08
45100 $ 231.13
45108 $ 299.70
45110 $ 1,284.96
45111 $ 906.34
45112 $ 1,357.52
45113 $ 1,343.89
45114 $ 1,235.27
45116 $ 1,058.16
45119 $ 1,362.67
45120 $ 1,303.56
45121 $ 1,316.91
45123 $ 804.09
45126 $ 1,739.79
45130 $ 742.45
45135 $ 967.64
45150 $ 339.73
45160 $ 676.57
45171 $ 386.55
45172 $ 530.40
45190 $ 444.44
45300 $ 54.68
45303 $ 62.59
45305 $ 73.21
45307 $ 123.08
45308 $ 97.99
45309 $ 124.67
45315 $ 151.02
45317 $ 149.21
45320 $ 164.43
45321 $ 109.54
45327 $ 88.17
45330 $ 74.94
45331 $ 102.19
45332 $ 149.83
45333 $ 151.75
45334 $ 162.88
45335 $ 126.42
Rev 1/1/2010
64 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
45337 $ 137.24 Effective January 1, 2010
45338 $ 181.26
45339 $ 202.44
45340 $ 291.13
45341 $ 195.86
45342 $ 225.65
45345 $ 151.32
45355 $ 158.37
45378 $ 290.95
45379 $ 354.26
45380 $ 315.67
45381 $ 340.47
45382 $ 410.37
45383 $ 411.75
45384 $ 354.33
45385 $ 403.07
45386 $ 653.76
45387 $ 306.35
45391 $ 245.47
45392 $ 309.93
45395 $ 1,507.59
45397 $ 1,636.70
45400 $ 880.10
45402 $ 1,191.37
45500 $ 417.04
45505 $ 364.96
45520 $ 40.39
45540 $ 720.66
45541 $ 634.70
45550 $ 962.95
45560 $ 441.20
45562 $ 653.02
45563 $ 1,007.86
45800 $ 749.51
45805 $ 909.23
45820 $ 760.44
45825 $ 885.53
45900 $ 85.12
45905 $ 114.54
45910 $ 145.30
45915 $ 153.02
45990 $ 85.31
46020 $ 217.74
46030 $ 92.84
46040 $ 280.90
46045 $ 222.67
46050 $ 103.48
46060 $ 344.49
46070 $ 158.12
46080 $ 176.66
46083 $ 128.28
Rev 1/1/2010
65 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
46200 $ 231.37 Effective January 1, 2010
46220 $ 84.14
46221 $ 107.04
46230 $ 166.01
46250 $ 286.55
46255 $ 358.66
46257 $ 359.86
46258 $ 385.39
46260 $ 426.83
46261 $ 467.87
46262 $ 490.09
46270 $ 235.84
46275 $ 316.60
46280 $ 367.85
46285 $ 239.25
46288 $ 371.73
46320 $ 124.79
46500 $ 100.74
46505 $ 194.30
46600 $ 33.44
46604 $ 65.89
46606 $ 47.16
46608 $ 98.02
46610 $ 81.25
46611 $ 106.65
46612 $ 140.37
46614 $ 121.19
46615 $ 144.17
46700 $ 418.01
46705 $ 375.17
46706 $ 120.71
46707 $ 296.41
46710 $ 794.78
46712 $ 1,662.71
46715 $ 388.04
46716 $ 624.05
46730 $ 1,103.73
46735 $ 1,306.48
46740 $ 1,156.16
46742 $ 1,595.09
46744 $ 1,721.14
46746 $ 1,944.70
46748 $ 2,096.00
46750 $ 454.08
46751 $ 451.81
46753 $ 364.61
46760 $ 603.19
46761 $ 579.61
46762 $ 521.46
46900 $ 123.23
46910 $ 129.38
Rev 1/1/2010
66 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
46916 $ 124.09 Effective January 1, 2010
46917 $ 164.28
46922 $ 141.81
46924 $ 213.02
46940 $ 133.27
46942 $ 119.14
46945 $ 142.48
46946 $ 193.14
46947 $ 284.74
47000 $ 208.34
47001 $ 100.43
47010 $ 563.62
47011 $ 248.79
47015 $ 538.98
47100 $ 392.16
47120 $ 1,185.85
47122 $ 1,790.03
47125 $ 1,634.64
47130 $ 1,769.13
47134 $ 1,930.94
47135 $ 4,397.55
47136 $ 3,553.87
47140 $ 2,651.40
47141 $ 3,203.89
47142 $ 3,528.38
47300 $ 556.04
47350 $ 672.35
47360 $ 931.10
47361 $ 1,516.49
47362 $ 604.97
47380 $ 954.54
47381 $ 943.59
47382 $ 569.49
47400 $ 1,021.86
47420 $ 871.10
47425 $ 909.69
47460 $ 906.51
47480 $ 539.71
47490 $ 397.37
47500 $ 98.40
47505 $ 263.63
47510 $ 451.91
47511 $ 554.15
47525 $ 250.02
47530 $ 282.30
47550 $ 148.50
47552 $ 258.51
47553 $ 300.76
47554 $ 422.85
47555 $ 323.99
47556 $ 359.61
Rev 1/1/2010
67 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
47560 $ 245.49 Effective January 1, 2010
47561 $ 276.62
47562 $ 597.08
47563 $ 642.28
47564 $ 762.52
47570 $ 686.01
47600 $ 619.41
47605 $ 667.11
47610 $ 829.82
47612 $ 911.54
47620 $ 923.91
47630 $ 405.55
47700 $ 770.56
47701 $ 1,306.05
47711 $ 1,028.53
47712 $ 1,276.58
47715 $ 824.77
47719 $ 850.72
47720 $ 742.20
47721 $ 891.10
47740 $ 848.02
47741 $ 1,017.80
47760 $ 1,117.65
47765 $ 1,159.63
47780 $ 1,166.11
47785 $ 1,333.03
47800 $ 1,059.93
47801 $ 646.52
47802 $ 964.26
47900 $ 950.21
48000 $ 750.51
48001 $ 929.05
48020 $ 701.25
48100 $ 554.81
48102 $ 305.65
48105 $ 2,063.37
48120 $ 772.52
48140 $ 1,102.45
48145 $ 1,184.96
48146 $ 1,305.75
48148 $ 819.11
48150 $ 2,209.82
48152 $ 2,058.31
48153 $ 2,208.23
48154 $ 2,062.38
48155 $ 1,325.69
48400 $ 91.30
48500 $ 721.55
48510 $ 669.59
48511 $ 243.17
48520 $ 787.25
Rev 1/1/2010
68 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
48540 $ 963.03 Effective January 1, 2010
48545 $ 832.96
48547 $ 1,160.44
48548 $ 1,203.84
49000 $ 615.02
49002 $ 559.29
49010 $ 652.42
49020 $ 778.56
49021 $ 247.79
49040 $ 545.32
49041 $ 260.85
49060 $ 590.34
49061 $ 246.20
49062 $ 636.96
49080 $ 106.61
49081 $ 99.33
49180 $ 182.23
49203 $ 802.90
49204 $ 1,022.82
49205 $ 1,169.78
49215 $ 1,077.35
49220 $ 844.10
49250 $ 443.84
49255 $ 568.64
49320 $ 296.87
49321 $ 316.44
49322 $ 328.66
49323 $ 507.95
49400 $ 90.71
49402 $ 617.62
49411 $ 339.32
49419 $ 349.95
49420 $ 115.92
49421 $ 323.18
49422 $ 333.60
49423 $ 75.57
49424 $ 38.62
49425 $ 652.60
49426 $ 517.21
49427 $ 41.75
49428 $ 131.46
49429 $ 371.93
49441 $ 1,043.67
49442 $ 850.60
49446 $ 871.35
49450 $ 612.45
49451 $ 647.89
49452 $ 791.14
49460 $ 650.64
49465 $ 134.78
49491 $ 616.74
Rev 1/1/2010
69 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
49492 $ 756.48 Effective January 1, 2010
49495 $ 345.63
49496 $ 495.86
49500 $ 294.45
49501 $ 410.97
49505 $ 363.81
49507 $ 453.89
49520 $ 449.97
49521 $ 519.82
49525 $ 417.01
49540 $ 476.78
49550 $ 397.08
49553 $ 426.13
49555 $ 443.50
49557 $ 510.03
49560 $ 523.40
49561 $ 609.61
49565 $ 538.16
49566 $ 627.74
49568 $ 241.25
49570 $ 293.51
49572 $ 350.86
49580 $ 230.65
49582 $ 344.18
49585 $ 317.04
49587 $ 357.75
49590 $ 417.69
49600 $ 533.03
49605 $ 1,101.71
49606 $ 923.33
49610 $ 558.92
49611 $ 551.62
49650 $ 345.78
49651 $ 443.22
49652 $ 604.23
49653 $ 754.44
49654 $ 693.57
49655 $ 834.93
49656 $ 696.19
49657 $ 1,004.91
49900 $ 589.67
49904 $ 1,209.02
49905 $ 323.39
50010 $ 633.95
50020 $ 775.13
50021 $ 287.33
50040 $ 773.01
50045 $ 811.72
50060 $ 995.52
50065 $ 1,081.95
Rev 1/1/2010
70 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
50070 $ 1,053.79 Effective January 1, 2010
50075 $ 1,313.32
50080 $ 849.09
50081 $ 1,168.40
50100 $ 891.65
50120 $ 842.89
50125 $ 876.87
50130 $ 929.87
50135 $ 1,076.91
50200 $ 144.45
50205 $ 575.64
50220 $ 940.24
50225 $ 1,110.73
50230 $ 1,212.03
50234 $ 1,194.10
50236 $ 1,338.39
50240 $ 1,200.56
50250 $ 964.89
50280 $ 835.92
50290 $ 770.62
50300 $ 511.97
50320 $ 1,199.74
50340 $ 775.44
50360 $ 1,767.39
50365 $ 2,101.11
50370 $ 806.23
50380 $ 1,074.94
50382 $ 1,454.01
50384 $ 1,405.45
50385 $ 1,175.10
50386 $ 758.31
50387 $ 706.40
50389 $ 484.25
50390 $ 101.61
50391 $ 122.15
50392 $ 165.30
50393 $ 205.24
50394 $ 242.49
50395 $ 182.28
50396 $ 86.08
50398 $ 71.00
50400 $ 1,029.24
50405 $ 1,288.00
50500 $ 1,050.66
50520 $ 915.12
50525 $ 1,173.06
50526 $ 1,166.36
50540 $ 1,048.22
50541 $ 738.45
50542 $ 941.09
Rev 1/1/2010
71 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
50543 $ 1,183.93 Effective January 1, 2010
50544 $ 1,017.26
50545 $ 1,284.32
50546 $ 943.81
50547 $ 1,212.62
50548 $ 1,107.40
50551 $ 293.30
50553 $ 489.05
50555 $ 497.53
50557 $ 590.00
50559 $ 282.08
50561 $ 600.88
50562 $ 499.07
50570 $ 389.94
50572 $ 519.61
50574 $ 543.56
50575 $ 707.50
50576 $ 572.36
50578 $ 506.86
50580 $ 516.39
50590 $ 623.04
50592 $ 5,452.81
50593 $ 3,724.80
50600 $ 821.38
50605 $ 751.24
50610 $ 863.93
50620 $ 823.80
50630 $ 836.44
50650 $ 926.86
50660 $ 1,018.86
50684 $ 247.91
50686 $ 127.93
50688 $ 67.43
50690 $ 266.75
50700 $ 852.81
50715 $ 997.82
50722 $ 864.70
50725 $ 979.05
50727 $ 457.82
50728 $ 660.50
50740 $ 989.93
50750 $ 1,041.19
50760 $ 992.31
50770 $ 1,061.22
50780 $ 993.98
50782 $ 1,046.52
50783 $ 1,082.10
50785 $ 1,106.21
50800 $ 878.14
50810 $ 1,090.73
Rev 1/1/2010
72 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
50815 $ 1,175.99 Effective January 1, 2010
50820 $ 1,236.62
50825 $ 1,683.34
50830 $ 1,636.24
50840 $ 1,066.74
50845 $ 1,080.35
50860 $ 831.04
50900 $ 745.49
50920 $ 768.11
50930 $ 985.57
50940 $ 791.56
50945 $ 780.75
50947 $ 1,386.62
50948 $ 1,267.69
50951 $ 295.61
50953 $ 500.30
50955 $ 465.54
50957 $ 466.76
50959 $ 225.63
50961 $ 598.91
50970 $ 363.84
50972 $ 290.38
50974 $ 472.39
50976 $ 457.74
50978 $ 270.96
50980 $ 315.45
51020 $ 420.27
51030 $ 385.01
51040 $ 290.30
51045 $ 392.30
51050 $ 426.83
51060 $ 550.47
51065 $ 503.70
51080 $ 364.99
51100 $ 49.26
51101 $ 101.86
51102 $ 260.67
51500 $ 553.41
51520 $ 547.11
51525 $ 764.40
51530 $ 684.07
51535 $ 665.97
51550 $ 836.31
51555 $ 1,080.39
51565 $ 1,160.83
51570 $ 1,258.54
51575 $ 1,632.49
51580 $ 1,608.47
51585 $ 1,858.27
51590 $ 1,743.99
Rev 1/1/2010
73 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
51595 $ 2,074.52 Effective January 1, 2010
51596 $ 2,190.29
51597 $ 2,082.58
51600 $ 250.37
51605 $ 250.60
51610 $ 269.42
51700 $ 89.80
51701 $ 51.50
51702 $ 81.50
51703 $ 111.65
51705 $ 77.16
51710 $ 130.19
51715 $ 230.44
51720 $ 131.97
51725 26 $ 68.96
51725 TC $ 14.02
51725 $ 82.98
51726 26 $ 79.65
51726 TC $ 17.84
51726 $ 97.49
51727 $ 72.24
51727 $ 123.50
51727 $ 195.74
51728 $ 71.36
51728 $ 124.23
51728 $ 195.59
51729 $ 84.92
51729 $ 125.69
51729 $ 210.61
51736 26 $ 28.22
51736 TC $ 5.42
51736 $ 33.63
51741 26 $ 50.10
51741 TC $ 7.95
51741 $ 58.07
51772 26 $ 71.40
51772 TC $ 15.93
51772 $ 87.33
51784 26 $ 70.52
51784 TC $ 14.35
51784 $ 84.86
51785 26 $ 70.21
51785 TC $ 14.35
51785 $ 84.57
51792 26 $ 53.38
51792 TC $ 49.06
51792 $ 102.44
51795 26 $ 68.95
51795 TC $ 32.15
Rev 1/1/2010
74 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
51795 $ 101.10 Effective January 1, 2010
51797 26 $ 70.46
51797 TC $ 16.89
51797 $ 87.33
51798 $ 17.87
51800 $ 924.21
51820 $ 881.43
51840 $ 613.69
51841 $ 743.93
51845 $ 603.71
51860 $ 651.16
51865 $ 821.59
51880 $ 421.72
51900 $ 751.05
51920 $ 629.43
51925 $ 833.63
51940 $ 1,436.01
51960 $ 1,322.04
51980 $ 613.47
51990 $ 605.71
51992 $ 659.23
52000 $ 136.41
52001 $ 126.70
52005 $ 190.84
52007 $ 164.55
52010 $ 210.68
52204 $ 205.58
52214 $ 263.18
52224 $ 243.88
52234 $ 338.20
52235 $ 392.16
52240 $ 636.50
52250 $ 221.99
52260 $ 186.70
52265 $ 173.91
52270 $ 268.66
52275 $ 319.84
52276 $ 351.58
52277 $ 320.26
52281 $ 185.91
52282 $ 401.14
52283 $ 245.52
52285 $ 269.36
52290 $ 216.46
52300 $ 263.78
52301 $ 272.35
52305 $ 264.42
52310 $ 365.68
52315 $ 478.91
52317 $ 688.58
Rev 1/1/2010
75 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
52318 $ 488.67 Effective January 1, 2010
52320 $ 264.08
52325 $ 353.62
52327 $ 263.27
52330 $ 525.23
52332 $ 598.95
52334 $ 242.48
52341 $ 319.06
52342 $ 345.35
52343 $ 382.58
52344 $ 408.89
52345 $ 435.88
52346 $ 490.29
52347 $ 268.49
52351 $ 326.10
52352 $ 404.20
52353 $ 468.27
52354 $ 409.08
52355 $ 480.00
52400 $ 572.37
52402 $ 241.36
52450 $ 430.97
52500 $ 504.79
52510 $ 432.86
52601 $ 731.24
52630 $ 468.52
52640 $ 410.86
52647 $ 614.40
52648 $ 685.94
52649 $ 750.81
52700 $ 369.28
53000 $ 209.48
53010 $ 240.58
53020 $ 134.70
53025 $ 118.04
53040 $ 387.95
53060 $ 188.56
53080 $ 406.36
53085 $ 598.06
53200 $ 183.55
53210 $ 645.25
53215 $ 815.64
53220 $ 390.87
53230 $ 543.66
53235 $ 514.90
53240 $ 362.16
53250 $ 331.67
53260 $ 203.94
53265 $ 227.84
53270 $ 204.12
Rev 1/1/2010
76 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
53275 $ 237.34 Effective January 1, 2010
53400 $ 663.82
53405 $ 777.81
53410 $ 821.60
53415 $ 986.00
53420 $ 777.78
53425 $ 821.48
53430 $ 796.31
53431 $ 1,007.29
53440 $ 757.49
53442 $ 456.92
53444 $ 724.22
53445 $ 857.33
53446 $ 674.81
53447 $ 708.62
53448 $ 1,210.08
53449 $ 560.90
53450 $ 319.07
53460 $ 352.29
53500 $ 621.49
53502 $ 421.55
53505 $ 419.07
53510 $ 555.72
53515 $ 705.54
53520 $ 472.78
53600 $ 105.48
53601 $ 96.09
53605 $ 57.33
53620 $ 150.54
53621 $ 139.95
53660 $ 84.52
53661 $ 85.16
53665 $ 35.75
53850 $ 529.75
53852 $ 520.34
53855 $ 439.39
54000 $ 143.60
54001 $ 174.99
54015 $ 306.37
54050 $ 82.71
54055 $ 145.85
54056 $ 93.33
54057 $ 107.37
54060 $ 162.76
54065 $ 202.01
54100 $ 127.88
54105 $ 224.94
54110 $ 554.30
54111 $ 739.93
54112 $ 864.70
Rev 1/1/2010
77 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
54115 $ 434.68 Effective January 1, 2010
54120 $ 556.13
54125 $ 781.27
54130 $ 1,094.93
54135 $ 1,389.89
54150 $ 154.82
54160 $ 198.65
54161 $ 175.17
54162 $ 213.40
54163 $ 200.05
54164 $ 175.84
54200 $ 76.48
54205 $ 453.07
54220 $ 135.34
54230 $ 74.58
54231 $ 123.16
54235 $ 62.88
54240 26 $ 59.51
54240 TC $ 18.14
54240 $ 77.65
54250 26 $ 93.87
54250 TC $ 11.16
54250 $ 105.03
54300 $ 593.78
54304 $ 706.90
54308 $ 629.30
54312 $ 763.23
54316 $ 941.12
54318 $ 643.92
54322 $ 696.29
54324 $ 900.58
54326 $ 866.04
54328 $ 858.68
54332 $ 948.70
54336 $ 1,196.23
54340 $ 520.36
54344 $ 973.72
54348 $ 941.92
54352 $ 1,301.39
54360 $ 642.22
54380 $ 754.16
54385 $ 870.15
54390 $ 1,168.49
54406 $ 593.51
54420 $ 643.38
54430 $ 571.91
54435 $ 360.41
54440 $ 479.96
54450 $ 63.25
54500 $ 137.42
Rev 1/1/2010
78 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
54505 $ 185.21 Effective January 1, 2010
54512 $ 510.80
54520 $ 318.62
54522 $ 581.13
54530 $ 488.86
54535 $ 658.77
54550 $ 420.17
54560 $ 601.44
54600 $ 374.84
54620 $ 266.76
54640 $ 425.42
54650 $ 615.58
54670 $ 346.81
54680 $ 677.07
54690 $ 589.88
54692 $ 605.38
54700 $ 254.43
54800 $ 198.54
54830 $ 293.47
54840 $ 309.06
54860 $ 360.19
54861 $ 497.93
54865 $ 277.79
54900 $ 692.27
54901 $ 957.49
55000 $ 82.78
55040 $ 314.26
55041 $ 453.77
55060 $ 307.66
55100 $ 223.42
55110 $ 302.42
55120 $ 249.89
55150 $ 401.77
55175 $ 304.86
55180 $ 568.87
55200 $ 221.23
55250 $ 287.60
55300 $ 182.65
55450 $ 297.49
55500 $ 318.34
55520 $ 317.92
55530 $ 334.16
55535 $ 354.71
55540 $ 408.05
55550 $ 347.02
55600 $ 347.32
55605 $ 435.26
55650 $ 608.99
55680 $ 304.93
55700 $ 132.04
Rev 1/1/2010
79 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
55705 $ 263.30 Effective January 1, 2010
55706 $ 335.29
55720 $ 396.66
55725 $ 478.86
55801 $ 950.80
55810 $ 1,223.26
55812 $ 1,420.66
55815 $ 1,664.58
55821 $ 825.35
55831 $ 896.04
55840 $ 1,218.54
55842 $ 1,328.90
55845 $ 1,589.50
55860 $ 722.83
55862 $ 965.10
55865 $ 1,353.22
55866 $ 1,391.55
55870 $ 142.57
55873 $ 1,060.98
55875 $ 606.04
55876 $ 123.76
55920 $ 323.10
56405 $ 96.20
56420 $ 95.28
56440 $ 194.37
56441 $ 131.59
56442 $ 38.08
56501 $ 94.85
56515 $ 143.84
56605 $ 75.40
56606 $ 47.48
56620 $ 434.30
56625 $ 526.25
56630 $ 759.79
56631 $ 1,002.20
56632 $ 1,170.25
56633 $ 965.67
56634 $ 1,100.39
56637 $ 1,291.86
56640 $ 1,270.86
56700 $ 162.38
56740 $ 229.54
56800 $ 221.80
56805 $ 963.38
56810 $ 225.68
56820 $ 103.98
56821 $ 134.62
57000 $ 169.58
57010 $ 306.29
57020 $ 84.61
Rev 1/1/2010
80 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
57022 $ 157.64 Effective January 1, 2010
57023 $ 157.64
57061 $ 89.67
57065 $ 180.20
57100 $ 64.32
57105 $ 94.04
57106 $ 291.19
57107 $ 1,043.62
57109 $ 1,273.28
57110 $ 723.82
57111 $ 1,276.88
57112 $ 1,358.82
57120 $ 438.20
57130 $ 157.95
57135 $ 165.73
57150 $ 35.95
57155 $ 367.12
57160 $ 54.16
57170 $ 56.07
57180 $ 95.42
57200 $ 223.94
57210 $ 282.25
57220 $ 271.02
57230 $ 316.13
57240 $ 383.91
57250 $ 347.58
57260 $ 501.06
57265 $ 644.56
57267 $ 245.49
57268 $ 412.92
57270 $ 618.73
57280 $ 764.02
57282 $ 525.43
57283 $ 585.72
57284 $ 678.77
57285 $ 467.71
57287 $ 673.61
57288 $ 721.77
57289 $ 627.89
57291 $ 444.63
57292 $ 659.46
57295 $ 405.40
57300 $ 466.85
57305 $ 709.15
57307 $ 771.42
57308 $ 549.30
57310 $ 369.86
57311 $ 438.08
57320 $ 496.45
57330 $ 654.45
Rev 1/1/2010
81 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
57335 $ 884.23 Effective January 1, 2010
57400 $ 100.49
57410 $ 104.26
57415 $ 130.05
57420 $ 108.43
57421 $ 141.28
57423 $ 650.01
57425 $ 776.32
57426 $ 567.11
57452 $ 69.12
57454 $ 89.33
57455 $ 130.09
57456 $ 123.07
57460 $ 159.47
57461 $ 291.33
57500 $ 63.69
57505 $ 77.29
57510 $ 118.81
57511 $ 113.68
57513 $ 137.07
57520 $ 256.86
57522 $ 228.75
57530 $ 276.25
57531 $ 1,452.89
57540 $ 623.56
57545 $ 616.08
57550 $ 347.87
57555 $ 554.11
57556 $ 514.08
57558 $ 100.40
57700 $ 199.10
57720 $ 234.69
57800 $ 50.77
58100 $ 53.38
58110 $ 44.82
58120 $ 213.15
58140 $ 746.51
58145 $ 484.34
58146 $ 939.37
58150 $ 791.90
58152 $ 827.68
58180 $ 797.84
58200 $ 1,114.64
58210 $ 1,484.46
58240 $ 2,069.85
58260 $ 661.55
58262 $ 732.43
58263 $ 799.31
58267 $ 809.20
58270 $ 728.15
Rev 1/1/2010
82 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
58275 $ 800.51 Effective January 1, 2010
58280 $ 808.13
58285 $ 970.44
58290 $ 939.94
58291 $ 1,033.53
58292 $ 1,094.52
58293 $ 1,137.25
58294 $ 1,008.17
58300 $ 62.48
58301 $ 72.99
58340 $ 191.68
58345 $ 239.16
58353 $ 1,339.97
58356 $ 2,347.45
58400 $ 371.36
58410 $ 622.95
58520 $ 570.87
58540 $ 692.32
58545 $ 755.42
58546 $ 952.28
58550 $ 740.78
58552 $ 735.70
58553 $ 946.53
58554 $ 936.31
58555 $ 186.47
58558 $ 242.66
58559 $ 310.67
58560 $ 343.43
58561 $ 482.53
58562 $ 241.20
58563 $ 2,157.98
58565 $ 1,971.32
58570 $ 646.15
58571 $ 707.02
58572 $ 801.22
58573 $ 902.73
58600 $ 241.37
58605 $ 227.22
58611 $ 35.40
58615 $ 228.50
58660 $ 564.99
58661 $ 573.96
58662 $ 574.74
58670 $ 321.54
58671 $ 331.15
58672 $ 620.81
58673 $ 660.71
58700 $ 388.96
58720 $ 602.64
58740 $ 363.56
Rev 1/1/2010
83 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
58770 $ 670.40 Effective January 1, 2010
58800 $ 245.32
58805 $ 364.33
58820 $ 233.47
58822 $ 483.80
58823 $ 199.32
58825 $ 334.73
58900 $ 349.52
58920 $ 408.52
58925 $ 586.82
58940 $ 423.00
58943 $ 976.04
58950 $ 835.97
58951 $ 1,217.17
58952 $ 1,339.72
58953 $ 1,759.93
58954 $ 1,912.61
58956 $ 1,150.45
58960 $ 839.59
59000 $ 85.14
59001 $ 159.47
59012 $ 182.84
59015 $ 114.65
59020 26 $ 39.04
59020 TC $ 19.34
59020 $ 58.37
59025 26 $ 27.64
59025 TC $ 8.58
59025 $ 36.21
59030 $ 105.91
59050 $ 49.36
59051 $ 43.42
59070 $ 346.38
59072 $ 411.02
59074 $ 329.30
59076 $ 411.02
59100 $ 580.45
59120 $ 612.06
59121 $ 576.92
59130 $ 701.33
59135 $ 755.24
59136 $ 663.44
59140 $ 322.58
59150 $ 372.42
59151 $ 476.51
59160 $ 194.21
59300 $ 122.75
59320 $ 134.83
59325 $ 217.11
59350 $ 256.54
Rev 1/1/2010
84 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
59400 $ 1,305.47 Effective January 1, 2010
59409 $ 797.43
59410 $ 901.00
59412 $ 96.88
59414 $ 91.87
59425 $ 284.91
59426 $ 488.24
59430 $ 96.12
59510 $ 1,416.74
59514 $ 1,096.43
59515 $ 1,200.00
59525 $ 403.30
59610 $ 1,323.17
59612 $ 820.04
59614 $ 901.00
59618 $ 1,605.00
59620 $ 1,096.43
59622 $ 1,200.00
59812 $ 239.13
59820 $ 270.04
59821 $ 274.39
59830 $ 341.20
59840 $ 231.04
59841 $ 336.67
59850 $ 307.44
59851 $ 318.64
59852 $ 440.54
59855 $ 327.11
59870 $ 239.33
59871 $ 131.44
60000 $ 102.34
60100 $ 83.29
60200 $ 531.36
60210 $ 622.78
60212 $ 834.54
60220 $ 608.13
60225 $ 790.61
60240 $ 876.30
60252 $ 1,019.22
60254 $ 1,365.89
60260 $ 727.03
60270 $ 1,049.00
60271 $ 865.07
60280 $ 397.89
60281 $ 478.75
60300 $ 77.19
60500 $ 879.44
60502 $ 1,051.76
60505 $ 1,163.62
60512 $ 220.92
Rev 1/1/2010
85 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
60520 $ 1,003.74 Effective January 1, 2010
60521 $ 1,135.81
60522 $ 1,298.28
60540 $ 908.38
60545 $ 1,074.39
60600 $ 1,054.88
60605 $ 1,160.69
61000 $ 96.67
61001 $ 90.66
61020 $ 107.56
61026 $ 122.25
61050 $ 90.89
61055 $ 120.60
61070 $ 142.25
61105 $ 346.03
61107 $ 328.60
61108 $ 684.17
61120 $ 521.70
61140 $ 989.69
61150 $ 1,070.36
61151 $ 630.40
61154 $ 993.98
61156 $ 1,050.36
61210 $ 375.88
61215 $ 340.37
61250 $ 632.31
61253 $ 741.94
61304 $ 1,430.12
61305 $ 1,725.90
61312 $ 1,559.07
61313 $ 1,573.39
61314 $ 1,569.08
61315 $ 1,704.80
61316 $ 74.85
61320 $ 1,507.51
61321 $ 1,644.39
61322 $ 1,527.02
61323 $ 1,580.59
61330 $ 1,305.40
61332 $ 1,645.71
61333 $ 1,592.53
61334 $ 1,088.75
61340 $ 1,128.19
61343 $ 1,905.68
61345 $ 1,607.68
61440 $ 1,506.20
61450 $ 1,546.66
61458 $ 1,734.85
61460 $ 1,730.19
61470 $ 1,409.65
Rev 1/1/2010
86 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
61480 $ 1,476.14 Effective January 1, 2010
61490 $ 1,381.77
61500 $ 1,168.47
61501 $ 966.33
61510 $ 1,786.06
61512 $ 2,123.05
61514 $ 1,612.82
61516 $ 1,607.07
61517 $ 64.03
61518 $ 2,252.83
61519 $ 2,456.14
61520 $ 3,094.72
61521 $ 2,611.35
61522 $ 1,718.20
61524 $ 1,771.42
61526 $ 2,903.79
61530 $ 2,575.74
61531 $ 958.57
61533 $ 1,219.80
61534 $ 1,089.67
61535 $ 682.37
61536 $ 2,035.39
61537 $ 1,472.26
61538 $ 1,759.32
61539 $ 1,893.24
61540 $ 1,777.43
61541 $ 1,681.92
61542 $ 1,801.80
61543 $ 1,642.56
61544 $ 1,621.84
61545 $ 2,470.58
61546 $ 1,920.87
61548 $ 1,402.55
61550 $ 816.76
61552 $ 1,044.40
61555 $ 2,703.14
61556 $ 1,253.63
61557 $ 1,286.09
61558 $ 1,483.13
61559 $ 1,920.80
61563 $ 1,549.47
61564 $ 1,849.42
61566 $ 1,762.11
61567 $ 2,015.96
61570 $ 1,405.41
61571 $ 1,523.47
61575 $ 2,135.78
61576 $ 2,840.00
61580 $ 1,701.58
61581 $ 1,911.05
Rev 1/1/2010
87 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
61582 $ 1,820.68 Effective January 1, 2010
61583 $ 2,115.48
61584 $ 2,014.17
61585 $ 2,236.51
61586 $ 1,497.21
61590 $ 2,354.00
61591 $ 2,490.06
61592 $ 2,310.18
61595 $ 1,678.41
61596 $ 2,017.31
61597 $ 2,170.71
61598 $ 1,919.09
61600 $ 1,455.66
61601 $ 1,622.21
61605 $ 1,642.06
61606 $ 2,262.78
61607 $ 2,107.90
61608 $ 2,460.73
61609 $ 567.58
61610 $ 1,676.45
61611 $ 415.27
61612 $ 1,581.03
61613 $ 2,401.47
61615 $ 1,837.06
61616 $ 2,518.23
61618 $ 989.65
61619 $ 1,198.37
61623 $ 466.02
61624 $ 1,021.62
61626 $ 835.44
61635 $ 1,133.37
61680 $ 1,967.11
61682 $ 3,431.17
61684 $ 2,378.27
61686 $ 3,595.83
61690 $ 1,822.03
61692 $ 2,850.08
61697 $ 3,198.22
61698 $ 3,078.51
61700 $ 2,870.65
61702 $ 2,860.11
61703 $ 1,027.81
61705 $ 2,167.70
61708 $ 1,817.61
61710 $ 1,515.29
61711 $ 2,244.49
61720 $ 1,111.71
61735 $ 1,183.67
61750 $ 1,082.65
61751 $ 1,161.14
Rev 1/1/2010
88 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
61760 $ 1,186.04 Effective January 1, 2010
61770 $ 1,331.51
61790 $ 679.22
61795 $ 261.05
61796 $ 611.80
61797 $ 167.06
61798 $ 611.80
61799 $ 230.95
61800 $ 118.22
61862 $ 1,102.81
61863 $ 1,055.35
61864 $ 253.36
61867 $ 1,601.00
61868 $ 422.73
61880 $ 371.08
61885 $ 273.54
61886 $ 483.20
61888 $ 289.08
62000 $ 604.32
62005 $ 913.06
62010 $ 1,250.90
62100 $ 1,399.97
62115 $ 1,201.57
62116 $ 1,372.25
62117 $ 1,573.35
62120 $ 1,353.28
62121 $ 1,299.22
62140 $ 870.63
62141 $ 989.29
62142 $ 721.42
62143 $ 780.25
62145 $ 1,114.17
62146 $ 944.65
62147 $ 1,115.42
62148 $ 102.21
62160 $ 147.36
62161 $ 1,054.38
62162 $ 1,350.99
62163 $ 856.05
62164 $ 1,462.02
62165 $ 1,146.98
62180 $ 1,233.71
62190 $ 738.09
62192 $ 817.97
62194 $ 235.08
62200 $ 1,158.41
62201 $ 854.33
62220 $ 867.01
62223 $ 855.50
62225 $ 348.26
62230 $ 666.63
Rev 1/1/2010
89 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
62252 $ 72.75 Effective January 1, 2010
62252 26 $ 34.88
62252 TC $ 37.87
62256 $ 439.88
62258 $ 932.57
62263 $ 361.36
62264 $ 522.75
62267 $ 202.91
62268 $ 245.08
62269 $ 229.82
62270 $ 107.29
62272 $ 117.54
62273 $ 110.26
62280 $ 170.00
62281 $ 158.74
62282 $ 191.46
62284 $ 141.32
62287 $ 468.98
62290 $ 200.35
62291 $ 198.18
62292 $ 478.12
62294 $ 585.63
62310 $ 171.04
62311 $ 172.67
62318 $ 178.47
62319 $ 173.91
62350 $ 348.03
62351 $ 556.94
62355 $ 286.85
62360 $ 139.42
62361 $ 278.16
62362 $ 367.89
62365 $ 297.55
62367 26 $ 24.77
62367 $ 26.53
62368 26 $ 37.96
62368 $ 41.65
63001 $ 1,057.22
63003 $ 1,068.75
63005 $ 993.80
63011 $ 821.23
63012 $ 1,003.10
63015 $ 1,291.36
63016 $ 1,276.88
63017 $ 1,063.70
63020 $ 996.40
63030 $ 815.83
63035 $ 200.09
63040 $ 1,246.33
63042 $ 1,157.52
63045 $ 1,105.87
Rev 1/1/2010
90 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
63046 $ 1,058.18 Effective January 1, 2010
63047 $ 975.66
63048 $ 206.72
63050 $ 1,222.65
63051 $ 1,391.98
63055 $ 1,448.71
63056 $ 1,321.14
63057 $ 299.58
63064 $ 1,570.28
63066 $ 187.12
63075 $ 1,226.80
63076 $ 258.74
63077 $ 1,305.88
63078 $ 186.47
63081 $ 1,573.43
63082 $ 278.87
63085 $ 1,725.39
63086 $ 201.70
63087 $ 2,091.05
63088 $ 272.18
63090 $ 1,779.59
63091 $ 177.81
63101 $ 1,834.12
63102 $ 1,834.12
63103 $ 213.80
63170 $ 1,275.23
63172 $ 1,193.76
63173 $ 1,318.14
63180 $ 1,059.54
63182 $ 1,220.17
63185 $ 961.93
63190 $ 1,150.41
63191 $ 1,029.04
63194 $ 1,133.39
63195 $ 1,141.53
63196 $ 1,287.37
63197 $ 1,226.88
63198 $ 1,389.49
63199 $ 1,609.29
63200 $ 1,118.12
63250 $ 2,268.53
63251 $ 2,279.88
63252 $ 2,362.55
63265 $ 1,384.18
63266 $ 1,465.49
63267 $ 1,178.69
63268 $ 1,045.42
63270 $ 1,563.37
63271 $ 1,712.00
63272 $ 1,572.65
63273 $ 1,432.71
Rev 1/1/2010
91 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
63275 $ 1,545.95 Effective January 1, 2010
63276 $ 1,523.78
63277 $ 1,359.81
63278 $ 1,340.48
63280 $ 1,803.19
63281 $ 1,779.66
63282 $ 1,642.91
63283 $ 1,452.94
63285 $ 2,087.51
63286 $ 2,138.87
63287 $ 2,143.64
63290 $ 2,187.63
63295 $ 275.40
63300 $ 1,428.24
63301 $ 1,572.82
63302 $ 1,632.10
63303 $ 1,678.38
63304 $ 1,788.01
63305 $ 1,833.70
63306 $ 1,849.04
63307 $ 1,798.35
63308 $ 302.80
63600 $ 757.53
63610 $ 451.53
63615 $ 959.67
63620 $ 611.80
63621 $ 192.07
63650 $ 397.79
63655 $ 682.28
63661 $ 360.46
63662 $ 457.91
63663 $ 530.83
63664 $ 476.64
63685 $ 439.27
63688 $ 344.98
63700 $ 955.06
63702 $ 1,077.55
63704 $ 1,215.67
63706 $ 1,336.22
63707 $ 743.52
63709 $ 936.28
63710 $ 829.95
63740 $ 757.88
63741 $ 528.87
63744 $ 527.07
63746 $ 377.74
64400 $ 79.24
64402 $ 114.71
64405 $ 91.47
64408 $ 103.56
64410 $ 97.55
Rev 1/1/2010
92 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
64412 $ 92.61 Effective January 1, 2010
64413 $ 99.44
64415 $ 95.86
64416 $ 136.70
64417 $ 95.24
64418 $ 93.14
64420 $ 85.62
64421 $ 111.06
64425 $ 102.96
64430 $ 101.03
64435 $ 99.72
64445 $ 105.18
64446 $ 142.07
64447 $ 66.46
64448 $ 130.59
64449 $ 130.85
64450 $ 76.22
64455 $ 41.49
64470 $ 176.58
64472 $ 148.30
64475 $ 157.15
64476 $ 148.93
64479 $ 191.58
64480 $ 173.03
64483 $ 176.91
64484 $ 163.62
64490 $ 109.56
64491 $ 53.82
64492 $ 54.55
64493 $ 99.25
64494 $ 48.32
64495 $ 49.04
64505 $ 89.27
64508 $ 85.21
64510 $ 88.46
64517 $ 164.22
64520 $ 112.01
64530 $ 116.28
64550 $ 20.96
64555 $ 117.79
64561 $ 785.25
64573 $ 399.27
64575 $ 261.42
64581 $ 716.43
64585 $ 152.01
64595 $ 109.34
64600 $ 194.48
64605 $ 270.91
64610 $ 452.90
64612 $ 135.10
64613 $ 119.47
64614 $ 211.91
Rev 1/1/2010
93 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
64620 $ 157.58 Effective January 1, 2010
64622 $ 196.18
64623 $ 96.70
64626 $ 223.80
64627 $ 134.35
64630 $ 172.69
64632 $ 67.65
64640 $ 177.83
64650 $ 52.44
64653 $ 60.26
64680 $ 153.37
64681 $ 409.47
64702 $ 274.30
64704 $ 287.68
64708 $ 402.53
64712 $ 485.19
64713 $ 619.14
64714 $ 510.09
64716 $ 373.71
64718 $ 399.23
64719 $ 319.05
64721 $ 314.84
64722 $ 294.52
64726 $ 196.82
64727 $ 186.49
64732 $ 289.07
64734 $ 308.57
64736 $ 277.32
64738 $ 339.30
64740 $ 330.00
64742 $ 369.77
64744 $ 348.15
64746 $ 352.66
64752 $ 400.09
64755 $ 744.28
64760 $ 413.07
64761 $ 353.82
64763 $ 400.42
64766 $ 508.17
64771 $ 451.90
64772 $ 454.19
64774 $ 280.03
64776 $ 278.67
64778 $ 177.48
64782 $ 344.34
64783 $ 213.09
64784 $ 535.76
64786 $ 914.47
64787 $ 242.23
64788 $ 271.93
64790 $ 629.88
64792 $ 817.72
Rev 1/1/2010
94 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
64795 $ 176.05 Effective January 1, 2010
64802 $ 507.58
64804 $ 857.76
64809 $ 770.53
64818 $ 603.67
64820 $ 598.37
64831 $ 487.25
64832 $ 266.28
64834 $ 516.21
64835 $ 595.16
64836 $ 611.10
64837 $ 342.20
64840 $ 756.42
64856 $ 758.34
64857 $ 811.20
64858 $ 935.80
64859 $ 243.17
64861 $ 1,089.04
64862 $ 1,282.72
64864 $ 692.51
64865 $ 893.99
64866 $ 884.12
64868 $ 830.29
64870 $ 938.28
64872 $ 110.83
64874 $ 164.18
64876 $ 180.06
64885 $ 987.23
64886 $ 1,169.28
64890 $ 888.09
64891 $ 887.63
64892 $ 839.71
64893 $ 942.59
64895 $ 1,070.74
64896 $ 1,206.83
64897 $ 1,013.04
64898 $ 1,106.01
64901 $ 618.20
64902 $ 702.23
64905 $ 756.21
64907 $ 1,050.51
65091 $ 487.85
65093 $ 511.81
65101 $ 521.88
65103 $ 552.82
65105 $ 607.70
65110 $ 936.61
65112 $ 992.16
65114 $ 1,042.74
65125 $ 223.77
65130 $ 524.34
65135 $ 486.67
Rev 1/1/2010
95 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
65140 $ 529.62 Effective January 1, 2010
65150 $ 468.84
65155 $ 619.55
65175 $ 470.42
65205 $ 118.80
65210 $ 127.67
65220 $ 150.80
65222 $ 131.43
65235 $ 449.26
65260 $ 685.76
65265 $ 791.48
65270 $ 136.26
65272 $ 233.11
65273 $ 269.45
65275 $ 264.81
65280 $ 510.44
65285 $ 844.72
65286 $ 387.21
65290 $ 372.56
65400 $ 433.15
65410 $ 101.76
65420 $ 322.19
65426 $ 383.93
65430 $ 158.47
65435 $ 63.83
65436 $ 245.60
65450 $ 270.53
65600 $ 233.19
65710 $ 806.79
65730 $ 943.42
65750 $ 991.07
65755 $ 985.73
65756 $ 844.11
65770 $ 1,047.20
65772 $ 322.71
65775 $ 427.63
65780 $ 668.45
65781 $ 1,016.83
65782 $ 877.04
65800 $ 126.64
65805 $ 127.93
65810 $ 370.86
65815 $ 369.71
65820 $ 584.01
65850 $ 694.81
65855 $ 316.93
65860 $ 243.32
65865 $ 388.09
65870 $ 410.19
65875 $ 428.52
65880 $ 459.71
65900 $ 677.62
Rev 1/1/2010
96 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
65920 $ 539.20 Effective January 1, 2010
65930 $ 502.65
66020 $ 117.65
66030 $ 82.43
66130 $ 451.74
66150 $ 572.95
66155 $ 571.04
66160 $ 675.90
66165 $ 552.05
66170 $ 781.66
66172 $ 906.09
66180 $ 942.15
66185 $ 552.27
66220 $ 509.97
66225 $ 721.87
66250 $ 432.59
66500 $ 257.59
66505 $ 257.22
66600 $ 592.45
66605 $ 814.95
66625 $ 390.16
66630 $ 447.48
66635 $ 427.51
66680 $ 378.00
66682 $ 450.32
66700 $ 364.18
66710 $ 368.69
66711 $ 445.61
66720 $ 363.86
66740 $ 339.53
66761 $ 281.58
66762 $ 311.20
66770 $ 346.53
66820 $ 311.88
66821 $ 168.18
66825 $ 540.34
66830 $ 466.34
66840 $ 506.97
66850 $ 577.60
66852 $ 629.98
66920 $ 563.11
66930 $ 650.27
66940 $ 587.72
66982 $ 849.45
66983 $ 546.93
66984 $ 644.35
66985 $ 533.73
66986 $ 744.35
66990 $ 72.13
67005 $ 339.30
67010 $ 409.62
67015 $ 457.32
Rev 1/1/2010
97 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
67025 $ 582.37 Effective January 1, 2010
67027 $ 782.95
67028 $ 275.06
67030 $ 348.44
67031 $ 250.58
67036 $ 749.55
67039 $ 933.54
67040 $ 1,095.60
67041 $ 823.40
67042 $ 941.27
67043 $ 989.03
67101 $ 551.56
67105 $ 517.73
67107 $ 969.10
67108 $ 1,347.55
67110 $ 749.04
67112 $ 1,075.79
67113 $ 992.45
67115 $ 356.66
67120 $ 540.89
67121 $ 690.49
67141 $ 385.61
67145 $ 369.09
67208 $ 470.35
67210 $ 558.68
67218 $ 873.60
67220 $ 638.11
67221 $ 327.72
67227 $ 468.52
67228 $ 734.31
67229 $ 716.95
67250 $ 569.26
67255 $ 626.20
67311 $ 442.17
67312 $ 554.47
67314 $ 493.57
67316 $ 614.89
67318 $ 474.99
67320 $ 408.88
67331 $ 365.54
67332 $ 407.10
67334 $ 322.07
67335 $ 148.19
67340 $ 402.19
67343 $ 450.18
67345 $ 196.70
67346 $ 144.57
67400 $ 689.65
67405 $ 574.06
67412 $ 701.48
67413 $ 651.81
67414 $ 733.74
Rev 1/1/2010
98 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
67415 $ 104.64 Effective January 1, 2010
67420 $ 1,239.22
67430 $ 863.31
67440 $ 902.46
67445 $ 909.80
67450 $ 933.51
67500 $ 160.38
67505 $ 140.50
67515 $ 122.78
67550 $ 679.19
67560 $ 671.18
67570 $ 821.87
67700 $ 143.84
67710 $ 144.82
67715 $ 72.85
67800 $ 155.99
67801 $ 184.67
67805 $ 198.46
67808 $ 220.93
67810 $ 136.68
67820 $ 60.33
67825 $ 179.70
67830 $ 228.76
67835 $ 358.61
67840 $ 187.07
67850 $ 181.97
67875 $ 211.14
67880 $ 348.50
67882 $ 464.20
67900 $ 410.17
67901 $ 463.50
67902 $ 466.71
67903 $ 472.19
67904 $ 518.46
67906 $ 454.54
67908 $ 395.61
67909 $ 414.81
67911 $ 371.65
67912 $ 870.79
67914 $ 351.16
67915 $ 267.72
67916 $ 486.06
67917 $ 453.96
67921 $ 334.15
67922 $ 261.42
67923 $ 516.95
67924 $ 434.66
67930 $ 303.46
67935 $ 486.69
67938 $ 164.01
67950 $ 419.47
67961 $ 410.02
Rev 1/1/2010
99 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
67966 $ 462.97 Effective January 1, 2010
67971 $ 627.52
67973 $ 807.70
67974 $ 817.32
67975 $ 486.87
68020 $ 146.39
68040 $ 125.74
68100 $ 156.98
68110 $ 186.71
68115 $ 214.01
68130 $ 270.50
68135 $ 171.57
68200 $ 116.49
68320 $ 360.73
68325 $ 482.07
68326 $ 469.51
68328 $ 531.84
68330 $ 350.70
68335 $ 456.04
68340 $ 385.94
68360 $ 322.96
68362 $ 496.32
68371 $ 316.41
68400 $ 210.17
68420 $ 237.13
68440 $ 136.24
68500 $ 631.29
68505 $ 659.54
68510 $ 382.32
68520 $ 492.88
68525 $ 243.08
68530 $ 350.86
68540 $ 626.51
68550 $ 791.98
68700 $ 358.89
68705 $ 187.69
68720 $ 578.96
68745 $ 504.35
68750 $ 568.05
68760 $ 169.12
68761 $ 152.46
68770 $ 517.06
68801 $ 146.17
68810 $ 209.01
68811 $ 137.09
68815 $ 287.19
68816 $ 467.71
68840 $ 169.26
68850 $ 240.21
69000 $ 82.76
69005 $ 125.33
69020 $ 87.21
Rev 1/1/2010
100 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
69100 $ 62.01 Effective January 1, 2010
69105 $ 62.24
69110 $ 210.76
69120 $ 209.72
69140 $ 517.83
69145 $ 177.65
69150 $ 794.89
69155 $ 1,201.20
69200 $ 52.36
69205 $ 78.85
69210 $ 42.30
69220 $ 56.17
69222 $ 88.57
69300 $ 373.23
69310 $ 671.22
69320 $ 1,026.53
69400 $ 55.53
69401 $ 43.56
69405 $ 137.93
69410 $ 38.12
69420 $ 86.08
69421 $ 111.31
69424 $ 59.99
69433 $ 104.16
69436 $ 130.29
69440 $ 501.27
69450 $ 376.76
69501 $ 594.49
69502 $ 801.56
69505 $ 842.89
69511 $ 874.74
69530 $ 1,156.70
69535 $ 2,018.92
69540 $ 90.71
69550 $ 715.28
69552 $ 1,160.12
69554 $ 1,857.23
69601 $ 856.10
69602 $ 878.21
69603 $ 905.92
69604 $ 904.97
69605 $ 1,092.10
69610 $ 223.20
69620 $ 401.44
69631 $ 650.10
69632 $ 835.49
69633 $ 795.80
69635 $ 865.00
69636 $ 989.57
69637 $ 982.01
69641 $ 826.86
69642 $ 1,088.86
Rev 1/1/2010
101 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
69643 $ 995.56 Effective January 1, 2010
69644 $ 1,096.09
69645 $ 1,060.17
69646 $ 1,160.98
69650 $ 629.80
69660 $ 768.12
69661 $ 1,011.75
69662 $ 992.88
69666 $ 635.81
69667 $ 636.11
69670 $ 707.40
69676 $ 593.13
69700 $ 502.38
69711 $ 628.69
69714 $ 867.50
69715 $ 1,097.82
69717 $ 892.56
69718 $ 1,110.95
69720 $ 936.62
69725 $ 1,373.87
69740 $ 911.01
69745 $ 1,034.54
69801 $ 563.03
69802 $ 797.67
69805 $ 850.10
69806 $ 804.83
69820 $ 627.31
69840 $ 623.29
69905 $ 726.07
69910 $ 880.07
69915 $ 1,255.06
69930 $ 1,073.44
69950 $ 1,441.01
69955 $ 1,561.66
69960 $ 1,510.79
69970 $ 1,648.28
69990 $ 186.01
70010 26 $ 52.68
70010 TC $ 147.24
70010 $ 199.91
70015 26 $ 53.00
70015 TC $ 46.28
70015 $ 99.28
70030 26 $ 7.84
70030 TC $ 14.37
70030 $ 22.22
70100 26 $ 8.47
70100 TC $ 17.57
70100 $ 26.04
70110 26 $ 11.30
70110 TC $ 21.08
70110 $ 32.37
Rev 1/1/2010
102 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
70120 26 $ 8.47 Effective January 1, 2010
70120 TC $ 21.08
70120 $ 29.54
70130 26 $ 15.06
70130 TC $ 26.81
70130 $ 41.87
70134 26 $ 15.06
70134 TC $ 25.22
70134 $ 40.27
70140 26 $ 8.79
70140 TC $ 21.08
70140 $ 29.86
70150 26 $ 11.61
70150 TC $ 26.81
70150 $ 38.42
70160 26 $ 7.84
70160 TC $ 17.57
70160 $ 25.41
70170 26 $ 13.50
70170 TC $ 32.55
70170 $ 46.05
70190 26 $ 9.73
70190 TC $ 21.08
70190 $ 30.81
70200 26 $ 12.56
70200 TC $ 26.81
70200 $ 39.37
70210 26 $ 7.84
70210 TC $ 21.08
70210 $ 28.92
70220 26 $ 11.30
70220 TC $ 26.81
70220 $ 38.11
70240 26 $ 8.79
70240 TC $ 14.37
70240 $ 23.16
70250 26 $ 10.97
70250 TC $ 21.08
70250 $ 32.05
70260 26 $ 15.06
70260 TC $ 30.63
70260 $ 45.70
70300 26 $ 5.02
70300 TC $ 9.25
70300 $ 14.25
70310 26 $ 7.52
70310 TC $ 14.37
70310 $ 21.89
70320 26 $ 10.03
70320 TC $ 26.81
70320 $ 36.86
70328 26 $ 8.47
Rev 1/1/2010
103 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
70328 TC $ 16.93 Effective January 1, 2010
70328 $ 25.40
70330 26 $ 10.97
70330 TC $ 28.74
70330 $ 39.73
70332 26 $ 24.48
70332 TC $ 71.53
70332 $ 95.99
70350 26 $ 7.84
70350 TC $ 13.08
70350 $ 20.93
70355 26 $ 9.09
70355 TC $ 19.47
70355 $ 28.57
70360 26 $ 7.84
70360 TC $ 14.37
70360 $ 22.22
70370 26 $ 14.44
70370 TC $ 44.39
70370 $ 58.83
70373 26 $ 19.76
70373 TC $ 60.99
70373 $ 80.74
70380 26 $ 7.84
70380 TC $ 22.68
70380 $ 30.52
70390 26 $ 16.92
70390 TC $ 60.99
70390 $ 77.90
70450 26 $ 37.64
70450 TC $ 160.62
70450 $ 198.27
70460 26 $ 50.48
70460 TC $ 192.57
70460 $ 243.06
70470 26 $ 56.45
70470 TC $ 240.48
70470 $ 296.93
70480 26 $ 57.09
70480 TC $ 160.62
70480 $ 217.70
70481 26 $ 61.16
70481 TC $ 192.57
70481 $ 253.73
70482 26 $ 64.60
70482 TC $ 240.48
70482 $ 305.08
70486 26 $ 50.80
70486 TC $ 160.62
70486 $ 211.41
70487 26 $ 57.70
70487 TC $ 192.57
Rev 1/1/2010
104 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
70487 $ 250.27 Effective January 1, 2010
70488 26 $ 63.35
70488 TC $ 240.48
70488 $ 303.83
70490 26 $ 57.09
70490 TC $ 160.62
70490 $ 217.70
70491 26 $ 61.16
70491 TC $ 192.57
70491 $ 253.73
70492 26 $ 64.29
70492 TC $ 240.48
70492 $ 304.76
70496 26 $ 91.73
70496 TC $ 280.12
70496 $ 371.84
70498 26 $ 91.73
70498 TC $ 280.12
70498 $ 371.84
70540 26 $ 66.17
70540 TC $ 381.02
70540 $ 447.20
70542 26 $ 59.51
70542 TC $ 515.31
70542 $ 574.82
70543 26 $ 80.27
70543 TC $ 953.76
70543 $ 1,034.03
70544 26 $ 62.00
70544 TC $ 435.52
70544 $ 497.52
70545 26 $ 62.00
70545 TC $ 435.52
70545 $ 497.52
70546 26 $ 91.62
70546 TC $ 854.05
70546 $ 945.66
70547 26 $ 62.00
70547 TC $ 435.52
70547 $ 497.52
70548 26 $ 62.00
70548 TC $ 435.52
70548 $ 497.52
70549 26 $ 91.62
70549 TC $ 854.05
70549 $ 945.66
70551 26 $ 66.17
70551 TC $ 381.02
70551 $ 447.20
70552 26 $ 79.67
70552 TC $ 456.71
70552 $ 536.38
Rev 1/1/2010
105 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
70553 26 $ 105.39 Effective January 1, 2010
70553 TC $ 846.32
70553 $ 951.71
70557 26 $ 127.41
70558 26 $ 140.89
70559 26 $ 141.49
71010 26 $ 8.15
71010 TC $ 16.30
71010 $ 24.44
71015 26 $ 9.73
71015 TC $ 17.57
71015 $ 27.31
71020 26 $ 10.03
71020 TC $ 21.08
71020 $ 31.11
71021 26 $ 11.91
71021 TC $ 25.22
71021 $ 37.13
71022 26 $ 13.80
71022 TC $ 25.22
71022 $ 39.02
71023 26 $ 16.95
71023 TC $ 26.81
71023 $ 43.76
71030 26 $ 13.80
71030 TC $ 26.81
71030 $ 40.62
71034 26 $ 21.03
71034 TC $ 49.17
71034 $ 70.19
71035 26 $ 8.15
71035 TC $ 17.57
71035 $ 25.73
71040 26 $ 26.04
71040 TC $ 49.82
71040 $ 75.86
71060 26 $ 33.25
71060 TC $ 75.34
71060 $ 108.59
71090 26 $ 25.45
71090 TC $ 57.78
71090 $ 83.20
71100 26 $ 10.03
71100 TC $ 19.47
71100 $ 29.50
71101 26 $ 12.24
71101 TC $ 22.68
71101 $ 34.92
71110 26 $ 12.24
71110 TC $ 26.81
71110 $ 39.06
71111 26 $ 14.44
Rev 1/1/2010
106 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
71111 TC $ 30.63 Effective January 1, 2010
71111 $ 45.08
71120 26 $ 9.09
71120 TC $ 22.04
71120 $ 31.12
71130 26 $ 10.03
71130 TC $ 23.95
71130 $ 33.99
71250 26 $ 51.75
71250 TC $ 201.19
71250 $ 252.93
71260 26 $ 55.20
71260 TC $ 240.48
71260 $ 295.67
71270 26 $ 61.16
71270 TC $ 300.54
71270 $ 361.71
71275 26 $ 63.20
71275 TC $ 341.31
71275 $ 404.51
71550 26 $ 71.21
71550 TC $ 381.02
71550 $ 452.22
71551 26 $ 66.08
71551 TC $ 516.67
71551 $ 582.73
71552 26 $ 86.49
71552 TC $ 949.02
71552 $ 1,035.50
71555 26 $ 79.33
71555 TC $ 381.02
71555 $ 460.34
72010 26 $ 20.39
72010 TC $ 35.12
72010 $ 55.51
72020 26 $ 6.90
72020 TC $ 14.37
72020 $ 21.27
72040 26 $ 10.03
72040 TC $ 20.44
72040 $ 30.47
72050 26 $ 13.80
72050 TC $ 30.63
72050 $ 44.44
72052 26 $ 16.01
72052 TC $ 38.64
72052 $ 54.65
72069 26 $ 10.03
72069 TC $ 16.93
72069 $ 26.96
72070 26 $ 10.03
72070 TC $ 22.04
Rev 1/1/2010
107 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
72070 $ 32.07 Effective January 1, 2010
72072 26 $ 10.03
72072 TC $ 25.22
72072 $ 35.26
72074 26 $ 10.03
72074 TC $ 31.28
72074 $ 41.32
72080 26 $ 10.03
72080 TC $ 22.68
72080 $ 32.72
72090 26 $ 12.56
72090 TC $ 22.68
72090 $ 35.23
72100 26 $ 10.03
72100 TC $ 22.68
72100 $ 32.72
72110 26 $ 13.80
72110 TC $ 31.28
72110 $ 45.08
72114 26 $ 16.30
72114 TC $ 40.58
72114 $ 56.87
72120 26 $ 10.03
72120 TC $ 30.63
72120 $ 40.68
72125 26 $ 51.75
72125 TC $ 201.19
72125 $ 252.93
72126 26 $ 54.25
72126 TC $ 240.48
72126 $ 294.73
72127 26 $ 56.45
72127 TC $ 300.54
72127 $ 356.99
72128 26 $ 51.75
72128 TC $ 201.19
72128 $ 252.93
72129 26 $ 54.25
72129 TC $ 240.48
72129 $ 294.73
72130 26 $ 56.45
72130 TC $ 300.54
72130 $ 356.99
72131 26 $ 51.75
72131 TC $ 201.19
72131 $ 252.93
72132 26 $ 54.25
72132 TC $ 240.48
72132 $ 294.73
72133 26 $ 56.76
72133 TC $ 300.54
72133 $ 357.32
Rev 1/1/2010
108 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
72141 26 $ 71.21 Effective January 1, 2010
72141 TC $ 381.02
72141 $ 452.22
72142 26 $ 85.93
72142 TC $ 456.71
72142 $ 542.64
72146 26 $ 71.21
72146 TC $ 422.87
72146 $ 494.07
72147 26 $ 85.93
72147 TC $ 456.71
72147 $ 542.64
72148 26 $ 66.17
72148 TC $ 422.87
72148 $ 489.04
72149 26 $ 79.67
72149 TC $ 456.71
72149 $ 536.38
72156 26 $ 114.49
72156 TC $ 846.32
72156 $ 960.79
72157 26 $ 114.49
72157 TC $ 846.32
72157 $ 960.79
72158 26 $ 105.39
72158 TC $ 846.32
72158 $ 951.71
72159 26 $ 72.04
72159 TC $ 361.99
72159 $ 434.04
72170 26 $ 7.84
72170 TC $ 17.57
72170 $ 25.41
72190 26 $ 9.73
72190 TC $ 22.68
72190 $ 32.41
72191 26 $ 63.20
72191 TC $ 328.14
72191 $ 391.33
72192 26 $ 48.30
72192 TC $ 201.19
72192 $ 249.49
72193 26 $ 51.75
72193 TC $ 232.83
72193 $ 284.55
72194 26 $ 54.25
72194 TC $ 288.42
72194 $ 342.68
72195 26 $ 55.86
72195 TC $ 431.46
72195 $ 487.31
72196 26 $ 71.21
Rev 1/1/2010
109 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
72196 TC $ 381.02 Effective January 1, 2010
72196 $ 452.22
72197 26 $ 87.17
72197 TC $ 955.79
72197 $ 1,042.97
72198 26 $ 74.03
72198 TC $ 326.06
72198 $ 400.09
72200 26 $ 7.84
72200 TC $ 17.57
72200 $ 25.41
72202 26 $ 8.79
72202 TC $ 21.08
72202 $ 29.86
72220 26 $ 7.84
72220 TC $ 19.47
72220 $ 27.31
72240 26 $ 40.44
72240 TC $ 161.59
72240 $ 202.03
72255 26 $ 40.44
72255 TC $ 147.24
72255 $ 187.68
72265 26 $ 36.99
72265 TC $ 138.59
72265 $ 175.58
72270 26 $ 59.26
72270 TC $ 207.58
72270 $ 266.84
72275 26 $ 22.80
72275 TC $ 73.22
72275 $ 96.01
72285 26 $ 49.52
72285 TC $ 284.89
72285 $ 334.41
72291 26 $ 54.43
72292 26 $ 55.49
72295 26 $ 37.63
72295 TC $ 267.02
72295 $ 304.66
73000 26 $ 7.20
73000 TC $ 17.57
73000 $ 24.78
73010 26 $ 7.84
73010 TC $ 17.57
73010 $ 25.41
73020 26 $ 6.90
73020 TC $ 16.30
73020 $ 23.19
73030 26 $ 8.15
73030 TC $ 19.47
73030 $ 27.62
Rev 1/1/2010
110 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
73040 26 $ 24.16 Effective January 1, 2010
73040 TC $ 71.53
73040 $ 95.69
73050 26 $ 9.09
73050 TC $ 22.68
73050 $ 31.77
73060 26 $ 7.84
73060 TC $ 19.47
73060 $ 27.31
73070 26 $ 6.90
73070 TC $ 17.57
73070 $ 24.47
73080 26 $ 7.84
73080 TC $ 19.47
73080 $ 27.31
73085 26 $ 24.48
73085 TC $ 71.53
73085 $ 95.99
73090 26 $ 7.20
73090 TC $ 17.57
73090 $ 24.78
73092 26 $ 7.20
73092 TC $ 16.93
73092 $ 24.14
73100 26 $ 7.52
73100 TC $ 16.93
73100 $ 24.46
73110 26 $ 7.84
73110 TC $ 17.90
73110 $ 25.73
73115 26 $ 24.48
73115 TC $ 53.95
73115 $ 78.43
73120 26 $ 7.52
73120 TC $ 16.93
73120 $ 24.46
73130 26 $ 7.84
73130 TC $ 17.90
73130 $ 25.73
73140 26 $ 6.27
73140 TC $ 14.37
73140 $ 20.64
73200 26 $ 48.30
73200 TC $ 168.63
73200 $ 216.93
73201 26 $ 51.75
73201 TC $ 201.19
73201 $ 252.93
73202 26 $ 54.25
73202 TC $ 252.30
73202 $ 306.56
73206 26 $ 63.20
Rev 1/1/2010
111 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
73206 TC $ 288.24 Effective January 1, 2010
73206 $ 351.43
73218 26 $ 50.00
73218 TC $ 429.76
73218 $ 479.76
73219 26 $ 59.51
73219 TC $ 515.31
73219 $ 574.82
73220 26 $ 66.17
73220 TC $ 381.02
73220 $ 447.20
73221 26 $ 62.01
73221 TC $ 381.02
73221 $ 443.03
73222 26 $ 59.51
73222 TC $ 515.31
73222 $ 574.82
73223 26 $ 80.27
73223 TC $ 953.76
73223 $ 1,034.03
73225 26 $ 70.09
73225 TC $ 326.06
73225 $ 396.14
73500 26 $ 7.84
73500 TC $ 16.30
73500 $ 24.13
73510 26 $ 9.73
73510 TC $ 19.47
73510 $ 29.20
73520 26 $ 11.61
73520 TC $ 22.68
73520 $ 34.29
73525 26 $ 24.16
73525 TC $ 71.53
73525 $ 95.69
73530 26 $ 12.85
73530 TC $ 17.57
73530 $ 30.43
73540 26 $ 9.42
73540 TC $ 19.47
73540 $ 28.88
73542 $ 93.39
73550 26 $ 7.84
73550 TC $ 19.47
73550 $ 27.31
73560 26 $ 7.84
73560 TC $ 17.57
73560 $ 25.41
73562 26 $ 8.47
73562 TC $ 19.47
73562 $ 27.94
73564 26 $ 10.03
Rev 1/1/2010
112 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
73564 TC $ 21.08 Effective January 1, 2010
73564 $ 31.11
73565 26 $ 7.84
73565 TC $ 16.93
73565 $ 24.77
73580 26 $ 24.16
73580 TC $ 89.10
73580 $ 113.26
73590 26 $ 7.84
73590 TC $ 17.57
73590 $ 25.41
73592 26 $ 7.52
73592 TC $ 16.93
73592 $ 24.46
73600 26 $ 7.52
73600 TC $ 16.93
73600 $ 24.46
73610 26 $ 7.84
73610 TC $ 17.90
73610 $ 25.73
73615 26 $ 24.48
73615 TC $ 71.53
73615 $ 95.99
73620 26 $ 7.52
73620 TC $ 16.93
73620 $ 24.46
73630 26 $ 7.84
73630 TC $ 17.90
73630 $ 25.73
73650 26 $ 7.52
73650 TC $ 16.30
73650 $ 23.83
73660 26 $ 6.27
73660 TC $ 14.37
73660 $ 20.64
73700 26 $ 48.30
73700 TC $ 168.63
73700 $ 216.93
73701 26 $ 51.75
73701 TC $ 201.19
73701 $ 252.93
73702 26 $ 54.25
73702 TC $ 252.30
73702 $ 306.56
73706 26 $ 63.20
73706 TC $ 288.24
73706 $ 351.43
73718 26 $ 50.00
73718 TC $ 429.76
73718 $ 479.76
73719 26 $ 59.51
73719 TC $ 515.31
Rev 1/1/2010
113 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
73719 $ 574.82 Effective January 1, 2010
73720 26 $ 66.17
73720 TC $ 381.02
73720 $ 447.20
73721 26 $ 62.01
73721 TC $ 381.02
73721 $ 443.03
73722 26 $ 59.51
73722 TC $ 515.31
73722 $ 574.82
73723 26 $ 80.27
73723 TC $ 953.76
73723 $ 1,034.03
73725 26 $ 78.35
73725 TC $ 381.02
73725 $ 459.37
74000 26 $ 8.15
74000 TC $ 17.57
74000 $ 25.73
74010 26 $ 10.36
74010 TC $ 19.47
74010 $ 29.82
74020 26 $ 12.24
74020 TC $ 21.08
74020 $ 33.31
74022 26 $ 14.44
74022 TC $ 25.22
74022 $ 39.65
74150 26 $ 53.00
74150 TC $ 192.57
74150 $ 245.56
74160 26 $ 56.45
74160 TC $ 232.83
74160 $ 289.27
74170 26 $ 62.41
74170 TC $ 288.42
74170 $ 350.82
74175 26 $ 63.20
74175 TC $ 328.14
74175 $ 391.33
74181 26 $ 71.21
74181 TC $ 381.02
74181 $ 452.22
74182 26 $ 66.08
74182 TC $ 516.67
74182 $ 582.73
74183 26 $ 87.17
74183 TC $ 955.79
74183 $ 1,042.97
74185 26 $ 78.69
74185 TC $ 381.02
74185 $ 459.71
Rev 1/1/2010
114 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
74190 26 $ 20.04 Effective January 1, 2010
74190 TC $ 44.39
74190 $ 64.43
74210 26 $ 16.01
74210 TC $ 40.58
74210 $ 56.58
74220 26 $ 20.70
74220 TC $ 40.58
74220 $ 61.27
74230 26 $ 23.85
74230 TC $ 44.39
74230 $ 68.24
74235 26 $ 53.00
74235 TC $ 89.10
74235 $ 142.09
74240 26 $ 31.05
74240 TC $ 49.82
74240 $ 80.86
74241 26 $ 31.05
74241 TC $ 50.77
74241 $ 81.81
74245 26 $ 40.77
74245 TC $ 81.12
74245 $ 121.88
74246 26 $ 31.05
74246 TC $ 56.20
74246 $ 87.24
74247 26 $ 31.05
74247 TC $ 57.78
74247 $ 88.83
74249 26 $ 40.77
74249 TC $ 87.50
74249 $ 128.26
74250 26 $ 21.01
74250 TC $ 44.39
74250 $ 65.40
74251 26 $ 29.12
74251 TC $ 44.39
74251 $ 73.52
74260 26 $ 22.58
74260 TC $ 50.77
74260 $ 73.36
74270 26 $ 31.05
74270 TC $ 58.42
74270 $ 89.46
74280 26 $ 44.22
74280 TC $ 76.32
74280 $ 120.53
74283 26 $ 90.02
74283 TC $ 87.17
74283 $ 177.19
74290 26 $ 14.44
Rev 1/1/2010
115 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
74290 TC $ 25.22 Effective January 1, 2010
74290 $ 39.65
74291 26 $ 9.09
74291 TC $ 14.37
74291 $ 23.47
74300 26 $ 16.01
74300 $ 31.19
74301 26 $ 9.73
74301 $ 22.61
74305 26 $ 18.81
74305 TC $ 26.81
74305 $ 45.62
74320 26 $ 24.16
74320 TC $ 107.31
74320 $ 131.47
74327 26 $ 31.37
74327 TC $ 60.34
74327 $ 91.70
74328 26 $ 31.37
74328 TC $ 107.31
74328 $ 138.68
74329 26 $ 31.37
74329 TC $ 107.31
74329 $ 138.68
74330 26 $ 38.85
74330 TC $ 107.31
74330 $ 146.16
74340 26 $ 24.16
74340 TC $ 89.10
74340 $ 113.26
74350 26 $ 34.19
74350 TC $ 107.31
74350 $ 141.50
74355 26 $ 34.19
74355 TC $ 89.10
74355 $ 123.29
74360 26 $ 24.79
74360 TC $ 107.31
74360 $ 132.10
74363 26 $ 36.64
74363 $ 247.09
74400 26 $ 21.97
74400 TC $ 57.78
74400 $ 79.72
74410 26 $ 21.97
74410 TC $ 66.42
74410 $ 88.38
74415 26 $ 21.97
74415 TC $ 72.17
74415 $ 94.11
74420 26 $ 16.30
74420 TC $ 89.10
Rev 1/1/2010
116 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
74420 $ 105.40 Effective January 1, 2010
74425 26 $ 16.01
74425 TC $ 44.39
74425 $ 60.40
74430 26 $ 14.44
74430 TC $ 36.08
74430 $ 50.52
74440 26 $ 17.24
74440 TC $ 38.64
74440 $ 55.90
74445 26 $ 51.41
74445 TC $ 38.64
74445 $ 90.06
74450 26 $ 14.74
74450 TC $ 49.82
74450 $ 64.56
74455 26 $ 14.74
74455 TC $ 53.95
74455 $ 68.70
74470 26 $ 24.16
74470 TC $ 42.47
74470 $ 66.63
74475 26 $ 24.16
74475 TC $ 138.59
74475 $ 162.75
74480 26 $ 24.16
74480 TC $ 138.59
74480 $ 162.75
74485 26 $ 24.16
74485 TC $ 107.31
74485 $ 131.47
74710 26 $ 15.06
74710 TC $ 36.08
74710 $ 51.14
74740 26 $ 17.24
74740 TC $ 44.39
74740 $ 61.63
74742 26 $ 26.66
74742 TC $ 107.31
74742 $ 133.97
74775 26 $ 28.24
74775 TC $ 49.82
74775 $ 78.03
75557 $ 426.96
75557 26 $ 91.31
75557 TC $ 335.65
75559 $ 624.10
75559 26 $ 116.74
75559 TC $ 507.36
75561 $ 578.81
75561 26 $ 101.00
75561 TC $ 477.81
Rev 1/1/2010
117 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
75563 $ 717.87 Effective January 1, 2010
75563 26 $ 121.50
75563 TC $ 596.38
75565 $ 8.46
75565 $ 53.32
75565 $ 61.77
75571 $ 18.65
75571 $ 38.70
75571 $ 57.35
75572 $ 57.13
75572 $ 120.09
75572 $ 177.21
75573 $ 81.79
75573 $ 170.03
75573 $ 251.84
75574 $ 77.96
75574 $ 230.95
75574 $ 308.91
75591 $ 55.78
75591 $ 138.36
75591 $ 194.14
75600 26 $ 22.91
75600 TC $ 428.28
75600 $ 451.21
75605 26 $ 51.47
75605 TC $ 428.28
75605 $ 479.75
75625 26 $ 51.12
75625 TC $ 428.28
75625 $ 479.40
75626 $ 294.58
75630 26 $ 76.79
75630 TC $ 446.48
75630 $ 523.25
75635 26 $ 98.71
75635 TC $ 328.14
75635 $ 426.85
75650 26 $ 66.49
75650 TC $ 428.28
75650 $ 494.78
75658 26 $ 59.94
75658 TC $ 428.28
75658 $ 488.23
75660 26 $ 58.66
75660 TC $ 428.28
75660 $ 486.95
75662 26 $ 75.31
75662 TC $ 428.28
75662 $ 503.60
75665 26 $ 58.96
75665 TC $ 428.28
75665 $ 487.24
Rev 1/1/2010
118 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
75671 26 $ 74.33 Effective January 1, 2010
75671 TC $ 428.28
75671 $ 502.61
75676 26 $ 58.96
75676 TC $ 428.28
75676 $ 487.24
75680 26 $ 74.33
75680 TC $ 428.28
75680 $ 502.61
75685 26 $ 58.34
75685 TC $ 428.28
75685 $ 486.63
75705 26 $ 97.54
75705 TC $ 428.28
75705 $ 525.82
75710 26 $ 51.43
75710 TC $ 428.28
75710 $ 479.73
75716 26 $ 58.34
75716 TC $ 428.28
75716 $ 486.63
75717 $ 196.37
75722 26 $ 51.47
75722 TC $ 428.28
75722 $ 479.75
75724 26 $ 68.44
75724 TC $ 428.28
75724 $ 496.73
75726 26 $ 50.80
75726 TC $ 428.28
75726 $ 479.08
75731 26 $ 50.80
75731 TC $ 428.28
75731 $ 479.08
75733 26 $ 58.66
75733 TC $ 428.28
75733 $ 486.95
75736 26 $ 50.80
75736 TC $ 428.28
75736 $ 479.08
75741 26 $ 58.34
75741 TC $ 428.28
75741 $ 486.63
75743 26 $ 74.01
75743 TC $ 428.28
75743 $ 502.29
75746 26 $ 50.49
75746 TC $ 428.28
75746 $ 478.79
75756 26 $ 53.07
75756 TC $ 428.28
75756 $ 481.35
Rev 1/1/2010
119 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
75774 26 $ 16.01 Effective January 1, 2010
75774 TC $ 428.28
75774 $ 444.29
75791 26
75791 TC
75791
75801 26 $ 36.69
75801 TC $ 184.25
75801 $ 220.95
75803 26 $ 52.05
75803 TC $ 184.25
75803 $ 236.31
75805 26 $ 36.39
75805 TC $ 207.58
75805 $ 243.97
75807 26 $ 52.05
75807 TC $ 207.58
75807 $ 259.63
75809 26 $ 20.69
75809 TC $ 26.81
75809 $ 47.51
75810 26 $ 50.80
75810 TC $ 428.28
75810 $ 479.08
75811 $ 142.44
75820 26 $ 31.37
75820 TC $ 32.55
75820 $ 63.91
75822 26 $ 47.05
75822 TC $ 50.45
75822 $ 97.49
75825 26 $ 50.80
75825 TC $ 428.28
75825 $ 479.08
75827 26 $ 50.80
75827 TC $ 428.28
75827 $ 479.08
75831 26 $ 50.80
75831 TC $ 428.28
75831 $ 479.08
75833 26 $ 66.49
75833 TC $ 428.28
75833 $ 494.78
75840 26 $ 50.80
75840 TC $ 428.28
75840 $ 479.08
75842 26 $ 66.49
75842 TC $ 428.28
75842 $ 494.78
75860 26 $ 51.12
75860 TC $ 428.28
75860 $ 479.40
Rev 1/1/2010
120 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
75870 26 $ 50.80 Effective January 1, 2010
75870 TC $ 428.28
75870 $ 479.08
75872 26 $ 50.80
75872 TC $ 428.28
75872 $ 479.08
75880 26 $ 31.37
75880 TC $ 32.55
75880 $ 63.91
75885 26 $ 63.96
75885 TC $ 428.28
75885 $ 492.26
75887 26 $ 63.96
75887 TC $ 428.28
75887 $ 492.26
75889 26 $ 50.80
75889 TC $ 428.28
75889 $ 479.08
75891 26 $ 50.80
75891 TC $ 428.28
75891 $ 479.08
75893 26 $ 24.16
75893 TC $ 428.28
75893 $ 452.44
75894 26 $ 58.34
75894 TC $ 820.46
75894 $ 878.81
75896 26 $ 58.98
75896 TC $ 713.47
75896 $ 772.45
75898 26 $ 74.02
75898 TC $ 36.08
75898 $ 110.09
75900 26 $ 20.53
75900 $ 735.41
75940 26 $ 24.16
75940 TC $ 428.28
75940 $ 452.44
75945 26 $ 19.77
75945 TC $ 155.52
75945 $ 175.28
75946 26 $ 19.47
75946 TC $ 78.23
75946 $ 97.70
75952 $ 228.08
75953 $ 92.63
75954 26 $ 78.23
75956 26 $ 342.85
75957 26 $ 280.39
75958 26 $ 186.94
75959 26 $ 163.66
75960 26 $ 37.32
Rev 1/1/2010
121 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
75960 TC $ 506.23 Effective January 1, 2010
75960 $ 543.55
75961 26 $ 189.46
75961 TC $ 357.07
75961 $ 546.51
75962 26 $ 24.48
75962 TC $ 535.26
75962 $ 559.73
75964 26 $ 16.30
75964 TC $ 285.21
75964 $ 301.51
75966 26 $ 59.63
75966 TC $ 535.26
75966 $ 594.88
75968 26 $ 16.32
75968 TC $ 285.21
75968 $ 301.55
75970 26 $ 37.66
75970 TC $ 392.50
75970 $ 430.15
75978 26 $ 29.48
75978 $ 563.58
75980 26 $ 63.96
75980 TC $ 184.25
75980 $ 248.23
75982 26 $ 63.96
75982 TC $ 207.58
75982 $ 271.54
75984 26 $ 32.31
75984 TC $ 66.42
75984 $ 98.73
75989 26 $ 53.00
75989 TC $ 107.31
75989 $ 160.31
75990 $ 327.06
75992 26 $ 24.79
75992 TC $ 535.26
75992 $ 560.06
75993 26 $ 16.65
75993 TC $ 285.21
75993 $ 301.86
75994 26 $ 59.91
75994 TC $ 535.26
75994 $ 595.18
75995 26 $ 58.69
75995 TC $ 535.26
75995 $ 593.94
75996 26 $ 16.32
75996 TC $ 285.21
75996 $ 301.55
76000 26 $ 7.84
76000 TC $ 44.39
Rev 1/1/2010
122 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
76000 $ 52.23 Effective January 1, 2010
76010 26 $ 8.15
76010 TC $ 17.57
76010 $ 25.73
76080 26 $ 24.16
76080 TC $ 36.08
76080 $ 60.23
76097 $ 58.22
76100 26 $ 26.04
76100 TC $ 42.47
76100 $ 68.52
76101 26 $ 26.04
76101 TC $ 48.53
76101 $ 74.57
76102 26 $ 26.04
76102 TC $ 59.38
76102 $ 85.42
76120 26 $ 17.57
76120 TC $ 36.08
76120 $ 53.65
76125 TC $ 26.81
76125 $ 39.06
76150 $ 14.37
76350 $ 65.63
76375 26 $ 7.20
76375 TC $ 120.10
76375 $ 127.31
76376 26 $ 9.11
76376 TC $ 116.75
76376 $ 125.86
76377 26 $ 35.80
76377 TC $ 123.55
76377 $ 159.35
76380 26 $ 43.91
76380 TC $ 118.83
76380 $ 162.74
76390 26 $ 71.31
76390 $ 444.06
76506 26 $ 28.85
76506 TC $ 48.53
76506 $ 77.39
76510 26 $ 74.48
76510 TC $ 77.27
76510 $ 151.75
76511 26 $ 41.41
76511 TC $ 42.47
76511 $ 83.87
76512 26 $ 31.75
76512 TC $ 52.03
76512 $ 83.77
76513 26 $ 31.42
76513 TC $ 52.03
Rev 1/1/2010
123 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
76513 $ 83.45 Effective January 1, 2010
76514 26 $ 8.38
76514 TC $ 2.31
76514 $ 10.69
76516 26 $ 26.08
76516 TC $ 42.47
76516 $ 68.54
76519 26 $ 26.08
76519 TC $ 42.47
76519 $ 68.54
76529 26 $ 27.65
76529 TC $ 46.61
76529 $ 74.26
76536 26 $ 25.10
76536 TC $ 48.53
76536 $ 73.62
76604 26 $ 24.79
76604 TC $ 44.39
76604 $ 69.18
76645 26 $ 24.16
76645 TC $ 36.08
76645 $ 60.23
76700 26 $ 36.07
76700 TC $ 67.07
76700 $ 103.14
76705 26 $ 26.37
76705 TC $ 48.53
76705 $ 74.88
76770 26 $ 33.25
76770 TC $ 67.07
76770 $ 100.31
76775 26 $ 26.05
76775 TC $ 48.53
76775 $ 74.57
76776 26 $ 29.54
76776 $ 106.49
76776 TC $ 76.96
76800 26 $ 50.81
76800 TC $ 48.53
76800 $ 99.34
76801 26 $ 44.06
76801 TC $ 37.20
76801 $ 81.25
76802 26 $ 37.06
76802 TC $ 26.32
76802 $ 63.38
76805 26 $ 44.86
76805 TC $ 71.53
76805 $ 116.39
76810 26 $ 88.48
76810 TC $ 142.76
76810 $ 231.23
Rev 1/1/2010
124 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
76811 26 $ 86.30 Effective January 1, 2010
76811 TC $ 126.23
76811 $ 212.52
76812 26 $ 80.68
76812 TC $ 44.19
76812 $ 124.88
76813 $ 106.06
76813 TC $ 61.54
76813 26 $ 45.06
76814 $ 69.77
76814 TC $ 31.96
76814 26 $ 37.81
76815 26 $ 29.50
76815 TC $ 48.53
76815 $ 78.03
76816 26 $ 26.05
76816 TC $ 38.01
76816 $ 64.06
76817 26 $ 33.31
76817 TC $ 51.25
76817 $ 84.55
76818 26 $ 35.14
76818 TC $ 55.24
76818 $ 90.37
76819 26 $ 29.57
76819 TC $ 56.64
76819 $ 86.21
76820 26 $ 23.64
76820 TC $ 59.19
76820 $ 82.84
76821 26 $ 32.87
76821 TC $ 59.19
76821 $ 92.05
76825 26 $ 69.86
76825 TC $ 67.07
76825 $ 136.92
76826 26 $ 43.42
76826 TC $ 24.25
76826 $ 67.67
76827 26 $ 33.10
76827 TC $ 59.35
76827 $ 92.44
76828 26 $ 26.39
76828 TC $ 38.60
76828 $ 64.97
76830 26 $ 31.05
76830 TC $ 52.03
76830 $ 83.09
76831 26 $ 32.62
76831 TC $ 52.03
76831 $ 84.66
76856 26 $ 31.05
Rev 1/1/2010
125 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
76856 TC $ 52.03 Effective January 1, 2010
76856 $ 83.09
76857 26 $ 17.24
76857 TC $ 36.08
76857 $ 53.33
76870 26 $ 28.84
76870 TC $ 52.03
76870 $ 80.88
76872 26 $ 31.37
76872 TC $ 52.03
76872 $ 83.40
76873 26 $ 58.88
76873 TC $ 71.45
76873 $ 130.31
76880 26 $ 26.37
76880 TC $ 48.53
76880 $ 74.88
76885 26 $ 32.93
76885 TC $ 52.03
76885 $ 84.96
76886 26 $ 27.30
76886 TC $ 48.53
76886 $ 75.81
76930 26 $ 31.09
76930 TC $ 52.03
76930 $ 83.12
76932 TC $ 52.03
76932 $ 83.44
76936 26 $ 96.69
76936 TC $ 214.29
76936 $ 310.97
76937 26 $ 14.39
76937 TC $ 15.39
76937 $ 29.78
76940 $ 148.84
76940 26 $ 89.25
76940 TC $ 59.59
76941 26 $ 56.03
76941 $ 114.22
76942 26 $ 30.43
76942 TC $ 52.03
76942 $ 82.45
76945 $ 87.61
76946 26 $ 17.26
76946 TC $ 52.03
76946 $ 69.29
76948 26 $ 17.24
76948 TC $ 52.03
76948 $ 69.27
76950 26 $ 26.66
76950 TC $ 44.39
76950 $ 71.06
Rev 1/1/2010
126 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
76965 26 $ 76.53 Effective January 1, 2010
76965 TC $ 189.39
76965 $ 265.92
76970 26 $ 18.19
76970 TC $ 36.08
76970 $ 54.28
76975 26 $ 36.39
76975 TC $ 52.03
76975 $ 88.42
76977 $ 30.26
76998 26 $ 49.92
+77001 26 $ 15.13
+77001 $ 71.19
+77001 TC $ 56.06
77002 26 $ 20.84
77002 $ 64.07
77002 TC $ 43.23
77003 26 $ 22.46
77003 $ 62.03
77003 TC $ 39.58
77011 26 $ 47.88
77011 $ 425.25
77011 TC $ 377.36
77012 26 $ 45.84
77012 $ 278.98
77012 TC $ 233.14
77014 26 $ 33.98
77014 $ 146.61
77014 TC $ 112.63
77021 26 $ 60.39
77021 $ 428.23
77021 TC $ 367.83
77031 26 $ 199.79
77031 $ 263.01
77031 TC $ 63.21
77032 26 $ 37.91
77032 $ 59.97
77032 TC $ 22.06
+77051 26 $ 2.62
+77051 $ 14.86
+77051 TC $ 12.26
77052 26 $ 2.62
77052 $ 14.86
77052 TC $ 12.26
77053 26 $ 14.53
77053 $ 88.03
77053 TC $ 73.51
77054 26 $ 18.01
77054 $ 126.53
77054 TC $ 108.51
77055 26 $ 27.54
77055 $ 66.51
Rev 1/1/2010
127 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
77055 TC $ 38.95 Effective January 1, 2010
77056 26 $ 34.21
77056 $ 83.09
77056 TC $ 48.88
77057 26 $ 27.54
77057 $ 69.78
77057 TC $ 42.24
77058 26 $ 64.08
77058 $ 697.16
77058 TC $ 633.09
77059 26 $ 64.08
77059 $ 862.61
77059 TC $ 798.53
77071 $ 24.05
77072 26 $ 7.21
77072 $ 19.09
77072 TC $ 11.88
77073 26 $ 10.75
77073 $ 36.13
77073 TC $ 25.38
77074 26 $ 18.01
77074 $ 54.65
77074 TC $ 36.63
77075 26 $ 21.50
77075 $ 76.32
77075 TC $ 54.82
77076 26 $ 27.54
77076 $ 61.56
77076 TC $ 34.01
77077 26 $ 12.48
77077 $ 46.45
77077 TC $ 33.97
77078 26 $ 9.86
77078 $ 125.16
77078 TC $ 115.29
77080 26 $ 8.81
77080 $ 96.81
77080 TC $ 88.00
77081 26 $ 9.03
77081 $ 34.41
77081 TC $ 25.38
77082 26 $ 6.98
77082 $ 30.03
77082 TC $ 23.05
77083 26 $ 8.15
77083 $ 30.86
77083 TC $ 22.72
77084 26 $ 63.25
77084 $ 470.12
77084 TC $ 406.87
77261 $ 63.72
77262 $ 96.66
Rev 1/1/2010
128 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
77263 $ 144.05 Effective January 1, 2010
77280 26 $ 32.01
77280 TC $ 117.87
77280 $ 149.87
77285 26 $ 47.37
77285 TC $ 189.68
77285 $ 237.06
77290 26 $ 70.91
77290 TC $ 221.63
77290 $ 292.55
77295 26 $ 207.42
77295 TC $ 950.08
77295 $ 1,157.50
77300 26 $ 27.93
77300 TC $ 45.67
77300 $ 73.60
77301 26 $ 394.74
77301 TC $ 995.67
77301 $ 1,390.40
77305 26 $ 32.01
77305 TC $ 63.54
77305 $ 95.53
77310 26 $ 47.37
77310 TC $ 79.51
77310 $ 126.88
77315 26 $ 70.91
77315 TC $ 90.38
77315 $ 161.30
77321 26 $ 43.30
77321 TC $ 137.33
77321 $ 180.63
77326 26 $ 42.35
77326 TC $ 80.47
77326 $ 122.82
77327 26 $ 63.06
77327 TC $ 117.87
77327 $ 180.91
77328 26 $ 94.44
77328 TC $ 168.63
77328 $ 263.07
77331 26 $ 39.23
77331 TC $ 17.25
77331 $ 56.48
77332 26 $ 24.48
77332 TC $ 45.67
77332 $ 70.14
77333 26 $ 37.96
77333 TC $ 64.50
77333 $ 102.47
77334 26 $ 56.16
77334 TC $ 110.20
77334 $ 166.35
Rev 1/1/2010
129 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
77336 $ 101.25 Effective January 1, 2010
77338 $ 150.93
77338 $ 170.28
77338 $ 321.21
77370 $ 118.50
77401 $ 60.65
77402 $ 60.65
77403 $ 60.65
77404 $ 60.65
77406 $ 60.65
77407 $ 71.21
77408 $ 71.21
77409 $ 71.21
77411 $ 71.21
77412 $ 79.51
77413 $ 79.51
77414 $ 79.51
77416 $ 79.51
77417 $ 20.11
77418 $ 582.89
77421 26 $ 16.99
77421 TC $ 115.01
77421 $ 132.00
77422 $ 60.87
77423 $ 79.21
77427 $ 141.05
77431 $ 83.81
77432 $ 389.37
77470 26 $ 94.76
77470 TC $ 379.08
77470 $ 473.86
77600 26 $ 70.28
77600 TC $ 103.50
77600 $ 173.76
77605 26 $ 95.70
77605 TC $ 138.27
77605 $ 233.95
77610 TC $ 103.50
77610 $ 173.76
77615 26 $ 94.44
77615 TC $ 138.27
77615 $ 232.71
77750 26 $ 219.28
77750 TC $ 45.35
77750 $ 264.63
77761 26 $ 168.68
77761 TC $ 85.58
77761 $ 254.26
77762 26 $ 257.52
77762 TC $ 122.64
77762 $ 380.16
77763 26 $ 384.86
Rev 1/1/2010
130 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
77763 TC $ 152.66 Effective January 1, 2010
77763 $ 537.53
77776 26 $ 205.66
77776 TC $ 74.38
77776 $ 280.04
77777 26 $ 337.20
77777 TC $ 144.03
77777 $ 481.23
77778 26 $ 501.24
77778 TC $ 174.70
77778 $ 675.94
77785 26 $ 60.70
77785 TC $ 97.73
77785 $ 158.43
77786 26 $ 136.64
77786 TC $ 339.25
77786 $ 475.89
77787 26 $ 209.94
77787 TC $ 497.24
77787 $ 707.18
77789 26 $ 50.19
77789 TC $ 15.65
77789 $ 65.85
77790 26 $ 47.37
77790 TC $ 17.25
77790 $ 64.63
78000 26 $ 8.79
78000 TC $ 33.20
78000 $ 41.99
78001 26 $ 11.61
78001 TC $ 44.39
78001 $ 56.00
78003 26 $ 14.74
78003 TC $ 33.20
78003 $ 47.96
78006 26 $ 21.97
78006 TC $ 81.12
78006 $ 103.06
78007 26 $ 22.58
78007 TC $ 87.50
78007 $ 110.09
78010 26 $ 17.56
78010 TC $ 62.26
78010 $ 79.81
78011 26 $ 20.39
78011 TC $ 82.06
78011 $ 102.47
78015 26 $ 30.43
78015 TC $ 87.50
78015 $ 117.92
78016 26 $ 37.02
Rev 1/1/2010
131 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
78016 TC $ 118.18 Effective January 1, 2010
78016 $ 155.20
78018 26 $ 39.24
78018 TC $ 184.58
78018 $ 223.81
78020 $ 30.89
78070 26 $ 34.14
78070 TC $ 62.26
78070 $ 96.39
78075 26 $ 33.57
78075 TC $ 184.58
78075 $ 218.15
78102 26 $ 24.79
78102 TC $ 69.61
78102 $ 94.38
78103 26 $ 33.89
78103 TC $ 107.96
78103 $ 141.83
78104 26 $ 36.08
78104 TC $ 138.59
78104 $ 174.67
78110 26 $ 8.79
78110 TC $ 32.55
78110 $ 41.34
78111 26 $ 10.03
78111 TC $ 87.50
78111 $ 97.54
78120 26 $ 10.68
78120 TC $ 59.38
78120 $ 70.05
78121 26 $ 14.44
78121 TC $ 98.71
78121 $ 113.14
78122 26 $ 20.39
78122 TC $ 156.48
78122 $ 176.87
78130 26 $ 27.31
78130 TC $ 96.80
78130 $ 124.09
78135 26 $ 28.55
78135 TC $ 165.76
78135 $ 194.31
78140 26 $ 27.31
78140 TC $ 133.80
78140 $ 161.11
78185 26 $ 18.19
78185 TC $ 80.47
78185 $ 98.66
78190 TC $ 194.48
78190 $ 244.39
78191 26 $ 27.31
Rev 1/1/2010
132 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
78191 TC $ 249.13 Effective January 1, 2010
78191 $ 276.43
78195 26 $ 50.10
78195 TC $ 138.59
78195 $ 188.70
78201 26 $ 19.76
78201 TC $ 80.47
78201 $ 100.23
78202 26 $ 22.91
78202 TC $ 97.75
78202 $ 120.66
78205 26 $ 32.00
78205 TC $ 201.19
78205 $ 233.19
78206 26 $ 40.09
78206 TC $ 192.69
78206 $ 232.76
78215 26 $ 21.97
78215 TC $ 99.67
78215 $ 121.63
78216 26 $ 25.41
78216 TC $ 118.18
78216 $ 143.59
78220 26 $ 21.97
78220 TC $ 126.49
78220 $ 148.44
78223 26 $ 37.33
78223 TC $ 124.56
78223 $ 161.89
78230 26 $ 20.70
78230 TC $ 74.38
78230 $ 95.10
78231 26 $ 23.53
78231 TC $ 107.96
78231 $ 131.49
78232 26 $ 21.33
78232 TC $ 120.10
78232 $ 141.43
78258 26 $ 33.25
78258 TC $ 97.75
78258 $ 130.99
78261 26 $ 31.37
78261 TC $ 139.54
78261 $ 170.92
78262 26 $ 30.43
78262 TC $ 144.68
78262 $ 175.12
78264 26 $ 35.13
78264 TC $ 140.51
78264 $ 175.64
78270 26 $ 9.42
78270 TC $ 52.99
Rev 1/1/2010
133 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
78270 $ 62.41 Effective January 1, 2010
78271 26 $ 9.42
78271 TC $ 56.20
78271 $ 65.61
78272 26 $ 12.24
78272 TC $ 79.19
78272 $ 91.43
78278 26 $ 44.54
78278 TC $ 165.76
78278 $ 210.30
78282 26 $ 16.95
78290 26 $ 30.73
78290 TC $ 103.50
78290 $ 134.23
78291 26 $ 39.22
78291 TC $ 104.13
78291 $ 143.35
78300 26 $ 27.61
78300 TC $ 84.94
78300 $ 112.54
78305 26 $ 37.01
78305 TC $ 124.56
78305 $ 161.58
78306 26 $ 38.27
78306 TC $ 145.32
78306 $ 183.59
78315 26 $ 45.48
78315 TC $ 162.55
78315 $ 208.02
78320 26 $ 46.42
78320 TC $ 201.19
78320 $ 247.61
78350 26 $ 10.03
78350 TC $ 25.85
78350 $ 35.89
78351 $ 75.85
78414 26 $ 20.70
78428 26 $ 36.43
78428 TC $ 76.94
78428 $ 113.37
78445 26 $ 22.28
78445 TC $ 63.54
78445 $ 85.82
78451 $ 44.74
78451 $ 104.98
78451 $ 149.72
78452 $ 52.95
78452 $ 202.93
78452 $ 255.89
78454 $ 43.04
78454 $ 82.32
78454 $ 125.36
Rev 1/1/2010
134 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
78456 $ 177.81 Effective January 1, 2010
78457 26 $ 34.50
78457 TC $ 90.38
78457 $ 124.89
78458 26 $ 40.17
78458 TC $ 136.70
78458 $ 176.86
78460 26 $ 38.59
78460 TC $ 80.47
78460 $ 119.06
78461 26 $ 55.55
78461 TC $ 160.62
78461 $ 216.18
78464 26 $ 48.95
78464 TC $ 240.48
78464 $ 289.42
78465 26 $ 66.22
78465 TC $ 401.12
78465 $ 467.36
78466 26 $ 31.37
78466 TC $ 89.10
78466 $ 120.47
78468 26 $ 35.77
78468 TC $ 124.56
78468 $ 160.32
78469 26 $ 41.43
78469 TC $ 177.88
78469 $ 219.29
78471 $ 236.91
78472 26 $ 44.55
78472 TC $ 187.77
78472 $ 232.31
78473 26 $ 66.21
78473 TC $ 280.43
78473 $ 346.65
78478 26 $ 28.26
78478 TC $ 53.31
78478 $ 81.56
78480 26 $ 28.26
78480 TC $ 53.31
78480 $ 81.56
78481 26 $ 44.57
78481 TC $ 177.88
78481 $ 222.46
78483 26 $ 67.50
78483 TC $ 267.63
78483 $ 335.14
78494 $ 285.32
78496 $ 79.92
78580 26 $ 33.25
78580 TC $ 116.58
78580 $ 149.83
Rev 1/1/2010
135 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
78584 26 $ 44.22 Effective January 1, 2010
78584 TC $ 108.91
78584 $ 153.14
78585 26 $ 48.30
78585 TC $ 191.92
78585 $ 240.22
78586 26 $ 18.19
78586 TC $ 88.14
78586 $ 106.33
78587 26 $ 21.97
78587 TC $ 95.19
78587 $ 117.14
78588 26 $ 45.10
78588 TC $ 185.80
78588 $ 230.89
78591 26 $ 18.19
78591 TC $ 96.80
78591 $ 114.98
78593 26 $ 21.97
78593 TC $ 117.23
78593 $ 139.17
78594 26 $ 23.85
78594 TC $ 169.27
78594 $ 193.13
78596 26 $ 56.76
78596 TC $ 240.48
78596 $ 297.25
78600 26 $ 20.08
78600 TC $ 97.75
78600 $ 117.82
78601 26 $ 22.91
78601 TC $ 115.62
78601 $ 138.53
78605 26 $ 24.17
78605 TC $ 115.62
78605 $ 139.79
78606 26 $ 28.55
78606 TC $ 131.59
78606 $ 160.15
78607 26 $ 55.21
78607 TC $ 223.23
78607 $ 278.44
78610 26 $ 13.50
78610 TC $ 53.95
78610 $ 67.44
78630 26 $ 30.73
78630 TC $ 171.49
78630 $ 202.23
78635 26 $ 28.58
78635 TC $ 86.86
78635 $ 115.44
78645 26 $ 25.41
Rev 1/1/2010
136 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
78645 TC $ 116.58 Effective January 1, 2010
78645 $ 141.99
78647 $ 241.35
78650 26 $ 27.31
78650 TC $ 157.76
78650 $ 185.06
78660 26 $ 23.85
78660 TC $ 72.17
78660 $ 96.00
78700 26 $ 20.07
78700 TC $ 103.50
78700 $ 123.55
78701 26 $ 21.97
78701 TC $ 120.75
78701 $ 142.71
78707 26 $ 42.97
78707 $ 194.99
78707 TC $ 152.02
78708 26 $ 52.02
78708 TC $ 152.03
78708 $ 204.05
78709 26 $ 59.22
78709 $ 211.23
78709 TC $ 152.02
78709 26 $ 59.21
78709 TC $ 152.03
78709 $ 211.24
78710 26 $ 29.79
78710 TC $ 201.19
78710 $ 230.99
78725 26 $ 16.95
78725 TC $ 60.99
78725 $ 77.93
78730 26 $ 16.63
78730 TC $ 49.82
78730 $ 66.43
78740 26 $ 25.41
78740 TC $ 72.17
78740 $ 97.58
78761 26 $ 32.00
78761 $ 140.91
78761 TC $ 108.91
78761 26 $ 32.00
78761 TC $ 108.91
78761 $ 140.91
78800 26 $ 29.79
78800 TC $ 115.62
78800 $ 145.41
78801 26 $ 35.45
78801 TC $ 143.72
78801 $ 179.17
78802 26 $ 38.59
Rev 1/1/2010
137 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
78802 TC $ 188.40 Effective January 1, 2010
78802 $ 226.99
78803 26 $ 48.95
78803 TC $ 223.23
78803 $ 272.17
78805 26 $ 32.94
78805 TC $ 115.62
78805 $ 148.56
78806 26 $ 38.27
78806 TC $ 219.06
78806 $ 257.33
78807 26 $ 48.62
78807 TC $ 223.23
78807 $ 271.85
78815 26 $ 111.25
78815 TC $ 2,016.23
78815 $ 2,127.48
78816 26 $ 113.87
78816 TC $ 2,016.23
78816 $ 2,130.00
78990 $ 187.25
79000 26 $ 80.62
79000 TC $ 89.10
79000 $ 169.72
79001 26 $ 47.06
79001 TC $ 44.39
79001 $ 91.45
79005 26 $ 81.35
79005 TC $ 94.60
79005 $ 175.96
79020 26 $ 80.94
79020 TC $ 89.10
79020 $ 170.02
79030 26 $ 94.10
79030 TC $ 89.10
79030 $ 183.21
79035 26 $ 113.27
79035 TC $ 89.10
79035 $ 202.35
79100 26 $ 59.30
79100 TC $ 89.10
79100 $ 148.39
79101 26 $ 88.94
79101 TC $ 94.60
79101 $ 183.54
79200 26 $ 89.42
79200 TC $ 89.10
79200 $ 178.52
79300 26 $ 71.83
79400 26 $ 87.52
79400 TC $ 89.10
Rev 1/1/2010
138 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
79400 $ 176.62 Effective January 1, 2010
79403 26 $ 104.66
79403 TC $ 147.79
79403 $ 252.45
79420 26 $ 68.07
79420 $ 51.35
79440 26 $ 89.71
79440 TC $ 89.10
79440 $ 178.82
79445 26 $ 109.57
79445 TC $ 95.23
79445 $ 204.80
86486 $ 4.99
88300 26 $ 5.35
88300 TC $ 8.95
88300 $ 14.30
88302 26 $ 8.19
88302 TC $ 26.87
88302 $ 35.06
88304 26 $ 12.93
88304 TC $ 17.25
88304 $ 30.18
88305 26 $ 38.72
88305 TC $ 27.16
88305 $ 65.88
88307 26 $ 76.07
88307 TC $ 57.23
88307 $ 133.30
88309 26 $ 106.51
88309 TC $ 81.27
88309 $ 187.78
88311 26 $ 11.62
88311 TC $ 3.81
88311 $ 15.45
88312 26 $ 23.54
88312 TC $ 19.84
88312 $ 43.39
88313 26 $ 11.62
88313 TC $ 33.30
88313 $ 44.91
88314 26 $ 23.62
88314 TC $ 65.00
88314 $ 88.62
88318 26 $ 18.52
88318 TC $ 17.27
88318 $ 35.79
88319 26 $ 25.15
88319 TC $ 61.48
88319 $ 86.63
88321 $ 59.02
Rev 1/1/2010
139 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
88323 26 $ 59.93 Effective January 1, 2010
88323 TC $ 33.27
88323 $ 93.21
88325 $ 95.02
88329 26 $ 47.24
88329 $ 36.87
88331 26 $ 56.58
88331 TC $ 18.19
88331 $ 74.76
88332 26 $ 28.28
88332 TC $ 9.25
88332 $ 37.53
88333 26 $ 55.97
88333 TC $ 19.53
88333 $ 75.49
88334 26 $ 27.51
88334 TC $ 11.93
88334 $ 39.44
88342 26 $ 38.95
88342 TC $ 32.64
88342 $ 71.58
88346 26 $ 38.94
88346 TC $ 32.00
88346 $ 70.93
88347 26 $ 35.42
88347 TC $ 18.54
88347 $ 53.94
88348 26 $ 79.66
88348 TC $ 199.81
88348 $ 279.47
88349 26 $ 43.50
88349 TC $ 109.15
88349 $ 152.66
88355 26 $ 88.64
88355 TC $ 44.09
88355 $ 132.74
88356 26 $ 141.35
88356 TC $ 61.69
88356 $ 203.04
88358 26 $ 130.69
88358 TC $ 45.03
88358 $ 175.72
88362 26 $ 102.40
88362 TC $ 64.60
88362 $ 167.00
88365 26 $ 42.72
88365 TC $ 45.46
88365 $ 88.18
88371 26 $ 17.96
88371 $ 27.95
Rev 1/1/2010
140 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
88372 26 $ 19.43 Effective January 1, 2010
88372 $ 28.61
88381 $ 167.91
88381 26 $ 41.50
88381 TC $ 126.41
88385 26 $ 73.17
88385 TC $ 227.18
88385 $ 300.35
88386 26 $ 92.03
88386 TC $ 220.11
88386 $ 312.25
89049 $ 163.79
90740 $ 8.00
90801 $ 119.16
90804 $ 53.03
90805 $ 59.28
90816 $ 55.24
90817 $ 60.84
90847 $ 94.38
90853 $ 28.92
90870 $ 80.92
90989 $ 470.25
90993 $ 18.81
91000 26 $ 37.77
91000 TC $ 2.86
91000 $ 40.63
91010 26 $ 71.24
91010 TC $ 28.39
91010 $ 99.63
91011 TC $ 35.12
91011 $ 120.53
91012 TC $ 39.57
91012 $ 123.08
91020 26 $ 81.91
91020 TC $ 26.47
91020 $ 108.39
91022 $ 195.45
91030 TC $ 7.95
91030 $ 48.44
91032 26 $ 67.42
91032 TC $ 25.82
91032 $ 93.26
91033 26 $ 74.05
91033 TC $ 46.55
91033 $ 120.60
91034 26 $ 44.94
91034 TC $ 170.68
91034 $ 215.61
91035 26 $ 72.56
91035 TC $ 354.64
Rev 1/1/2010
141 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
91035 $ 427.22 Effective January 1, 2010
91037 26 $ 44.94
91037 TC $ 91.08
91037 $ 136.03
91038 26 $ 50.86
91038 TC $ 64.90
91038 $ 115.77
91040 26 $ 44.94
91040 TC $ 373.60
91040 $ 418.53
91052 TC $ 11.81
91052 $ 50.46
91055 TC $ 10.52
91055 $ 54.44
91060 TC $ 7.95
91060 $ 33.81
91065 26 $ 11.65
91065 TC $ 12.45
91065 $ 24.11
91100 $ 50.16
91105 $ 20.79
91110 26 $ 159.84
91110 TC $ 665.79
91110 $ 825.64
91122 26 $ 86.95
91122 TC $ 25.14
91122 $ 112.08
92002 $ 54.28
92004 $ 90.69
92012 $ 46.16
92014 $ 66.56
92018 $ 68.43
92019 $ 60.25
92020 $ 30.29
92060 TC $ 18.88
92060 $ 49.31
92065 $ 30.71
92070 $ 59.59
92081 26 $ 16.97
92081 TC $ 24.33
92081 $ 41.30
92082 26 $ 22.67
92082 TC $ 24.33
92082 $ 47.00
92083 26 $ 29.64
92083 TC $ 21.12
92083 $ 50.76
92100 $ 46.23
92120 $ 43.44
Rev 1/1/2010
142 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
92130 $ 48.26 Effective January 1, 2010
92135 $ 61.50
92136 26 $ 24.07
92136 TC $ 43.91
92136 $ 67.97
92140 $ 35.41
92225 $ 48.99
92226 $ 48.40
92230 $ 53.90
92235 26 $ 43.13
92235 TC $ 46.66
92235 $ 89.78
92240 26 $ 54.41
92240 TC $ 59.16
92240 $ 113.56
92250 26 $ 21.70
92250 TC $ 31.06
92250 $ 52.76
92260 $ 19.35
92265 26 $ 32.22
92265 TC $ 25.27
92265 $ 57.50
92270 26 $ 38.00
92270 TC $ 17.90
92270 $ 55.89
92275 26 $ 48.69
92275 TC $ 11.81
92275 $ 60.49
92283 26 $ 9.76
92283 TC $ 13.43
92283 $ 23.19
92285 26 $ 11.34
92285 TC $ 32.67
92285 $ 44.00
92286 26 $ 40.71
92286 TC $ 38.08
92286 $ 78.79
92287 $ 86.07
92340 $ 28.21
92341 $ 33.89
92342 $ 37.36
92370 $ 23.43
92502 $ 87.01
92504 $ 22.56
92506 $ 54.94
92507 $ 39.55
92508 $ 26.35
92511 $ 57.52
92512 $ 39.85
Rev 1/1/2010
143 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
92516 $ 31.65 Effective January 1, 2010
92520 $ 41.25
92540 $ 52.56
92540 $ 11.16
92540 $ 63.73
92541 TC $ 8.28
92541 $ 32.26
92542 26 $ 19.55
92542 TC $ 9.25
92542 $ 28.80
92543 26 $ 6.30
92543 TC $ 3.81
92543 $ 10.12
92544 26 $ 15.13
92544 TC $ 7.65
92544 $ 22.77
92545 26 $ 12.92
92545 TC $ 7.65
92545 $ 20.56
92546 26 $ 16.71
92546 TC $ 8.60
92546 $ 25.31
92547 $ 19.74
92548 26 $ 28.36
92548 TC $ 51.31
92548 $ 79.67
92550 $ 13.81
92551 $ 8.05
92552 $ 15.62
92553 $ 22.95
92555 $ 13.39
92556 $ 17.10
92557 $ 42.04
92559 $ 6.40
92560 $ 12.80
92561 $ 24.87
92562 $ 14.35
92563 $ 13.39
92564 $ 16.89
92565 $ 14.02
92567 $ 18.47
92568 $ 13.39
92570 $ 21.05
92571 $ 13.70
92572 $ 3.18
92575 $ 10.52
92576 $ 15.93
92577 $ 25.16
92579 $ 25.19
Rev 1/1/2010
144 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
92582 $ 25.18 Effective January 1, 2010
92583 $ 31.22
92584 $ 86.39
92585 26 $ 45.67
92585 TC $ 64.10
92585 $ 109.76
92586 $ 73.32
92587 26 $ 7.23
92587 TC $ 45.28
92587 $ 52.51
92588 26 $ 19.21
92588 TC $ 51.31
92588 $ 70.52
92589 $ 18.77
92596 $ 20.70
92601 $ 117.15
92602 $ 82.21
92603 $ 78.91
92604 $ 53.85
92609 $ 52.97
92610 $ 37.65
92611 $ 40.95
92612 $ 152.61
92950 $ 189.40
92953 $ 12.92
92960 $ 138.20
92961 $ 201.90
92970 $ 191.99
92971 $ 88.04
92973 $ 167.15
92974 $ 185.74
92975 $ 381.22
92977 $ 274.58
92978 26 $ 88.65
92978 TC $ 155.52
92978 $ 244.17
92979 26 $ 70.75
92979 TC $ 78.23
92979 $ 148.98
92980 $ 906.81
92981 $ 254.83
92982 $ 671.15
92984 $ 181.61
92986 $ 1,146.69
92987 $ 1,187.78
92990 $ 900.41
92992 $ 2,022.08
92995 $ 738.71
92996 $ 199.85
Rev 1/1/2010
145 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
92997 $ 728.34 Effective January 1, 2010
92998 $ 314.00
93000 $ 25.09
93005 $ 15.65
93010 $ 9.45
93012 $ 81.65
93014 $ 27.04
93015 $ 99.06
93016 $ 23.94
93017 $ 57.78
93018 $ 17.34
93024 26 $ 67.77
93024 TC $ 38.91
93024 $ 106.70
93025 $ 260.66
93040 $ 13.27
93041 $ 5.11
93042 $ 8.17
93224 $ 147.38
93225 $ 42.45
93226 $ 75.00
93227 $ 29.94
93230 $ 156.65
93231 $ 52.32
93232 $ 74.38
93233 $ 29.94
93235 $ 114.96
93236 $ 89.10
93237 $ 25.86
93268 $ 150.82
93270 $ 42.45
93271 $ 81.65
93272 $ 26.74
93278 26 $ 14.50
93278 TC $ 40.47
93278 $ 54.98
93279 26 $ 30.75
93279 TC $ 16.81
93279 $ 47.55
93280 26 $ 36.92
93280 TC $ 19.34
93280 $ 56.26
93282 26 $ 40.26
93282 TC $ 20.53
93282 $ 60.78
93283 26 $ 50.70
93283 TC $ 23.31
93283 $ 74.01
93288 26 $ 20.62
Rev 1/1/2010
146 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
93288 TC $ 16.19 Effective January 1, 2010
93288 $ 36.81
93289 26 $ 37.23
93289 TC $ 19.34
93289 $ 56.57
93292 26 $ 20.62
93292 TC $ 11.23
93292 $ 31.86
93293 26 $ 14.39
93293 TC $ 36.24
93293 $ 50.63
93294 $ 31.31
93295 $ 56.56
93303 26 $ 66.71
93303 TC $ 132.16
93303 $ 198.86
93304 26 $ 40.64
93304 TC $ 66.69
93304 $ 107.33
93306 26 $ 61.19
93306 TC $ 166.29
93306 $ 227.48
93307 26 $ 53.28
93307 TC $ 132.16
93307 $ 185.42
93308 26 $ 30.58
93308 TC $ 66.69
93308 $ 97.27
93312 26 $ 108.73
93312 TC $ 131.06
93312 $ 239.80
93313 $ 120.18
93314 26 $ 59.70
93314 TC $ 131.06
93314 $ 190.76
93315 26 $ 116.49
93315 $ 261.69
93316 $ 69.87
93317 26 $ 69.73
93317 $ 213.58
93320 26 $ 22.07
93320 TC $ 59.02
93320 $ 81.11
93321 26 $ 8.82
93321 $ 47.41
93325 26 $ 3.76
93325 TC $ 100.16
93325 $ 103.91
93350 26 $ 45.10
Rev 1/1/2010
147 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
93350 TC $ 60.92 Effective January 1, 2010
93350 $ 106.03
93351 $ 235.69
93352 $ 32.88
93501 26 $ 182.61
93501 TC $ 574.19
93501 $ 756.79
93503 $ 154.89
93505 26 $ 235.40
93505 TC $ 67.93
93505 $ 303.32
93508 26 $ 219.98
93508 TC $ 424.77
93508 $ 644.75
93510 26 $ 234.77
93510 TC $ 1,254.64
93510 $ 1,489.41
93511 26 $ 256.34
93511 TC $ 1,221.13
93511 $ 1,477.48
93514 26 $ 373.71
93514 TC $ 1,221.13
93514 $ 1,594.86
93524 26 $ 372.23
93524 TC $ 1,595.84
93524 $ 1,968.06
93526 26 $ 345.57
93526 TC $ 1,639.55
93526 $ 1,985.13
93527 26 $ 428.93
93527 TC $ 1,595.84
93527 $ 2,024.76
93528 26 $ 455.61
93528 TC $ 1,595.84
93528 $ 2,051.45
93529 26 $ 248.46
93529 TC $ 1,595.84
93529 $ 1,844.30
93530 26 $ 237.50
93530 TC $ 574.19
93530 $ 811.68
93531 26 $ 443.60
93531 TC $ 1,639.55
93531 $ 2,083.17
93532 26 $ 540.13
93532 TC $ 1,595.84
93532 $ 2,135.98
93533 26 $ 324.50
93533 TC $ 1,595.84
93533 $ 1,920.34
Rev 1/1/2010
148 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
93539 $ 40.33 Effective January 1, 2010
93540 $ 41.58
93541 $ 17.03
93542 $ 17.03
93543 $ 27.28
93544 $ 25.72
93545 $ 32.96
93555 26 $ 36.39
93555 TC $ 211.72
93555 $ 248.11
93556 26 $ 40.22
93556 TC $ 333.13
93556 $ 373.34
93561 26 $ 28.67
93561 TC $ 18.77
93561 $ 47.45
93562 26 $ 9.45
93562 TC $ 11.14
93562 $ 20.59
93571 26 $ 80.32
93571 TC $ 153.27
93571 $ 233.59
93572 $ 214.35
93580 $ 839.05
93581 $ 1,122.90
93600 26 $ 123.28
93600 TC $ 67.02
93600 $ 190.29
93602 26 $ 113.94
93602 TC $ 38.31
93602 $ 152.24
93603 26 $ 121.30
93603 TC $ 57.78
93603 $ 179.07
93609 26 $ 457.98
93609 TC $ 92.89
93609 $ 550.87
93610 26 $ 157.96
93610 TC $ 46.59
93610 $ 204.55
93612 26 $ 158.90
93612 TC $ 55.53
93612 $ 214.43
93615 26 $ 43.85
93615 TC $ 11.16
93615 $ 55.01
93616 26 $ 78.30
93616 TC $ 11.16
93616 $ 89.46
93618 26 $ 246.91
93618 TC $ 135.65
93618 $ 382.55
Rev 1/1/2010
149 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
93619 26 $ 424.41 Effective January 1, 2010
93619 TC $ 263.67
93619 $ 688.08
93620 26 $ 670.35
93620 TC $ 306.16
93620 $ 976.51
93621 26 $ 734.94
93622 26 $ 736.20
93623 26 $ 159.43
93624 26 $ 238.99
93624 TC $ 67.97
93624 $ 306.96
93631 26 $ 399.94
93631 TC $ 216.56
93631 $ 616.49
93640 26 $ 203.99
93640 TC $ 245.18
93640 $ 449.17
93641 26 $ 343.69
93641 TC $ 245.18
93641 $ 588.87
93642 26 $ 282.20
93642 TC $ 245.18
93642 $ 527.39
93650 $ 610.14
93651 $ 940.84
93652 $ 996.87
93660 26 $ 98.51
93662 $ 302.71
93701 $ 34.58
93720 $ 34.94
93721 $ 24.55
93722 $ 10.40
93724 26 $ 240.22
93724 TC $ 135.65
93724 $ 375.88
93740 26 $ 13.60
93740 TC $ 5.25
93740 $ 18.84
93750 $ 35.01
93770 26 $ 10.13
93770 TC $ 0.94
93770 $ 11.08
93860 $ 62.40
93870 $ 120.76
93875 26 $ 12.60
93875 TC $ 38.86
93875 $ 51.47
93880 26 $ 29.82
93880 TC $ 130.61
93880 $ 160.44
93882 26 $ 20.08
Rev 1/1/2010
150 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
93882 TC $ 86.67 Effective January 1, 2010
93882 $ 106.77
93886 26 $ 43.92
93886 TC $ 147.52
93886 $ 191.44
93888 26 $ 29.17
93888 TC $ 98.74
93888 $ 127.91
93890 26 $ 47.98
93890 TC $ 167.13
93890 $ 215.09
93892 26 $ 54.89
93892 TC $ 174.01
93892 $ 228.91
93893 26 $ 54.89
93893 TC $ 169.54
93893 $ 224.42
93922 26 $ 14.80
93922 TC $ 41.06
93922 $ 55.84
93923 26 $ 26.43
93923 TC $ 77.07
93923 $ 103.49
93924 26 $ 29.56
93924 TC $ 84.04
93924 $ 113.59
93925 26 $ 29.20
93925 TC $ 131.25
93925 $ 160.45
93926 26 $ 19.77
93926 TC $ 87.61
93926 $ 107.37
93930 26 $ 24.52
93930 TC $ 139.21
93930 $ 163.74
93931 26 $ 16.34
93931 TC $ 92.40
93931 $ 108.73
93965 26 $ 20.16
93965 TC $ 38.83
93965 $ 58.99
93970 26 $ 33.25
93970 TC $ 144.93
93970 $ 178.18
93971 26 $ 21.97
93971 TC $ 96.51
93971 $ 118.46
93975 26 $ 75.41
93975 TC $ 164.41
93975 $ 239.82
93976 26 $ 50.08
93976 TC $ 110.21
Rev 1/1/2010
151 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
93976 $ 160.28 Effective January 1, 2010
93978 26 $ 32.00
93978 TC $ 135.38
93978 $ 167.37
93979 26 $ 21.65
93979 TC $ 89.83
93979 $ 111.48
93980 26 $ 62.17
93980 TC $ 122.62
93980 $ 184.79
93981 26 $ 23.90
93981 TC $ 113.38
93981 $ 137.28
93982 $ 32.09
93990 26 $ 13.22
93990 TC $ 87.61
93990 $ 100.83
94002 $ 68.96
94003 $ 50.61
94004 $ 36.80
94010 26 $ 11.36
94010 TC $ 14.37
94010 $ 25.73
94011 $ 64.60
94012 $ 99.43
94013 $ 20.99
94014 $ 36.96
94016 $ 23.21
94060 26 $ 17.33
94060 TC $ 32.24
94060 $ 49.56
94070 26 $ 28.92
94070 TC $ 50.10
94070 $ 79.02
94150 26 $ 6.76
94150 TC $ 2.56
94150 $ 9.88
94200 26 $ 6.29
94200 TC $ 8.92
94200 $ 15.20
94240 26 $ 13.85
94240 TC $ 23.61
94240 $ 37.46
94250 26 $ 6.29
94250 TC $ 4.79
94250 $ 11.07
94260 26 $ 7.56
94260 TC $ 18.51
94260 $ 26.06
94350 26 $ 13.52
94350 TC $ 18.51
94350 $ 32.04
Rev 1/1/2010
152 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
94360 26 $ 13.21 Effective January 1, 2010
94360 TC $ 33.20
94360 $ 46.41
94370 26 $ 12.25
94370 TC $ 9.56
94370 $ 21.80
94375 26 $ 15.09
94375 TC $ 16.62
94375 $ 31.71
94400 26 $ 23.31
94400 TC $ 12.05
94400 $ 35.36
94450 26 $ 19.18
94450 TC $ 13.41
94450 $ 32.58
94452 26 $ 13.74
94452 TC $ 32.66
94452 $ 46.40
94453 26 $ 17.69
94453 TC $ 48.51
94453 $ 66.19
94620 26 $ 36.22
94620 TC $ 48.82
94620 $ 85.04
94621 $ 113.20
94640 $ 17.25
94642 $ 28.22
94660 $ 46.69
94662 $ 33.58
94664 $ 16.90
94667 $ 21.05
94668 $ 16.93
94680 26 $ 14.82
94680 TC $ 18.14
94680 $ 32.95
94681 26 $ 11.34
94681 TC $ 48.12
94681 $ 59.47
94690 26 $ 3.76
94690 TC $ 18.19
94690 $ 21.96
94720 26 $ 13.85
94720 TC $ 29.03
94720 $ 42.88
94725 26 $ 12.90
94725 TC $ 59.98
94725 $ 72.88
94750 26 $ 12.92
94750 TC $ 19.79
94750 $ 32.71
94760 $ 9.08
94761 $ 23.26
Rev 1/1/2010
153 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
94762 $ 23.19 Effective January 1, 2010
94770 26 $ 7.53
94770 TC $ 11.71
94770 $ 19.24
94772 26 $ 20.31
94772 TC $ 17.31
94772 $ 37.62
95004 $ 3.50
95010 $ 13.31
95015 $ 13.94
95024 $ 5.11
95027 $ 5.11
95028 $ 7.98
95044 $ 7.02
95052 $ 8.62
95056 $ 6.06
95060 $ 12.13
95065 $ 7.02
95070 $ 75.26
95071 $ 96.08
95075 $ 78.26
95078 $ 8.92
95115 $ 13.41
95117 $ 17.25
95120 $ 4.70
95125 $ 5.17
95130 $ 6.04
95131 $ 7.05
95132 $ 28.22
95144 $ 8.26
95145 $ 15.62
95146 $ 22.68
95147 $ 30.36
95148 $ 30.69
95149 $ 31.65
95165 $ 7.93
95170 $ 12.09
95180 $ 91.67
95250 $ 52.24
95251 $ 23.01
95803 $ 32.85
95803 $ 46.50
95803 $ 79.35
95805 26 $ 80.57
95805 TC $ 228.38
95805 $ 308.94
95807 26 $ 93.61
95807 TC $ 221.15
95807 $ 314.75
95808 26 $ 142.32
95808 TC $ 249.35
95808 $ 391.67
Rev 1/1/2010
154 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
95810 26 $ 174.50 Effective January 1, 2010
95810 TC $ 356.70
95810 $ 531.20
95811 26 $ 187.07
95811 $ 552.40
95812 26 $ 50.56
95812 TC $ 67.71
95812 $ 118.26
95813 26 $ 75.55
95813 TC $ 88.22
95813 $ 163.76
95816 26 $ 46.70
95816 TC $ 68.05
95816 $ 114.76
95819 26 $ 50.56
95819 TC $ 47.86
95819 $ 98.42
95822 26 $ 51.51
95822 TC $ 59.31
95822 $ 110.84
95824 26 $ 39.01
95824 TC $ 8.60
95824 $ 47.62
95827 26 $ 56.33
95827 TC $ 78.52
95827 $ 134.85
95829 26 $ 246.52
95829 TC $ 71.09
95829 $ 317.61
95830 $ 114.34
95831 $ 20.56
95832 $ 19.27
95833 $ 29.98
95834 $ 38.84
95851 $ 16.50
95852 $ 12.06
95857 $ 35.38
95860 26 $ 50.34
95860 TC $ 13.08
95860 $ 63.43
95861 26 $ 82.47
95861 TC $ 25.51
95861 $ 107.97
95863 26 $ 97.54
95863 TC $ 32.24
95863 $ 129.78
95864 26 $ 108.63
95864 TC $ 61.27
95864 $ 169.90
95865 26 $ 76.60
95865 TC $ 23.57
95865 $ 100.17
Rev 1/1/2010
155 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
95866 26 $ 59.40 Effective January 1, 2010
95866 TC $ 7.56
95866 $ 66.96
95867 26 $ 41.21
95867 TC $ 19.79
95867 $ 61.00
95868 26 $ 68.06
95868 TC $ 23.93
95868 $ 92.00
95869 26 $ 20.17
95869 TC $ 7.65
95869 $ 27.81
95870 26 $ 20.17
95870 TC $ 7.65
95870 $ 27.81
95872 26 $ 70.32
95872 TC $ 20.73
95872 $ 91.05
95873 26 $ 17.37
95873 TC $ 7.26
95873 $ 24.63
95874 26 $ 17.71
95874 TC $ 7.26
95874 $ 24.96
95875 26 $ 55.74
95875 TC $ 15.26
95875 $ 71.00
95900 26 $ 22.66
95900 TC $ 9.89
95900 $ 32.54
95903 26 $ 29.55
95903 TC $ 8.92
95903 $ 38.48
95904 26 $ 19.23
95904 TC $ 7.95
95904 $ 27.19
95905 $ 1.90
95905 $ 49.42
95905 $ 51.32
95920 26 $ 108.18
95920 TC $ 44.39
95920 $ 152.57
95921 26 $ 21.86
95921 $ 52.93
95922 26 $ 43.29
95922 TC $ 13.08
95922 $ 56.38
95923 26 $ 40.78
95923 TC $ 49.30
95923 $ 90.07
95925 26 $ 32.17
95925 TC $ 31.28
Rev 1/1/2010
156 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
95925 $ 63.44 Effective January 1, 2010
95926 26 $ 32.17
95926 TC $ 31.28
95926 $ 63.44
95927 26 $ 32.80
95927 TC $ 31.28
95927 $ 64.09
95928 26 $ 72.75
95928 TC $ 82.58
95928 $ 155.34
95929 26 $ 72.75
95929 TC $ 89.13
95929 $ 161.88
95930 26 $ 23.70
95930 TC $ 15.03
95930 $ 38.74
95933 26 $ 31.16
95933 TC $ 27.12
95933 $ 58.27
95934 26 $ 26.10
95934 TC $ 7.65
95934 $ 33.73
95936 26 $ 27.35
95936 TC $ 7.65
95936 $ 35.00
95937 26 $ 33.00
95937 TC $ 11.81
95937 $ 44.82
95950 26 $ 79.90
95950 TC $ 165.04
95950 $ 244.95
95951 26 $ 259.19
95951 TC $ 459.16
95951 $ 718.35
95953 26 $ 140.57
95953 TC $ 217.92
95953 $ 358.50
95954 26 $ 128.04
95954 TC $ 50.18
95954 $ 178.22
95955 26 $ 56.67
95955 TC $ 68.22
95955 $ 124.90
95956 26 $ 145.71
95956 TC $ 484.86
95956 $ 630.56
95957 26 $ 88.12
95957 TC $ 58.71
95957 $ 146.83
95958 26 $ 219.58
95958 TC $ 60.29
95958 $ 279.86
Rev 1/1/2010
157 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
95961 26 $ 141.34 Effective January 1, 2010
95961 TC $ 44.39
95961 $ 185.74
95962 26 $ 150.38
95962 TC $ 44.39
95962 $ 194.77
95971 $ 34.44
95974 $ 131.25
95975 $ 74.88
95978 $ 185.25
95979 $ 85.48
95980 $ 29.74
95981 $ 21.42
95982 $ 32.12
96000 $ 88.25
96001 $ 105.28
96004 $ 90.15
96101 $ 80.68
96102 $ 37.77
96103 $ 23.37
96105 $ 62.10
96110 $ 11.77
96111 $ 62.10
96116 $ 90.53
96118 $ 109.20
96119 $ 56.35
96120 $ 41.04
96360 $ 48.20
96361 $ 14.01
96365 $ 58.71
96366 $ 18.64
96367 $ 29.47
96368 $ 17.40
96369 $ 128.11
96370 $ 13.37
96371 $ 62.16
96372 $ 17.88
96373 $ 15.35
96374 $ 46.50
96375 $ 20.20
96401 $ 57.81
96402 $ 30.85
96405 $ 50.77
96406 $ 69.75
96409 $ 106.91
96411 $ 61.65
96413 $ 151.08
96415 $ 33.62
96416 $ 162.59
96417 $ 73.59
96420 $ 42.76
96422 $ 42.11
Rev 1/1/2010
158 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
96423 $ 16.62 Effective January 1, 2010
96425 $ 48.85
96440 $ 204.09
96445 $ 203.33
96450 $ 164.52
96521 $ 133.99
96522 $ 96.64
96523 $ 24.54
96530 $ 36.41
96542 $ 119.80
96570 $ 65.31
96571 $ 35.33
96900 $ 13.73
96910 $ 19.79
96912 $ 22.65
97003 $ 49.84
97004 $ 23.84
97010 $ 9.66
97012 $ 15.14
97014 $ 12.96
97016 $ 13.92
97018 $ 9.54
97022 $ 12.97
97024 $ 9.22
97026 $ 8.89
97028 $ 9.53
97032 $ 14.50
97033 $ 15.13
97034 $ 12.61
97035 $ 10.69
97036 $ 17.67
97110 $ 20.07
97112 $ 21.03
97113 $ 22.32
97116 $ 18.85
97140 $ 22.98
97150 $ 16.39
97530 $ 19.52
97532 $ 24.92
97533 $ 27.18
97535 $ 20.91
97542 $ 13.94
97597 $ 43.04
97598 $ 54.64
97601 $ 37.90
97602 $ 34.11
97605 $ 30.32
97606 $ 32.60
97750 $ 20.98
99170 $ 116.12
99175 $ 47.86
99183 $ 117.20
Rev 1/1/2010
159 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
99185 $ 21.72 Effective January 1, 2010
99186 $ 69.52
99190 $ 94.31
99191 $ 57.68
99192 $ 42.98
99195 $ 15.33
99201 $ 35.13
99202 $ 54.57
99203 $ 76.53
99204 $ 110.51
99205 $ 137.12
99211 $ 17.46
99212 $ 29.67
99213 $ 40.70
99214 $ 62.71
99215 $ 93.46
99217 $ 57.41
99218 $ 60.29
99219 $ 98.89
99220 $ 132.67
99221 $ 60.29
99222 $ 99.20
99223 $ 132.67
99231 $ 30.80
99232 $ 48.02
99233 $ 67.47
99234 $ 108.72
99235 $ 147.02
99236 $ 180.51
99238 $ 57.11
99241 $ 48.05
99242 $ 78.78
99243 $ 100.50
99244 $ 139.12
99245 $ 180.61
99251 $ 38.10
99252 $ 65.63
99253 $ 87.91
99254 $ 123.04
99255 $ 167.90
99281 $ 17.28
99282 $ 27.00
99283 $ 54.80
99284 $ 84.21
99285 $ 132.41
99291 $ 163.48
99292 $ 81.55
99304 $ 54.93
99305 $ 72.87
99306 $ 89.84
99307 $ 28.45
99308 $ 47.12
Rev 1/1/2010
160 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
99309 $ 66.37 Effective January 1, 2010
99310 $ 83.12
99318 $ 54.93
99324 $ 49.06
99325 $ 71.76
99326 $ 103.84
99327 $ 136.57
99328 $ 168.99
99334 $ 38.03
99335 $ 60.09
99336 $ 92.48
99337 $ 135.91
99341 $ 50.30
99342 $ 72.23
99343 $ 106.14
99344 $ 135.87
99345 $ 147.25
99347 $ 39.65
99348 $ 60.65
99349 $ 91.64
99350 $ 132.35
99354 $ 90.61
99355 $ 88.37
99356 $ 79.12
99357 $ 79.72
99381 $ 55.38
99382 $ 55.38
99383 $ 75.38
99384 $ 75.38
99385 $ 75.38
99391 $ 55.38
99392 $ 55.38
99393 $ 75.38
99394 $ 75.38
99395 $ 75.38
99460 $ 64.89
99461 $ 71.86
99462 $ 34.66
99463 $ 83.17
99464 $ 82.53
99465 $ 162.57
99468 $ 683.12
99469 $ 341.09
99471 $ 690.72
99472 $ 342.03
99475 $ 454.31
99476 $ 270.25
99478 $ 118.51
99479 $ 113.54
99480 $ 111.75
99477 $ 247.49
A4644 $ 36.80
Rev 1/1/2010
161 of 162 Department of Community Health
Schedule of Maximum Allowable Payments
For
Physicians, Podiatry, Nurse Midwife, Advance Nurse Practitioner, and Oral Maxillofacial
04000 $ 43.00 Surgery
A4645 $ 45.47 Effective January 1, 2010
A4646 $ 46.40
A9500 $ 95.00
A9502 $ 112.14
A9505 $ 71.91
A9537 $ 46.48
A9552 $ 203.15
C9003 $ 655.78
D9220 $ 198.72
D9242 $ 97.80
G0104 $ 87.94
G0105 $ 304.93
G0106 26 $ 47.36
G0106 TC $ 81.14
G0106 $ 128.49
G0120 26 $ 47.36
G0120 TC $ 81.14
G0120 $ 128.49
G0202 $ 111.77
G0202 26 $ 31.52
G0202 TC $ 80.24
G0204 $ 117.98
G0204 26 $ 39.03
G0204 TC $ 78.95
G0206 $ 95.26
G0206 26 $ 31.52
G0206 TC $ 63.74
G0364 $ 11.23
M0064 $ 17.66
Q9661 $ 45.47
Q9960 $ 45.47
Q9962 $ 46.40
Q9963 $ 46.40
Q9965 $ 1.53
Q9966 $ 0.96
Q9967 $ 0.25
S0130 $ 16.40
S0190 $ 90.00
S0191 $ 0.71
S9122 $ 20.00
S9123 $ 40.00
S9124 $ 35.00
Z4685 $ 0.46
Rev 1/1/2010
162 of 162 Department of Community Health
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