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charset="us-ascii"
 INDEX   Definitions   LadiesFirst   Vision   PAC 8   PAC 9 
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INDEX (To view a specific section, click the name of the section below.)
Definitions
Ladies First
Vision
<= span style=3D'font-size:13.5pt'>PAC 8 Codes
PAC 9 Codes
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Retu= rn to Index Tab
Code Key
Provider Type Codes<= /td> GOTO  &nbs= p; Provider Specialty Code Descriptions
Code Description
1 General Hospital
2 Freestanding Psych= iatric Hospital GOTO  &nb= sp; Pricing Action Code (P.A.C.) Descriptions
4 Dentist
5 Physician
6 Podiatrist GOTO  &nb= sp; Type of Service Code Descriptions
7 Optometrist
8 Optician
9 Pharmacy GOTO  &nb= sp; APC Status Code Descriptions
10 Home Health Agen= cy
11 Independent Radi= ology
12 Independent Lab<= /td>
13 Ambulance
14 DME Supplier
15 Prosthetics/Orth= otics
16 Clinic
17 Licensed Therapi= st
18 Chiropractor
19 Masters Level Psychologist/Counselor
20 Nursing Home = 211; Medicare Participating
21 Nursing Home - Non-Medicare Participating
22 Vermont State Nu= rsing Home
27 Hospice
28 ICF-MR State Fac= ility
29 ICF-MR Private F= acility
30 Psychologist
31 Rural Health Cli= nic
32 Outpatient Rehab=
34 State Mental Hea= lth Hospital
35 Audiologist
36 Other
37 MH Clinic
38 MR Clinic
39 MH Waiver
39 Baird
39 NFI
40 MH/DS Clinic = 211; VHAP
42 MR Waiver
39 NF Waiver
T01 Psychiatric Res= idential Treatment Center (IMD)
T02 Freestanding Di= alysis
T03 Ambulatory Surg= ical Center
T04 Personal Care Aide/Assistant
T05 Dental Lab
T06 Nurse Practitio= ner
T07 Licensed Nurse<= /td>
T08 School Nurse
T09 Public Health N= urse
T10 Indian Health S= ervice (100% federally funded, like rural health centers)
T11 Federally Quali= fied Health Center
T13 Nonprofit Trans= portation Agency
T14 Aged/Disabled W= aiver (Home Health Waiver)
T15 Waiver Case Man= ager-Aging and Adult Services
T16 Targeted Case M= anagement
T17 Case Manager/So= cial Worker
T18 Developmental D= isability Agency (VDH)
T19 Vocational Reha= b Agency
T20 SRS
T21 Children's Medi= cal Services
T22 Community-Suppo= rted Living Arrangement
T23 Non-Medical Res= idential Facility
T24 Rehab Nursing H= ome
T25 OADAP Facility<= /td>
T26 Adult Day Care<= /td>
T27 Department of E= ducation
T28 School District=
T29 School
T30 County Health D= epartment
T31 Sole Source Eye= glass Lab (Chadwick)
T32 Sole Source Oxy= gen
T33 HMO
T34 DDMHS Case Rate=
T35 Dental Clinic (= VA Hospital)
T36 Independently B= illing High Tech Nurses
T37 Physicians Assi= stant
T38 Certified Adole= scent ADAP Counselor
T39 Licensed Midwife (layperson)
T40 Ladies First Pr= ogram
0 All providers
999 Default Banner P= age
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Provider Specialty Codes
Code Description/Ph= ysician
1 General Practice<= /td>
2 General Surgery
3 Allergy/Immunolog= y
4 Otalaryngology
5 Anesthesiology
6 Cardiology
7 Dermatology
8 Family Practice
10 Gastroenterology=
11 Internal Medicin= e
12 Osteopathic Mani= pulative Therapy
13 Neurology
14 Neurosurgery
16 Obstetrics/Gynec= ology
17 PPNE Gynecology<= /td>
18 Ophthalmology
19 Oral Surgery (De= ntistonly)
20 Orthopedic Surge= ry
22 Pathology
24 Plastic And Reco= nstructive Surgery
25 Physical Medicin= e And Rehabilitation
26 Psychiatric
28 Colorectal Surge= ry (Formerly Proctology)
29 Pulmonary Diseas= e
30 Diagnostic Radio= logy
33 Thoracic Surgery=
34 Urology
35 Chiropractic
36 Nuclear Medicine=
37 Pediatric Medici= ne
38 Geriatric Medici= ne
39 Nephrology
40 Hand Surgery
41 Optometrist
42 Certified Nurse = Midwife
43 Certified Regist= ered Nurse Anesthetist, Anesthesia Assistant
44 Infectious Disea= se
46 Endocrinology
48 Podiatry
50 Nurse Practition= er
51 Medical Supply C= ompany with Certified Orthotist
52 Medical Supply C= ompany with Certified Prosthetist
53 Medical Supply C= ompany with Certified Orthotist-Prosthetist
54 Medical Supply C= ompany Not Included In 51, 52, Or 53
55 Individual Certi= fied Orthotist
56 Individual Certi= fied Prosthetic
57 Individual Certi= fied Orthotist/Prosthetic
58 Individual Not I= ncluded In 55, 56, Or 57
59 Ambulance Servic= e Center
60 Public Health Or= Welfare Agency
61 Voluntary Health= Or Charitable Agencies
62 Independently-Bi= lling Psychologist
63 Portable X-Ray S= upplier
64 Independently-Bi= lling Audiologist
65 Independently-Pr= acticing Physical Therapist
66 Rheumatology
67 Licensed Occupat= ional Therapist - PCP
68 Clinical Psychol= ogist
69 Independantly-Bi= lling Clinical Laboratory
76 Peripheral Vascu= lar Disease
77 Vascular Surgery=
78 Cardiac Surgery<= /td>
79 Addiction Medici= ne
80 LCSW/LCMHC
81 Critical Care (Intensiveness)
82 Ophthalmology
83 Hematology/Oncol= ogy
84 Preventive Medic= ine
85 Maxillofacial Su= rgery
86 Neuropsychiatry<= /td>
87 All Other Suppli= ers
89 Certified Clinic= al Nurse Specialist
90 Medical Oncology=
93 Emergency Medici= ne
94 Interventional R= adiology
98 Diabetic Counsel= ors
99 Unknown Supplier= /Provider
S01 Hospital with S= wing Bed
S02 Teaching Hospit= al
S03 Non Teaching Ho= spital Without Swing Beds
S04 Rehabilitation<= /td>
S05 Psychiatric Hos= pital
S06 General Dentist= ry
S07 Pharmacy
S08 Air Ambulance
S09 Medicare Partic= ipating
S11 Medicare Non-Participating
S12 Mental Health S= ervices
S13 Mental Retardati= on Services
S14 Cost Based Clin= ic
S15 Certified Family Practitioner
S16 Certified Pedia= tric Practitioner
S17 Other Certified= Nurse Practitioner
S18 Substance Abuse= Treatment Facility
S19 Private
S20 Non-Profit
S21 Aide or Attenda= nt
S22 RN
S23 LPN
S24 School Nurse
S25 Waiver (Any &am= p; all who have waiver programs =3D DDMHS, Home Health, etc.)
S26 Case Management=
S27 Other Medical C= are
S28 DME Supplier (H= igh Tech)
S29 Clinic Multidis= ciplinary Organization
S30 Speech Patholog= ist
S31 DDMHS Case Rate=
S32 Day Hospital Se= rvices
S34 Ladies First No= n-Facility
S35 Ladies First Fac= ility
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Pricing Action Codes
Level III Pricing F= ile (Screen RFPR)
Code Description
A  LOWER OF BILLED OR (RELATIVE VAL= UE UNITS (RVU) + BILLED UNITS)*COEFFICIENT ON FILE   
Type of Service Codes
Code Description
1 Medical Care
2 Surgery
3 Consultation
4 Diagnostic X-ray<= /td>
5 Diagnostic Lab
6 X-ray Therapy
7 Anesthesia
8 Assistant Surgeon=
9 Mental Health/Psychotherapy/Psychiatry
A DME Rental
B DME Purchase
C Ambulance
D Regular Drugs
E Unit Dose Drugs
H Supplies Purchase=
K Prosthetics
L Orthotics
M Physician's Assis= tant
N Nurse Midwife
Q Long Term Care
S Service Codes
U Default - Unassig= ned Procedure
X Crossover
Y ICD-9 Surgical Pr= ocedure
Z Dental
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APC Status Code
Code Description
T  SIGNIFICANT PROCEDURE, MULTIPLE REDUCTION APPLIES
A  FEE SCHEDULE OTHER THAN OPPS
B  NOT RECOG. BY OPPS WHEN SUBMITTE= D ON AN OUTPAT CLAIM
C  INPATIENT PROCEDURE, NOT PAID UN= DER OPPS.
D  DISCONTINUED CODES, NOT PAID UND= ER OPPS.
F  CORNEAL TISSUE ACQ, CERTAIN CRNA= SCVS, & HEPATITIS B VAC
G  PASS-THROUGH DRUGS AND BIOLOGICA= LS
H  PASS-THROUGH DEVICE CAT, OR RADIOPHARM. AGENTS
K  DRUGS, BIOLOGICALS, BRACHYTHERP,= BLOOD AND BLOOD PROD.
E  NOT COV BY MCARE,PER STATUTE RSN INC/EXC,OR AN ALT CDE EXIST
L  INFLUENZA VACCINE: PNEUMONOCOCCAL PNEUMONIA VACCINE
M  ITEMS OR SRV NOT BILLABLE TO FIS= CAL INTERMEDIARY
N  ITEMS AND SCVS PACKAGED INTO APC= RATES
P  PARTIAL HOSPITALIZATION
Q  PACKAGED SCVS SUBJECT TO SEP PAY= UNDER OPPS
S  SIGNIFICANT PROCEDURE, NOT DISCO= UNTED WHEN MULTIPLE
V  CLINIC OR EMERGENCY DEPT VISIT
Y  NON-IMPLANTABLE DURABLE MED EQUI= P
X  ANCILLARY SERVICES
CPT codes, descript= ions and other data only are copyright 2007 American Medical Association. All righ= ts
reserved.
CPT is a registered= trademark of the American Medical Association.
Applicable FARS\DFA= RS Restrictions Apply to Government Use.
Fee schedules, rela= tive value units, conversion factors and/or related components are not assigned by t= he
AMA, are not part o= f CPT, and the AMA is not recommending their use. The AMA does not directly or
indirectly practice= medicine or dispense medical services. The AMA assumes no liability for data
contained or not co= ntained herein.
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Return to Index Tab
Procedure Code Provider Type Provider Specialty P.A.C. Pricing Effective Date Pricing End Date Max Allowable PA Type of Service
00= 400 T40 S34 3 20090101 23821231 21.99 N ANESTHESIA
00= 400 T40 S35 3 20090101 23821231 21.99 N ANESTHESIA
10= 021 T40 S35 3 20090101 23821231 68.62 N SURGERY
10= 021 T40 S34 3 20090101 23821231 135.24 N SURGERY
10= 022 T40 S35 3 20090101 23821231 68.24 N SURGERY
10= 022 T40 S34 3 20090101 23821231 139.12 N SURGERY
19= 000 T40 S35 3 20090101 23821231 46.25 N SURGERY
19= 000 T40 S34 3 20090101 23821231 109.39 N SURGERY
19= 001 T40 S35 3 20090101 23821231 23.13 N SURGERY
19= 001 T40 S34 3 20090101 23821231 27.39 N SURGERY
19= 100 T40 S35 3 20090101 23821231 67.45 N SURGERY
19= 100 T40 S34 3 20090101 23821231 133.31 N SURGERY
19= 101 T40 S35 3 20090101 23821231 204.87 N SURGERY
19= 101 T40 S34 3 20090101 23821231 303.63 N SURGERY
19= 102 T40 S35 3 20090101 23821231 109.78 N SURGERY
19= 102 T40 S34 3 20090101 23821231 220.17 N SURGERY
19= 103 T40 S35 3 20090101 23821231 201.14 N SURGERY
19= 103 T40 S34 3 20090101 23821231 554.77 N SURGERY
19= 120 T40 S35 3 20090101 23821231 373.93 N SURGERY
19= 120 T40 S34 3 20090101 23821231 436.68 N SURGERY
19= 125 T40 S35 3 20090101 23821231 414.91 N SURGERY
19= 125 T40 S34 3 20090101 23821231 483.46 N SURGERY
19= 126 T40 S34 3 20090101 23821231 155.69 N SURGERY
19= 126 T40 S35 3 20090101 23821231 155.69 N SURGERY
19= 290 T40 S35 3 20090101 23821231 69.60 N SURGERY
19= 290 T40 S34 3 20090101 23821231 163.33 N SURGERY
19= 291 T40 S35 3 20090101 23821231 34.50 N SURGERY
19= 291 T40 S34 3 20090101 23821231 70.52 N SURGERY
19= 295 T40 S34 3 20090101 23821231 91.22 N SURGERY
19= 295 T40 S35 3 20090101 23821231 91.22 N SURGERY
36= 415 T40 S35 3 20050701 23821231 3.00 N DIAGNOSTIC LAB
36= 415 T40 S34 3 20060101 23821231 3.00 N DIAGNOSTIC LAB
57= 452 T40 S35 3 20090101 23821231 92.01 N SURGERY
57= 452 T40 S34 3 20090101 23821231 109.43 N SURGERY
57= 454 T40 S35 3 20090101 23821231 137.10 N SURGERY
57= 454 T40 S34 3 20090101 23821231 154.63 N SURGERY
57= 455 T40 S35 3 20090101 23821231 111.70 N SURGERY
57= 455 T40 S34 3 20090101 23821231 143.85 N SURGERY
57= 456 T40 S35 3 20090101 23821231 104.25 N SURGERY
57= 456 T40 S34 3 20090101 23821231 136.01 N SURGERY
57= 460 T40 S35 3 20090101 23821231 164.54 Y SURGERY
57= 460 T40 S34 3 20090101 23821231 298.94 Y SURGERY
57= 461 T40 S35 3 20090101 23821231 189.92 Y SURGERY
57= 461 T40 S34 3 20090101 23821231 355.17 Y SURGERY
57= 500 T40 S35 3 20090101 23821231 74.77 N SURGERY
57= 500 T40 S34 3 20090101 23821231 132.49 N SURGERY
57= 505 T40 S35 3 20090101 23821231 90.24 N SURGERY
57= 505 T40 S34 3 20090101 23821231 101.07 N SURGERY
57= 520 T40 S35 3 20090101 23821231 271.68 Y SURGERY
57= 520 T40 S34 3 20090101 23821231 306.53 Y SURGERY
57= 522 T40 S35 3 20090101 23821231 241.17 Y SURGERY
57= 522 T40 S34 3 20090101 23821231 262.48 Y SURGERY
58= 100 T40 S35 3 20090101 23821231 88.16 Y SURGERY
58= 100 T40 S34 3 20090101 23821231 110.24 Y SURGERY
58= 110 T40 S35 3 20090101 23821231 41.76 Y SURGERY
58= 110 T40 S34 3 20090101 23821231 49.12 Y SURGERY
71= 020 T40 S35 3 20090101 23821231 21.31 Y DIAGNOSTIC X-RAY
71= 020 T40 S34 3 20090101 23821231 33.26 Y DIAGNOSTIC X-RAY
76= 090 T40 S34 8 20070101 23821231 0.00 N DIAGNOSTIC X-RAY
76= 090 T40 S35 8 20070101 23821231 0.00 N DIAGNOSTIC X-RAY
76= 091 T40 S34 8 20070101 23821231 0.00 N DIAGNOSTIC X-RAY
76= 091 T40 S35 8 20070101 23821231 0.00 N DIAGNOSTIC X-RAY
76= 092 T40 S34 8 20070101 23821231 0.00 N DIAGNOSTIC X-RAY
76= 092 T40 S35 8 20070101 23821231 0.00 N DIAGNOSTIC X-RAY
76= 095 T40 S34 8 20070101 23821231 0.00 N DIAGNOSTIC X-RAY
76= 095 T40 S35 8 20070101 23821231 0.00 N DIAGNOSTIC X-RAY
76= 096 T40 S34 8 20070101 23821231 0.00 N DIAGNOSTIC X-RAY
76= 096 T40 S35 8 20070101 23821231 0.00 N DIAGNOSTIC X-RAY
76= 098 T40 S34 3 20090101 23821231 20.83 N DIAGNOSTIC X-RAY
76= 098 T40 S35 3 20090101 23821231 20.83 N DIAGNOSTIC X-RAY
76= 645 T40 S34 3 20090101 23821231 95.24 N DIAGNOSTIC X-RAY
76= 645 T40 S35 3 20090101 23821231 95.24 N DIAGNOSTIC X-RAY
76= 942 T40 S34 3 20090101 23821231 195.45 N DIAGNOSTIC X-RAY
76= 942 T40 S35 3 20090101 23821231 195.45 N DIAGNOSTIC X-RAY
76= 970 T40 S34 3 20090101 23821231 86.64 N DIAGNOSTIC X-RAY
76= 970 T40 S35 3 20090101 23821231 86.64 N DIAGNOSTIC X-RAY
77= 031 T40 S34 3 20090101 23821231 201.27 N DIAGNOSTIC X-RAY
77= 031 T40 S35 3 20090101 23821231 201.27 N DIAGNOSTIC X-RAY
77= 032 T40 S34 3 20090101 23821231 62.92 N DIAGNOSTIC X-RAY
77= 032 T40 S35 3 20090101 23821231 62.92 N DIAGNOSTIC X-RAY
77= 055 T40 S34 3 20090101 23821231 89.73 N DIAGNOSTIC X-RAY
77= 055 T40 S35 3 20090101 23821231 89.73 N DIAGNOSTIC X-RAY
77= 056 T40 S34 3 20090101 23821231 113.86 N DIAGNOSTIC X-RAY
77= 056 T40 S35 3 20090101 23821231 113.86 N DIAGNOSTIC X-RAY
77= 057 T40 S34 3 20090101 23821231 86.05 N DIAGNOSTIC X-RAY
77= 057 T40 S35 3 20090101 23821231 86.05 N DIAGNOSTIC X-RAY
80= 048 T40 S34 3 20090101 23821231 12.36 N DIAGNOSTIC LAB
80= 048 T40 S35 3 20090101 23821231 12.36 N DIAGNOSTIC LAB
80= 053 T40 S34 3 20090101 23821231 15.44 N DIAGNOSTIC LAB
80= 053 T40 S35 3 20090101 23821231 15.44 N DIAGNOSTIC LAB
80= 061 T40 S34 3 20090101 23821231 16.03 N DIAGNOSTIC LAB
80= 061 T40 S35 3 20090101 23821231 16.03 N DIAGNOSTIC LAB
82= 465 T40 S34 3 20090101 23821231 6.36 N DIAGNOSTIC LAB
82= 465 T40 S35 3 20090101 23821231 6.36 N DIAGNOSTIC LAB
82= 947 T40 S34 3 20090101 23821231 5.73 N DIAGNOSTIC LAB
82= 947 T40 S35 3 20090101 23821231 5.73 N DIAGNOSTIC LAB
82= 948 T40 S34 3 20090101 23821231 3.73 N DIAGNOSTIC LAB
82= 948 T40 S35 3 20090101 23821231 3.73 N DIAGNOSTIC LAB
82= 951 T40 S34 3 20090101 23821231 18.80 N DIAGNOSTIC LAB
82= 951 T40 S35 3 20090101 23821231 18.80 N DIAGNOSTIC LAB
83= 036 T40 S34 3 20090101 23821231 14.17 N DIAGNOSTIC LAB
83= 036 T40 S35 3 20090101 23821231 14.17 N DIAGNOSTIC LAB
83= 718 T40 S34 3 20090101 23821231 8.42 N DIAGNOSTIC LAB
83= 718 T40 S35 3 20090101 23821231 8.42 N DIAGNOSTIC LAB
83= 721 T40 S34 3 20060716 23821231 12.81 N DIAGNOSTIC LAB
83= 721 T40 S35 3 20060716 23821231 12.81 N DIAGNOSTIC LAB
87= 621 T40 S34 3 20090101 23821231 38.03 N DIAGNOSTIC LAB
87= 621 T40 S35 3 20090101 23821231 38.03 N DIAGNOSTIC LAB
88= 104 T40 S34 3 20090101 23821231 64.66 N DIAGNOSTIC LAB
88= 104 T40 S35 3 20090101 23821231 64.66 N DIAGNOSTIC LAB
88= 141 T40 S34 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 141 T40 S35 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 142 T40 S34 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 142 T40 S35 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 143 T40 S34 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 143 T40 S35 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 150 T40 S34 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 150 T40 S35 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 160 T40 S34 3 20090101 23821231 54.56 N DIAGNOSTIC LAB
88= 160 T40 S35 3 20090101 23821231 54.56 N DIAGNOSTIC LAB
88= 161 T40 S34 3 20090101 23821231 56.89 N DIAGNOSTIC LAB
88= 161 T40 S35 3 20090101 23821231 56.89 N DIAGNOSTIC LAB
88= 162 T40 S34 3 20090101 23821231 82.43 N DIAGNOSTIC LAB
88= 162 T40 S35 3 20090101 23821231 82.43 N DIAGNOSTIC LAB
88= 164 T40 S34 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 164 T40 S35 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 172 T40 S34 3 20090101 23821231 55.40 N DIAGNOSTIC LAB
88= 172 T40 S35 3 20090101 23821231 55.40 N DIAGNOSTIC LAB
88= 173 T40 S34 3 20090101 23821231 140.94 N DIAGNOSTIC LAB
88= 173 T40 S35 3 20090101 23821231 140.94 N DIAGNOSTIC LAB
88= 174 T40 S34 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 174 T40 S35 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 175 T40 S34 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 175 T40 S35 3 20090101 23821231 28.95 N DIAGNOSTIC LAB
88= 305 T40 S34 3 20090101 23821231 110.69 N DIAGNOSTIC LAB
88= 305 T40 S35 3 20090101 23821231 110.69 N DIAGNOSTIC LAB
88= 307 T40 S34 3 20090101 23821231 221.84 N DIAGNOSTIC LAB
88= 307 T40 S35 3 20090101 23821231 221.84 N DIAGNOSTIC LAB
88= 321 T40 S35 3 20090101 23821231 84.56 Y DIAGNOSTIC LAB
88= 321 T40 S34 3 20090101 23821231 93.85 Y DIAGNOSTIC LAB
88= 331 T40 S34 3 20090101 23821231 94.52 Y DIAGNOSTIC LAB
88= 331 T40 S35 3 20090101 23821231 94.52 Y DIAGNOSTIC LAB
88= 332 T40 S34 3 20090101 23821231 42.23 N DIAGNOSTIC LAB
88= 332 T40 S35 3 20090101 23821231 42.23 N DIAGNOSTIC LAB
90= 780 T40 S34 8 20060716 23821231 0.00 Y MEDICAL CARE
90= 780 T40 S35 8 20060716 23821231 0.00 Y MEDICAL CARE
93= 000 T40 S34 3 20090101 23821231 21.99 Y MEDICAL CARE
93= 000 T40 S35 3 20090101 23821231 21.99 Y MEDICAL CARE
99= 070 T40 S34 6 20060715 23821231 0.00 Y MEDICAL CARE
99= 070 T40 S35 6 20060715 23821231 0.00 Y MEDICAL CARE
99= 201 T40 S35 3 20090101 23821231 24.90 N MEDICAL CARE
99= 201 T40 S34 3 20090101 23821231 39.23 N MEDICAL CARE
99= 202 T40 S35 3 20090101 23821231 48.04 N MEDICAL CARE
99= 202 T40 S34 3 20090101 23821231 67.79 N MEDICAL CARE
99= 203 T40 S35 3 20090101 23821231 72.36 N MEDICAL CARE
99= 203 T40 S34 3 20090101 23821231 97.91 N MEDICAL CARE
99= 204 T40 S35 3 20090101 23821231 72.36 N MEDICAL CARE
99= 204 T40 S34 3 20090101 23821231 97.91 N MEDICAL CARE
99= 205 T40 S35 3 20090101 23821231 72.36 N MEDICAL CARE
99= 205 T40 S34 3 20090101 23821231 97.91 N MEDICAL CARE
99= 211 T40 S35 3 20090101 23821231 9.21 N MEDICAL CARE
99= 211 T40 S34 3 20090101 23821231 20.06 N MEDICAL CARE
99= 212 T40 S35 3 20090101 23821231 24.51 N MEDICAL CARE
99= 212 T40 S34 3 20090101 23821231 39.62 N MEDICAL CARE
99= 213 T40 S35 3 20090101 23821231 48.06 N MEDICAL CARE
99= 213 T40 S34 3 20090101 23821231 65.88 N MEDICAL CARE
99= 214 T40 S35 3 20090101 23821231 48.06 N MEDICAL CARE
99= 214 T40 S34 3 20090101 23821231 65.88 N MEDICAL CARE
99= 215 T40 S35 3 20090101 23821231 48.06 N MEDICAL CARE
99= 215 T40 S34 3 20090101 23821231 65.88 N MEDICAL CARE
99= 241 T40 S35 3 20090101 23821231 35.09 N CONSULTATION
99= 241 T40 S34 3 20090101 23821231 51.74 N CONSULTATION
99= 242 T40 S35 3 20090101 23821231 74.09 N CONSULTATION
99= 242 T40 S34 3 20090101 23821231 96.55 N CONSULTATION
99= 243 T40 S35 3 20090101 23821231 103.30 N CONSULTATION
99= 243 T40 S34 3 20090101 23821231 132.74 N CONSULTATION
99= 244 T40 S35 3 20090101 23821231 164.30 N CONSULTATION
99= 244 T40 S34 3 20090101 23821231 196.83 N CONSULTATION
99= 245 T40 S35 3 20090101 23821231 164.30 N CONSULTATION
99= 245 T40 S34 3 20090101 23821231 196.83 N CONSULTATION
99= 385 T40 S35 3 20090101 23821231 120.60 N MEDICAL CARE
99= 385 T40 S34 3 20090101 23821231 151.42 N MEDICAL CARE
99= 386 T40 S35 3 20090101 23821231 120.60 N MEDICAL CARE
99= 386 T40 S34 3 20090101 23821231 151.42 N MEDICAL CARE
99= 387 T40 S35 3 20090101 23821231 120.60 N MEDICAL CARE
99= 387 T40 S34 3 20090101 23821231 151.42 N MEDICAL CARE
99= 395 T40 S35 3 20090101 23821231 96.12 N MEDICAL CARE
99= 395 T40 S34 3 20090101 23821231 131.76 N MEDICAL CARE
99= 396 T40 S35 3 20090101 23821231 96.12 N MEDICAL CARE
99= 396 T40 S34 3 20090101 23821231 131.76 N MEDICAL CARE
99= 397 T40 S35 3 20090101 23821231 96.12 N MEDICAL CARE
99= 397 T40 S34 3 20090101 23821231 131.76 N MEDICAL CARE
G0= 202 T40 S34 3 20090101 23821231 86.05 N DIAGNOSTIC X-RAY
G0= 202 T40 S35 3 20090101 23821231 86.05 N DIAGNOSTIC X-RAY
G0= 204 T40 S34 3 20090101 23821231 113.86 N DIAGNOSTIC X-RAY
G0= 204 T40 S35 3 20090101 23821231 113.86 N DIAGNOSTIC X-RAY
G0= 206 T40 S34 3 20090101 23821231 89.73 N DIAGNOSTIC X-RAY
G02= 06 T40 S35 3 20090101 23821231 89.73 N DIAGNOSTIC X-RAY
<= /td>
CPT codes, descriptions and other data only are copyright 2007 American Medic= al Association.
 All rights reserved.
CPT is a registered trademark of the American Medical Association.
Applicable FARS\DFARS Restrictions Apply to Government Use.
Fee schedules, relative value units, conversion factors and/or related compon= ents are not assigned 
by the AMA, are not part of CPT, and the AMA is not recommending their use. = The AMA does not 
directly or indirectly practice medicine or dispense medical services. The AMA ass= umes no liability
 for data contained or not contain= ed herein.
------=_NextPart_01C9C741.3720FC00 Content-Location: file:///C:/0A85DE0C/AprLF_Vis_PAC8-9FeeSchedhtml_sheet004.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii"
Return to Index Tab
Procedure Code Provider Type Provider Specialty P.A.C. Pricing Effective Date Pricing End Date Max Allowable PA? Type of Service
92= 015 000 000 3 20040701 23821231 17.20 N H
92= 120 000 000 3 20021001 23821231 12.34 N H
92= 130 000 000 3 20021001 23821231 12.34 N H
92= 140 000 000 3 20021001 23821231 13.58 N H
92= 225 000 000 3 20050701 23821231 12.56 N H
92= 311 000 000 6 20080101 23821231 0.00 N H
92= 313 000 000 3 20050701 23821231 101.11 Y H
92= 341 000 000 3 20060101 23821231 32.50 N H
92= 342 000 000 3 20060101 23821231 32.50 N H
92= 352 000 000 3 20021001 23821231 4.23 N H
92= 353 000 000 3 20021001 23821231 6.76 N H
92= 370 000 000 3 20060101 23821231 30.00 N H
92= 371 000 000 3 20021001 23821231 6.04 N H
92= 499 000 000 6 19810101 23821231 0.00 Y H
V2= 020 000 000 4 19911201 23821231 0.00 N H
V2= 025 000 000 4 20040201 23821231 0.00 Y H
V2= 100 000 000 4 19911201 23821231 0.00 N H
V2= 101 000 000 4 19911201 23821231 0.00 N H
V2= 102 000 000 4 19911201 23821231 0.00 N H
V2= 103 000 000 4 19911201 23821231 0.00 N H
V2= 104 000 000 4 19911201 23821231 0.00 N H
V2= 105 000 000 4 19911201 23821231 0.00 N H
V2= 106 000 000 4 19911201 23821231 0.00 N H
V2= 107 000 000 4 19911201 23821231 0.00 N H
V2= 108 000 000 4 19911201 23821231 0.00 N H
V2= 109 000 000 4 19911201 23821231 0.00 N H
V2= 110 000 000 4 19911201 23821231 0.00 N H
V2= 111 000 000 4 19911201 23821231 0.00 N H
V2= 112 000 000 4 19911201 23821231 0.00 N H
V2= 113 000 000 4 19911201 23821231 0.00 N H
V2= 114 000 000 4 19911201 23821231 0.00 N H
V2= 115 000 000 4 19911201 23821231 0.00 N H
V2= 118 000 000 4 19911201 23821231 0.00 N H
V2= 121 000 000 4 20061101 23821231 0.00 N H
V2= 199 000 000 4 19911201 23821231 0.00 N H
V2= 200 000 000 4 19911201 23821231 0.00 N H
V2= 201 000 000 4 19911201 23821231 0.00 N H
V2= 202 000 000 4 19911201 23821231 0.00 N H
V2= 203 000 000 4 19911201 23821231 0.00 N H
V2= 204 000 000 4 19911201 23821231 0.00 N H
V2= 205 000 000 4 19911201 23821231 0.00 N H
V2= 206 000 000 4 19911201 23821231 0.00 N H
V2= 207 000 000 4 19911201 23821231 0.00 N H
V2= 208 000 000 4 19911201 23821231 0.00 N H
V2= 209 000 000 4 19911201 23821231 0.00 N H
V2= 210 000 000 4 19911201 23821231 0.00 N H
V2= 211 000 000 4 19911201 23821231 0.00 N H
V2= 212 000 000 4 19911201 23821231 0.00 N H
V2= 213 000 000 4 19911201 23821231 0.00 N H
V2= 214 000 000 4 19911201 23821231 0.00 N H
V2= 215 000 000 4 19911201 23821231 0.00 N H
V2= 218 000 000 4 19911201 23821231 0.00 N H
V2= 219 000 000 4 19911201 23821231 0.00 N H
V2= 220 000 000 4 19911201 23821231 0.00 N H
V2= 221 000 000 4 20061101 23821231 0.00 N H
V2= 299 000 000 4 19911201 23821231 0.00 N H
V2= 300 000 000 4 19911201 23821231 0.00 N H
V2= 301 000 000 4 19911201 23821231 0.00 N H
V2= 302 000 000 4 19911201 23821231 0.00 N H
V2= 303 000 000 4 19911201 23821231 0.00 N H
V2= 304 000 000 4 19911201 23821231 0.00 N H
V2= 305 000 000 4 19911201 23821231 0.00 N H
V2= 306 000 000 4 19911201 23821231 0.00 N H
V2= 307 000 000 4 19911201 23821231 0.00 N H
V2= 308 000 000 4 19911201 23821231 0.00 N H
V2= 309 000 000 4 19911201 23821231 0.00 N H
V2= 310 000 000 4 19911201 23821231 0.00 N H
V2= 311 000 000 4 19911201 23821231 0.00 N H
V2= 312 000 000 4 19911201 23821231 0.00 N H
V2= 313 000 000 4 19911201 23821231 0.00 N H
V2= 314 000 000 4 19911201 23821231 0.00 N H
V2= 315 000 000 4 19911201 23821231 0.00 N H
V2= 318 000 000 4 19911201 23821231 0.00 N H
V2= 319 000 000 4 19911201 23821231 0.00 N H
V2= 320 000 000 4 19911201 23821231 0.00 N H
V2= 399 000 000 4 19911201 23821231 0.00 N H
V2= 410 000 000 4 19911201 23821231 0.00 N H
V2= 430 000 000 4 19911201 23821231 0.00 N H
V2= 499 000 000 4 19911201 23821231 0.00 N H
V2= 500 000 000 3 19820101 23821231 30.00 Y H
V2= 510 000 000 3 19820101 23821231 30.00 Y H
V2= 511 000 000 3 20010514 23821231 162.50 Y H
V2= 513 000 000 3 19820101 23821231 30.00 Y H
V2= 520 000 000 3 19820101 23821231 30.00 Y H
V2= 521 000 000 3 19911101 23821231 50.00 Y H
V2= 523 000 000 3 19950901 23821231 81.00 Y H
V2= 599 000 000 6 19810101 23821231 0.00 Y H
V2= 615 000 000 6 20040201 23821231 0.00 N B
V2= 623 000 000 3 20011201 23821231 747.00 N K
V2= 624 000 000 3 20011201 23821231 48.00 N K
V2= 625 000 000 3 20011201 23821231 277.00 N K
V2= 626 000 000 3 20011201 23821231 150.00 N K
V2= 627 000 000 3 20011201 23821231 966.00 N K
V2= 628 000 000 3 20011201 23821231 240.00 N K
V2= 629 000 000 6 20040201 23821231 0.00 Y K
V2= 630 000 000 4 20040201 23821231 0.00 N H
V2= 631 000 000 I 20080101 23821231 0.00 N H
V2= 632 000 000 4 20040201 23821231 0.00 N H
V2= 700 000 000 3 20040201 23821231 36.82 N H
V2= 710 000 000 4 19911201 23821231 0.00 N H
V2= 715 000 000 4 19911201 23821231 0.00 N H
V2= 718 000 000 3 20040201 23821231 29.60 N H
V2= 730 000 000 4 19911201 23821231 0.00 N H
V2= 744 000 000 4 19911201 23821231 0.00 Y H
V2= 745 000 000 4 20061101 23821231 0.00 Y H
V2= 756 000 000 3 20060101 23821231 3.50 N H
V2= 760 000 000 4 19911201 23821231 0.00 N H
V2= 762 000 000 4 20061101 23821231 0.00 N H
V2= 780 000 000 4 19911201 23821231 0.00 N H
V2= 781 000 000 I 20030101 23821231 0.00 Y H
V2= 784 000 000 4 20040101 23821231 0.00 N H
V2= 790 000 000 I 20080101 23821231 0.00 N H
V2= 799 000 000 4 20050101 23821231 0.00 N B
V27= 99 000 000 4 20050101 23821231 0.00 Y B
<= /td>
<= /td>
CPT codes, descriptions and other data only are copyright 2007 American Medic= al Association. All rights
reserved.
CPT is a registered trademark of the American Medical Association.
Applicable FARS\DFARS Restrictions Apply to Government Use.
Fee schedules, relative value units, conversion factors and/or related compon= ents are not assigned by the
AMA, are not part of CPT, and the AMA is not recommending their use. The AMA d= oes not directly or
indirectly practice medicine or dispense medical services. The AMA assumes no liabil= ity for data
contained or not contained herein.
------=_NextPart_01C9C741.3720FC00 Content-Location: file:///C:/0A85DE0C/AprLF_Vis_PAC8-9FeeSchedhtml_sheet005.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" <
Return to Index Tab
Procedure Code Provider Type Provider Specialty PAC Pricing Effective Date Pricing End Date
000 000 000 8 20060101 23821231
002 000 000 8 20060101 23821231
0026T 000 000 8 20090101 23821231
0027T 000 000 8 20090101 23821231
0028T 000 000 8 20090101 23821231
0029T 000 000 8 20090101 23821231
003 000 000 8 20060101 23821231
0031T 000 000 8 20090101 23821231
0032T 000 000 8 20090101 23821231
0041T 000 000 8 20090101 23821231
0043T 000 000 8 20090101 23821231
0046T 000 000 8 20090101 23821231
0047T 000 000 8 20090101 23821231
0049T 000 000 8 20090101 23821231
0056T 000 000 8 20080101 23821231
0058T 000 000 8 20090101 23821231
0059T 000 000 8 20090101 23821231
006 000 000 8 20060101 23821231
0060T 000 000 8 20090101 23821231
009 000 000 8 20060101 23821231
0090T 000 000 8 20090101 23821231
010 000 000 8 20060101 23821231
011 000 000 8 20060101 23821231
012 000 000 8 20060101 23821231
015 000 000 8 20060101 23821231
01905 000 000 8 20080101 23821231
01964 000 000 8 20060101 23821231
01995 000 000 8 20070101 23821231
020 000 000 8 20060101 23821231
021 000 000 8 20060101 23821231
023 000 000 8 20060101 23821231
024 000 000 8 20060101 23821231
029 000 000 8 20060101 23821231
030 000 000 8 20060101 23821231
032 000 000 8 20060101 23821231
033 000 000 8 20060101 23821231
035 000 000 8 20060101 23821231
037 000 000 8 20060101 23821231
040 000 000 8 20060101 23821231
041 000 000 8 20060101 23821231
044 000 000 8 20060101 23821231
047 000 000 8 20060101 23821231
048 000 000 8 20060101 23821231
049 000 000 8 20060101 23821231
051 000 000 8 20060101 23821231
052 000 000 8 20060101 23821231
053 000 000 8 20060101 23821231
058 000 000 8 20060101 23821231
060 000 000 8 20060101 23821231
061 000 000 8 20060101 23821231
063 000 000 8 20060101 23821231
065 000 000 8 20060101 23821231
068 000 000 8 20060101 23821231
069 000 000 8 20060101 23821231
070 000 000 8 20060101 23821231
071 000 000 8 20060101 23821231
072 000 000 8 20060101 23821231
074 000 000 8 20060101 23821231
075 000 000 8 20060101 23821231
076 000 000 8 20060101 23821231
077 000 000 8 20060101 23821231
078 000 000 8 20060101 23821231
079 000 000 8 20060101 23821231
080 000 000 8 20060101 23821231
081 000 000 8 20060101 23821231
082 000 000 8 20060101 23821231
083 000 000 8 20060101 23821231
084 000 000 8 20060101 23821231
085 000 000 8 20060101 23821231
086 000 000 8 20060101 23821231
087 000 000 8 20060101 23821231
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