Ambulatory Surgery Center Fee Schedule - Washington Department ...

Ambulatory Surgery Center Fee Schedule 

Effective Dates of Service 7/1/2012 thru 8/31/2012 

The procedure codes and fee schedule amounts in this document do not necessarily indicate 

coverage or payment. All coverage and payments are subject to Offender Health Plan Coverage, 

exclusions, limitations, and pre-authorization requirements. For detailed billing and coverage 

information, refer to the Department of Corrections (DOC) Billing Instructions for Offsite Professional 

Providers, Facilities and Hospitals and the Offender Health Plan. 

Fees in this publication are subject to change without notice. Although we make every effort to 

ensure the accuracy of the fees in our publications, changes or corrections may occur throughout 

the year. 

Visit the DOC web site at www.doc.wa.gov/business/healthcareproviders to download the latest 

versions of this fee schedule, and all other DOC publications mentioned in this document. 

 

Current Procedural Terminology (CPT ) five-digit codes, descriptions, and other data only are copyright 2012 American Medical Association 

(AMA). All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. AMA does not directly or 

indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein. Applicable 

FARS/DFARS Apply. CPT is a registered trademark of the AMA

DOC ASC Fee Schedule 


Refer to the 2012 CPT® and HCPCS coding books for complete code descriptions 

DOC ASC Payment Policy Information 

General Information 

The Department of Corrections (DOC) Ambulatory Surgery Center Fee Schedule contains the maximum 

allowances for services provided in ambulatory surgery centers (ASC). 

All DOC coverage rules regarding the medical necessity of a given procedure for a given patient are applicable to 

ASC services in the same manner as all other covered services. 

ASC Payment Methodology and Conversion Factors 

DOC follows Medicare payment policies and billing requirements for ASCs. 

The list of procedures covered in an ASC include the majority of procedures covered in an outpatient hospital 

setting. The ASC payment rates are based on the ambulatory payment classifications (APCs) used to group 

procedures under the Outpatient Prospective Payment System (OPPS). 

The fee schedule for 2012 includes OPPS weights and codes for 2010. The standard ASC payment for covered 

surgical procedures is calculated by multiplying the DOC ASC conversion factor by the APC payment weight for 

each separately payable procedure. 

Effective for dates of service on or after January 1, 2012, the following conversion factors will apply. 

Billing Information 

Conversion Factor Coverage Description 

$62.83 most surgical procedures 

$96.47 pain management and gastrointestinal procedures 

(see the fee schedule for a list of specific CPT and 

HCPCS codes paid using this conversion factor) 

Ambulatory Surgery Centers should bill the same procedure code(s) reported by the surgeon. ASCs can submit 

paper claims and use either a CMS 1500 or UB-04 claim form for payment consideration. The ASC charges 

must be billed with place of service code "24." The modifier “TC” must be used unless the code has no 

professional component. 

Although the “SG” modifier is no longer required by Medicare, however DOC requires this modifier on the claim. 

CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply 

Page | 2




The DOC ASC fee schedule uses Current Procedural Terminology (CPT) and Healthcare Common Procedure 

Coding System (HCPCS) codes. For billing purposes, use the most recent edition of the CPT and HCPCS 

level II coding references, which include complete descriptions of the codes. 

Packaged Services and Supplies 

ASC services for which payment is included in the ASC allowed amount for a covered procedure include, but are 

not limited to the following. 

• Administrative, record keeping and housekeeping items and services 

• Anesthesia supplies/materials 

• Blood, blood plasma, and platelets 

• Drugs and biologicals for which separate payment is not allowed under the outpatient prospective payment 

system (OPPS). 

• Implanted DME and related accessories and supplies not on pass-through status 

• Implanted prosthetic devices not on pass-through status, including intraocular lenses (IOLS) inserted during 

or subsequent to cataract surgery. 

• Nursing, technician and related services 

• Radiology services for which separate payment is not allowed under the OPPS and other diagnostic or 

therapeutic services or items integral to the surgical procedure (including routine pre-op lab services) 

• Surgical dressings, surgical trays, supplies, splints, screws, casts, post-op shoes 

• Use of ASC facilities (including operating/recovery rooms and patient preparation areas) 

ASC Services and Supplies that May be Paid Separately 

DOC will pay separately for certain covered ancillary services that are provided integral to covered 

surgical procedures in ASCs including the following. 

• Brachytherapy sources 

• Certain implantable items that have pass through status under OPPS 

• Certain radiology services for which separate payment is allowed under the OPPS 

• Corneal tissue procurement (HCPCS code V2785) 

• Drugs and biologicals that are separately paid under the OPPS 

• New Technology Intraocular Lens (NTIOLS) 

Other Services Provided by ASCs that May be Paid Separately 

• Ambulance services 

• Artificial limbs 

• Durable medical equipment for use in the patient's home 

• Leg, arm, back and neck braces 

• Professional services, including; physician services, surgeon, assistant surgeon, anesthesiologist and nurse 

anesthetist 

• Pre/post-operative professional services (E/M codes subject to global surgery rules) 

• Services furnished by an independent laboratory 

Multiple Surgery Rules 

In general, the following procedure for multiple surgery rules applies. In some cases due to automated claims 

adjudication and additional logic built into the processing system, these rules may be overridden and procedures 

that might otherwise result in reduced payment may not have the reduction for multiple surgeries taken. Please 

contact DOC Customer Service if you have any questions regarding how the claim was processed for multiple 

surgeries as outlined below. 


Page | 3




Payment Rule for Multiple Procedures (modifier 51) 

If multiple procedures are performed on the same patient at the same operative session or on the same day, the 

total maximum allowance is equal to the sum of the following: 

100% of the DOC ASC Fee Schedule allowed amount for the highest fee-schedule-valued procedure. 

50% of the DOC ASC Fee Schedule allowed amount for any other ASC covered surgical procedure(s) 

Payment Rule for Bilateral Procedures (modifier 50) 

When a bilateral procedure is performed, the DOC allowed charge is based on 150% of the DOC ASC Fee 

Schedule amount. Providers must bill using the single procedure code with the modifier. 

Payment Rules for Terminated Procedures 

DOC will not pay claims for an ASC procedure that is terminated either for non-medical or medical 

reasons before expending substantial resources. For example, DOC would not pay a claim for a 

scheduled surgery that was cancelled or postponed because the patient on intake complained of a 

cold or flu. 

Termination of a Procedure After Anesthesia (Modifier 74) 

An ASC may be paid when a medical complication arises causing the covered procedure to be terminated after 

inducement of an anesthetic agent. Resources of the facility are consumed in essentially the same manner and 

to the same extent as they would have been had the surgery been completed. In these circumstances, modifier 

74 (representing a discontinued procedure after administration of anesthesia) must be present with the procedure 

code. 

Termination of a Procedure Before Anesthesia (Modifier 73) 

An ASC may be paid when a surgical procedure is terminated due to the onset of medical complications after the 

patient has been prepared for surgery and taken to the operating room but before anesthesia has been induced. 

Modifier 73 must be present with the procedure code. The DOC ASC Fee Schedule amount is generally reduced 

by 50% for payment of covered procedures in these situations. 

Note: supporting documentation may be requested on a periodic basis by DOC when modifiers 

73 or 74 are used. 

Request for Pre-Authorization 

Pre-Authorization is not required for ASCs. In the unlikely event that the cost of a procedure (procedure plus 

implant) is estimated to exceed the DOC allowed amount ASCs may request a preauthorization. Preauthorization 

must be obtained prior to delivery of services to be considered for additional payment. 

Please see www.doc.wa.gov/Business/HealthCareProviders for the appropriate fax number for Pre-Authorization. 

Fax your request and include the following information: 

• Diagnosis code 

• Provider/facility name, phone number, fax number 

• Reason for requesting the pre-auth including supporting documentation 

• Specific procedure being requested with CPT or HCPCS code 

• Estimated cost of any implants (must submit invoice at the time of claim submission) 

• DOC offender number 


Page | 4

Pain Management Procedures 




Procedure 

Code 

Allowed 

Amount 

Procedure 

Code 

Allowed 

Amount 

Procedure 

Code 

Allowed 

Amount 

Procedure 

Code 

Allowed 

Amount 

62263 $694.57 63030 $4,748.59 64430 $694.57 64622 $1,277.58 

62264 $1,277.58 63035 $4,748.59 64435 $359.06 64623 $694.57 

62268 $694.57 63040 $4,748.59 64445 $694.57 64626 $694.57 

62269 $932.50 63042 $4,748.59 64446 $694.57 64627 $246.55 

62270 $359.06 63045 $4,748.59 64447 $359.06 64630 $694.57 

62272 $359.06 63046 $4,748.59 64448 $694.57 64640 $694.57 

62273 $359.06 63047 $4,748.59 64449 $694.57 64680 $694.57 

62280 $694.57 63048 $4,748.59 64450 $359.06 64681 $1,277.58 

62281 $694.57 63055 $4,748.59 64479 $694.57 62267 $443.66 

62282 $694.57 63056 $4,748.59 64480 $359.06 63620 $0.00 

62284 $0.00 63057 $4,748.59 64483 $694.57 63621 $0.00 

62287 $3,596.31 63064 $4,748.59 64484 $359.06 63661 $1,894.41 

62290 $0.00 63066 $4,748.59 64505 $246.55 63662 $1,894.41 

62291 $0.00 63075 $4,748.59 64508 $246.55 63663 $1,894.41 

62292 $694.57 63600 $1,805.84 64510 $694.57 63664 $1,894.41 

62294 $694.57 63610 $1,805.84 64517 $694.57 64455 $246.55 

62310 $694.57 63615 $1,805.84 64520 $694.57 64490 $694.57 

62311 $694.57 63650 $6,338.73 64530 $694.57 64491 $246.55 

62318 $694.57 63655 $8,345.95 64553 $6,338.73 64492 $246.55 

62319 $694.57 63685 $19,881.73 64555 $6,338.73 64493 $694.57 

62350 $3,957.88 63688 $2,765.06 64560 $6,338.73 64494 $246.55 

62351 $4,748.59 63741 $3,957.88 64561 $6,338.73 64495 $246.55 

62355 $1,277.58 63744 $3,957.88 64565 $6,338.73 64632 $246.55 

62360 $3,957.88 63746 $1,277.58 64573 $15,235.73 

62361 $19,163.65 64400 $246.55 64575 $8,345.95 

62362 $19,163.65 64402 $246.55 64577 $8,345.95 

62365 $3,596.31 64405 $359.06 64580 $8,345.95 

62367 $245.08 64408 $694.57 64581 $8,345.95 

62368 $245.08 64410 $694.57 64585 $1,894.41 

63001 $4,748.59 64412 $694.57 64590 $19,881.73 

63003 $4,748.59 64413 $359.06 64595 $2,765.06 

63005 $4,748.59 64415 $359.06 64600 $1,277.58 

63011 $4,748.59 64416 $694.57 64605 $1,805.84 

63012 $4,748.59 64417 $359.06 64610 $1,805.84 

63015 $4,748.59 64418 $359.06 64612 $246.55 

63016 $4,748.59 64420 $359.06 64613 $359.06 

63017 $4,748.59 64421 $694.57 64614 $359.06 

63020 $4,748.59 64425 $359.06 64620 $694.57 


Page | 5

Gastrointestinal Procedures 




Procedure 

Code 

Allowed 

Amount 

Procedure 

Code 

Allowed 

Amount 

Procedure 

Code 

Allowed 

Amount 

43200 $843.71 44388 $878.33 46040 $2,312.32 

43202 $843.71 44389 $878.33 46060 $2,312.32 

43235 $843.71 45171 $1,361.52 46080 $2,312.32 

43239 $843.71 45172 $2,312.32 46200 $2,312.32 

43243 $843.71 45331 $557.06 46220 $1,361.52 

43245 $843.71 45333 $891.83 46230 $2,312.32 

43247 $843.71 45338 $891.83 46250 $2,312.32 

43248 $843.71 45339 $891.83 46260 $2,312.32 

43249 $843.71 45355 $878.33 46270 $2,312.32 

43250 $843.71 45378 $878.33 46280 $2,312.32 

43251 $843.71 45380 $878.33 46615 $2,201.43 

43255 $843.71 45381 $878.33 46707 $3,104.39 

43273 $2,181.20 45382 $878.33 46924 $2,051.38 

43450 $575.15 45383 $878.33 46930 $517.54 

44360 $950.22 45384 $878.33 46947 $3,104.39 

44361 $950.22 45385 $878.33 

44377 $950.22 45560 $3,104.39 

44386 $878.33 45990 $2,312.32 


Page | 6




2011 ASC Fee Schedule 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

10021 $94.94 Y 

10022 $288.96 Y 

10040 $55.22 Y 

10060 $91.46 Y 

10061 $91.46 Y 

10080 $91.46 Y 

10081 $793.02 Y 

10120 $175.81 Y 

10121 $1,099.36 Y 

10140 $793.02 Y 

10160 $91.46 Y 

10180 $1,219.29 Y 

11000 $96.83 Y 

11001 $55.22 Y 

11010 $274.10 Y 

11011 $274.10 Y 

11012 $274.10 Y 

11040 $96.83 Y 

11041 $96.83 Y 

11042 $175.81 Y 

11043 $175.81 Y 

11044 $515.38 Y 

11055 $55.22 Y 

11056 $55.22 Y 

11057 $55.22 Y 

11100 $96.83 Y 

11101 $55.22 Y 

11200 $55.22 Y 

11201 $55.22 Y 

11300 $55.22 Y 

11301 $55.22 Y 

11302 $55.22 Y 

11303 $96.83 Y 

11305 $55.22 Y 

11306 $55.22 Y 

11307 $55.22 Y 

11308 $55.22 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

11310 $55.22 Y 

11311 $55.22 Y 

11312 $55.22 Y 

11313 $55.22 Y 

11400 $274.10 Y 

11401 $274.10 Y 

11402 $274.10 Y 

11403 $515.38 Y 

11404 $1,099.36 Y 

11406 $1,099.36 Y 

11420 $515.38 Y 

11421 $515.38 Y 

11422 $515.38 Y 

11423 $1,099.36 Y 

11424 $1,099.36 Y 

11426 $1,469.46 Y 

11440 $274.10 Y 

11441 $274.10 Y 

11442 $515.38 Y 

11443 $515.38 Y 

11444 $515.38 Y 

11446 $1,469.46 Y 

11450 $1,469.46 Y 

11451 $1,469.46 Y 

11462 $1,469.46 Y 

11463 $1,469.46 Y 

11470 $1,469.46 Y 

11471 $1,469.46 Y 

11600 $515.38 Y 

11601 $274.10 Y 

11602 $274.10 Y 

11603 $515.38 Y 

11604 $515.38 Y 

11606 $1,099.36 Y 

11620 $515.38 Y 

11621 $274.10 Y 

11622 $515.38 Y 


Page | 7




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

11623 $1,099.36 Y 

11624 $1,099.36 Y 

11626 $1,469.46 Y 

11640 $515.38 Y 

11641 $515.38 Y 

11642 $515.38 Y 

11643 $515.38 Y 

11644 $1,099.36 Y 

11646 $1,469.46 Y 

11719 $27.87 Y 

11720 $55.22 Y 

11721 $55.22 Y 

11730 $55.22 Y 

11732 $55.22 Y 

11740 $27.87 Y 

11750 $274.10 Y 

11752 $1,469.46 Y 

11755 $274.10 Y 

11760 $85.08 Y 

11762 $1,008.68 Y 

11765 $55.22 Y 

11770 $1,469.46 Y 

11771 $1,469.46 Y 

11772 $1,469.46 Y 

11900 $55.22 Y 

11901 $55.22 Y 

11920 $197.96 Y 

11921 $197.96 Y 

11922 $197.96 Y 

11950 $85.08 Y 

11951 $85.08 Y 

11952 $85.08 Y 

11954 $85.08 Y 

11960 $1,503.62 Y 

11970 $2,926.52 Y 

11971 $1,469.46 Y 

11976 $274.10 Y 

11980 $42.05 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

11981 $42.05 Y 

11982 $42.05 Y 

11983 $42.05 Y 

12001 $85.08 Y 

12002 $85.08 Y 

12004 $85.08 Y 

12005 $85.08 Y 

12006 $85.08 Y 

12007 $85.08 Y 

12011 $85.08 Y 

12013 $85.08 Y 

12014 $85.08 Y 

12015 $85.08 Y 

12016 $85.08 Y 

12017 $85.08 Y 

12018 $85.08 Y 

12020 $278.88 Y 

12021 $197.96 Y 

12031 $85.08 Y 

12032 $197.96 Y 

12034 $85.08 Y 

12035 $85.08 Y 

12036 $197.96 Y 

12037 $197.96 Y 

12041 $85.08 Y 

12042 $85.08 Y 

12044 $85.08 Y 

12045 $197.96 Y 

12046 $197.96 Y 

12047 $197.96 Y 

12051 $85.08 Y 

12052 $85.08 Y 

12053 $85.08 Y 

12054 $85.08 Y 

12055 $197.96 Y 

12056 $197.96 Y 

12057 $197.96 Y 

13100 $278.88 Y 


Page | 8




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

13101 $278.88 Y 

13102 $278.88 Y 

13120 $197.96 Y 

13121 $197.96 Y 

13122 $85.08 Y 

13131 $197.96 Y 

13132 $278.88 Y 

13133 $197.96 Y 

13150 $278.88 Y 

13151 $278.88 Y 

13152 $278.88 Y 

13153 $197.96 Y 

13160 $1,503.62 Y 

14000 $1,008.68 Y 

14001 $1,008.68 Y 

14020 $1,008.68 Y 

14021 $1,008.68 Y 

14040 $1,008.68 Y 

14041 $1,008.68 Y 

14060 $1,008.68 Y 

14061 $1,008.68 Y 

14301 $1,503.62 Y 

14302 $1,503.62 Y 

14350 $1,503.62 Y 

15002 $278.88 Y 

15003 $278.88 Y 

15004 $278.88 Y 

15005 $278.88 Y 

15040 $197.96 Y 

15050 $278.88 Y 

15100 $1,503.62 Y 

15101 $1,503.62 Y 

15110 $278.88 Y 

15111 $278.88 Y 

15115 $278.88 Y 

15116 $278.88 Y 

15120 $1,503.62 Y 

15121 $1,503.62 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

15130 $1,008.68 Y 

15131 $1,008.68 Y 

15135 $1,008.68 Y 

15136 $1,008.68 Y 

15150 $278.88 Y 

15151 $278.88 Y 

15152 $278.88 Y 

15155 $278.88 Y 

15156 $278.88 Y 

15157 $278.88 Y 

15170 $278.88 Y 

15171 $197.96 Y 

15175 $278.88 Y 

15176 $278.88 Y 

15200 $1,008.68 Y 

15201 $1,008.68 Y 

15220 $1,008.68 Y 

15221 $278.88 Y 

15240 $1,008.68 Y 

15241 $278.88 Y 

15260 $1,008.68 Y 

15261 $1,008.68 Y 

15300 $278.88 Y 

15301 $278.88 Y 

15320 $278.88 Y 

15321 $278.88 Y 

15330 $278.88 Y 

15331 $278.88 Y 

15335 $278.88 Y 

15336 $278.88 Y 

15340 $197.96 Y 

15341 $197.96 Y 

15360 $197.96 Y 

15361 $197.96 Y 

15365 $197.96 Y 

15366 $197.96 Y 

15400 $278.88 Y 

15401 $278.88 Y 


Page | 9




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

15420 $278.88 Y 

15421 $278.88 Y 

15430 $278.88 Y 

15431 $278.88 Y 

15570 $1,503.62 Y 

15572 $1,503.62 Y 

15574 $1,503.62 Y 

15576 $1,503.62 Y 

15600 $1,503.62 Y 

15610 $1,503.62 Y 

15620 $1,503.62 Y 

15630 $1,503.62 Y 

15650 $1,503.62 Y 

15731 $1,503.62 Y 

15732 $1,503.62 Y 

15734 $1,503.62 Y 

15736 $1,503.62 Y 

15738 $1,503.62 Y 

15740 $1,008.68 Y 

15750 $1,503.62 Y 

15760 $1,503.62 Y 

15770 $1,503.62 Y 

15775 $85.08 Y 

15776 $85.08 Y 

15780 $1,469.46 Y 

15781 $274.10 Y 

15782 $274.10 Y 

15783 $175.81 Y 

15786 $55.22 Y 

15787 $55.22 Y 

15788 $55.22 Y 

15789 $96.83 Y 

15792 $96.83 Y 

15793 $55.22 Y 

15819 $197.96 Y 

15820 $1,503.62 Y 

15821 $1,503.62 Y 

15822 $1,503.62 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

15823 $1,503.62 Y 

15824 $1,503.62 Y 

15825 $1,503.62 Y 

15826 $1,503.62 Y 

15828 $1,503.62 Y 

15829 $1,503.62 Y 

15832 $1,469.46 Y 

15833 $1,469.46 Y 

15834 $1,469.46 Y 

15835 $1,469.46 Y 

15836 $1,099.36 Y 

15837 $1,099.36 Y 

15838 $1,099.36 Y 

15839 $1,099.36 Y 

15840 $1,503.62 Y 

15841 $1,503.62 Y 

15842 $1,503.62 Y 

15845 $1,503.62 Y 

15850 $175.81 Y 

15851 $175.81 Y 

15852 $42.05 Y 

15860 $42.05 Y 

15877 By Report N 

15920 $274.10 Y 

15922 $1,503.62 Y 

15931 $1,469.46 Y 

15933 $1,469.46 Y 

15934 $1,503.62 Y 

15935 $1,503.62 Y 

15936 $1,008.68 Y 

15937 $1,503.62 Y 

15940 $1,469.46 Y 

15941 $1,469.46 Y 

15944 $1,503.62 Y 

15945 $1,503.62 Y 

15946 $1,503.62 Y 

15950 $1,469.46 Y 

15951 $1,469.46 Y 


Page | 10




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

15952 $1,008.68 Y 

15953 $1,008.68 Y 

15956 $1,008.68 Y 

15958 $1,008.68 Y 

15999 $274.10 Y 

16000 $55.22 Y 

16020 $96.83 Y 

16025 $96.83 Y 

16030 $96.83 Y 

16035 $96.83 Y 

17000 $55.22 Y 

17003 $27.87 Y 

17004 $175.81 Y 

17106 $175.81 Y 

17107 $175.81 Y 

17108 $175.81 Y 

17110 $55.22 Y 

17111 $96.83 Y 

17250 $96.83 Y 

17260 $96.83 Y 

17261 $96.83 Y 

17262 $96.83 Y 

17263 $96.83 Y 

17264 $96.83 Y 

17266 $175.81 Y 

17270 $96.83 Y 

17271 $96.83 Y 

17272 $96.83 Y 

17273 $175.81 Y 

17274 $175.81 Y 

17276 $175.81 Y 

17280 $96.83 Y 

17281 $175.81 Y 

17282 $175.81 Y 

17283 $175.81 Y 

17284 $175.81 Y 

17286 $175.81 Y 

17311 $309.98 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

17312 $309.98 Y 

17313 $309.98 Y 

17314 $309.98 Y 

17315 $309.98 Y 

17340 $55.22 Y 

17360 $55.22 Y 

17999 $27.87 Y 

19000 $288.96 Y 

19001 $94.94 Y 

19020 $1,219.29 Y 

19030 Packaged N 

19100 $288.96 Y 

19101 $1,555.14 Y 

19102 $490.98 Y 

19103 $973.88 Y 

19110 $1,555.14 Y 

19112 $1,555.14 Y 

19120 $1,555.14 Y 

19125 $1,555.14 Y 

19126 $1,555.14 Y 

19260 $1,099.36 Y 




19296 $3,658.44 Y 

19297 $3,658.44 Y 

19298 $3,658.44 Y 

19301 $1,555.14 Y 

19302 $2,638.83 Y 

19303 $2,146.61 Y 

19304 $2,146.61 Y 

19307 $2,638.83 Y 

19316 $2,146.61 Y 

19318 $2,638.83 Y 

19324 $2,638.83 Y 

19325 $3,658.44 Y 

19328 $2,146.61 Y 

19330 $2,146.61 Y 


Page | 11




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

19340 $2,638.83 Y 

19342 $3,658.44 Y 

19350 $1,555.14 Y 

19355 $2,146.61 Y 

19357 $3,658.44 Y 

19366 $2,146.61 Y 

19370 $2,146.61 Y 

19371 $2,146.61 Y 

19380 $2,638.83 Y 

19396 $2,146.61 Y 

19499 $1,555.14 Y 

20000 $91.46 Y 

20005 $1,383.19 Y 

20100 $478.74 Y 

20101 $1,503.62 Y 

20102 $1,503.62 Y 

20103 $793.02 Y 

20150 $2,926.52 Y 

20200 $1,099.36 Y 

20205 $1,099.36 Y 

20206 $490.98 Y 

20220 $515.38 Y 

20225 $1,099.36 Y 

20240 $1,469.46 Y 

20245 $1,469.46 Y 

20250 $1,383.19 Y 

20251 $1,383.19 Y 

20500 $478.74 Y 


20520 $274.10 Y 

20525 $1,469.46 Y 

20526 $160.58 Y 

20550 $160.58 Y 

20551 $160.58 Y 

20552 $160.58 Y 

20553 $160.58 Y 

20555 $1,996.21 Y 

20600 $160.58 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

20605 $160.58 Y 

20610 $160.58 Y 

20612 $160.58 Y 

20615 $288.96 Y 

20650 $1,383.19 Y 

20662 $1,383.19 Y 

20663 $1,383.19 Y 

20665 $42.05 Y 

20670 $1,099.36 Y 

20680 $1,469.46 Y 

20690 $1,996.21 Y 

20692 $1,996.21 Y 

20693 $1,383.19 Y 

20694 $1,383.19 Y 



20822 $1,774.16 Y 

20900 $1,996.21 Y 

20902 $1,996.21 Y 

20910 $1,503.62 Y 

20912 $1,503.62 Y 

20920 $1,008.68 Y 

20922 $1,008.68 Y 

20924 $1,996.21 Y 

20926 $278.88 Y 

20931 $1,996.21 Y 

20937 $1,996.21 Y 

20950 $91.46 Y 

20972 $3,300.19 Y 

20973 $3,300.19 Y 


20979 $42.05 N 

20982 $2,926.52 Y 


20999 $1,383.19 Y 

21010 $1,568.46 Y 

21011 $515.38 Y 

21012 $515.38 Y 


Page | 12




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

21013 $515.38 Y 

21014 $515.38 Y 

21015 $1,099.36 Y 

21016 $1,469.46 Y 

21025 $2,700.59 Y 

21026 $2,700.59 Y 

21029 $2,700.59 Y 

21030 $1,568.46 Y 

21031 $1,568.46 Y 

21032 $1,568.46 Y 

21034 $2,700.59 Y 

21040 $1,568.46 Y 

21044 $2,700.59 Y 

21046 $2,700.59 Y 

21047 $2,700.59 Y 

21048 $2,700.59 Y 

21049 $2,700.59 Y 

21050 $2,700.59 Y 

21060 $2,700.59 Y 

21070 $2,700.59 Y 


21076 $1,568.46 Y 

21077 $2,700.59 Y 

21079 $2,700.59 Y 

21080 $2,700.59 Y 

21081 $2,700.59 Y 

21082 $2,700.59 Y 

21083 $2,700.59 Y 

21084 $2,700.59 Y 

21085 $1,079.91 Y 

21086 $2,700.59 Y 

21087 $2,700.59 Y 

21088 $2,700.59 Y 

21089 $72.39 Y 

21100 $2,700.59 Y 

21110 $478.74 Y 


21120 $1,568.46 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

21121 $1,568.46 Y 

21122 $1,568.46 Y 

21123 $1,568.46 Y 

21125 $1,568.46 Y 

21127 $2,700.59 Y 

21137 $1,568.46 Y 

21138 $2,700.59 Y 

21139 $2,700.59 Y 

21150 $2,700.59 Y 

21175 $2,700.59 Y 

21181 $1,568.46 Y 

21195 $2,700.59 Y 

21198 $2,700.59 Y 

21199 $2,700.59 Y 

21206 $2,700.59 Y 

21208 $2,700.59 Y 

21209 $2,700.59 Y 

21210 $2,700.59 Y 

21215 $2,700.59 Y 

21230 $2,700.59 Y 

21235 $1,568.46 Y 

21240 $2,700.59 Y 

21242 $2,700.59 Y 

21243 $2,700.59 Y 

21244 $2,700.59 Y 

21245 $2,700.59 Y 

21246 $2,700.59 Y 

21248 $2,700.59 Y 

21249 $2,700.59 Y 

21260 $2,700.59 Y 

21261 $2,700.59 Y 

21263 $2,700.59 Y 

21267 $2,700.59 Y 

21270 $2,700.59 Y 

21275 $2,700.59 Y 

21280 $2,700.59 Y 

21282 $1,079.91 Y 

21295 $478.74 Y 


Page | 13




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

21296 $1,568.46 Y 

21299 $72.39 Y 

21310 $72.39 Y 

21315 $1,079.91 Y 

21320 $1,079.91 Y 

21325 $1,568.46 Y 

21330 $1,568.46 Y 

21335 $1,568.46 Y 

21336 $1,623.81 Y 

21337 $1,079.91 Y 

21338 $1,568.46 Y 

21339 $1,568.46 Y 

21340 $2,700.59 Y 

21345 $1,568.46 Y 

21355 $2,700.59 Y 

21356 $1,568.46 Y 

21360 $1,568.46 Y 

21365 $2,700.59 Y 

21385 $2,700.59 Y 

21390 $2,700.59 Y 

21400 $478.74 Y 

21401 $1,079.91 Y 

21406 $2,700.59 Y 

21407 $2,700.59 Y 

21408 $2,700.59 Y 

21421 $1,568.46 Y 

21440 $1,568.46 Y 

21445 $1,568.46 Y 

21450 $215.19 Y 

21451 $478.74 Y 

21452 $1,079.91 Y 

21453 $2,700.59 Y 

21454 $1,568.46 Y 

21461 $2,700.59 Y 

21462 $2,700.59 Y 

21465 $2,700.59 Y 

21470 $2,700.59 Y 

21480 $72.39 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

21485 $1,079.91 Y 

21490 $2,700.59 Y 

21495 $1,079.91 Y 

21497 $1,079.91 Y 

21499 $72.39 Y 

21501 $1,219.29 Y 

21502 $1,383.19 Y 

21550 $1,099.36 Y 

21552 $1,469.46 Y 

21554 $1,469.46 Y 

21555 $1,099.36 Y 

21556 $1,469.46 Y 

21557 $1,099.36 Y 

21558 $1,469.46 Y 

21600 $1,996.21 Y 

21610 $1,996.21 Y 

21685 $478.74 Y 

21700 $1,383.19 Y 

21720 $1,383.19 Y 

21725 $91.46 Y 

21742 $2,926.52 Y 

21743 $2,926.52 Y 

21800 $104.15 Y 

21805 $1,623.81 Y 

21820 $104.15 Y 

21899 $72.39 Y 

21920 $515.38 Y 

21925 $1,469.46 Y 

21930 $1,099.36 Y 

21931 $1,469.46 Y 

21932 $1,099.36 Y 

21933 $1,469.46 Y 

21935 $1,099.36 Y 

21936 $1,469.46 Y 

22100 $3,092.83 Y 

22101 $3,092.83 Y 

22102 $3,092.83 Y 

22103 $3,092.83 Y 


Page | 14




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

22206 $3,314.30 Y 

22207 $3,271.40 Y 

22208 $833.80 Y 

22222 $3,092.83 Y 

22305 $104.15 Y 

22310 $301.24 Y 

22315 $1,155.83 Y 

22505 $960.81 Y 

22520 $1,996.21 Y 

22521 $1,996.21 Y 

22522 $1,996.21 Y 

22554 $3,092.83 Y 

22585 $3,092.83 Y 

22612 $3,092.83 Y 

22614 $3,092.83 Y 

22845 $3,092.83 Y 

22846 $3,092.83 Y 

22851 $1,383.19 Y 




22899 $1,383.19 Y 

22900 $1,469.46 Y 

22901 $1,469.46 Y 

22902 $1,099.36 Y 

22903 $1,469.46 Y 

22904 $1,099.36 Y 

22905 $1,469.46 Y 

22999 $1,383.19 Y 

23000 $1,099.36 Y 

23020 $2,926.52 Y 

23030 $1,219.29 Y 

23031 $1,219.29 Y 

23035 $1,383.19 Y 

23040 $1,996.21 Y 

23044 $1,996.21 Y 

23065 $515.38 Y 

23066 $1,469.46 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

23071 $1,469.46 Y 

23073 $1,469.46 Y 

23075 $1,099.36 Y 

23076 $1,099.36 Y 

23077 $1,099.36 Y 

23078 $1,469.46 Y 

23100 $1,383.19 Y 

23101 $1,996.21 Y 

23105 $1,996.21 Y 

23106 $1,996.21 Y 

23107 $1,996.21 Y 

23120 $1,996.21 Y 

23125 $1,996.21 Y 

23130 $2,926.52 Y 

23140 $1,383.19 Y 

23145 $1,996.21 Y 

23146 $1,996.21 Y 

23150 $1,996.21 Y 

23155 $1,996.21 Y 

23156 $1,996.21 Y 

23170 $1,996.21 Y 

23172 $1,996.21 Y 

23174 $1,996.21 Y 

23180 $1,996.21 Y 

23182 $1,996.21 Y 

23184 $1,996.21 Y 

23190 $1,996.21 Y 

23195 $1,996.21 Y 

23330 $515.38 Y 

23331 $1,469.46 Y 


23395 $2,926.52 Y 

23397 $5,569.99 Y 

23400 $1,996.21 Y 

23405 $1,996.21 Y 

23406 $1,996.21 Y 

23410 $2,926.52 Y 

23412 $2,926.52 Y 


Page | 15




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

23415 $2,926.52 Y 

23420 $2,926.52 Y 

23430 $2,926.52 Y 

23440 $2,926.52 Y 

23450 $5,569.99 Y 

23455 $5,569.99 Y 

23460 $5,569.99 Y 

23462 $2,926.52 Y 

23465 $5,569.99 Y 

23466 $2,926.52 Y 

23470 $7,462.11 Y 

23480 $2,926.52 Y 

23485 $5,569.99 Y 

23490 $2,926.52 Y 

23491 $5,569.99 Y 

23500 $104.15 Y 

23505 $1,155.83 Y 

23515 $4,113.79 Y 

23520 $301.24 Y 

23525 $301.24 Y 

23530 $2,856.73 Y 

23532 $1,623.81 Y 

23540 $104.15 Y 

23545 $301.24 Y 

23550 $2,856.73 Y 

23552 $2,856.73 Y 

23570 $104.15 Y 

23575 $301.24 Y 

23585 $4,113.79 Y 

23600 $104.15 Y 

23605 $1,155.83 Y 

23615 $4,113.79 Y 

23616 $4,113.79 Y 

23620 $104.15 Y 

23625 $1,155.83 Y 

23630 $4,113.79 Y 

23650 $104.15 Y 

23655 $960.81 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

23660 $2,856.73 Y 

23665 $301.24 Y 

23670 $4,113.79 Y 

23675 $104.15 Y 

23680 $2,856.73 Y 

23700 $960.81 Y 

23800 $5,569.99 Y 

23802 $2,926.52 Y 

23921 $1,008.68 Y 

23929 $104.15 Y 

23930 $1,219.29 Y 

23931 $1,219.29 Y 

23935 $1,383.19 Y 

24000 $1,996.21 Y 

24006 $1,996.21 Y 

24065 $1,099.36 Y 

24066 $1,099.36 Y 

24071 $1,469.46 Y 

24073 $1,469.46 Y 

24075 $1,099.36 Y 

24076 $1,099.36 Y 

24077 $1,099.36 Y 

24079 $1,469.46 Y 

24100 $1,383.19 Y 

24101 $1,996.21 Y 

24102 $1,996.21 Y 

24105 $1,383.19 Y 

24110 $1,383.19 Y 

24115 $1,996.21 Y 

24116 $1,996.21 Y 

24120 $1,383.19 Y 

24125 $1,996.21 Y 

24126 $1,996.21 Y 

24130 $1,996.21 Y 

24134 $1,996.21 Y 

24136 $1,996.21 Y 

24138 $1,996.21 Y 

24140 $1,996.21 Y 


Page | 16




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

24145 $1,996.21 Y 

24147 $1,996.21 Y 

24149 $1,996.21 Y 

24150 $2,926.52 Y 

24152 $2,926.52 Y 

24155 $2,926.52 Y 

24160 $1,996.21 Y 

24164 $1,996.21 Y 

24200 $274.10 Y 

24201 $1,099.36 Y 


24300 $960.81 Y 

24301 $1,996.21 Y 

24305 $1,996.21 Y 

24310 $1,383.19 Y 

24320 $2,926.52 Y 

24330 $5,569.99 Y 

24331 $2,926.52 Y 

24332 $1,383.19 Y 

24340 $2,926.52 Y 

24341 $2,926.52 Y 

24342 $2,926.52 Y 

24343 $1,996.21 Y 

24344 $5,569.99 Y 

24345 $1,996.21 Y 

24346 $2,926.52 Y 

24357 $1,996.21 Y 

24358 $1,996.21 Y 

24359 $1,996.21 Y 

24360 $2,506.14 Y 

24361 $7,462.11 Y 

24362 $3,649.39 Y 

24363 $7,462.11 Y 

24365 $2,506.14 Y 

24366 $7,462.11 Y 

24400 $2,926.52 Y 

24410 $2,926.52 Y 

24420 $2,926.52 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

24430 $5,569.99 Y 

24435 $5,569.99 Y 

24470 $2,926.52 Y 

24495 $1,996.21 Y 

24498 $5,569.99 Y 

24500 $104.15 Y 

24505 $104.15 Y 

24515 $4,113.79 Y 

24516 $4,113.79 Y 

24530 $104.15 Y 

24535 $301.24 Y 

24538 $1,623.81 Y 

24545 $4,113.79 Y 

24546 $4,113.79 Y 

24560 $104.15 Y 

24565 $104.15 Y 

24566 $1,623.81 Y 

24575 $4,113.79 Y 

24576 $104.15 Y 

24577 $301.24 Y 

24579 $4,113.79 Y 

24582 $1,623.81 Y 

24586 $4,113.79 Y 

24587 $4,113.79 Y 

24600 $104.15 Y 

24605 $960.81 Y 

24615 $4,113.79 Y 

24620 $1,155.83 Y 

24635 $4,113.79 Y 

24640 $104.15 Y 

24650 $104.15 Y 

24655 $301.24 Y 

24665 $2,856.73 Y 

24666 $4,113.79 Y 

24670 $104.15 Y 

24675 $104.15 Y 

24685 $2,856.73 Y 

24800 $2,926.52 Y 


Page | 17




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

24802 $2,926.52 Y 

24925 $1,383.19 Y 

24935 $5,569.99 Y 

24999 $104.15 Y 

25000 $1,383.19 Y 

25001 $1,383.19 Y 

25020 $1,996.21 Y 

25023 $1,996.21 Y 

25024 $1,996.21 Y 

25025 $1,996.21 Y 

25028 $1,383.19 Y 

25031 $1,383.19 Y 

25035 $1,383.19 Y 

25040 $1,996.21 Y 

25065 $515.38 Y 

25066 $1,469.46 Y 

25071 $1,469.46 Y 

25073 $1,469.46 Y 

25075 $1,099.36 Y 

25076 $1,099.36 Y 

25077 $1,099.36 Y 

25078 $1,469.46 Y 

25085 $1,383.19 Y 

25100 $1,383.19 Y 

25101 $1,996.21 Y 

25105 $1,996.21 Y 

25107 $1,996.21 Y 

25109 $1,383.19 Y 

25110 $1,383.19 Y 

25111 $1,383.19 Y 

25112 $1,383.19 Y 

25115 $1,383.19 Y 

25116 $1,383.19 Y 

25118 $1,996.21 Y 

25119 $1,996.21 Y 

25120 $1,996.21 Y 

25125 $1,996.21 Y 

25126 $1,996.21 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

25130 $1,996.21 Y 

25135 $1,996.21 Y 

25136 $1,996.21 Y 

25145 $1,996.21 Y 

25150 $1,996.21 Y 

25151 $1,996.21 Y 

25170 $2,926.52 Y 

25210 $1,996.21 Y 

25215 $1,996.21 Y 

25230 $1,996.21 Y 

25240 $1,996.21 Y 


25248 $1,383.19 Y 

25250 $1,996.21 Y 

25251 $1,996.21 Y 

25259 $1,155.83 Y 

25260 $1,996.21 Y 

25263 $1,996.21 Y 

25265 $1,996.21 Y 

25270 $1,996.21 Y 

25272 $1,996.21 Y 

25274 $1,996.21 Y 

25275 $1,996.21 Y 

25280 $1,996.21 Y 

25290 $1,996.21 Y 

25295 $1,383.19 Y 

25300 $1,996.21 Y 

25301 $1,996.21 Y 

25310 $2,926.52 Y 

25312 $2,926.52 Y 

25315 $2,926.52 Y 

25316 $5,569.99 Y 

25320 $2,926.52 Y 

25332 $2,506.14 Y 

25335 $2,926.52 Y 

25337 $2,926.52 Y 

25350 $2,926.52 Y 

25355 $2,926.52 Y 


Page | 18




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

25360 $2,926.52 Y 

25365 $2,926.52 Y 

25370 $2,926.52 Y 

25375 $2,926.52 Y 

25390 $2,926.52 Y 

25391 $2,926.52 Y 

25392 $1,996.21 Y 

25393 $2,926.52 Y 

25394 $2,926.52 Y 

25400 $2,926.52 Y 

25405 $5,569.99 Y 

25415 $5,569.99 Y 

25420 $5,569.99 Y 

25425 $2,926.52 Y 

25426 $2,926.52 Y 

25430 $2,926.52 Y 

25431 $2,926.52 Y 

25440 $5,569.99 Y 

25441 $7,462.11 Y 

25442 $7,462.11 Y 

25443 $3,649.39 Y 

25444 $3,649.39 Y 

25445 $3,649.39 Y 

25446 $7,462.11 Y 

25447 $2,506.14 Y 

25449 $2,506.14 Y 

25450 $2,926.52 Y 

25455 $2,926.52 Y 

25490 $2,926.52 Y 

25491 $2,926.52 Y 

25492 $2,926.52 Y 

25500 $104.15 Y 

25505 $301.24 Y 

25515 $2,856.73 Y 

25520 $301.24 Y 

25525 $2,856.73 Y 

25526 $2,856.73 Y 

25530 $104.15 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

25535 $104.15 Y 

25545 $2,856.73 Y 

25560 $104.15 Y 

25565 $301.24 Y 

25574 $4,113.79 Y 

25575 $4,113.79 Y 

25600 $104.15 Y 

25605 $301.24 Y 

25606 $1,623.81 Y 

25607 $4,113.79 Y 

25608 $4,113.79 Y 

25609 $4,113.79 Y 

25622 $104.15 Y 

25624 $301.24 Y 

25628 $2,856.73 Y 

25630 $104.15 Y 

25635 $301.24 Y 

25645 $2,856.73 Y 

25650 $104.15 Y 

25651 $1,623.81 Y 

25652 $2,856.73 Y 

25660 $104.15 Y 

25670 $1,623.81 Y 

25671 $1,623.81 Y 

25675 $104.15 Y 

25676 $1,623.81 Y 

25680 $104.15 Y 

25685 $1,623.81 Y 

25690 $1,155.83 Y 

25695 $1,623.81 Y 

25800 $5,569.99 Y 

25805 $2,926.52 Y 

25810 $5,569.99 Y 

25820 $2,926.52 Y 

25825 $5,569.99 Y 

25830 $5,569.99 Y 

25907 $1,383.19 Y 

25922 $1,383.19 Y 


Page | 19




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

25929 $1,008.68 Y 

25931 $1,383.19 Y 

25999 $104.15 Y 

26010 $91.46 Y 

26011 $793.02 Y 

26020 $1,070.75 Y 

26025 $1,070.75 Y 

26030 $1,070.75 Y 

26034 $1,070.75 Y 

26035 $1,070.75 Y 

26037 $1,070.75 Y 

26040 $1,774.16 Y 

26045 $1,774.16 Y 

26055 $1,070.75 Y 

26060 $1,070.75 Y 

26070 $1,070.75 Y 

26075 $1,070.75 Y 

26080 $1,070.75 Y 

26100 $1,070.75 Y 

26105 $1,070.75 Y 

26110 $1,070.75 Y 

26111 $1,469.46 Y 

26113 $1,469.46 Y 

26115 $1,099.36 Y 

26116 $1,099.36 Y 

26117 $1,099.36 Y 

26118 $1,469.46 Y 

26121 $1,774.16 Y 

26123 $1,774.16 Y 

26125 $1,070.75 Y 

26130 $1,070.75 Y 

26135 $1,774.16 Y 

26140 $1,070.75 Y 

26145 $1,070.75 Y 

26160 $1,070.75 Y 

26170 $1,070.75 Y 

26180 $1,070.75 Y 

26185 $1,070.75 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

26200 $1,070.75 Y 

26205 $1,774.16 Y 

26210 $1,070.75 Y 

26215 $1,070.75 Y 

26230 $1,070.75 Y 

26235 $1,070.75 Y 

26236 $1,070.75 Y 

26250 $1,070.75 Y 

26260 $1,070.75 Y 

26262 $1,070.75 Y 

26320 $1,099.36 Y 

26340 $301.24 Y 

26350 $1,774.16 Y 

26352 $1,774.16 Y 

26356 $1,774.16 Y 

26357 $1,774.16 Y 

26358 $1,774.16 Y 

26370 $1,774.16 Y 

26372 $1,774.16 Y 

26373 $1,774.16 Y 

26390 $1,774.16 Y 

26392 $1,774.16 Y 

26410 $1,070.75 Y 

26412 $1,774.16 Y 

26415 $1,774.16 Y 

26416 $1,774.16 Y 

26418 $1,070.75 Y 

26420 $1,774.16 Y 

26426 $1,774.16 Y 

26428 $1,774.16 Y 

26432 $1,070.75 Y 

26433 $1,070.75 Y 

26434 $1,774.16 Y 

26437 $1,070.75 Y 

26440 $1,070.75 Y 

26442 $1,774.16 Y 

26445 $1,070.75 Y 

26449 $1,774.16 Y 


Page | 20




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

26450 $1,070.75 Y 

26455 $1,070.75 Y 

26460 $1,070.75 Y 

26471 $1,070.75 Y 

26474 $1,070.75 Y 

26476 $1,070.75 Y 

26477 $1,070.75 Y 

26478 $1,070.75 Y 

26479 $1,070.75 Y 

26480 $1,774.16 Y 

26483 $1,774.16 Y 

26485 $1,774.16 Y 

26489 $1,774.16 Y 

26490 $1,774.16 Y 

26492 $1,774.16 Y 

26494 $1,774.16 Y 

26496 $1,774.16 Y 

26497 $1,774.16 Y 

26498 $1,774.16 Y 

26499 $1,774.16 Y 

26500 $1,070.75 Y 

26502 $1,774.16 Y 

26508 $1,070.75 Y 

26510 $1,774.16 Y 

26516 $1,774.16 Y 

26517 $1,774.16 Y 

26518 $1,774.16 Y 

26520 $1,070.75 Y 

26525 $1,070.75 Y 

26530 $2,506.14 Y 

26531 $3,649.39 Y 

26535 $2,506.14 Y 

26536 $3,649.39 Y 

26540 $1,070.75 Y 

26541 $1,774.16 Y 

26542 $1,070.75 Y 

26545 $1,774.16 Y 

26546 $1,774.16 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

26548 $1,774.16 Y 

26550 $1,774.16 Y 

26555 $1,774.16 Y 

26560 $1,070.75 Y 

26561 $1,774.16 Y 

26562 $1,774.16 Y 

26565 $1,774.16 Y 

26567 $1,774.16 Y 

26568 $1,774.16 Y 

26580 $1,070.75 Y 

26587 $1,070.75 Y 

26590 $1,070.75 Y 

26591 $1,774.16 Y 

26593 $1,070.75 Y 

26596 $1,070.75 Y 

26600 $104.15 Y 

26605 $104.15 Y 

26607 $1,155.83 Y 

26608 $1,623.81 Y 

26615 $2,856.73 Y 

26641 $104.15 Y 

26645 $301.24 Y 

26650 $1,623.81 Y 

26665 $2,856.73 Y 

26670 $104.15 Y 

26675 $301.24 Y 

26676 $1,623.81 Y 

26685 $1,623.81 Y 

26686 $4,113.79 Y 

26700 $104.15 Y 

26705 $104.15 Y 

26706 $1,155.83 Y 

26715 $1,623.81 Y 

26720 $104.15 Y 

26725 $104.15 Y 

26727 $1,623.81 Y 

26735 $1,623.81 Y 

26740 $104.15 Y 


Page | 21




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

26742 $104.15 Y 

26746 $1,623.81 Y 

26750 $104.15 Y 

26755 $104.15 Y 

26756 $1,623.81 Y 

26765 $1,623.81 Y 

26770 $104.15 Y 

26775 $960.81 Y 

26776 $1,623.81 Y 

26785 $1,623.81 Y 

26820 $1,774.16 Y 

26841 $1,774.16 Y 

26842 $1,774.16 Y 

26843 $1,774.16 Y 

26844 $1,774.16 Y 

26850 $1,774.16 Y 

26852 $1,774.16 Y 

26860 $1,774.16 Y 

26861 $1,774.16 Y 

26862 $1,774.16 Y 

26863 $1,774.16 Y 

26910 $1,774.16 Y 

26951 $1,070.75 Y 

26952 $1,070.75 Y 

26989 $104.15 Y 

26990 $1,383.19 Y 

26991 $1,383.19 Y 

26992 $1,383.19 Y 

27000 $1,383.19 Y 

27001 $1,996.21 Y 

27003 $1,996.21 Y 

27006 $1,996.21 Y 

27027 $1,383.19 Y 

27033 $2,926.52 Y 

27035 $2,926.52 Y 

27040 $515.38 Y 

27041 $515.38 Y 

27043 $1,469.46 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

27045 $1,469.46 Y 

27047 $1,099.36 Y 

27048 $1,099.36 Y 

27049 $1,099.36 Y 

27050 $1,383.19 Y 

27052 $1,383.19 Y 

27057 $1,383.19 Y 

27059 $1,469.46 Y 

27060 $1,383.19 Y 

27062 $1,383.19 Y 

27065 $1,383.19 Y 

27066 $1,996.21 Y 

27067 $1,996.21 Y 

27080 $1,996.21 Y 

27086 $515.38 Y 

27087 $1,383.19 Y 



27096 $694.57 Y 

27097 $1,996.21 Y 

27098 $1,996.21 Y 

27100 $2,926.52 Y 

27105 $2,926.52 Y 

27110 $2,926.52 Y 

27111 $2,926.52 Y 

27193 $104.15 Y 

27194 $960.81 Y 

27200 $104.15 Y 

27202 $2,856.73 Y 

27216 $1,417.35 Y 

27220 $104.15 Y 

27230 $104.15 Y 

27235 $1,996.21 Y 

27238 $301.24 Y 

27246 $301.24 Y 

27250 $104.15 Y 

27252 $960.81 Y 

27256 $104.15 Y 


Page | 22




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

27257 $960.81 Y 

27265 $104.15 Y 

27266 $960.81 Y 

27267 $104.15 Y 

27268 $704.00 Y 

27269 $1,695.65 Y 

27275 $960.81 Y 

27299 $104.15 Y 

27301 $1,219.29 Y 

27305 $1,383.19 Y 

27306 $1,383.19 Y 

27307 $1,383.19 Y 

27310 $1,996.21 Y 

27323 $515.38 Y 

27324 $1,469.46 Y 

27325 $1,176.17 Y 

27326 $1,176.17 Y 

27327 $1,469.46 Y 

27328 $1,099.36 Y 

27329 $1,099.36 Y 

27330 $1,996.21 Y 

27331 $1,996.21 Y 

27332 $1,996.21 Y 

27333 $1,996.21 Y 

27334 $1,996.21 Y 

27335 $1,996.21 Y 

27337 $1,469.46 Y 

27339 $1,469.46 Y 

27340 $1,383.19 Y 

27345 $1,383.19 Y 

27347 $1,383.19 Y 

27350 $1,996.21 Y 

27355 $1,996.21 Y 

27356 $1,996.21 Y 

27357 $1,996.21 Y 

27358 $1,996.21 Y 

27360 $1,996.21 Y 

27364 $1,469.46 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 


27372 $1,469.46 Y 

27380 $1,383.19 Y 

27381 $1,383.19 Y 

27385 $1,383.19 Y 

27386 $1,383.19 Y 

27390 $1,383.19 Y 

27391 $1,383.19 Y 

27392 $1,383.19 Y 

27393 $1,996.21 Y 

27394 $1,996.21 Y 

27395 $2,926.52 Y 

27396 $1,996.21 Y 

27397 $2,926.52 Y 

27400 $2,926.52 Y 

27403 $1,996.21 Y 

27405 $2,926.52 Y 

27407 $5,569.99 Y 

27409 $2,926.52 Y 

27412 $5,569.99 Y 

27415 $5,569.99 Y 

27416 $2,926.52 Y 

27418 $2,926.52 Y 

27420 $2,926.52 Y 

27422 $2,926.52 Y 

27424 $2,926.52 Y 

27425 $1,996.21 Y 

27427 $2,926.52 Y 

27428 $5,569.99 Y 

27429 $5,569.99 Y 

27430 $2,926.52 Y 

27435 $2,926.52 Y 

27437 $2,506.14 Y 

27438 $3,649.39 Y 

27440 $2,506.14 Y 

27441 $2,506.14 Y 

27442 $2,506.14 Y 

27443 $2,506.14 Y 


Page | 23




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

27446 $7,462.11 Y 

27475 $1,996.21 Y 

27496 $1,996.21 Y 

27497 $1,383.19 Y 

27498 $1,996.21 Y 

27499 $1,996.21 Y 

27500 $301.24 Y 

27501 $104.15 Y 

27502 $1,155.83 Y 

27503 $104.15 Y 

27508 $104.15 Y 

27509 $1,623.81 Y 

27510 $301.24 Y 

27516 $104.15 Y 

27517 $104.15 Y 

27520 $104.15 Y 

27524 $2,856.73 Y 

27530 $104.15 Y 

27532 $1,155.83 Y 

27535 $2,856.73 Y 

27538 $104.15 Y 

27550 $104.15 Y 

27552 $960.81 Y 

27560 $104.15 Y 

27562 $960.81 Y 

27566 $2,856.73 Y 

27570 $960.81 Y 

27594 $1,383.19 Y 

27599 $104.15 Y 

27600 $1,383.19 Y 

27601 $1,383.19 Y 

27602 $1,383.19 Y 

27603 $1,219.29 Y 

27604 $1,383.19 Y 

27605 $1,372.45 Y 

27606 $1,383.19 Y 

27607 $1,383.19 Y 

27610 $1,996.21 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

27612 $1,996.21 Y 

27613 $515.38 Y 

27614 $1,469.46 Y 

27615 $1,099.36 Y 

27616 $1,469.46 Y 

27618 $1,099.36 Y 

27619 $1,099.36 Y 

27620 $1,996.21 Y 

27625 $1,996.21 Y 

27626 $1,996.21 Y 

27630 $1,383.19 Y 

27632 $1,469.46 Y 

27634 $1,469.46 Y 

27635 $1,996.21 Y 

27637 $1,996.21 Y 

27638 $1,996.21 Y 

27640 $2,926.52 Y 

27641 $1,996.21 Y 

27647 $2,926.52 Y 


27650 $2,926.52 Y 

27652 $5,569.99 Y 

27654 $2,926.52 Y 

27656 $1,383.19 Y 

27658 $1,383.19 Y 

27659 $1,383.19 Y 

27664 $1,996.21 Y 

27665 $1,996.21 Y 

27675 $1,383.19 Y 

27676 $1,996.21 Y 

27680 $1,996.21 Y 

27681 $1,996.21 Y 

27685 $1,996.21 Y 

27686 $1,996.21 Y 

27687 $1,996.21 Y 

27690 $2,926.52 Y 

27691 $2,926.52 Y 

27692 $2,926.52 Y 


Page | 24




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

27695 $1,996.21 Y 

27696 $1,996.21 Y 

27698 $1,996.21 Y 

27700 $2,506.14 Y 

27704 $1,383.19 Y 

27705 $2,926.52 Y 

27707 $1,383.19 Y 

27709 $1,996.21 Y 

27720 $2,856.73 Y 

27722 $4,113.79 Y 

27726 $2,856.73 Y 

27730 $1,996.21 Y 

27732 $1,996.21 Y 

27734 $1,996.21 Y 

27740 $1,996.21 Y 

27742 $2,926.52 Y 

27745 $5,569.99 Y 

27750 $104.15 Y 

27752 $1,155.83 Y 

27756 $1,623.81 Y 

27758 $2,856.73 Y 

27759 $4,113.79 Y 

27760 $104.15 Y 

27762 $1,155.83 Y 

27766 $2,856.73 Y 

27767 $104.15 Y 

27768 $104.15 Y 

27769 $2,856.73 Y 

27780 $104.15 Y 

27781 $1,155.83 Y 

27784 $2,856.73 Y 

27786 $104.15 Y 

27788 $104.15 Y 

27792 $2,856.73 Y 

27808 $104.15 Y 

27810 $301.24 Y 

27814 $2,856.73 Y 

27816 $104.15 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

27818 $301.24 Y 

27822 $2,856.73 Y 

27823 $4,113.79 Y 

27824 $104.15 Y 

27825 $1,155.83 Y 

27826 $2,856.73 Y 

27827 $4,113.79 Y 

27828 $4,113.79 Y 

27829 $2,856.73 Y 

27830 $104.15 Y 

27831 $1,155.83 Y 

27832 $2,856.73 Y 

27840 $301.24 Y 

27842 $960.81 Y 

27846 $2,856.73 Y 

27848 $2,856.73 Y 

27860 $960.81 Y 

27870 $5,569.99 Y 

27871 $5,569.99 Y 

27884 $1,383.19 Y 

27889 $1,996.21 Y 

27892 $1,996.21 Y 

27893 $1,996.21 Y 

27894 $1,996.21 Y 

27899 $104.15 Y 

28001 $793.02 Y 

28002 $1,383.19 Y 

28003 $1,383.19 Y 

28005 $1,372.45 Y 

28008 $1,372.45 Y 

28010 $1,372.45 Y 

28011 $1,372.45 Y 

28020 $1,372.45 Y 

28022 $1,372.45 Y 

28024 $1,372.45 Y 

28035 $1,176.17 Y 

28039 $1,469.46 Y 

28041 $1,469.46 Y 


Page | 25




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

28043 $1,099.36 Y 

28045 $1,099.36 Y 

28046 $1,099.36 Y 

28047 $1,469.46 Y 

28050 $1,372.45 Y 

28052 $1,372.45 Y 

28054 $1,372.45 Y 

28055 $1,176.17 Y 

28060 $1,372.45 Y 

28062 $1,372.45 Y 

28070 $1,372.45 Y 

28072 $1,372.45 Y 

28080 $1,372.45 Y 

28086 $1,372.45 Y 

28088 $1,372.45 Y 

28090 $1,372.45 Y 

28092 $1,372.45 Y 

28100 $1,372.45 Y 

28102 $3,300.19 Y 

28103 $3,300.19 Y 

28104 $1,372.45 Y 

28106 $3,300.19 Y 

28107 $3,300.19 Y 

28108 $1,372.45 Y 

28110 $1,372.45 Y 

28111 $1,372.45 Y 

28112 $1,372.45 Y 

28113 $1,372.45 Y 

28114 $1,372.45 Y 

28116 $1,372.45 Y 

28118 $1,372.45 Y 

28119 $1,372.45 Y 

28120 $1,372.45 Y 

28122 $1,372.45 Y 

28124 $1,372.45 Y 

28126 $1,372.45 Y 

28130 $1,372.45 Y 

28140 $1,372.45 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

28150 $1,372.45 Y 

28153 $1,372.45 Y 

28160 $1,372.45 Y 

28171 $1,372.45 Y 

28173 $1,372.45 Y 

28175 $1,372.45 Y 

28190 $515.38 Y 

28192 $1,099.36 Y 

28193 $515.38 Y 

28200 $1,372.45 Y 

28202 $1,372.45 Y 

28208 $1,372.45 Y 

28210 $3,300.19 Y 

28220 $1,372.45 Y 

28222 $1,372.45 Y 

28225 $1,372.45 Y 

28226 $1,372.45 Y 

28230 $1,372.45 Y 

28232 $1,372.45 Y 

28234 $1,372.45 Y 

28238 $3,300.19 Y 

28240 $1,372.45 Y 

28250 $1,372.45 Y 

28260 $1,372.45 Y 

28261 $1,372.45 Y 

28262 $1,372.45 Y 

28264 $3,300.19 Y 

28270 $1,372.45 Y 

28272 $1,372.45 Y 

28280 $1,372.45 Y 

28285 $1,372.45 Y 

28286 $1,372.45 Y 

28288 $1,372.45 Y 

28289 $1,372.45 Y 

28290 $1,982.49 Y 

28292 $1,982.49 Y 

28293 $1,982.49 Y 

28294 $1,982.49 Y 


Page | 26




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

28296 $1,982.49 Y 

28297 $1,982.49 Y 

28298 $1,982.49 Y 

28299 $1,982.49 Y 

28300 $3,300.19 Y 

28302 $1,372.45 Y 

28304 $3,300.19 Y 

28305 $3,300.19 Y 

28306 $1,372.45 Y 

28307 $1,372.45 Y 

28308 $1,372.45 Y 

28309 $3,300.19 Y 

28310 $1,372.45 Y 

28312 $1,372.45 Y 

28313 $1,372.45 Y 

28315 $1,372.45 Y 

28320 $3,300.19 Y 

28322 $3,300.19 Y 

28340 $1,372.45 Y 

28341 $1,372.45 Y 

28344 $1,372.45 Y 

28345 $1,372.45 Y 

28360 $3,300.19 Y 

28400 $104.15 Y 

28405 $1,155.83 Y 

28406 $1,623.81 Y 

28415 $4,113.79 Y 

28420 $2,856.73 Y 

28430 $104.15 Y 

28435 $104.15 Y 

28436 $1,623.81 Y 

28445 $2,856.73 Y 

28446 $3,300.19 Y 

28450 $104.15 Y 

28455 $104.15 Y 

28456 $1,623.81 Y 

28465 $2,856.73 Y 

28470 $104.15 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

28475 $104.15 Y 

28476 $1,623.81 Y 

28485 $2,856.73 Y 

28490 $104.15 Y 

28495 $104.15 Y 

28496 $1,623.81 Y 

28505 $1,623.81 Y 

28510 $104.15 Y 

28515 $104.15 Y 

28525 $1,623.81 Y 

28530 $104.15 Y 

28531 $1,623.81 Y 

28540 $104.15 Y 

28545 $1,623.81 Y 

28546 $1,623.81 Y 

28555 $2,856.73 Y 

28570 $301.24 Y 

28575 $1,155.83 Y 

28576 $1,623.81 Y 

28585 $1,623.81 Y 

28600 $104.15 Y 

28605 $104.15 Y 

28606 $1,623.81 Y 

28615 $2,856.73 Y 

28630 $104.15 Y 

28635 $960.81 Y 

28636 $1,623.81 Y 

28645 $1,623.81 Y 

28660 $104.15 Y 

28665 $960.81 Y 

28666 $1,623.81 Y 

28675 $1,623.81 Y 

28705 $3,300.19 Y 

28715 $5,569.99 Y 

28725 $3,300.19 Y 

28730 $3,300.19 Y 

28735 $3,300.19 Y 

28737 $3,300.19 Y 


Page | 27




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

28740 $3,300.19 Y 

28750 $3,300.19 Y 

28755 $1,372.45 Y 

28760 $3,300.19 Y 

28810 $1,372.45 Y 

28820 $1,372.45 Y 

28825 $1,372.45 Y 

28899 $104.15 Y 

29000 $66.20 Y 

29010 $147.38 Y 

29015 $147.38 Y 

29020 $66.20 Y 

29025 $66.20 Y 

29035 $147.38 Y 

29040 $66.20 Y 

29044 $147.38 Y 

29046 $147.38 Y 

29049 $66.20 Y 

29055 $147.38 N 

29058 $66.20 N 

29065 $147.38 N 

29075 $147.38 N 

29085 $66.20 N 

29086 $66.20 N 

29105 $66.20 N 

29125 $66.20 N 

29126 $66.20 N 

29130 $66.20 N 

29131 $66.20 N 

29200 $66.20 N 

29240 $66.20 N 

29260 $66.20 N 

29280 $66.20 N 

29305 $147.38 N 

29325 $147.38 N 

29345 $147.38 N 

29355 $147.38 N 

29358 $147.38 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

29365 $147.38 N 

29405 $147.38 N 

29425 $147.38 N 

29435 $147.38 N 

29440 $66.20 N 

29445 $147.38 N 

29450 $66.20 N 

29505 $66.20 N 

29515 $66.20 N 

29520 $66.20 N 

29530 $66.20 N 

29540 $66.20 N 

29550 $66.20 N 

29580 $66.20 N 

29581 $66.20 N 

29590 $66.20 N 

29700 $66.20 N 

29705 $66.20 N 

29710 $147.38 N 

29715 $66.20 N 

29720 $66.20 N 

29730 $66.20 N 

29740 $66.20 N 

29750 $66.20 N 

29799 $66.20 N 

29800 $1,879.86 Y 

29804 $1,879.86 Y 

29805 $1,879.86 Y 

29806 $3,067.20 Y 

29807 $3,067.20 Y 

29819 $3,067.20 Y 

29820 $3,067.20 Y 

29821 $3,067.20 Y 

29822 $1,879.86 Y 

29823 $3,067.20 Y 

29824 $1,879.86 Y 

29825 $3,067.20 Y 

29826 $3,067.20 Y 


Page | 28




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

29827 $3,067.20 Y 

29828 $3,067.20 Y 

29830 $1,879.86 Y 

29834 $1,879.86 Y 

29835 $1,879.86 Y 

29836 $1,879.86 Y 

29837 $1,879.86 Y 

29838 $1,879.86 Y 

29840 $1,879.86 Y 

29843 $1,879.86 Y 

29844 $1,879.86 Y 

29845 $1,879.86 Y 

29846 $1,879.86 Y 

29847 $3,067.20 Y 

29848 $1,879.86 Y 

29850 $1,879.86 Y 

29851 $3,067.20 Y 

29855 $3,067.20 Y 

29856 $3,067.20 Y 

29860 $3,067.20 Y 

29861 $3,067.20 Y 

29862 $3,067.20 Y 

29863 $3,067.20 Y 

29870 $1,879.86 Y 

29871 $1,879.86 Y 

29873 $1,879.86 Y 

29874 $1,879.86 Y 

29875 $1,879.86 Y 

29876 $1,879.86 Y 

29877 $1,879.86 Y 

29879 $1,879.86 Y 

29880 $1,879.86 Y 

29881 $1,879.86 Y 

29882 $1,879.86 Y 

29883 $1,879.86 Y 

29884 $1,879.86 Y 

29885 $3,067.20 Y 

29886 $1,879.86 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

29887 $1,879.86 Y 

29888 $5,569.99 Y 

29889 $5,569.99 Y 

29891 $3,067.20 Y 

29892 $5,569.99 Y 

29893 $1,372.45 Y 

29894 $1,879.86 Y 

29895 $1,879.86 Y 

29897 $1,879.86 Y 

29898 $1,879.86 Y 

29899 $3,067.20 Y 

29900 $1,879.86 Y 

29901 $1,879.86 Y 

29902 $1,879.86 Y 

29904 $1,879.86 Y 

29905 $1,879.86 Y 

29906 $1,879.86 Y 

29907 $3,067.20 Y 

29999 $1,879.86 Y 

30000 $215.19 Y 

30020 $215.19 Y 

30100 $478.74 Y 

30110 $1,079.91 Y 

30115 $1,079.91 Y 

30117 $1,079.91 Y 

30118 $1,568.46 Y 

30120 $1,568.46 Y 

30124 $478.74 Y 

30125 $2,700.59 Y 

30130 $1,079.91 Y 

30140 $1,568.46 Y 

30150 $2,700.59 Y 

30160 $2,700.59 Y 

30200 $478.74 Y 

30210 $478.74 Y 

30220 $478.74 Y 

30300 $42.05 N 

30310 $1,079.91 Y 


Page | 29




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

30320 $1,079.91 Y 

30400 $2,700.59 Y 

30410 $2,700.59 Y 

30420 $2,700.59 Y 

30430 $1,568.46 Y 

30435 $2,700.59 Y 

30450 $2,700.59 Y 

30460 $2,700.59 Y 

30462 $2,700.59 Y 

30465 $2,700.59 Y 

30520 $1,568.46 Y 

30540 $2,700.59 Y 

30545 $2,700.59 Y 

30560 $215.19 Y 

30580 $2,700.59 Y 

30600 $2,700.59 Y 

30620 $2,700.59 Y 

30630 $1,568.46 Y 

30801 $478.74 Y 

30802 $1,079.91 Y 

30901 $72.39 Y 

30903 $72.39 Y 

30905 $72.39 Y 

30906 $72.39 Y 

30915 $1,669.47 Y 

30920 $1,669.47 Y 

30930 $1,079.91 Y 

30999 $72.39 Y 

31000 $215.19 Y 

31002 $478.74 Y 

31020 $1,568.46 Y 

31030 $2,700.59 Y 

31032 $2,700.59 Y 

31040 $1,568.46 Y 

31050 $2,700.59 Y 

31051 $2,700.59 Y 

31070 $1,568.46 Y 

31075 $2,700.59 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

31080 $2,700.59 Y 

31081 $2,700.59 Y 

31084 $2,700.59 Y 

31085 $2,700.59 Y 

31086 $2,700.59 Y 

31087 $2,700.59 Y 

31090 $2,700.59 Y 

31200 $2,700.59 Y 

31201 $2,700.59 Y 

31205 $2,700.59 Y 

31231 $115.76 Y 

31233 $115.76 Y 

31235 $1,360.72 Y 

31237 $1,360.72 Y 

31238 $1,360.72 Y 

31239 $1,839.14 Y 

31240 $1,360.72 Y 

31254 $1,839.14 Y 

31255 $1,839.14 Y 

31256 $1,839.14 Y 

31267 $1,839.14 Y 

31276 $1,839.14 Y 

31287 $1,839.14 Y 

31288 $1,839.14 Y 

31292 $1,839.14 Y 

31293 $1,839.14 Y 

31294 $1,839.14 Y 

31299 $72.39 Y 

31300 $1,568.46 Y 

31320 $2,700.59 Y 

31400 $2,700.59 Y 

31420 $2,700.59 Y 

31500 $154.27 N 

31502 $88.85 N 

31505 $50.31 Y 

31510 $1,360.72 Y 

31511 $115.76 Y 

31512 $1,360.72 Y 


Page | 30




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

31513 $115.76 Y 

31515 $1,360.72 Y 

31520 $115.76 Y 

31525 $1,360.72 Y 

31526 $1,360.72 Y 

31527 $1,839.14 Y 

31528 $1,360.72 Y 

31529 $1,360.72 Y 

31530 $1,360.72 Y 

31531 $1,360.72 Y 

31535 $1,360.72 Y 

31536 $1,360.72 Y 

31540 $1,360.72 Y 

31541 $1,360.72 Y 

31545 $1,839.14 Y 

31546 $1,839.14 Y 

31560 $1,839.14 Y 

31561 $1,839.14 Y 

31570 $1,360.72 Y 

31571 $1,839.14 Y 

31575 $115.76 Y 

31576 $1,360.72 Y 

31577 $277.20 Y 

31578 $1,839.14 Y 

31579 $277.20 Y 

31580 $2,700.59 Y 

31582 $2,700.59 Y 

31588 $2,700.59 Y 

31590 $2,700.59 Y 

31595 $2,700.59 Y 

31599 $72.39 Y 

31600 $1,568.46 Y 

31601 $1,568.46 Y 

31603 $478.74 Y 

31605 $478.74 Y 

31610 $1,568.46 Y 

31611 $1,568.46 Y 

31612 $1,568.46 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

31613 $1,568.46 Y 

31614 $2,700.59 Y 

31615 $478.74 Y 


31622 $651.59 Y 

31623 $651.59 Y 

31624 $651.59 Y 

31625 $651.59 Y 

31626 $651.59 Y 


31628 $651.59 Y 

31629 $651.59 Y 

31630 $1,627.44 Y 

31631 $1,627.44 Y 

31632 $651.59 Y 

31633 $651.59 Y 

31635 $651.59 Y 

31636 $1,627.44 Y 

31637 $651.59 Y 

31638 $1,627.44 Y 

31640 $1,627.44 Y 

31641 $1,627.44 Y 

31643 $651.59 Y 

31645 $651.59 Y 

31646 $651.59 Y 

31656 $651.59 Y 


31717 $277.20 Y 

31720 $25.50 N 

31730 $277.20 Y 

31750 $2,700.59 Y 

31755 $2,700.59 Y 

31785 $1,568.46 Y 

31820 $1,568.46 Y 

31825 $1,568.46 Y 

31830 $1,568.46 Y 

31899 $651.59 Y 

32201 $348.84 Y 


Page | 31




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

32400 $607.35 Y 

32405 $607.35 Y 

32420 $348.84 Y 

32421 $348.84 Y 

32422 $348.84 Y 

32550 $1,913.81 Y 

32551 $348.84 Y 

32552 $88.85 Y 

32553 $864.39 Y 

32560 $348.84 Y 

32561 $348.84 Y 

32562 $348.84 Y 

32601 $2,136.74 Y 

32602 $2,136.74 Y 

32603 $2,136.74 Y 

32604 $2,136.74 Y 

32605 $2,136.74 Y 

32606 $2,136.74 Y 

32960 $348.84 Y 

32999 $348.84 Y 

33010 $348.84 Y 

33011 $348.84 Y 

33206 $7,469.37 Y 

33207 $7,469.37 Y 

33208 $8,932.03 Y 

33210 $3,074.65 Y 

33211 $3,074.65 Y 

33212 $6,167.22 Y 

33213 $6,796.25 Y 

33214 $8,932.03 Y 

33215 $1,441.39 Y 

33216 $3,074.65 Y 

33217 $3,074.65 Y 

33218 $1,441.39 Y 

33220 $1,441.39 Y 

33222 $1,008.68 Y 

33223 $1,008.68 Y 

33224 $12,825.17 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

33225 $12,825.17 Y 

33226 $1,441.39 Y 

33233 $1,441.39 Y 

33234 $1,441.39 Y 

33235 $1,441.39 Y 

33240 $20,471.76 Y 

33241 $1,441.39 Y 

33244 $1,441.39 Y 

33249 $25,909.26 Y 

33257 $845.35 N 

33258 $954.80 N 

33259 $1,246.85 N 

33282 $4,904.88 N 

33284 $515.38 Y 


33782 $4,852.10 Y 

33783 $5,244.25 Y 

33864 $4,761.90 Y 




33999 $348.84 Y 

34101 $2,569.76 Y 

34111 $2,569.76 Y 

34201 $2,569.76 Y 

34203 $2,569.76 Y 

34421 $2,569.76 Y 

34471 $2,569.76 Y 

34490 $2,569.76 Y 

34501 $2,569.76 Y 

34510 $2,569.76 Y 

34520 $2,569.76 Y 

34530 $2,569.76 Y 

34806 $160.60 N 

35011 $2,933.42 Y 

35180 $2,236.55 Y 

35184 $2,236.55 Y 

35188 $2,569.76 Y 


Page | 32




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

35190 $2,236.55 Y 

35201 $2,236.55 Y 

35206 $2,236.55 Y 

35207 $2,569.76 Y 

35226 $515.38 Y 

35231 $2,236.55 Y 

35236 $2,236.55 Y 

35256 $2,236.55 Y 

35261 $2,933.42 Y 

35266 $2,933.42 Y 

35286 $2,933.42 Y 

35321 $2,236.55 Y 

35458 $3,184.27 Y 

35459 $3,184.27 Y 

35460 $3,184.27 Y 

35470 $3,184.27 Y 

35471 $3,184.27 Y 

35472 $3,184.27 Y 

35473 $3,184.27 Y 

35474 $3,184.27 Y 

35475 $3,184.27 Y 

35476 $3,184.27 Y 

35484 $5,863.55 Y 

35485 $5,863.55 Y 

35490 $5,863.55 Y 

35491 $5,863.55 Y 

35492 $5,863.55 Y 

35493 $5,863.55 Y 

35494 $5,863.55 Y 

35495 $5,863.55 Y 

35500 $1,121.11 Y 

35523 $1,926.10 Y 

35535 $3,050.85 Y 

35570 $2,357.85 Y 


35632 $2,896.85 Y 

35633 $3,127.85 Y 

35634 $2,835.25 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

35685 $2,236.55 Y 

35686 $2,236.55 Y 

35761 $2,236.55 Y 

35860 $2,236.55 Y 

35875 $2,569.76 Y 

35876 $2,569.76 Y 

35879 $2,569.76 Y 

35881 $2,569.76 Y 

35883 $2,569.76 Y 

35884 $2,569.76 Y 

35903 $2,236.55 Y 


36002 $144.54 N 











36147 $150.50 Y 












36260 $1,912.51 Y 

36261 $1,441.39 Y 

36262 $1,441.39 Y 


Page | 33




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 







36420 $14.58 Y 

36425 $14.58 Y 

36430 $212.42 N 

36440 $212.42 N 

36450 $212.42 N 

36455 $212.42 N 

36460 $212.42 N 

36468 $55.22 Y 

36469 $55.22 Y 

36470 $55.22 Y 

36471 $55.22 Y 

36475 $2,829.18 Y 

36476 $1,669.47 Y 

36478 $1,669.47 Y 

36479 $1,669.47 Y 




36511 $750.34 N 

36512 $750.34 N 

36513 $750.34 N 

36514 $750.34 N 

36515 $2,093.53 N 

36516 $2,093.53 N 

36522 $2,093.53 N 

36555 $701.56 Y 

36556 $701.56 Y 

36557 $1,591.76 Y 

36558 $1,591.76 Y 

36560 $1,912.51 Y 

36561 $1,912.51 Y 

36563 $1,912.51 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

36565 $1,912.51 Y 

36566 $1,912.51 Y 

36568 $701.56 Y 

36569 $701.56 Y 

36570 $1,591.76 Y 

36571 $1,591.76 Y 

36575 $400.49 Y 

36576 $701.56 Y 

36578 $1,591.76 Y 

36580 $701.56 Y 

36581 $1,591.76 Y 

36582 $1,912.51 Y 

36583 $1,912.51 Y 

36584 $701.56 Y 

36585 $1,591.76 Y 

36589 $400.49 Y 

36590 $701.56 Y 



36593 $150.50 Y 

36595 $1,591.76 Y 

36596 $701.56 Y 

36597 $701.56 Y 

36598 $150.50 Y 




36640 $1,912.51 Y 

36680 $94.94 Y 

36800 $1,946.37 Y 

36810 $1,946.37 Y 

36815 $1,946.37 Y 

36818 $2,569.76 Y 

36819 $2,569.76 Y 

36820 $2,569.76 Y 

36821 $2,569.76 Y 

36825 $2,569.76 Y 

36830 $2,569.76 Y 


Page | 34




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

36831 $2,569.76 Y 

36832 $2,569.76 Y 

36833 $2,569.76 Y 

36835 $1,946.37 Y 

36838 $2,569.76 Y 

36860 $150.50 Y 

36861 $1,946.37 Y 

36870 $2,933.42 Y 

37183 $6,112.77 Y 

37195 $150.50 Y 

37200 $1,912.51 Y 

37201 $1,121.11 Y 

37202 $1,121.11 Y 

37203 $1,912.51 Y 

37204 $5,863.55 Y 

37205 $6,112.77 Y 

37206 $6,112.77 Y 

37207 $6,112.77 Y 

37208 $6,112.77 Y 

37209 $1,912.51 Y 

37210 $6,112.77 Y 



37500 $2,829.18 Y 

37501 $1,669.47 Y 

37565 $2,236.55 Y 

37600 $2,236.55 Y 

37605 $2,829.18 Y 

37606 $1,669.47 Y 

37607 $1,669.47 Y 

37609 $1,099.36 Y 

37615 $1,669.47 Y 

37620 $2,829.18 Y 

37650 $1,669.47 Y 

37700 $1,669.47 Y 

37718 $1,669.47 Y 

37722 $2,829.18 Y 

37735 $2,829.18 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

37760 $1,669.47 Y 

37761 $1,669.47 Y 

37765 $1,669.47 Y 

37766 $1,669.47 Y 

37780 $1,669.47 Y 

37785 $1,669.47 Y 

37790 $2,191.74 Y 

37799 $38.53 Y 

38120 $2,942.95 Y 

38129 $2,390.93 Y 



38206 $750.34 N 

38220 $194.76 Y 

38221 $194.76 Y 

38230 $2,093.53 N 

38240 $2,093.53 N 

38241 $2,093.53 N 

38242 $750.34 N 

38300 $793.02 Y 

38305 $1,219.29 Y 

38308 $1,546.53 Y 

38500 $1,546.53 Y 

38505 $490.98 Y 

38510 $1,546.53 Y 

38520 $1,546.53 Y 

38525 $1,546.53 Y 

38530 $1,546.53 Y 

38542 $3,063.34 Y 

38550 $1,546.53 Y 

38555 $1,546.53 Y 

38570 $2,942.95 Y 

38571 $4,583.95 Y 

38572 $2,942.95 Y 

38589 $2,390.93 Y 

38700 $1,546.53 Y 

38720 $1,546.53 Y 

38740 $3,063.34 Y 


Page | 35




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

38745 $3,063.34 Y 

38760 $1,546.53 Y 




38999 $212.42 N 

39400 $2,136.74 Y 

40490 $215.19 Y 

40500 $1,079.91 Y 

40510 $1,568.46 Y 

40520 $1,079.91 Y 

40525 $1,568.46 Y 

40527 $1,568.46 Y 

40530 $1,568.46 Y 

40650 $478.74 Y 

40652 $478.74 Y 

40654 $478.74 Y 

40700 $2,700.59 Y 

40701 $2,700.59 Y 

40702 $2,700.59 Y 

40720 $2,700.59 Y 

40761 $2,700.59 Y 

40799 $72.39 Y 

40800 $91.46 Y 

40801 $478.74 Y 

40804 $42.05 N 

40805 $478.74 Y 

40806 $215.19 Y 

40808 $215.19 Y 

40810 $1,079.91 Y 

40812 $1,079.91 Y 

40814 $1,079.91 Y 

40816 $1,568.46 Y 

40818 $215.19 Y 

40819 $478.74 Y 

40820 $1,079.91 Y 

40830 $215.19 Y 

40831 $478.74 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

40840 $1,568.46 Y 

40842 $1,568.46 Y 

40843 $1,568.46 Y 

40844 $2,700.59 Y 

40845 $2,700.59 Y 

40899 $72.39 Y 

41000 $1,079.91 Y 

41005 $215.19 Y 

41006 $1,568.46 Y 

41007 $1,079.91 Y 

41008 $1,079.91 Y 

41009 $215.19 Y 

41010 $478.74 Y 

41015 $215.19 Y 

41016 $478.74 Y 

41017 $478.74 Y 

41018 $478.74 Y 

41019 $1,568.46 Y 

41100 $478.74 Y 

41105 $1,079.91 Y 

41108 $274.10 Y 

41110 $1,079.91 Y 

41112 $1,079.91 Y 

41113 $1,079.91 Y 

41114 $1,568.46 Y 

41115 $478.74 Y 

41116 $1,079.91 Y 

41120 $1,568.46 Y 

41250 $72.39 Y 

41251 $215.19 Y 

41252 $478.74 Y 

41500 $1,568.46 Y 

41510 $1,079.91 Y 

41512 $478.74 Y 

41520 $478.74 Y 

41530 $1,568.46 Y 

41599 $72.39 Y 

41800 $91.46 Y 


Page | 36




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

41805 $1,568.46 Y 

41806 $1,079.91 Y 

41820 $478.74 Y 

41821 $478.74 Y 

41822 $1,079.91 Y 

41823 $1,568.46 Y 

41825 $1,079.91 Y 

41826 $1,568.46 Y 

41827 $1,568.46 Y 

41828 $1,079.91 Y 

41830 $1,079.91 Y 

41850 $1,079.91 Y 

41870 $1,568.46 Y 

41872 $1,079.91 Y 

41874 $1,568.46 Y 

41899 $72.39 Y 

42000 $215.19 Y 

42100 $478.74 Y 

42104 $1,079.91 Y 

42106 $1,079.91 Y 

42107 $1,568.46 Y 

42120 $2,700.59 Y 

42140 $478.74 Y 

42145 $1,568.46 Y 

42160 $1,079.91 Y 

42180 $215.19 Y 

42182 $2,700.59 Y 

42200 $2,700.59 Y 

42205 $2,700.59 Y 

42210 $2,700.59 Y 

42215 $2,700.59 Y 

42220 $2,700.59 Y 

42225 $2,700.59 Y 

42226 $2,700.59 Y 

42227 $2,700.59 Y 

42235 $1,079.91 Y 

42260 $1,568.46 Y 

42280 $215.19 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

42281 $1,079.91 Y 

42299 $72.39 Y 

42300 $1,079.91 Y 

42305 $1,079.91 Y 

42310 $215.19 Y 

42320 $215.19 Y 

42330 $1,079.91 Y 

42335 $1,079.91 Y 

42340 $1,079.91 Y 

42400 $490.98 Y 

42405 $1,568.46 Y 

42408 $1,079.91 Y 

42409 $1,079.91 Y 

42410 $2,700.59 Y 

42415 $2,700.59 Y 

42420 $2,700.59 Y 

42425 $2,700.59 Y 

42440 $2,700.59 Y 

42450 $1,568.46 Y 

42500 $1,568.46 Y 

42505 $2,700.59 Y 

42507 $2,700.59 Y 

42508 $2,700.59 Y 

42509 $2,700.59 Y 

42510 $2,700.59 Y 


42600 $1,079.91 Y 

42650 $478.74 Y 

42660 $215.19 Y 

42665 $1,568.46 Y 

42699 $72.39 Y 

42700 $215.19 Y 

42720 $1,079.91 Y 

42725 $2,700.59 Y 

42800 $1,079.91 Y 

42802 $1,079.91 Y 

42804 $1,079.91 Y 

42806 $1,568.46 Y 


Page | 37




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

42808 $1,568.46 Y 

42809 $42.05 N 

42810 $1,568.46 Y 

42815 $2,700.59 Y 

42820 $1,568.46 Y 

42821 $1,568.46 Y 

42825 $1,568.46 Y 

42826 $1,568.46 Y 

42830 $1,568.46 Y 

42831 $1,568.46 Y 

42835 $1,568.46 Y 

42836 $1,568.46 Y 

42842 $1,568.46 Y 

42844 $2,700.59 Y 

42860 $1,568.46 Y 

42870 $1,568.46 Y 

42890 $2,700.59 Y 

42892 $2,700.59 Y 

42900 $478.74 Y 

42950 $1,568.46 Y 

42955 $1,568.46 Y 

42960 $72.39 Y 

42962 $2,700.59 Y 

42970 $72.39 Y 

42972 $1,079.91 Y 

42999 $72.39 Y 

43020 $478.74 Y 

43030 $1,079.91 Y 

43130 $2,700.59 Y 

43200 $843.71 Y 

43201 $549.52 Y 

43202 $843.71 Y 

43204 $549.52 Y 

43205 $549.52 Y 

43215 $549.52 Y 

43216 $549.52 Y 

43217 $549.52 Y 

43219 $1,664.44 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

43220 $549.52 Y 

43226 $549.52 Y 

43227 $549.52 Y 

43228 $1,524.90 Y 

43231 $549.52 Y 

43232 $549.52 Y 

43234 $549.52 Y 

43235 $843.71 Y 

43236 $549.52 Y 

43237 $549.52 Y 

43238 $549.52 Y 

43239 $843.71 Y 

43240 $549.52 Y 

43241 $549.52 Y 

43242 $549.52 Y 

43243 $843.71 Y 

43244 $549.52 Y 

43245 $843.71 Y 

43246 $549.52 Y 

43247 $843.71 Y 

43248 $843.71 Y 

43249 $843.71 Y 

43250 $843.71 Y 

43251 $843.71 Y 

43255 $843.71 Y 

43256 $1,664.44 Y 

43258 $549.52 Y 

43259 $549.52 Y 

43260 $1,420.65 Y 

43261 $1,420.65 Y 

43262 $1,420.65 Y 

43263 $1,420.65 Y 

43264 $1,420.65 Y 

43265 $1,420.65 Y 

43267 $1,420.65 Y 

43268 $1,664.44 Y 

43269 $1,664.44 Y 

43271 $1,420.65 Y 


Page | 38




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

43272 $1,420.65 Y 

43273 $2,181.20 N 

43279 $1,762.20 Y 

43280 $4,583.95 Y 

43281 $2,291.30 Y 

43282 $2,576.75 Y 

43289 $2,390.93 Y 

43450 $575.15 Y 

43453 $374.60 Y 

43456 $374.60 Y 

43458 $549.52 Y 

43499 $549.52 Y 

43510 $549.52 Y 

43600 $549.52 Y 

43647 $5,435.85 N 

43648 $2,390.93 Y 

43651 $4,583.95 Y 

43652 $4,583.95 Y 

43653 $2,942.95 Y 

43659 $2,390.93 Y 

43752 $79.75 N 

43760 $150.50 Y 

43761 $549.52 Y 


43830 $1,524.90 Y 

43831 $549.52 Y 

43870 $549.52 Y 

43999 $549.52 Y 

44100 $549.52 Y 

44180 $2,942.95 Y 

44186 $2,942.95 Y 

44206 $4,583.95 Y 

44207 $4,583.95 Y 

44208 $4,583.95 Y 

44213 $2,390.93 Y 

44238 $2,390.93 Y 

44312 $1,503.62 Y 

44340 $1,503.62 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

44360 $950.22 Y 

44361 $950.22 Y 

44363 $618.89 Y 

44364 $618.89 Y 

44365 $618.89 Y 

44366 $618.89 Y 

44369 $618.89 Y 

44370 $1,664.44 Y 

44372 $618.89 Y 

44373 $618.89 Y 

44376 $618.89 Y 

44377 $950.22 Y 

44378 $618.89 Y 

44379 $1,664.44 Y 

44380 $618.89 Y 

44382 $618.89 Y 

44383 $1,664.44 Y 

44385 $572.07 Y 

44386 $878.33 Y 

44388 $878.33 Y 

44389 $878.33 Y 

44390 $572.07 Y 

44391 $572.07 Y 

44392 $572.07 Y 

44393 $572.07 Y 

44394 $572.07 Y 

44397 $1,664.44 Y 

44500 $400.49 Y 


44799 $1,708.06 Y 

44901 $973.88 Y 

44970 $2,942.95 Y 

44979 $2,390.93 Y 

45000 $886.78 Y 

45005 $886.78 Y 

45020 $886.78 Y 

45100 $1,506.05 Y 

45108 $1,506.05 Y 


Page | 39




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

45150 $1,506.05 Y 

45160 $1,506.05 Y 

45171 $1,361.52 Y 

45172 $2,312.32 Y 

45190 $1,506.05 Y 

45300 $362.82 Y 

45303 $580.86 Y 

45305 $580.86 Y 

45307 $1,433.83 Y 

45308 $580.86 Y 

45309 $580.86 Y 

45315 $580.86 Y 

45317 $580.86 Y 

45320 $1,433.83 Y 

45321 $1,433.83 Y 

45327 $1,664.44 Y 

45330 $362.82 Y 

45331 $557.06 Y 

45332 $362.82 Y 

45333 $891.83 Y 

45334 $580.86 Y 

45335 $362.82 Y 

45337 $362.82 Y 

45338 $891.83 Y 

45339 $891.83 Y 

45340 $580.86 Y 

45341 $580.86 Y 

45342 $580.86 Y 

45345 $1,664.44 Y 

45355 $878.33 Y 

45378 $878.33 Y 

45379 $572.07 Y 

45380 $878.33 Y 

45381 $878.33 Y 

45382 $878.33 Y 

45383 $878.33 Y 

45384 $878.33 Y 

45385 $878.33 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

45386 $572.07 Y 

45387 $1,664.44 Y 

45391 $572.07 Y 

45392 $572.07 Y 

45499 $2,390.93 Y 

45500 $1,506.05 Y 

45505 $2,021.94 Y 

45520 $55.22 Y 

45541 $2,021.94 Y 

45560 $3,104.39 Y 

45900 $337.08 Y 

45905 $1,506.05 Y 

45910 $1,506.05 Y 

45915 $886.78 Y 

45990 $1,506.05 Y 

45999 $337.08 Y 

46020 $1,506.05 Y 

46030 $337.08 Y 

46040 $2,312.32 Y 

46045 $1,506.05 Y 

46050 $886.78 Y 

46060 $2,312.32 Y 

46070 $886.78 Y 

46080 $2,312.32 Y 

46083 $126.88 Y 

46200 $2,312.32 Y 

46220 $1,361.52 Y 

46221 $337.08 Y 

46230 $1,506.05 Y 

46250 $1,506.05 Y 

46255 $1,506.05 Y 

46257 $1,506.05 Y 

46258 $1,506.05 Y 

46260 $1,506.05 Y 

46261 $1,506.05 Y 

46262 $1,506.05 Y 

46270 $1,506.05 Y 

46275 $1,506.05 Y 


Page | 40




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

46280 $1,506.05 Y 

46285 $1,506.05 Y 

46288 $1,506.05 Y 

46320 $1,506.05 Y 

46500 $886.78 Y 

46505 $1,506.05 Y 

46600 $42.05 N 

46604 $580.86 Y 

46606 $362.82 Y 

46608 $580.86 Y 

46610 $1,433.83 Y 

46611 $580.86 Y 

46612 $1,433.83 Y 

46614 $362.82 Y 

46615 $1,433.83 Y 

46700 $1,506.05 Y 

46706 $2,021.94 Y 


46750 $2,021.94 Y 

46753 $1,506.05 Y 

46754 $1,506.05 Y 

46760 $2,021.94 Y 

46761 $2,021.94 Y 

46762 $2,021.94 Y 

46900 $175.81 Y 

46910 $1,336.09 Y 

46916 $96.83 Y 

46917 $1,336.09 Y 

46922 $1,336.09 Y 

46924 $1,336.09 Y 

46930 $517.54 Y 

46940 $1,506.05 Y 

46942 $337.08 Y 

46945 $886.78 Y 

46946 $886.78 Y 

46947 $2,021.94 Y 

46999 $337.08 Y 

47000 $607.35 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 


47011 $973.88 Y 

47370 $6,906.48 Y 

47371 $6,906.48 Y 

47379 $2,390.93 Y 

47382 $3,227.05 Y 

47399 $288.96 Y 

47490 $1,931.58 Y 



47510 $1,931.58 Y 

47511 $1,931.58 Y 

47525 $961.94 Y 

47530 $961.94 Y 

47552 $1,931.58 Y 

47553 $1,931.58 Y 

47554 $1,931.58 Y 

47555 $1,931.58 Y 

47556 $1,931.58 Y 

47560 $2,390.93 Y 

47561 $2,390.93 Y 

47562 $2,942.95 Y 

47563 $2,942.95 Y 

47564 $2,942.95 Y 

47579 $2,390.93 Y 

47630 $1,931.58 Y 

47999 $1,931.58 Y 

48102 $607.35 Y 

48511 $973.88 Y 

48999 $288.96 Y 

49021 $973.88 Y 

49041 $973.88 Y 

49061 $973.88 Y 

49080 $348.84 Y 

49081 $348.84 Y 

49180 $607.35 Y 

49203 $1,636.25 Y 

49204 $2,088.90 Y 


Page | 41




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

49205 $2,391.95 Y 

49250 $1,708.06 Y 

49320 $2,390.93 Y 

49321 $2,390.93 Y 

49322 $2,390.93 Y 

49323 $2,390.93 Y 

49324 $2,390.93 Y 

49325 $2,390.93 Y 

49326 $2,390.93 Y 

49329 $2,390.93 Y 


49402 $1,708.06 Y 

49411 $864.39 Y 

49419 $1,946.37 Y 

49420 $1,913.81 Y 

49421 $1,913.81 Y 

49422 $1,441.39 Y 

49423 $961.94 Y 


49426 $1,708.06 Y 


49429 $1,441.39 Y 

49435 $961.94 Y 

49436 $961.94 Y 

49440 $549.52 Y 

49441 $549.52 Y 

49442 $886.78 Y 

49446 $549.52 Y 

49450 $400.49 Y 

49451 $400.49 Y 

49452 $400.49 Y 

49460 $400.49 Y 


49491 $2,008.56 Y 

49492 $2,008.56 Y 

49495 $2,008.56 Y 

49496 $2,008.56 Y 

49500 $2,008.56 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

49501 $2,008.56 Y 

49505 $2,008.56 Y 

49507 $2,008.56 Y 

49520 $2,008.56 Y 

49521 $2,008.56 Y 

49525 $2,008.56 Y 

49540 $2,008.56 Y 

49550 $2,008.56 Y 

49553 $2,008.56 Y 

49555 $2,008.56 Y 

49557 $2,008.56 Y 

49560 $2,008.56 Y 

49561 $2,008.56 Y 

49565 $2,008.56 Y 

49566 $2,008.56 Y 

49568 $2,008.56 Y 

49570 $2,008.56 Y 

49572 $2,008.56 Y 

49580 $2,008.56 Y 

49582 $2,008.56 Y 

49585 $2,008.56 Y 

49587 $2,008.56 Y 

49590 $2,008.56 Y 

49600 $2,008.56 Y 

49650 $2,942.95 Y 

49651 $2,942.95 Y 

49652 $4,583.95 Y 

49653 $4,583.95 Y 

49654 $4,583.95 Y 

49655 $4,583.95 Y 

49656 $4,583.95 Y 

49657 $4,583.95 Y 

49659 $2,390.93 Y 

49999 $1,708.06 Y 

50020 $1,603.56 Y 

50021 $973.88 Y 

50080 $2,932.90 Y 

50081 $2,932.90 Y 


Page | 42




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

50200 $607.35 Y 

50382 $1,603.56 Y 

50384 $1,070.27 Y 

50385 $1,603.56 Y 

50386 $448.24 Y 

50387 $961.94 Y 

50389 $448.24 Y 

50390 $607.35 Y 

50391 $68.85 Y 

50392 $1,070.27 Y 

50393 $1,603.56 Y 


50395 $1,603.56 Y 

50396 $126.88 Y 

50398 $961.94 Y 

50541 $2,390.93 Y 

50542 $6,906.48 Y 

50543 $2,942.95 Y 

50544 $2,390.93 Y 

50549 $2,390.93 Y 

50551 $448.24 Y 

50553 $1,603.56 Y 

50555 $448.24 Y 

50557 $1,603.56 Y 

50561 $1,603.56 Y 

50562 $448.24 Y 

50570 $448.24 Y 

50572 $448.24 Y 

50574 $448.24 Y 

50575 $2,274.50 Y 

50576 $1,070.27 Y 

50580 $1,070.27 Y 

50590 $2,598.80 Y 

50593 $3,227.05 Y 


50686 $68.85 Y 

50688 $961.94 Y 


Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

50945 $2,942.95 Y 

50947 $2,942.95 Y 

50948 $2,942.95 Y 

50949 $2,390.93 Y 

50951 $448.24 Y 

50953 $448.24 Y 

50955 $1,603.56 Y 

50957 $1,603.56 Y 

50961 $1,603.56 Y 

50970 $448.24 Y 

50972 $448.24 Y 

50974 $1,070.27 Y 

50976 $1,070.27 Y 

50980 $1,603.56 Y 

51020 $1,603.56 Y 

51030 $1,603.56 Y 

51040 $1,603.56 Y 

51045 $448.24 Y 

51050 $1,603.56 Y 

51065 $1,603.56 Y 

51080 $1,219.29 Y 

51100 $126.88 Y 

51101 $68.85 Y 

51102 $1,258.12 Y 

51500 $2,008.56 Y 

51520 $1,603.56 Y 

51535 $1,603.56 Y 




51700 $126.88 Y 

51701 $42.05 N 

51702 $42.05 N 

51703 $68.85 Y 

51705 $126.88 Y 

51710 $400.49 Y 

51715 $1,971.41 Y 

51720 $189.83 Y 


Page | 43




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

51725 $189.83 Y 

51726 $189.83 Y 

51727 $189.83 Y 

51728 $189.83 Y 

51729 $189.83 Y 

51736 $68.85 Y 

51741 $68.85 Y 

51784 $68.85 Y 

51785 $126.88 Y 

51792 $68.85 Y 

51797 $126.88 Y 

51798 $42.05 N 

51880 $1,603.56 Y 

51990 $2,942.95 Y 

51992 $2,942.95 Y 

51999 $2,390.93 Y 

52000 $448.24 Y 

52001 $1,070.27 Y 

52005 $1,603.56 Y 

52007 $1,603.56 Y 

52010 $448.24 Y 

52204 $1,603.56 Y 

52214 $1,603.56 Y 

52224 $1,603.56 Y 

52234 $1,603.56 Y 

52235 $1,603.56 Y 

52240 $1,603.56 Y 

52250 $1,603.56 Y 

52260 $1,070.27 Y 

52265 $448.24 Y 

52270 $1,070.27 Y 

52275 $1,603.56 Y 

52276 $1,603.56 Y 

52277 $1,603.56 Y 

52281 $1,070.27 Y 

52282 $2,274.50 Y 

52283 $1,603.56 Y 

52285 $1,070.27 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

52290 $1,603.56 Y 

52300 $1,603.56 Y 

52301 $1,603.56 Y 

52305 $1,603.56 Y 

52310 $1,070.27 Y 

52315 $1,603.56 Y 

52317 $1,603.56 Y 

52318 $1,603.56 Y 

52320 $1,603.56 Y 

52325 $1,603.56 Y 

52327 $2,274.50 Y 

52330 $1,603.56 Y 

52332 $1,603.56 Y 

52334 $1,603.56 Y 

52341 $1,603.56 Y 

52342 $1,603.56 Y 

52343 $1,603.56 Y 

52344 $1,603.56 Y 

52345 $1,603.56 Y 

52346 $1,603.56 Y 

52351 $1,603.56 Y 

52352 $1,603.56 Y 

52353 $2,274.50 Y 

52354 $1,603.56 Y 

52355 $1,603.56 Y 

52400 $1,603.56 Y 

52402 $1,603.56 Y 

52450 $1,603.56 Y 

52500 $1,603.56 Y 

52601 $2,274.50 Y 

52630 $2,274.50 Y 

52640 $1,603.56 Y 

52647 $2,932.90 Y 

52648 $2,932.90 Y 

52649 $2,932.90 Y 

52700 $1,603.56 Y 

53000 $1,277.79 Y 

53010 $1,277.79 Y 


Page | 44




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

53020 $1,277.79 Y 

53025 $1,277.79 Y 

53040 $1,277.79 Y 

53060 $1,277.79 Y 

53080 $1,277.79 Y 

53085 $1,277.79 Y 

53200 $1,277.79 Y 

53210 $1,971.41 Y 

53215 $1,277.79 Y 

53220 $1,971.41 Y 

53230 $1,971.41 Y 

53235 $1,277.79 Y 

53240 $1,971.41 Y 

53250 $1,277.79 Y 

53260 $1,277.79 Y 

53265 $1,277.79 Y 

53270 $1,277.79 Y 

53275 $1,277.79 Y 

53400 $1,971.41 Y 

53405 $1,971.41 Y 

53410 $1,971.41 Y 

53420 $1,971.41 Y 

53425 $1,971.41 Y 

53430 $1,971.41 Y 

53431 $1,971.41 Y 

53440 $6,162.77 N 

53442 $1,971.41 Y 

53444 $6,162.77 N 

53445 $10,324.19 N 

53446 $1,971.41 Y 

53447 $10,324.19 N 

53449 $1,971.41 Y 

53450 $1,971.41 Y 

53460 $1,277.79 Y 

53500 $1,971.41 Y 

53502 $1,277.79 Y 

53505 $1,971.41 Y 

53510 $1,277.79 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

53515 $1,971.41 Y 

53520 $1,971.41 Y 

53600 $189.83 Y 

53601 $68.85 Y 

53605 $1,070.27 Y 

53620 $1,258.12 Y 

53621 $126.88 Y 

53660 $68.85 Y 

53661 $68.85 Y 

53665 $1,277.79 Y 

53850 $2,932.90 Y 

53852 $2,932.90 Y 

53855 $126.88 Y 

53899 $68.85 Y 

54000 $1,277.79 Y 

54001 $1,277.79 Y 

54015 $1,219.29 Y 

54050 $55.22 Y 

54055 $1,336.09 Y 

54056 $55.22 Y 

54057 $1,336.09 Y 

54060 $1,336.09 Y 

54065 $1,336.09 Y 

54100 $1,099.36 Y 

54105 $1,469.46 Y 

54110 $2,191.74 Y 

54111 $2,191.74 Y 

54112 $2,191.74 Y 

54115 $1,219.29 Y 

54120 $2,191.74 Y 

54150 $1,462.92 Y 

54160 $1,462.92 Y 

54161 $1,462.92 Y 

54162 $1,462.92 Y 

54163 $1,462.92 Y 

54164 $1,462.92 Y 

54200 $126.88 Y 

54205 $2,191.74 Y 


Page | 45




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

54220 $126.88 Y 


54231 $1,258.12 Y 

54235 $126.88 Y 

54240 $68.85 Y 

54250 $126.88 Y 

54300 $2,191.74 Y 

54304 $2,191.74 Y 

54308 $2,191.74 Y 

54312 $2,191.74 Y 

54316 $2,191.74 Y 

54318 $2,191.74 Y 

54322 $2,191.74 Y 

54324 $2,191.74 Y 

54326 $2,191.74 Y 

54328 $2,191.74 Y 

54340 $2,191.74 Y 

54344 $2,191.74 Y 

54348 $2,191.74 Y 

54352 $2,191.74 Y 

54360 $2,191.74 Y 

54380 $2,191.74 Y 

54385 $2,191.74 Y 

54400 $6,162.77 N 

54401 $10,324.19 N 

54405 $10,324.19 N 

54406 $2,191.74 Y 

54408 $2,191.74 Y 

54410 $10,324.19 N 

54415 $2,191.74 Y 

54416 $10,324.19 N 

54420 $2,191.74 Y 

54435 $2,191.74 Y 

54440 $2,191.74 Y 

54450 $189.83 Y 

54500 $973.88 Y 

54505 $1,462.92 Y 

54512 $1,462.92 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

54520 $1,462.92 Y 

54522 $1,462.92 Y 

54530 $2,008.56 Y 

54550 $2,008.56 Y 

54560 $1,462.92 Y 

54600 $1,462.92 Y 

54620 $1,462.92 Y 

54640 $2,008.56 Y 

54660 $1,462.92 Y 

54670 $1,462.92 Y 

54680 $1,462.92 Y 

54690 $2,942.95 Y 

54692 $4,583.95 Y 

54699 $2,390.93 Y 

54700 $1,462.92 Y 

54800 $288.96 Y 

54830 $1,462.92 Y 

54840 $1,462.92 Y 

54860 $1,462.92 Y 

54861 $1,462.92 Y 

54865 $1,462.92 Y 

54900 $1,462.92 Y 

54901 $1,462.92 Y 

55000 $288.96 Y 

55040 $2,008.56 Y 

55041 $2,008.56 Y 

55060 $1,462.92 Y 

55100 $793.02 Y 

55110 $1,462.92 Y 

55120 $1,462.92 Y 

55150 $1,462.92 Y 

55175 $1,462.92 Y 

55180 $1,462.92 Y 

55200 $1,462.92 Y 

55250 $1,462.92 Y 


55450 $1,462.92 Y 

55500 $1,462.92 Y 


Page | 46




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

55520 $1,462.92 Y 

55530 $1,462.92 Y 

55535 $2,008.56 Y 

55540 $2,008.56 Y 

55550 $2,942.95 Y 

55559 $2,390.93 Y 

55600 $1,462.92 Y 

55680 $1,462.92 Y 

55700 $781.06 Y 

55705 $781.06 Y 

55706 $781.06 Y 

55720 $1,603.56 Y 

55725 $1,603.56 Y 

55860 $1,258.12 Y 

55870 $214.16 Y 

55873 $7,153.96 Y 

55875 $2,274.50 N 

55876 $864.39 Y 

55899 $68.85 Y 

55920 $1,708.06 Y 

56405 $95.99 Y 

56420 $95.99 Y 

56440 $1,259.44 Y 

56441 $1,259.44 Y 

56442 $1,259.44 Y 

56501 $1,336.09 Y 

56515 $1,336.09 Y 

56605 $214.16 Y 

56606 $95.99 Y 

56620 $1,259.44 Y 

56625 $1,259.44 Y 

56700 $1,259.44 Y 

56740 $1,259.44 Y 

56800 $1,259.44 Y 

56805 $1,259.44 Y 

56810 $1,259.44 Y 

56820 $95.99 Y 

56821 $95.99 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

57000 $1,259.44 Y 

57010 $1,259.44 Y 

57020 $426.92 Y 

57022 $793.02 Y 

57023 $1,219.29 Y 

57061 $1,259.44 Y 

57065 $1,259.44 Y 

57100 $426.92 Y 

57105 $1,259.44 Y 

57106 $1,259.44 Y 

57107 $2,215.79 Y 

57109 $2,215.79 Y 

57120 $2,215.79 Y 

57130 $1,259.44 Y 

57135 $1,259.44 Y 

57150 $95.99 Y 

57155 $426.92 Y 

57160 $95.99 Y 

57170 $8.29 Y 

57180 $95.99 Y 

57200 $1,259.44 Y 

57210 $1,259.44 Y 

57220 $2,826.68 Y 

57230 $2,215.79 Y 

57240 $2,215.79 Y 

57250 $2,215.79 Y 

57260 $2,215.79 Y 

57265 $2,826.68 Y 

57267 $2,215.79 Y 

57268 $2,215.79 Y 

57282 $2,826.68 Y 

57283 $2,826.68 Y 

57284 $2,826.68 Y 

57285 $2,826.68 Y 

57287 $2,215.79 Y 

57288 $2,826.68 Y 

57289 $2,215.79 Y 

57291 $2,215.79 Y 


Page | 47




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

57292 $2,215.79 Y 

57295 $1,259.44 Y 

57300 $2,215.79 Y 

57310 $2,826.68 Y 

57320 $2,215.79 Y 

57330 $2,215.79 Y 

57335 $2,215.79 Y 

57400 $1,259.44 Y 

57410 $1,259.44 Y 

57415 $1,259.44 Y 

57420 $214.16 Y 

57421 $214.16 Y 

57423 $2,826.68 Y 

57425 $2,390.93 Y 


57452 $95.99 Y 

57454 $214.16 Y 

57455 $214.16 Y 

57456 $214.16 Y 

57460 $1,259.44 Y 

57461 $1,259.44 Y 

57500 $426.92 Y 

57505 $426.92 Y 

57510 $1,259.44 Y 

57511 $95.99 Y 

57513 $1,259.44 Y 

57520 $1,259.44 Y 

57522 $1,259.44 Y 

57530 $2,215.79 Y 

57550 $2,215.79 Y 

57555 $2,215.79 Y 

57556 $2,826.68 Y 

57558 $1,259.44 Y 

57700 $1,259.44 Y 

57720 $1,259.44 Y 

57800 $1,259.44 Y 

58100 $95.99 Y 


Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

58120 $1,259.44 Y 

58145 $2,215.79 Y 

58260 $2,215.79 Y 

58262 $2,215.79 Y 

58263 $2,215.79 Y 

58270 $2,215.79 Y 

58290 $2,826.68 Y 

58291 $2,826.68 Y 

58292 $2,826.68 Y 

58294 $2,826.68 Y 

58301 $95.99 Y 


58345 $1,259.44 Y 

58346 $1,259.44 Y 

58350 $2,215.79 Y 

58353 $2,215.79 Y 

58356 $2,826.68 Y 

58541 $4,583.95 Y 

58542 $4,583.95 Y 

58543 $4,583.95 Y 

58544 $4,583.95 Y 

58545 $2,390.93 Y 

58546 $2,942.95 Y 

58550 $4,583.95 Y 

58552 $2,942.95 Y 

58553 $2,942.95 Y 

58554 $2,942.95 Y 

58555 $1,419.49 Y 

58558 $1,419.49 Y 

58559 $1,419.49 Y 

58560 $2,338.52 Y 

58561 $2,338.52 Y 

58562 $1,419.49 Y 

58563 $2,338.52 Y 

58565 $2,826.68 Y 

58570 $2,942.95 Y 

58571 $2,942.95 Y 

58572 $2,942.95 Y 


Page | 48




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

58573 $2,942.95 Y 

58578 $2,390.93 Y 

58579 $1,419.49 Y 

58600 $2,215.79 Y 

58615 $1,259.44 Y 

58660 $2,942.95 Y 

58661 $2,942.95 Y 

58662 $2,942.95 Y 

58670 $2,942.95 Y 

58671 $2,942.95 Y 

58672 $2,942.95 Y 

58673 $2,942.95 Y 

58679 $2,390.93 Y 

58770 $2,215.79 Y 

58800 $1,259.44 Y 

58805 $2,215.79 Y 

58820 $2,215.79 Y 

58823 $1,259.44 Y 

58900 $1,259.44 Y 

58920 $2,215.79 Y 

58925 $2,215.79 Y 

58999 $8.29 Y 

59000 $214.16 Y 

59001 $426.92 Y 

59012 $214.16 Y 

59015 $214.16 Y 

59020 $95.99 Y 

59025 $95.99 Y 

59030 $214.16 Y 

59070 $95.99 Y 

59072 $214.16 Y 

59074 $214.16 Y 

59076 $214.16 Y 

59100 $2,215.79 Y 

59150 $2,942.95 Y 

59151 $2,942.95 Y 

59160 $1,259.44 Y 

59200 $95.99 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

59300 $1,259.44 Y 

59320 $1,259.44 Y 

59409 $1,259.44 Y 

59412 $1,259.44 Y 

59414 $1,259.44 Y 

59612 $1,259.44 Y 

59812 $1,259.44 Y 

59820 $1,259.44 Y 

59821 $1,259.44 Y 

59840 $1,259.44 Y 

59841 $1,259.44 Y 

59866 $214.16 Y 

59870 $1,259.44 Y 

59871 $1,259.44 Y 

59897 $8.29 Y 

59898 $2,390.93 Y 

59899 $8.29 Y 

60000 $478.74 Y 

60100 $288.96 Y 

60200 $3,063.34 Y 

60210 $3,063.34 Y 

60212 $3,063.34 Y 

60220 $3,063.34 Y 

60225 $3,063.34 Y 

60240 $3,063.34 Y 

60252 $2,700.59 Y 

60260 $2,700.59 Y 

60271 $2,700.59 Y 

60280 $3,063.34 Y 

60281 $3,063.34 Y 

60300 $288.96 Y 

60500 $2,700.59 Y 

60502 $2,700.59 Y 

60512 $1,469.46 Y 

60520 $2,700.59 Y 

60659 $2,390.93 Y 

60699 $3,063.34 Y 

61000 $452.39 Y 


Page | 49




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

61001 $452.39 Y 

61020 $452.39 Y 

61026 $452.39 Y 

61050 $452.39 Y 

61055 $452.39 Y 

61070 $400.49 Y 

61215 $2,577.83 Y 

61330 $2,700.59 Y 

61334 $2,700.59 Y 

61623 $5,863.55 Y 

61626 $5,863.55 Y 

61720 $2,342.33 Y 

61770 $2,342.33 Y 

61790 $1,176.17 Y 

61791 $832.11 Y 


61796 $1,076.35 N 

61797 $294.25 N 

61798 $1,076.35 N 

61799 $406.45 N 

61800 $207.35 N 

61880 $1,233.86 Y 

61885 $12,949.29 N 

61886 $17,261.84 N 

61888 $1,800.93 Y 

62000 $1,568.46 Y 


62194 $452.39 Y 

62225 $961.94 Y 

62230 $2,577.83 Y 

62252 $159.63 N 

62263 $694.57 Y 

62264 $1,277.58 Y 

62267 $443.66 Y 

62268 $694.57 Y 

62269 $932.50 Y 

62270 $359.06 Y 

62272 $359.06 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

62273 $359.06 Y 

62280 $694.57 Y 

62281 $694.57 Y 

62282 $694.57 Y 


62287 $3,596.31 Y 



62292 $694.57 Y 

62294 $694.57 Y 

62310 $694.57 Y 

62311 $694.57 Y 

62318 $694.57 Y 

62319 $694.57 Y 

62350 $3,957.88 Y 

62351 $4,748.59 Y 

62355 $1,277.58 Y 

62360 $3,957.88 Y 

62361 $19,163.65 Y 

62362 $19,163.65 Y 

62365 $3,596.31 Y 

62367 $245.08 N 

62368 $245.08 N 

63001 $4,748.59 Y 

63003 $4,748.59 Y 

63005 $4,748.59 Y 

63011 $4,748.59 Y 

63012 $4,748.59 Y 

63015 $4,748.59 Y 

63016 $4,748.59 Y 

63017 $4,748.59 Y 

63020 $4,748.59 Y 

63030 $4,748.59 Y 

63035 $4,748.59 Y 

63040 $4,748.59 Y 

63042 $4,748.59 Y 

63045 $4,748.59 Y 

63046 $4,748.59 Y 


Page | 50




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

63047 $4,748.59 Y 

63048 $4,748.59 Y 

63055 $4,748.59 Y 

63056 $4,748.59 Y 

63057 $4,748.59 Y 

63064 $4,748.59 Y 

63066 $4,748.59 Y 

63075 $4,748.59 Y 

63076 $3,092.83 Y 

63081 $3,092.83 Y 

63082 $3,092.83 Y 

63600 $1,805.84 Y 

63610 $1,805.84 Y 

63615 $1,805.84 Y 



63650 $6,338.73 N 

63655 $8,345.95 N 

63661 $1,894.41 Y 

63662 $1,894.41 Y 

63663 $1,894.41 Y 

63664 $1,894.41 Y 

63685 $19,881.73 N 

63688 $2,765.06 Y 

63741 $3,957.88 Y 

63744 $3,957.88 Y 

63746 $1,277.58 Y 

64400 $246.55 Y 

64402 $246.55 Y 

64405 $359.06 Y 

64408 $694.57 Y 

64410 $694.57 Y 

64412 $694.57 Y 

64413 $359.06 Y 

64415 $359.06 Y 

64416 $694.57 Y 

64417 $359.06 Y 

64418 $359.06 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

64420 $359.06 Y 

64421 $694.57 Y 

64425 $359.06 Y 

64430 $694.57 Y 

64435 $359.06 Y 

64445 $694.57 Y 

64446 $694.57 Y 

64447 $359.06 Y 

64448 $694.57 Y 

64449 $694.57 Y 

64450 $359.06 Y 

64455 $246.55 Y 

64479 $694.57 Y 

64480 $359.06 Y 

64483 $694.57 Y 

64484 $359.06 Y 

64490 $694.57 Y 

64491 $246.55 Y 

64492 $246.55 Y 

64493 $694.57 Y 

64494 $246.55 Y 

64495 $246.55 Y 

64505 $246.55 Y 

64508 $246.55 Y 

64510 $694.57 Y 

64517 $694.57 Y 

64520 $694.57 Y 

64530 $694.57 Y 

64553 $6,338.73 N 

64555 $6,338.73 N 

64560 $6,338.73 N 

64561 $6,338.73 N 

64565 $6,338.73 N 

64573 $15,235.73 N 

64575 $8,345.95 N 

64577 $8,345.95 N 

64580 $8,345.95 N 

64581 $8,345.95 N 


Page | 51




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

64585 $1,894.41 Y 

64590 $19,881.73 N 

64595 $2,765.06 Y 

64600 $1,277.58 Y 

64605 $1,805.84 Y 

64610 $1,805.84 Y 

64612 $246.55 Y 

64613 $359.06 Y 

64614 $359.06 Y 

64620 $694.57 Y 

64622 $1,277.58 Y 

64623 $694.57 Y 

64626 $694.57 Y 

64627 $246.55 Y 

64630 $694.57 Y 

64632 $246.55 Y 

64640 $694.57 Y 

64680 $694.57 Y 

64681 $1,277.58 Y 

64702 $1,176.17 Y 

64704 $1,176.17 Y 

64708 $1,176.17 Y 

64712 $1,176.17 Y 

64713 $1,176.17 Y 

64714 $1,176.17 Y 

64716 $1,176.17 Y 

64718 $1,176.17 Y 

64719 $1,176.17 Y 

64721 $1,176.17 Y 

64722 $1,176.17 Y 

64726 $1,176.17 Y 

64727 $1,176.17 Y 

64732 $1,176.17 Y 

64734 $1,176.17 Y 

64736 $1,176.17 Y 

64738 $1,176.17 Y 

64740 $1,176.17 Y 

64742 $1,176.17 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

64744 $1,176.17 Y 

64746 $1,176.17 Y 

64761 $1,176.17 Y 

64763 $1,176.17 Y 

64766 $2,342.33 Y 

64771 $1,176.17 Y 

64772 $1,176.17 Y 

64774 $1,176.17 Y 

64776 $1,176.17 Y 

64778 $1,176.17 Y 

64782 $1,176.17 Y 

64783 $1,176.17 Y 

64784 $1,176.17 Y 

64786 $2,342.33 Y 

64787 $1,176.17 Y 

64788 $1,176.17 Y 

64790 $1,176.17 Y 

64792 $2,342.33 Y 

64795 $1,176.17 Y 

64802 $1,176.17 Y 

64804 $1,176.17 Y 

64820 $1,176.17 Y 

64821 $1,774.16 Y 

64822 $1,774.16 Y 

64823 $1,774.16 Y 

64831 $2,342.33 Y 

64832 $2,342.33 Y 

64834 $2,342.33 Y 

64835 $2,342.33 Y 

64836 $2,342.33 Y 

64837 $2,342.33 Y 

64840 $2,342.33 Y 

64856 $2,342.33 Y 

64857 $2,342.33 Y 

64858 $2,342.33 Y 

64859 $2,342.33 Y 

64861 $2,342.33 Y 

64862 $2,342.33 Y 


Page | 52




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

64864 $2,342.33 Y 

64865 $2,342.33 Y 

64870 $2,342.33 Y 

64872 $2,342.33 Y 

64874 $2,342.33 Y 

64876 $2,342.33 Y 

64885 $2,342.33 Y 

64886 $2,342.33 Y 

64890 $2,342.33 Y 

64891 $2,342.33 Y 

64892 $2,342.33 Y 

64893 $2,342.33 Y 

64895 $2,342.33 Y 

64896 $2,342.33 Y 

64897 $2,342.33 Y 

64898 $2,342.33 Y 

64901 $2,342.33 Y 

64902 $2,342.33 Y 

64905 $2,342.33 Y 

64907 $2,342.33 Y 

64910 $2,342.33 Y 

64911 $2,342.33 Y 

64999 $160.58 Y 

65091 $2,451.08 Y 

65093 $2,451.08 Y 

65101 $2,451.08 Y 

65103 $2,451.08 Y 

65105 $2,451.08 Y 

65110 $2,451.08 Y 

65112 $2,451.08 Y 

65114 $2,451.08 Y 

65125 $1,686.33 Y 

65130 $1,686.33 Y 

65135 $1,686.33 Y 

65140 $2,451.08 Y 

65150 $1,686.33 Y 

65155 $2,451.08 Y 

65175 $1,140.86 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

65205 $60.02 N 

65210 $60.02 N 

65220 $60.02 N 

65222 $60.02 N 

65235 $1,020.89 Y 

65260 $367.54 Y 

65265 $1,301.49 Y 

65270 $1,140.86 Y 

65272 $1,533.18 Y 

65275 $1,533.18 Y 

65280 $1,301.49 Y 

65285 $2,510.95 Y 

65286 $283.20 Y 

65290 $1,474.58 Y 

65400 $1,020.89 Y 

65410 $1,020.89 Y 

65420 $1,020.89 Y 

65426 $1,533.18 Y 

65430 $60.02 N 

65435 $480.15 Y 

65436 $1,020.89 Y 

65450 $122.99 N 

65600 $1,140.86 Y 

65710 $2,358.56 Y 

65730 $2,358.56 Y 

65750 $2,358.56 Y 

65755 $2,358.56 Y 

65756 $2,358.56 Y 


65770 $6,346.82 Y 

65772 $1,020.89 Y 

65775 $1,020.89 Y 

65780 $2,358.56 Y 

65781 $2,358.56 Y 

65782 $2,358.56 Y 

65800 $1,020.89 Y 

65805 $1,020.89 Y 

65810 $1,533.18 Y 


Page | 53




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

65815 $1,533.18 Y 

65820 $283.20 Y 

65850 $1,533.18 Y 

65855 $333.09 Y 

65860 $333.09 Y 

65865 $1,020.89 Y 

65870 $1,533.18 Y 

65875 $1,533.18 Y 

65880 $1,020.89 Y 

65900 $1,020.89 Y 

65920 $1,533.18 Y 

65930 $1,533.18 Y 

66020 $1,020.89 Y 

66030 $283.20 Y 

66130 $1,533.18 Y 

66150 $1,533.18 Y 

66155 $1,533.18 Y 

66160 $1,533.18 Y 

66165 $1,533.18 Y 

66170 $1,533.18 Y 

66172 $1,533.18 Y 

66180 $2,631.56 Y 

66185 $1,533.18 Y 

66220 $2,510.95 Y 

66225 $2,631.56 Y 

66250 $1,020.89 Y 

66500 $283.20 Y 

66505 $283.20 Y 

66600 $1,533.18 Y 

66605 $1,533.18 Y 

66625 $1,020.89 Y 

66630 $1,533.18 Y 

66635 $1,533.18 Y 

66680 $1,533.18 Y 

66682 $1,533.18 Y 

66700 $1,020.89 Y 

66710 $1,020.89 Y 

66711 $1,020.89 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

66720 $1,020.89 Y 

66740 $1,533.18 Y 

66761 $333.09 Y 

66762 $333.09 Y 

66770 $333.09 Y 

66820 $283.20 Y 

66821 $333.09 Y 

66825 $1,533.18 Y 

66830 $283.20 Y 

66840 $993.24 Y 

66850 $1,905.58 Y 

66852 $1,905.58 Y 

66920 $1,905.58 Y 

66930 $1,905.58 Y 

66940 $993.24 Y 

66982 $1,526.00 Y 

66983 $1,526.00 Y 

66984 $1,526.00 Y 

66985 $1,526.00 Y 

66986 $1,526.00 Y 


66999 $283.20 Y 

67005 $1,301.49 Y 

67010 $2,510.95 Y 

67015 $2,510.95 Y 

67025 $1,301.49 Y 

67027 $2,510.95 Y 

67028 $202.73 N 

67030 $1,301.49 Y 

67031 $333.09 Y 

67036 $2,510.95 Y 

67039 $2,510.95 Y 

67040 $2,510.95 Y 

67041 $2,510.95 Y 

67042 $2,510.95 Y 

67043 $2,510.95 Y 

67101 $1,301.49 Y 

67105 $333.09 Y 


Page | 54




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

67107 $2,510.95 Y 

67108 $2,510.95 Y 

67110 $1,301.49 Y 

67112 $2,510.95 Y 

67113 $2,510.95 Y 

67115 $1,301.49 Y 

67120 $1,301.49 Y 

67121 $1,301.49 Y 

67141 $367.54 Y 

67145 $333.09 Y 

67208 $367.54 Y 

67210 $333.09 Y 

67218 $1,301.49 Y 

67220 $367.54 Y 

67221 $367.54 Y 

67225 $367.54 Y 

67227 $1,301.49 Y 

67228 $333.09 Y 

67229 $333.09 Y 

67250 $1,140.86 Y 

67255 $1,301.49 Y 

67299 $367.54 Y 

67311 $1,474.58 Y 

67312 $1,474.58 Y 

67314 $1,474.58 Y 

67316 $1,474.58 Y 

67318 $1,474.58 Y 

67320 $1,474.58 Y 

67331 $1,474.58 Y 

67332 $1,474.58 Y 

67334 $1,474.58 Y 

67335 $1,474.58 Y 

67340 $1,474.58 Y 

67343 $1,474.58 Y 

67345 $202.73 Y 

67346 $976.42 Y 

67399 $1,474.58 Y 

67400 $1,140.86 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

67405 $1,686.33 Y 

67412 $1,140.86 Y 

67413 $1,686.33 Y 

67414 $2,451.08 Y 

67415 $1,140.86 Y 

67420 $2,451.08 Y 

67430 $2,451.08 Y 

67440 $2,451.08 Y 

67445 $2,451.08 Y 

67450 $2,451.08 Y 

67500 $122.99 N 

67505 $202.73 Y 

67515 $202.73 Y 

67550 $2,451.08 Y 

67560 $1,686.33 Y 

67570 $2,451.08 Y 

67599 $202.73 Y 

67700 $202.73 Y 

67710 $480.15 Y 

67715 $1,140.86 Y 

67800 $202.73 Y 

67801 $480.15 Y 

67805 $202.73 Y 

67808 $1,140.86 Y 

67810 $202.73 Y 

67820 $60.02 N 

67825 $202.73 Y 

67830 $480.15 Y 

67835 $1,140.86 Y 

67840 $480.15 Y 

67850 $480.15 Y 

67875 $480.15 Y 

67880 $1,020.89 Y 

67882 $1,140.86 Y 

67900 $1,686.33 Y 

67901 $1,140.86 Y 

67902 $1,686.33 Y 

67903 $1,140.86 Y 


Page | 55




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

67904 $1,140.86 Y 

67906 $1,140.86 Y 

67908 $1,140.86 Y 

67909 $1,140.86 Y 

67911 $1,140.86 Y 

67912 $1,140.86 Y 

67914 $1,140.86 Y 

67915 $1,140.86 Y 

67916 $1,140.86 Y 

67917 $1,140.86 Y 

67921 $1,140.86 Y 

67922 $1,140.86 Y 

67923 $1,140.86 Y 

67924 $1,140.86 Y 

67930 $1,140.86 Y 

67935 $1,140.86 Y 

67938 $122.99 N 

67950 $1,140.86 Y 

67961 $1,140.86 Y 

67966 $1,140.86 Y 

67971 $1,140.86 Y 

67973 $1,686.33 Y 

67974 $1,140.86 Y 

67975 $1,140.86 Y 

67999 $202.73 Y 

68020 $202.73 Y 

68040 $60.02 N 

68100 $283.20 Y 

68110 $976.42 Y 

68115 $1,140.86 Y 

68130 $1,020.89 Y 

68135 $480.15 Y 

68200 $60.02 N 

68320 $1,686.33 Y 

68325 $1,686.33 Y 

68326 $1,140.86 Y 

68328 $1,686.33 Y 

68330 $1,533.18 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

68335 $1,686.33 Y 

68340 $1,140.86 Y 

68360 $1,533.18 Y 

68362 $1,533.18 Y 

68371 $1,020.89 Y 

68399 $202.73 Y 

68400 $202.73 Y 

68420 $1,140.86 Y 

68440 $202.73 Y 

68500 $1,686.33 Y 

68505 $1,686.33 Y 

68510 $1,140.86 Y 

68520 $1,686.33 Y 

68525 $1,140.86 Y 

68530 $202.73 Y 

68540 $1,140.86 Y 

68550 $1,686.33 Y 

68700 $1,140.86 Y 

68705 $202.73 Y 

68720 $1,686.33 Y 

68745 $1,686.33 Y 

68750 $1,686.33 Y 

68760 $202.73 N 

68761 $202.73 N 

68770 $1,686.33 Y 

68801 $60.02 N 

68810 $202.73 N 

68811 $1,140.86 Y 

68815 $1,140.86 Y 

68816 $1,140.86 Y 

68840 $122.99 N 


68899 $202.73 Y 

69000 $91.46 Y 

69005 $1,219.29 Y 

69020 $91.46 Y 

69100 $215.19 Y 

69105 $1,079.91 Y 


Page | 56




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

69110 $1,099.36 Y 

69120 $1,568.46 Y 

69140 $1,568.46 Y 

69145 $1,099.36 Y 

69150 $478.74 Y 

69200 $42.05 N 

69205 $1,469.46 Y 

69210 $42.05 N 

69220 $55.22 Y 

69222 $1,079.91 Y 

69300 $1,568.46 Y 

69310 $2,700.59 Y 

69320 $2,700.59 Y 

69399 $72.39 Y 

69400 $215.19 Y 

69401 $215.19 Y 

69405 $478.74 Y 

69420 $215.19 Y 

69421 $1,079.91 Y 

69424 $1,079.91 Y 

69433 $478.74 Y 

69436 $1,079.91 Y 

69440 $1,568.46 Y 

69450 $2,700.59 Y 

69501 $2,700.59 Y 

69502 $1,568.46 Y 

69505 $2,700.59 Y 

69511 $2,700.59 Y 

69530 $2,700.59 Y 

69540 $1,079.91 Y 

69550 $2,700.59 Y 

69552 $2,700.59 Y 

69601 $2,700.59 Y 

69602 $2,700.59 Y 

69603 $2,700.59 Y 

69604 $2,700.59 Y 

69605 $2,700.59 Y 

69610 $1,568.46 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

69620 $1,568.46 Y 

69631 $2,700.59 Y 

69632 $2,700.59 Y 

69633 $2,700.59 Y 

69635 $2,700.59 Y 

69636 $2,700.59 Y 

69637 $2,700.59 Y 

69641 $2,700.59 Y 

69642 $2,700.59 Y 

69643 $2,700.59 Y 

69644 $2,700.59 Y 

69645 $2,700.59 Y 

69646 $2,700.59 Y 

69650 $1,568.46 Y 

69660 $2,700.59 Y 

69661 $2,700.59 Y 

69662 $2,700.59 Y 

69666 $2,700.59 Y 

69667 $2,700.59 Y 

69670 $2,700.59 Y 

69676 $2,700.59 Y 

69700 $2,700.59 Y 

69711 $2,700.59 Y 

69714 $7,462.11 Y 

69715 $7,462.11 Y 

69717 $7,462.11 Y 

69718 $7,462.11 Y 

69720 $2,700.59 Y 

69725 $2,700.59 Y 

69740 $2,700.59 Y 

69745 $2,700.59 Y 

69799 $72.39 Y 

69801 $1,568.46 Y 

69802 $1,568.46 Y 

69805 $2,700.59 Y 

69806 $2,700.59 Y 

69820 $2,700.59 Y 

69840 $2,700.59 Y 


Page | 57




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

69905 $2,700.59 Y 

69910 $2,700.59 Y 

69915 $2,700.59 Y 

69930 $26,943.70 Y 

69949 $72.39 Y 

69955 $2,700.59 Y 

69960 $2,700.59 Y 

69970 $2,700.59 Y 

69979 $72.39 Y 




70030 $41.85 N 

70100 $41.85 N 

70110 $41.85 N 

70120 $41.85 N 

70130 $41.85 N 

70134 $70.12 N 

70140 $41.85 N 

70150 $41.85 N 

70160 $41.85 N 


70190 $41.85 N 

70200 $41.85 N 

70210 $41.85 N 

70220 $41.85 N 

70240 $41.85 N 

70250 $41.85 N 

70260 $70.12 N 

70300 $28.08 N 

70310 $28.08 N 

70320 $28.08 N 

70328 $41.85 N 

70330 $41.85 N 


70336 $325.80 N 

70350 $41.85 N 

70355 $41.85 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

70360 $41.85 N 

70370 $79.75 N 

70371 $79.75 N 


70380 $41.85 N 


70450 $181.83 N 

70460 $276.87 N 

70470 $310.88 N 

70480 $181.83 N 

70481 $276.87 N 

70482 $310.88 N 

70486 $181.83 N 

70487 $276.87 N 

70488 $310.88 N 

70490 $181.83 N 

70491 $276.87 N 

70492 $310.88 N 

70496 $317.36 N 

70498 $317.36 N 

70540 $325.80 N 

70542 $395.21 N 

70543 $499.07 N 

70544 $325.80 N 

70545 $395.21 N 

70546 $499.07 N 

70547 $325.80 N 

70548 $395.21 N 

70549 $499.07 N 

70551 $325.80 N 

70552 $395.21 N 

70553 $499.07 N 

70557 $325.80 N 

70558 $395.21 N 

70559 $499.07 N 

71010 $41.85 N 

71015 $41.85 N 

71020 $41.85 N 


Page | 58




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

71021 $41.85 N 

71022 $41.85 N 

71023 $79.75 N 

71030 $41.85 N 

71034 $79.75 N 

71035 $41.85 N 




71100 $41.85 N 

71101 $41.85 N 

71110 $41.85 N 

71111 $70.12 N 

71120 $41.85 N 

71130 $41.85 N 

71250 $181.83 N 

71260 $276.87 N 

71270 $310.88 N 

71275 $317.36 N 

71550 $325.80 N 

71551 $395.21 N 

71552 $499.07 N 

72010 $70.12 N 

72020 $41.85 N 

72040 $41.85 N 

72050 $70.12 N 

72052 $70.12 N 

72069 $41.85 N 

72070 $41.85 N 

72072 $41.85 N 

72074 $41.85 N 

72080 $41.85 N 

72090 $70.12 N 

72100 $41.85 N 

72110 $70.12 N 

72114 $70.12 N 

72120 $70.12 N 

72125 $181.83 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

72126 $276.87 N 

72127 $310.88 N 

72128 $181.83 N 

72129 $276.87 N 

72130 $310.88 N 

72131 $181.83 N 

72132 $276.87 N 

72133 $310.88 N 

72141 $325.80 N 

72142 $395.21 N 

72146 $325.80 N 

72147 $395.21 N 

72148 $325.80 N 

72149 $395.21 N 

72156 $499.07 N 

72157 $499.07 N 

72158 $499.07 N 

72170 $41.85 N 

72190 $41.85 N 

72191 $317.36 N 

72192 $181.83 N 

72193 $276.87 N 

72194 $310.88 N 

72195 $325.80 N 

72196 $395.21 N 

72197 $499.07 N 

72200 $41.85 N 

72202 $41.85 N 

72220 $41.85 N 











Page | 59




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

73000 $41.85 N 

73010 $41.85 N 

73020 $41.85 N 

73030 $41.85 N 


73050 $41.85 N 

73060 $41.85 N 

73070 $41.85 N 

73080 $41.85 N 


73090 $41.85 N 

73092 $41.85 N 

73100 $41.85 N 

73110 $41.85 N 


73120 $41.85 N 

73130 $41.85 N 

73140 $41.85 N 

73200 $181.83 N 

73201 $276.87 N 

73202 $310.88 N 

73206 $317.36 N 

73218 $325.80 N 

73219 $395.21 N 

73220 $499.07 N 

73221 $325.80 N 

73222 $395.21 N 

73223 $499.07 N 

73500 $41.85 N 

73510 $41.85 N 

73520 $70.12 N 



73540 $41.85 N 


73550 $41.85 N 

73560 $41.85 N 

73562 $41.85 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

73564 $41.85 N 

73565 $41.85 N 


73590 $41.85 N 

73592 $41.85 N 

73600 $41.85 N 

73610 $41.85 N 


73620 $41.85 N 

73630 $41.85 N 

73650 $41.85 N 

73660 $41.85 N 

73700 $181.83 N 

73701 $276.87 N 

73702 $310.88 N 

73706 $317.36 N 

73718 $325.80 N 

73719 $395.21 N 

73720 $499.07 N 

73721 $325.80 N 

73722 $395.21 N 

73723 $499.07 N 

74000 $41.85 N 

74010 $41.85 N 

74020 $41.85 N 

74022 $70.12 N 

74150 $181.83 N 

74160 $276.87 N 

74170 $310.88 N 

74175 $317.36 N 

74181 $325.80 N 

74182 $395.21 N 

74183 $499.07 N 


74210 $81.58 N 

74220 $81.58 N 

74230 $81.58 N 



Page | 60




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

74240 $81.58 N 

74241 $81.58 N 

74245 $131.95 N 

74246 $81.58 N 

74247 $81.58 N 

74249 $131.95 N 

74250 $81.58 N 

74251 $131.95 N 

74260 $81.58 N 




74270 $81.58 N 

74280 $131.95 N 

74283 $81.58 N 

74290 $81.58 N 

74291 $81.58 N 













74400 $159.96 N 

74410 $159.96 N 

74415 $159.96 N 

74420 $159.96 N 






Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 






74710 $70.12 N 



74775 $159.96 N 

75557 $325.80 N 

75559 $325.80 N 

75561 $499.07 N 

75563 $499.07 N 



























Page | 61




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 







































Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 





















76010 $41.85 N 


76098 $351.92 N 

76100 $70.12 N 

76101 $195.98 N 

76102 $195.98 N 

76120 $79.75 N 


76150 $41.85 N 




76380 $102.36 N 

76496 $79.75 N 

76497 $102.36 N 

76498 $325.80 N 

76499 $41.85 N 

76506 $58.22 N 


Page | 62




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

76510 $283.20 Y 

76511 $90.69 N 

76512 $90.69 N 

76513 $90.69 N 

76514 $14.58 N 

76516 $58.22 N 

76519 $90.69 N 

76529 $58.22 N 

76536 $90.69 N 

76604 $58.22 N 

76645 $58.22 N 

76700 $90.69 N 

76705 $90.69 N 

76770 $90.69 N 

76775 $90.69 N 

76776 $90.69 N 

76800 $90.69 N 

76801 $90.69 N 

76802 $58.22 N 

76805 $90.69 N 

76810 $90.69 N 

76811 $144.54 N 

76812 $58.22 N 

76813 $58.22 N 

76814 $58.22 N 

76815 $58.22 N 

76816 $58.22 N 

76817 $58.22 N 

76818 $90.69 N 

76819 $90.69 N 

76820 $58.22 N 

76821 $58.22 N 

76825 $555.57 N 

76826 $420.35 N 

76827 $58.22 N 

76828 $58.22 N 

76830 $90.69 N 

76831 $144.54 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

76856 $90.69 N 

76857 $58.22 N 

76870 $90.69 N 

76872 $90.69 N 

76873 $90.69 N 

76880 $90.69 N 

76885 $58.22 N 

76886 $58.22 N 



76936 $101.00 N 










76970 $58.22 N 


76977 $42.05 N 


76999 $58.22 N 















Page | 63




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

77071 $41.85 N 

77072 $41.85 N 

77073 $41.85 N 

77074 $70.12 N 

77075 $70.12 N 

77076 $70.12 N 

77077 $41.85 N 

77078 $67.57 N 

77079 $102.36 N 

77080 $67.57 N 

77081 $27.13 N 

77082 $41.85 N 

77083 $70.12 N 

77084 $325.80 N 

77280 $95.95 N 

77285 $248.24 N 

77290 $248.24 N 

77295 $864.39 N 

77299 $95.95 N 

77300 $95.95 N 

77301 $864.39 N 

77305 $95.95 N 

77310 $95.95 N 

77315 $248.24 N 

77321 $248.24 N 

77326 $95.95 N 

77327 $248.24 N 

77328 $248.24 N 

77331 $95.95 N 

77332 $177.68 N 

77333 $177.68 N 

77334 $177.68 N 

77336 $95.95 N 

77338 $177.68 N 

77370 $95.95 N 

77371 $6,845.67 N 

77399 $95.95 N 

77401 $86.48 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

77402 $86.48 N 

77403 $86.48 N 

77404 $86.48 N 

77406 $144.70 N 

77407 $86.48 N 

77408 $86.48 N 

77409 $86.48 N 

77411 $144.70 N 

77412 $144.70 N 

77413 $144.70 N 

77414 $144.70 N 

77416 $144.70 N 


77418 $392.62 N 


77422 $144.70 N 

77423 $144.70 N 


77470 $354.74 N 

77520 $878.34 N 

77522 $878.34 N 

77523 $1,148.99 N 

77525 $1,148.99 N 

77600 $354.74 N 

77605 $354.74 N 

77610 $354.74 N 

77615 $354.74 N 

77620 $354.74 N 

77750 $144.70 N 

77761 $281.77 N 

77762 $281.77 N 

77763 $281.77 N 

77776 $281.77 N 

77777 $281.77 N 

77778 $832.84 N 

77785 $724.76 N 

77786 $724.76 N 

77787 $724.76 N 


Page | 64




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

77789 $86.48 N 


77799 $281.77 N 

78000 $104.89 N 

78001 $104.89 N 

78003 $104.89 N 

78006 $206.67 N 

78007 $206.67 N 

78010 $135.68 N 

78011 $135.68 N 

78015 $270.38 N 

78016 $270.38 N 

78018 $270.38 N 


78070 $206.67 N 

78075 $897.67 N 

78099 $135.68 N 

78102 $240.90 N 

78103 $240.90 N 

78104 $240.90 N 

78110 $363.61 N 

78111 $363.61 N 

78120 $363.61 N 

78121 $363.61 N 

78122 $363.61 N 

78130 $363.61 N 

78135 $363.61 N 

78140 $363.61 N 

78185 $240.90 N 

78190 $168.49 N 

78191 $168.49 N 

78195 $240.90 N 

78199 $240.90 N 

78201 $271.04 N 

78202 $271.04 N 

78205 $271.04 N 

78206 $271.04 N 

78215 $271.04 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

78216 $271.04 N 

78220 $271.04 N 

78223 $271.04 N 

78230 $230.60 N 

78231 $230.60 N 

78232 $230.60 N 

78258 $230.60 N 

78261 $230.60 N 

78262 $230.60 N 

78264 $230.60 N 

78270 $168.49 N 

78271 $168.49 N 

78272 $168.49 N 

78278 $230.60 N 

78282 $230.60 N 

78290 $230.60 N 

78291 $230.60 N 

78299 $230.60 N 

78300 $230.63 N 

78305 $230.63 N 

78306 $230.63 N 

78315 $230.63 N 

78320 $230.63 N 

78399 $230.63 N 

78414 $285.03 N 

78428 $285.03 N 

78445 $186.47 N 

78451 $722.47 N 

78452 $722.47 N 

78453 $722.47 N 

78454 $722.47 N 

78456 $186.47 N 

78457 $186.47 N 

78458 $186.47 N 

78459 $1,335.59 N 

78466 $285.03 N 

78468 $285.03 N 

78469 $285.03 N 


Page | 65




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

78472 $285.03 N 

78473 $285.03 N 

78481 $285.03 N 

78483 $285.03 N 

78491 $1,335.59 N 

78492 $1,335.59 N 

78494 $285.03 N 


78499 $285.03 N 

78580 $192.42 N 

78584 $301.78 N 

78585 $301.78 N 

78586 $192.42 N 

78587 $192.42 N 

78588 $301.78 N 

78591 $192.42 N 

78593 $192.42 N 

78594 $192.42 N 

78596 $301.78 N 

78599 $192.42 N 

78600 $183.34 N 

78601 $539.36 N 

78605 $183.34 N 

78606 $539.36 N 

78607 $539.36 N 

78608 $966.92 N 

78610 $183.34 N 

78630 $539.36 N 

78635 $539.36 N 

78645 $183.34 N 

78647 $539.36 N 

78650 $539.36 N 

78660 $183.34 N 

78699 $183.34 N 

78700 $302.97 N 

78701 $302.97 N 

78707 $302.97 N 

78708 $302.97 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

78709 $302.97 N 

78710 $302.97 N 

78725 $168.49 N 

78730 $104.89 N 

78740 $302.97 N 

78761 $302.97 N 

78799 $302.97 N 

78800 $270.38 N 

78801 $475.76 N 

78802 $475.76 N 

78803 $475.76 N 

78804 $897.67 N 

78805 $475.76 N 

78806 $475.76 N 

78807 $270.38 N 


78811 $966.92 N 

78812 $966.92 N 

78813 $966.92 N 

78814 $966.92 N 

78815 $966.92 N 

78816 $966.92 N 

78999 $104.89 N 

79005 $203.29 N 

79101 $203.29 N 

79200 $326.76 N 

79300 $203.29 N 

79403 $326.76 N 

79440 $326.76 N 

79445 $203.29 N 

79999 $203.29 N 


80500 $15.59 N 

80502 $9.71 N 

85097 $33.31 N 


86077 $15.59 N 

86078 $33.31 N 


Page | 66




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

86079 $15.59 N 

86485 $5.02 N 

86486 $5.02 N 

86490 $5.02 N 

86510 $5.02 N 

86580 $5.02 N 

86780 $25.89 N 

86825 $106.14 N 

86826 $35.38 N 

86850 $13.79 N 

86860 $23.46 N 

86870 $23.46 N 

86880 $7.29 N 

86885 $7.29 N 

86886 $7.29 N 

86890 $46.39 N 

86891 $13.79 N 

86900 $7.29 N 

86901 $7.29 N 

86903 $13.79 N 

86904 $13.79 N 

86905 $13.79 N 

86906 $13.79 N 

86920 $13.79 N 

86921 $13.79 N 

86922 $23.46 N 

86923 $13.79 N 

86927 $13.79 N 

86930 $46.39 N 

86931 $46.39 N 

86932 $46.39 N 

86945 $13.79 N 

86950 $13.79 N 

86960 $13.79 N 

86965 $23.46 N 

86970 $13.79 N 

86971 $13.79 N 

86972 $13.79 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

86975 $23.46 N 

86976 $13.79 N 

86977 $46.39 N 

86978 $23.46 N 

86985 $13.79 N 

86999 $13.79 N 

87150 $68.62 N 

87153 $225.53 N 

87493 $68.62 N 

87500 $69.96 N 

87809 $23.91 N 

87905 $24.35 N 

88104 $15.59 N 

88106 $15.59 N 

88107 $33.31 N 

88108 $15.59 N 

88112 $33.31 N 

88125 $15.59 N 


88160 $15.59 N 

88161 $15.59 N 

88162 $33.31 N 

88172 $33.31 N 

88173 $33.31 N 

88182 $33.31 N 

88184 $15.59 N 

88185 $15.59 N 

88187 $9.71 N 

88188 $33.31 N 

88189 $33.31 N 

88199 $9.71 N 

88299 $9.71 N 

88300 $15.59 N 

88302 $15.59 N 

88304 $33.31 N 

88305 $33.31 N 

88307 $50.44 N 

88309 $50.44 N 


Page | 67




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

88311 $9.71 N 

88312 $15.59 N 

88313 $15.59 N 

88314 $15.59 N 

88318 $15.59 N 

88319 $50.44 N 

88321 $15.59 N 

88323 $33.31 N 

88325 $50.44 N 

88329 $15.59 N 

88331 $33.31 N 

88332 $15.59 N 

88333 $15.59 N 

88334 $15.59 N 

88342 $33.31 N 

88346 $33.31 N 

88347 $33.31 N 

88348 $153.62 N 

88349 $153.62 N 

88355 $33.31 N 

88356 $50.44 N 

88358 $33.31 N 

88360 $33.31 N 

88361 $50.44 N 

88362 $50.44 N 

88365 $50.44 N 

88367 $50.44 N 

88368 $50.44 N 





88399 $9.71 N 

88720 $9.20 N 


88740 $9.20 N 

88741 $9.20 N 

89049 $9.71 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

89100 $95.52 N 

89105 $95.52 N 

89130 $95.52 N 

89132 $95.52 N 

89135 $95.52 N 

89136 $95.52 N 

89140 $95.52 N 

89141 $95.52 N 

89230 $33.31 N 

89240 $9.71 N 

89264 $50.44 N 






90371 $114.20 N 

90375 $150.91 N 

90376 $140.06 N 



90396 $147.59 N 

90470 $31.90 N 

90471 $23.93 N 

90472 $23.93 N 

90473 $23.93 N 

90474 $23.93 N 




90585 $108.14 N 









Page | 68




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 











90663 Bundled N 

90665 $0.93 N 



90675 $173.25 N 

90676 $96.27 N 

90680 $72.37 N 

90681 $106.60 N 





















Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 








90733 $98.54 N 

90734 $102.46 N 

90735 $100.15 N 








91000 $256.59 N 

91010 $256.59 N 

91011 $256.59 N 

91012 $256.59 N 

91020 $256.59 N 

91022 $256.59 N 

91030 $256.59 N 

91034 $256.59 N 

91035 $256.59 N 

91037 $256.59 N 

91038 $256.59 N 

91040 $95.52 N 

91052 $256.59 N 

91055 $95.52 N 

91065 $95.52 N 

91105 $95.52 N 

91110 $618.89 Y 

91120 $68.85 Y 

91122 $189.83 Y 


91132 $95.52 N 


Page | 69




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

91133 $95.52 N 

91299 $95.52 N 

92018 $976.42 Y 

92019 $976.42 Y 

92020 $37.35 N 

92025 $60.02 N 

92060 $60.02 N 


92081 $37.35 N 

92082 $60.02 N 

92083 $60.02 N 


92120 $60.02 N 

92130 $37.35 N 

92135 $37.35 N 

92136 $60.02 N 

92140 $37.35 N 

92225 $37.35 N 

92226 $60.02 N 

92230 $122.99 N 

92235 $122.99 N 

92240 $122.99 N 

92250 $60.02 N 

92260 $37.35 N 

92265 $60.02 N 

92270 $37.35 N 

92275 $122.99 N 

92283 $37.35 N 

92284 $60.02 N 

92285 $60.02 N 

92286 $122.99 N 

92287 $122.99 N 

92311 $60.02 N 

92312 $60.02 N 

92313 $37.35 N 

92315 $37.35 N 

92316 $60.02 N 

92317 $37.35 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

92325 $37.35 N 

92326 $60.02 N 

92352 $60.02 N 

92353 $37.35 N 

92354 $37.35 N 

92355 $37.35 N 

92358 $37.35 N 

92371 $37.35 N 

92499 $37.35 N 

92502 $215.19 Y 


92511 $50.31 Y 

92516 $94.36 N 

92520 $94.36 N 





92540 $94.36 N 

92541 $56.93 N 

92542 $56.93 N 

92543 $94.36 N 

92544 $56.93 N 

92545 $56.93 N 

92546 $94.36 N 


92548 $94.36 N 

92550 $29.53 N 

92552 $29.53 N 

92553 $79.64 N 

92555 $29.53 N 

92556 $29.53 N 

92557 $79.64 N 

92561 $29.53 N 

92562 $29.53 N 

92563 $29.53 N 

92564 $29.53 N 

92565 $29.53 N 


Page | 70




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

92567 $29.53 N 

92568 $29.53 N 

92570 $29.53 N 

92571 $29.53 N 

92572 $102.05 N 

92575 $29.53 N 

92576 $29.53 N 

92577 $102.05 N 

92579 $79.64 N 

92582 $79.64 N 

92583 $29.53 N 

92584 $168.58 N 

92585 $168.58 N 

92586 $75.18 N 

92587 $56.93 N 

92588 $56.93 N 

92596 $29.53 N 

92601 $102.05 N 

92602 $102.05 N 

92603 $102.05 N 

92604 $102.05 N 

92620 $79.64 N 


92625 $79.64 N 

92626 $102.05 N 


92640 $79.64 N 

92700 $29.53 N 

92950 $154.27 N 

92953 $154.27 N 

92960 $345.86 N 

92961 $345.86 N 

92973 $2,569.76 Y 

92974 $1,121.11 Y 

92977 $150.50 Y 



92980 $5,326.54 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

92981 $5,326.54 Y 

92982 $3,184.27 Y 

92984 $3,184.27 Y 

92986 $3,184.27 Y 

92987 $3,184.27 Y 

92990 $3,184.27 Y 

92995 $5,863.55 Y 

92996 $5,863.55 Y 

92997 $3,184.27 Y 

92998 $3,184.27 Y 

93005 $24.75 N 


93017 $164.21 N 

93024 $164.21 N 

93025 $164.21 N 

93041 $14.58 N 

93225 $61.87 N 

93226 $61.87 N 

93228 $39.05 N 

93229 $718.24 N 

93231 $61.87 N 

93232 $61.87 N 

93236 $61.87 N 

93270 $61.87 N 

93271 $100.53 N 

93278 $14.58 N 

93279 $22.03 N 

93280 $22.03 N 

93281 $22.03 N 

93282 $35.69 N 

93283 $35.69 N 

93284 $35.69 N 

93285 $22.03 N 

93286 $35.69 N 

93287 $35.69 N 

93288 $22.03 N 

93289 $35.69 N 

93290 $22.03 N 


Page | 71




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

93291 $22.03 N 

93292 $35.69 N 

93293 $22.03 N 

93294 $22.03 N 

93295 $35.69 N 

93296 $35.69 N 

93297 $35.69 N 

93298 $22.03 N 

93299 $22.03 N 

93303 $555.57 N 

93304 $420.35 N 

93306 $420.35 N 

93307 $246.44 N 

93308 $246.44 N 

93312 $555.57 N 

93313 $420.35 N 


93315 $555.57 N 

93316 $555.57 N 


93318 $555.57 N 




93350 $420.35 N 

93351 $555.57 N 

93352 $58.30 N 

93501 $2,501.25 Y 

93503 $1,121.11 Y 

93505 $1,121.11 Y 

93508 $2,501.25 Y 

93510 $2,501.25 Y 

93511 $2,501.25 Y 

93514 $2,501.25 Y 

93524 $2,501.25 Y 

93526 $2,501.25 Y 

93527 $2,501.25 Y 

93528 $2,501.25 Y 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

93529 $2,501.25 Y 

93530 $2,501.25 Y 

93531 $2,501.25 Y 

93532 $2,501.25 Y 

93533 $2,501.25 Y 














93580 $9,259.40 Y 

93581 $9,259.40 Y 

93600 $679.25 N 

93602 $679.25 N 

93603 $679.25 N 


93610 $679.25 N 

93612 $679.25 N 


93615 $679.25 N 

93616 $679.25 N 

93618 $679.25 N 




93624 $3,291.54 Y 




93642 $679.25 N 


Page | 72




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

93660 $274.60 N 


93701 $24.75 N 

93721 $53.37 N 

93724 $22.03 N 

93740 $53.37 N 

93745 $35.69 N 

93750 $100.53 N 


93786 $61.87 N 

93788 $61.87 N 

93797 $35.76 N 

93798 $35.76 N 

93799 $61.87 N 

93875 $101.00 N 

93880 $144.54 N 

93882 $144.54 N 

93886 $144.54 N 

93888 $58.22 N 

93890 $90.69 N 

93892 $90.69 N 

93893 $90.69 N 

93922 $61.87 N 

93923 $101.00 N 

93924 $101.00 N 

93925 $144.54 N 

93926 $90.69 N 

93930 $144.54 N 

93931 $90.69 N 

93965 $101.00 N 

93970 $144.54 N 

93971 $90.69 N 

93975 $144.54 N 

93976 $144.54 N 

93978 $144.54 N 

93979 $90.69 N 

93980 $144.54 N 

93981 $144.54 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

93982 $61.87 N 

93990 $90.69 N 

94002 $193.92 N 

94003 $193.92 N 

94010 $53.37 N 

94011 $53.37 N 

94012 $53.37 N 

94013 $164.79 N 

94014 $37.50 N 

94015 $37.50 N 

94060 $88.85 N 

94070 $164.79 N 

94150 $37.50 N 

94200 $37.50 N 

94240 $53.37 N 

94250 $53.37 N 

94260 $53.37 N 

94350 $53.37 N 

94360 $37.50 N 

94370 $14.58 N 

94375 $53.37 N 

94400 $37.50 N 

94450 $53.37 N 

94452 $53.37 N 

94453 $53.37 N 

94610 $25.50 N 

94620 $53.37 N 

94621 $164.79 N 

94640 $25.50 N 

94642 $88.85 N 

94644 $42.05 N 

94645 $42.05 N 

94660 $88.85 N 

94662 $193.92 N 

94664 $25.50 N 

94667 $25.50 N 

94668 $25.50 N 

94680 $164.79 N 


Page | 73




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

94681 $53.37 N 

94690 $37.50 N 

94720 $53.37 N 

94725 $53.37 N 

94750 $37.50 N 



94770 $37.50 N 

94772 $164.79 N 

94775 $61.87 N 

94776 $61.87 N 

94799 $37.50 N 

95004 $27.09 N 

95010 $27.09 N 

95015 $27.09 N 

95024 $27.09 N 

95027 $27.09 N 

95028 $27.09 N 

95044 $27.09 N 

95052 $27.09 N 

95056 $91.72 N 

95060 $91.72 N 

95065 $27.09 N 

95070 $164.79 N 

95071 $164.79 N 

95075 $256.59 N 

95115 $23.93 N 

95117 $23.93 N 

95144 $34.90 N 

95145 $34.90 N 

95146 $70.55 N 

95147 $70.55 N 

95148 $34.90 N 

95149 $34.90 N 

95165 $23.93 N 

95170 $34.90 N 

95180 $91.72 N 

95199 $27.09 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 


95805 $718.24 N 

95806 $151.06 N 

95807 $718.24 N 

95808 $718.24 N 

95810 $718.24 N 

95811 $718.24 N 

95812 $151.06 N 

95813 $151.06 N 

95816 $151.06 N 

95819 $151.06 N 

95822 $151.06 N 

95824 $168.58 N 

95827 $151.06 N 


95857 $75.18 N 

95860 $75.18 N 

95861 $75.18 N 

95863 $75.18 N 

95864 $75.18 N 

95865 $75.18 N 

95866 $75.18 N 

95867 $75.18 N 

95868 $75.18 N 

95869 $38.55 N 

95870 $38.55 N 

95872 $75.18 N 



95875 $38.55 N 

95900 $38.55 N 

95903 $38.55 N 

95904 $38.55 N 



95921 $75.18 N 

95922 $38.55 N 

95923 $75.18 N 


Page | 74




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

95925 $168.58 N 

95926 $168.58 N 

95927 $168.58 N 

95928 $75.18 N 

95929 $75.18 N 

95930 $168.58 N 

95933 $38.55 N 

95934 $38.55 N 

95936 $38.55 N 

95937 $75.18 N 

95950 $718.24 N 

95951 $718.24 N 

95953 $718.24 N 

95954 $75.18 N 


95956 $718.24 N 


95958 $151.06 N 

95961 $168.58 N 

95962 $168.58 N 

95965 $3,329.29 N 

95966 $897.26 N 

95967 $897.26 N 

95970 $75.18 N 

95971 $100.53 N 

95972 $100.53 N 

95973 $100.53 N 

95974 $100.53 N 

95975 $100.53 N 

95978 $100.53 N 

95979 $100.53 N 


95981 $75.18 N 

95982 $100.53 N 

95990 $118.17 Y 

95991 $118.17 Y 

95992 $56.10 N 

95999 $38.55 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

96000 $168.58 N 

96001 $168.58 N 

96002 $75.18 N 

96003 $38.55 N 


96360 $70.55 N 

96361 $23.93 N 

96365 $118.17 N 

96366 $23.93 N 

96367 $34.90 N 


96369 $118.17 N 

96370 $34.90 N 

96371 $23.93 N 

96372 $23.93 N 

96373 $34.90 N 

96374 $34.90 N 

96375 $34.90 N 


96379 $23.93 N 

96401 $34.90 N 

96402 $34.90 N 

96405 $34.90 N 

96406 $118.17 N 

96409 $118.17 N 

96411 $70.55 N 

96413 $205.03 N 

96415 $34.90 N 

96416 $205.03 N 

96417 $70.55 N 

96420 $70.55 N 

96422 $205.03 N 

96423 $70.55 N 

96425 $205.03 N 

96440 $118.17 N 

96445 $205.03 N 

96450 $205.03 N 

96521 $118.17 N 


Page | 75




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

96522 $118.17 N 

96542 $70.55 N 

96549 $23.93 N 

96567 $175.81 N 

96570 $96.83 N 

96571 $96.83 N 

96900 $33.31 N 



96910 $33.31 N 

96912 $33.31 N 

96913 $168.32 N 

96920 $96.83 Y 

96921 $96.83 Y 

96922 $96.83 Y 

96999 $27.87 N 







99170 $8.29 Y 



99195 $38.53 N 

0016T $367.54 Y 

0017T $367.54 Y 

0042T Packaged N 

0071T $3,329.29 N 

0072T $3,329.29 N 

0073T $392.62 N 


0123T $1,533.18 Y 

0124T $283.20 Y 


0173T By Report N 


Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

































A4218 Packaged N 







Page | 76




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 



A4264 By Report N 




































Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 








































Page | 77




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 




















A9517 $16.51 N 




A9527 $35.35 N 



A9530 $11.02 N 










A9543 $30,110.81 N 


Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

A9545 $22,693.52 N 

















A9563 $196.49 N 

A9564 $113.44 N 













A9581 $13.50 N 

A9582 $2,284.77 N 

A9583 $12.89 N 

A9600 $778.98 N 

A9604 $5,504.70 N 




Page | 78




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

C1300 $99.77 N 

C1713 Packaged N 



C1716 $39.94 N 

C1717 $215.67 N 

C1719 $59.67 N 
































Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 








































Page | 79




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 
















C2616 $14,708.09 N 














C2634 $55.74 N 

C2635 $26.65 N 

C2636 $18.05 N 

C2638 $39.60 N 

C2639 $33.73 N 

C2640 $56.26 N 

C2641 $53.24 N 

C2642 $102.38 N 

C2643 $61.60 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

C2698 $39.60 N 

C2699 $26.65 N 

C8900 $395.21 N 

C8901 $325.80 N 

C8902 $499.07 N 

C8903 $395.21 N 

C8904 $325.80 N 

C8905 $499.07 N 

C8906 $395.21 N 

C8907 $325.80 N 

C8908 $499.07 N 

C8909 $395.21 N 

C8910 $325.80 N 

C8911 $499.07 N 

C8912 $395.21 N 

C8913 $325.80 N 

C8914 $499.07 N 

C8918 $395.21 N 

C8919 $325.80 N 

C8920 $499.07 N 

C8921 $606.96 N 

C8922 $606.96 N 

C8923 $606.96 N 

C8924 $606.96 N 

C8925 $606.96 N 

C8926 $606.96 N 

C8927 $606.96 N 

C8928 $606.96 N 

C8929 $606.96 N 

C8930 $606.96 N 

C8957 $205.03 N 


C9121 $17.87 N 

C9250 $135.36 N 

C9254 $0.18 N 

C9255 $6.71 N 

C9256 $196.10 N 

C9257 $1.41 N 


Page | 80




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 





C9356 $26.37 N 

C9358 $10.64 N 

C9359 $61.47 N 

C9360 $11.14 N 

C9361 $250.53 N 

C9362 $63.60 N 

C9363 $28.30 N 

C9364 $18.09 N 


C9716 $2,021.94 N 

C9724 $1,524.90 Y 

C9725 $337.08 N 

C9726 $1,555.14 N 

C9727 $478.74 N 

C9728 $864.39 N 


D0150 $648.57 N 

D0240 $648.57 N 

D0250 $648.57 N 

D0260 $648.57 N 

D0270 $648.57 N 

D0272 $648.57 N 

D0274 $648.57 N 

D0277 $648.57 N 

D0417 By Report N 


D0460 $648.57 N 

D1510 $648.57 N 

D1515 $648.57 N 

D1520 $648.57 N 

D1525 $648.57 N 

D1550 $648.57 N 

D2999 $648.57 N 


Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

D3460 $648.57 N 

D3999 $648.57 N 

D4260 $648.57 N 

D4263 $648.57 N 

D4264 $648.57 N 

D4268 $648.57 N 

D4270 $648.57 N 

D4271 $648.57 N 

D4273 $648.57 N 

D4355 $648.57 N 

D4381 $648.57 N 

D5911 $648.57 N 

D5912 $648.57 N 

D5983 $648.57 N 

D5984 $648.57 N 

D5985 $648.57 N 

D5987 $648.57 N 


D6920 $648.57 N 

D7111 $648.57 N 

D7140 $648.57 N 

D7210 $648.57 N 

D7220 $648.57 N 

D7230 $648.57 N 

D7240 $648.57 N 

D7241 $648.57 N 

D7250 $648.57 N 

D7260 $648.57 N 

D7261 $648.57 N 

D7291 $648.57 N 

D7940 $648.57 N 

D9110 Packaged N 



D9630 $648.57 N 

D9930 $648.57 N 

D9940 $648.57 N 

D9950 $648.57 N 


Page | 81




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

D9951 $648.57 N 

D9952 $648.57 N 

E0328 By Report N 




E0487 Packaged N 












G0008 $23.93 N 

G0009 $23.93 N 

G0102 Packaged N 

G0104 $233.90 N 

G0105 $508.37 Y 

G0106 $78.61 N 

G0117 $60.02 N 

G0118 $37.35 N 

G0120 $78.61 N 

G0121 $508.37 Y 

G0127 $27.87 Y 

G0130 $41.85 N 

G0166 $97.15 Y 

G0173 $3,329.29 N 


G0186 $367.54 Y 

G0237 $25.50 N 

G0238 $25.50 N 

G0239 $25.50 N 

G0251 $897.26 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

G0257 $428.57 N 


G0260 $452.39 Y 







G0290 $6,960.73 Y 

G0291 $6,960.73 Y 

G0293 $42.05 N 

G0294 $42.05 N 

G0302 $718.24 N 

G0303 $718.24 N 

G0304 $151.06 N 

G0305 $151.06 N 

G0339 $3,329.29 N 

G0340 $2,319.17 N 

G0364 $42.05 Y 

G0365 $144.54 N 


G0389 $90.69 N 

G0390 $777.31 N 

G0396 By Report N 


G0398 $151.06 N 

G0399 $151.06 N 

G0400 $151.06 N 











Page | 82




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 




















G3001 $1,618.96 N 


G9141 $23.93 N 


J0120 Packaged N 

J0128 By Report N 

J0129 $19.15 N 

J0130 $454.71 N 

J0132 $2.33 N 


J0135 $359.89 N 

J0150 $10.01 N 

J0152 $79.40 N 


J0180 $133.68 N 



J0205 $41.20 N 

J0207 $333.69 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

J0210 $32.60 N 

J0215 $30.14 N 

J0220 $124.69 N 

J0256 $3.67 N 





J0287 $9.47 N 

J0288 $13.74 N 

J0289 $15.51 N 





J0348 $1.22 N 




J0365 $2.60 N 







J0470 $26.88 N 

J0475 $199.42 N 

J0476 $73.00 N 

J0480 $1,696.29 N 








J0583 $2.41 N 


Page | 83




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

J0585 $5.40 N 

J0586 $7.93 N 

J0587 $10.38 N 


J0594 $14.18 N 


J0598 $41.40 N 

J0600 $78.86 N 



J0630 $48.34 N 


J0637 $11.54 N 


J0641 $1.36 N 














J0718 $3.72 N 



J0735 $110.46 N 

J0740 $746.87 N 






Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 


J0795 $4.22 N 

J0800 $2,394.31 N 

J0833 $64.19 N 

J0834 $89.48 N 

J0850 $862.24 N 

J0878 $0.42 N 

J0881 $2.78 N 

J0885 $9.36 N 

J0894 $28.68 N 



J0945 $9.24 N 















J1162 $467.59 N 




J1190 $367.10 N 


J1205 $304.91 N 

J1212 $68.40 N 





Page | 84




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 




J1267 $0.55 N 


J1300 $177.56 N 


J1324 $0.48 N 


J1327 $18.50 N 






J1410 $87.05 N 

J1430 $147.14 N 


J1436 $25.02 N 

J1438 $188.41 N 

J1440 $215.57 N 

J1441 $336.26 N 


J1451 $7.56 N 


J1453 $1.57 N 


J1458 $334.14 N 

J1459 $35.14 N 

J1460 $15.85 N 

J1470 $31.70 N 

J1480 $47.53 N 

J1490 $63.39 N 

J1500 $79.24 N 

J1510 $95.12 N 

J1520 $110.86 N 

J1530 $126.78 N 

J1540 $158.48 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

J1550 $158.48 N 

J1560 $158.48 N 

J1561 $36.91 N 

J1562 $7.04 N 

J1566 $29.90 N 

J1568 $37.00 N 

J1569 $37.81 N 


J1571 $50.22 N 

J1572 $36.42 N 

J1573 $50.22 N 



J1595 $81.34 N 


J1610 $82.64 N 

J1620 $32.12 N 




J1640 $7.98 N 





J1652 $6.04 N 


J1670 $207.82 N 

J1680 $0.24 N 




J1730 $112.16 N 

J1740 $138.94 N 

J1742 $395.62 N 

J1743 $446.44 N 

J1745 $57.56 N 

J1756 $0.37 N 


Page | 85




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

J1785 $4.12 N 




J1817 $3.37 N 

J1830 $175.51 N 






J1930 $26.62 N 

J1931 $25.08 N 


J1945 $226.90 N 

J1950 $483.41 N 

J1953 $0.46 N 







J2020 $30.94 N 








J2248 $1.11 N 






J2278 $6.38 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 




J2315 $2.10 N 

J2320 $7.00 N 

J2321 $7.00 N 

J2322 $14.73 N 

J2323 $8.08 N 

J2325 $37.25 N 

J2353 $106.19 N 


J2355 $241.17 N 

J2357 $18.86 N 






J2425 $11.11 N 

J2430 $19.98 N 



J2469 $17.18 N 


J2503 $1,014.11 N 

J2504 $242.67 N 

J2505 $2,320.08 N 


J2513 $158.77 N 






J2562 $268.72 N 





Page | 86




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 








J2724 $11.96 N 


J2730 $89.08 N 



J2770 $144.34 N 

J2778 $397.01 N 


J2783 $169.23 N 

J2785 $50.85 N 

J2788 $25.47 N 

J2790 $84.51 N 

J2791 $5.12 N 

J2792 $18.22 N 

J2793 $23.64 N 

J2794 $4.94 N 


J2796 $43.60 N 




J2820 $23.81 N 

J2850 $19.93 N 





J2940 $4.89 N 

J2941 $54.38 N 


J2993 $1,258.72 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

J2995 $78.00 N 

J2997 $36.23 N 



J3030 $42.72 N 


J3101 $41.84 N 







J3240 $1,043.80 N 

J3243 $1.15 N 

J3246 $7.74 N 





J3285 $54.83 N 

J3300 $3.16 N 




J3305 $146.89 N 


J3315 $153.42 N 



J3355 $57.43 N 



J3365 $449.09 N 


J3396 $9.31 N 




Page | 87




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 














J3487 $215.25 N 

J3488 $218.49 N 














J7185 $1.07 N 

J7186 $0.90 N 

J7187 $0.86 N 

J7189 $1.30 N 

J7190 $0.85 N 

J7191 $8.21 N 

J7192 $1.08 N 

J7193 $0.87 N 

J7194 $0.86 N 

J7195 $1.09 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

J7197 $2.28 N 

J7198 $1.52 N 


J7308 $127.08 N 

J7310 $16,640.00 N 

J7311 $18,980.00 N 

J7321 $90.54 N 

J7323 $111.88 N 

J7324 $172.73 N 

J7325 $11.52 N 


J7501 $93.84 N 

J7502 $3.12 N 

J7504 $456.47 N 

J7505 $1,111.55 N 


J7507 $3.57 N 



J7511 $401.93 N 

J7513 $381.18 N 

J7515 $0.81 N 

J7516 $23.37 N 

J7517 $2.55 N 


J7520 $9.47 N 

J7525 $137.01 N 



J7605 $5.75 N 

J7606 $5.20 N 





J8501 $5.42 N 


J8520 $6.11 N 


Page | 88




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

J8521 $20.04 N 



J8560 $29.69 N 




J8700 $8.63 N 

J8705 $73.00 N 


J9001 $462.49 N 

J9010 $555.50 N 

J9015 $830.93 N 

J9017 $36.83 N 

J9020 $59.27 N 

J9025 $4.79 N 

J9027 $113.36 N 

J9031 $108.55 N 

J9033 $18.51 N 

J9035 $56.37 N 


J9041 $37.52 N 


J9050 $173.53 N 

J9055 $48.79 N 



J9065 $23.52 N 

J9070 Bundled N 










Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

J9098 $480.16 N 



J9120 $556.34 N 



J9150 $16.65 N 

J9151 $55.33 N 

J9155 $2.87 N 

J9160 $1,467.55 N 

J9165 $3.83 N 

J9171 $17.29 N 


J9178 $2.60 N 


J9185 $158.63 N 


J9200 $42.85 N 

J9201 $142.20 N 

J9202 $200.02 N 

J9206 $6.81 N 

J9207 $63.74 N 

J9208 $29.51 N 

J9209 $4.55 N 

J9211 $100.89 N 

J9212 $4.71 N 

J9213 $10.60 N 

J9214 $15.54 N 

J9215 $17.89 N 

J9216 $294.03 N 

J9217 $202.62 N 

J9218 $4.68 N 

J9219 $4,728.88 N 

J9225 $1,462.69 N 

J9226 $14,841.08 N 

J9230 $151.24 N 

J9245 $1,520.24 N 



Page | 89




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 


J9261 $101.35 N 

J9263 $7.47 N 

J9264 $9.20 N 


J9266 $2,695.46 N 

J9268 $1,318.44 N 


J9280 $16.83 N 

J9290 $67.30 N 

J9291 $134.60 N 

J9293 $46.87 N 

J9300 $2,573.49 N 

J9303 $85.35 N 

J9305 $49.63 N 

J9310 $553.12 N 

J9320 $278.77 N 

J9328 $4.90 N 

J9330 $48.90 N 

J9340 $103.08 N 

J9350 $1,012.44 N 

J9355 $63.56 N 

J9357 $933.57 N 






J9395 $80.66 N 

J9600 $2,748.96 N 


L8600 Packaged N 







Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 



L8627 By Report N 















P9010 $192.25 N 

P9011 $81.46 N 

P9012 $43.42 N 

P9016 $174.06 N 

P9017 $70.86 N 

P9019 $62.09 N 

P9020 $127.51 N 

P9021 $132.11 N 

P9022 $229.30 N 

P9023 $47.68 N 

P9031 $97.64 N 

P9032 $140.24 N 

P9033 $123.00 N 

P9034 $437.26 N 

P9035 $477.34 N 

P9036 $333.66 N 

P9037 $630.64 N 

P9038 $210.47 N 

P9039 $339.21 N 

P9040 $228.39 N 

P9041 $16.89 N 


Page | 90




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

P9043 $61.28 N 

P9044 $88.18 N 

P9045 $60.58 N 

P9046 $25.67 N 

P9047 $62.05 N 

P9048 $100.63 N 

P9050 $41.87 N 

P9051 $126.14 N 

P9052 $686.67 N 

P9053 $612.14 N 

P9054 $96.59 N 

P9055 $390.77 N 

P9056 $153.95 N 

P9057 $338.39 N 

P9058 $273.96 N 

P9059 $72.20 N 

P9060 $67.00 N 

P9615 Packaged N 

Q0091 $8.29 N 

Q0092 Packaged N 

Q0138 $0.82 N 













Q0515 $1.77 N 

Q1003 $50.00 N 

Q2004 $5.11 N 


Q2017 $319.21 N 

Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 

Q3025 $187.31 N 



Q4101 $32.10 N 

Q4102 $4.30 N 

Q4103 $4.30 N 

Q4104 $14.65 N 

Q4105 $10.57 N 

Q4106 $39.37 N 

Q4107 $89.87 N 

Q4108 $18.78 N 


Q4110 $35.09 N 

Q4111 $7.64 N 

Q4112 $338.32 N 

Q4113 $338.32 N 

Q4114 $910.19 N 

Q4115 $9.36 N 

Q4116 $31.78 N 

















Q9968 $2.46 N 

V2630 Packaged N 



Page | 91




Procedure 

Code 

Allowed 

Amount 

Multiple 

Procedure 

Discounting 


V2785 By Report N 

V2787 By Report N 



Page | 92

Ambulatory Surgery Center Fee Schedule - Washington Department ...

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