|
| 1 | +cpt,description,allowed_amount |
| 2 | +99202,"Office/outpatient visit, new patient, 15-29 min",73.40 |
| 3 | +99203,"Office/outpatient visit, new patient, 30-44 min",113.00 |
| 4 | +99204,"Office/outpatient visit, new patient, 45-59 min",167.00 |
| 5 | +99205,"Office/outpatient visit, new patient, 60-74 min",220.00 |
| 6 | +99211,"Office/outpatient visit, est patient, minimal problems",23.00 |
| 7 | +99212,"Office/outpatient visit, est patient, 10-19 min",56.00 |
| 8 | +99213,"Office/outpatient visit, est patient, 20-29 min",92.05 |
| 9 | +99214,"Office/outpatient visit, est patient, 30-39 min",129.80 |
| 10 | +99215,"Office/outpatient visit, est patient, 40-54 min",183.00 |
| 11 | +G2211,"Visit complex inherent to E/M",16.05 |
| 12 | +36415,"Collection of venous blood by venipuncture",3.00 |
| 13 | +80053,"Comprehensive metabolic panel",11.20 |
| 14 | +85025,"Blood count; complete (CBC), automated",8.50 |
| 15 | +80061,"Lipid panel",10.50 |
| 16 | +84443,"Thyroid stimulating hormone (TSH)",18.00 |
| 17 | +93000,"Electrocardiogram, routine ECG with at least 12 leads",15.50 |
| 18 | +71046,"Radiologic examination, chest; 2 views",30.15 |
| 19 | +73030,"Radiologic examination, shoulder; complete, min 2 views",28.32 |
| 20 | +97110,"Therapeutic procedure, 1 or more areas, each 15 min; exercises",26.50 |
| 21 | +97140,"Manual therapy techniques (eg, mobilization/manipulation)",24.00 |
| 22 | +90834,"Psychotherapy, 45 minutes with patient",105.00 |
| 23 | +90837,"Psychotherapy, 60 minutes with patient",155.00 |
| 24 | +99283,"Emergency department visit, moderate severity",185.00 |
| 25 | +99284,"Emergency department visit, high severity",310.00 |
| 26 | +99285,"Emergency department visit, high severity, threat to function",480.00 |
| 27 | +10060,"Incision and drainage of abscess",120.00 |
| 28 | +17000,"Destruction of premalignant lesions (eg, actinic keratoses)",80.00 |
| 29 | +17110,"Destruction of benign lesions up to 14",110.00 |
| 30 | +20610,"Arthrocentesis, aspiration and/or injection, major joint",75.00 |
| 31 | +27447,"Arthroplasty, knee, condyle and plateau (Total Knee)",1400.00 |
| 32 | +27130,"Arthroplasty, acetabular and proximal femoral (Total Hip)",1350.00 |
| 33 | +45378,"Colonoscopy, flexible; diagnostic",240.00 |
| 34 | +43239,"EGD upper GI endoscopy, biopsy",280.00 |
| 35 | +66984,"Extracapsular cataract removal with insertion of IOL",600.00 |
| 36 | +K0001,"Standard wheelchair",45.00 |
| 37 | +E0570,"Nebulizer, with compressor",30.00 |
| 38 | +J7613,"Albuterol, inhalation solution, fda-approved final product",0.15 |
| 39 | +J1100,"Injection, dexamethasone sodium phosphate, 1 mg",0.10 |
| 40 | +J3301,"Injection, triamcinolone acetonide, not otherwise specified, 10 mg",2.50 |
| 41 | +90471,"Immunization administration",25.00 |
| 42 | +90677,"Pneumococcal conjugate vaccine, 20 valent",260.00 |
| 43 | +90715,"Tetanus, diphtheria toxoids and acellular pertussis vaccine",45.00 |
| 44 | +J0171,"Injection, Adrenalin, 0.1 mg",0.80 |
| 45 | +A0427,"Ambulance service, advanced life support, emergency transport",450.00 |
| 46 | +A0425,"Ground mileage, per statute mile",8.50 |
| 47 | +10061,"Incision and drainage of abscess; complicated or multiple",285.00 |
| 48 | +11042,"Debridement, subcutaneous tissue; first 20 sq cm",140.00 |
| 49 | +11730,"Avulsion of nail plate, partial or complete, simple; single",95.00 |
| 50 | +12001,"Simple repair of superficial wounds of scalp, neck, axillae, ext genitalia, trunk/extremities",130.00 |
| 51 | +17004,"Destruction of premalignant lesions, 15 or more lesions",170.00 |
| 52 | +17260,"Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery)",115.00 |
| 53 | +20550,"Injection(s); single tendon sheath, or ligament, aponeurosis",55.00 |
| 54 | +20605,"Arthrocentesis, aspiration and/or injection, intermediate joint or bursa",50.00 |
| 55 | +27445,"Arthroplasty, knee, hinge prothesis",1600.00 |
| 56 | +29881,"Arthroscopy, knee, surgical; with meniscectomy",600.00 |
| 57 | +31231,"Nasal endoscopy, diagnostic, unilateral or bilateral",190.00 |
| 58 | +43235,"Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum",350.00 |
| 59 | +45380,"Colonoscopy, flexible; with biopsy, single or multiple",480.00 |
| 60 | +45385,"Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s)",520.00 |
| 61 | +59400,"Routine obstetric care including antepartum care, vaginal delivery",2100.00 |
| 62 | +59510,"Routine obstetric care including antepartum care, cesarean delivery",2400.00 |
| 63 | +64483,"Injection(s), anesthetic agent and/or steroid, transforaminal epidural",310.00 |
| 64 | +66982,"Extracapsular cataract removal with insertion of intraocular lens prosthesis",750.00 |
| 65 | +67028,"Intravitreal injection of a pharmacologic agent",100.00 |
| 66 | +70450,"CT head or brain; without contrast material",140.00 |
| 67 | +70553,"MRI brain stem; without contrast material followed by contrast",320.00 |
| 68 | +71045,"Radiologic examination, chest; single view",25.00 |
| 69 | +72148,"MRI lumbar spine; without contrast material",290.00 |
| 70 | +73721,"MRI joint of lower extremity; without contrast material",280.00 |
| 71 | +74176,"CT abdomen and pelvis; without contrast material",310.00 |
| 72 | +76700,"Ultrasound, abdominal, real time with image documentation; complete",130.00 |
| 73 | +73502,"Radiologic examination, hip, unilateral; with pelvis",35.00 |
| 74 | +80048,"Basic metabolic panel (Calcium, total)",9.50 |
| 75 | +80305,"Drug test(s), presumptive, any number of drug classes, optical observation",12.00 |
| 76 | +81001,"Urinalysis, by dip stick or tablet reagent; automated",3.50 |
| 77 | +82306,"Vitamin D; 25 hydroxy, includes fraction(s), if performed",35.00 |
| 78 | +83036,"Hemoglobin; glycosylated (A1C)",11.00 |
| 79 | +84153,"Prostate specific antigen (PSA); total",22.00 |
| 80 | +84439,"Thyroxine; free",10.50 |
| 81 | +85018,"Blood count; hemoglobin",2.50 |
| 82 | +85610,"Prothrombin time",4.50 |
| 83 | +87086,"Culture, bacterial; quantitative colony count, urine",9.00 |
| 84 | +87804,"Infectious agent antigen detection by immunoassay with direct optical observation; Influenza",14.00 |
| 85 | +87880,"Infectious agent antigen detection by immunoassay with direct optical observation; Strep A",14.00 |
| 86 | +90791,"Psychiatric diagnostic evaluation",145.00 |
| 87 | +90853,"Group psychotherapy (other than of a multiple-family group)",30.00 |
| 88 | +92004,"Ophthalmological services: medical examination and evaluation",140.00 |
| 89 | +92014,"Ophthalmological services: medical examination and evaluation, est patient",110.00 |
| 90 | +93306,"Echocardiography, transthoracic, real-time with image documentation",210.00 |
| 91 | +94010,"Spirometry, including graphic record, total and timed vital capacity",35.00 |
| 92 | +94640,"Pressurized or nonpressurized inhalation treatment for acute airway obstruction",18.00 |
| 93 | +95810,"Polysomnography; age 6 years or older, sleep staging with 4 or more params",650.00 |
| 94 | +96360,"Intravenous infusion, hydration; initial, 31 minutes to 1 hour",45.00 |
| 95 | +96372,"Therapeutic, prophylactic, or diagnostic injection (specify substance or drug)",20.00 |
| 96 | +97112,"Therapeutic procedure, 1 or more areas, each 15 min; neuromuscular reeducation",28.00 |
| 97 | +97530,"Therapeutic activities, direct (one-on-one) patient contact",30.00 |
| 98 | +98941,"Chiropractic manipulative treatment (CMT); spinal, 3-4 regions",35.00 |
| 99 | +99281,"Emergency department visit, low severity",25.00 |
| 100 | +99282,"Emergency department visit, low to moderate severity",45.00 |
| 101 | +A0428,"Ambulance service, basic life support, non-emergency transport",220.00 |
| 102 | +G0402,"Initial preventive physical examination; face-to-face visit",130.00 |
| 103 | +G0438,"Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit",135.00 |
| 104 | +G0439,"Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit",95.00 |
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