reimbursement by procedure codes 30000 - 39999 … · reimbursement by procedure codes 30000 -...

Reimbursement by Procedure Codes 30000 - 39999

Effective Jan. 1, 2015

CPT Code Reimbursement

30000 $97.00

30020 $105.00

30100 $87.00

30110 $156.00

30115 $342.00

30117 $313.00

30118 $706.68

30120 $455.73

30124 $232.00

30125 $554.08

30130 $261.00

30140 $309.00

30150 $722.00

30160 $745.54

30200 $62.00

30210 $124.46

30220 $156.00

30300 $77.00

30310 $153.00

30320 $378.00

30400 $834.00

30410 $1,052.00

30420 $1,256.00

30430 $559.00

30435 $860.00

30450 $1,266.00

30460 $745.79

30462 $1,506.09

30465 $839.00

30520 $514.00

30540 $551.00

30545 $896.39

30560 $93.00

30580 $521.00

30600 $432.00

30620 $551.88

30630 $567.61

30801 $79.00

30802 $156.00

30901 $95.00

30903 $128.00

30905 $211.53

30906 $242.00

30915 $524.04

30920 $746.82

30930 $104.00

Confidential

These rates are provided for informational purposes only

and are not to be considered a guarantee of payment.

Actual payment will be based on Health Options policies,

procedures, and Customer Benefit Plans.




31000 $81.00

31002 $123.00

31020 $279.00

31030 $477.00

31032 $520.71

31040 $714.34

31050 $443.53

31051 $581.48

31070 $389.11

31075 $714.30

31080 $871.00

31081 $973.00

31084 $1,055.65

31085 $1,117.00

31086 $994.00

31087 $999.97

31090 $820.00

31200 $410.00

31201 $649.00

31205 $765.00

31225 $1,528.00

31230 $1,674.16

31231 $137.00

31233 $218.00

31235 $240.00

31237 $263.67

31238 $262.39

31239 $632.33

31240 $159.57

31254 $274.23

31255 $406.60

31256 $198.71

31267 $320.63

31276 $512.52

31287 $233.78

31288 $271.10

31290 $1,113.40

31291 $1,173.42

31292 $963.64

31293 $1,048.65

31294 $1,206.94

31295 $1,916.20

31296 $2,167.33

31297 $2,132.60

31300 $1,146.33

31320 $596.68

Confidential








31360 $1,531.00

31365 $2,090.00

31367 $1,560.00

31368 $2,196.84

31370 $1,727.00

31375 $1,589.00

31380 $1,651.47

31382 $1,703.88

31390 $2,324.00

31395 $2,404.54

31400 $934.40

31420 $771.32

31500 $106.29

31502 $33.96

31505 $50.00

31510 $196.14

31511 $197.84

31512 $182.83

31513 $129.93

31515 $160.00

31520 $150.91

31525 $214.00

31526 $156.26

31527 $188.27

31528 $139.80

31529 $160.04

31530 $195.42

31531 $212.76

31535 $187.91

31536 $210.84

31540 $242.16

31541 $265.42

31545 $352.29

31546 $542.03

31560 $312.00

31561 $340.90

31570 $342.90

31571 $249.75

31575 $111.31

31576 $178.00

31577 $232.44

31578 $265.09

31579 $201.00

31580 $1,120.25

31582 $1,793.69

31584 $1,400.00

Confidential








31587 $900.18

31588 $1,044.79

31590 $850.00

31595 $304.00

31600 $387.99

31601 $251.75

31603 $217.98

31605 $178.93

31610 $655.74

31611 $486.82

31612 $76.24

31613 $350.00

31614 $650.14

31615 $174.06

31620 $253.00

31622 $149.75

31623 $245.00

31624 $151.20

31625 $239.00

31626 $418.00

31627 $1,125.50

31628 $194.24

31629 $209.04

31630 $204.42

31631 $226.20

31632 $72.28

31633 $87.29

31634 $1,700.40

31635 $295.00

31636 $223.28

31637 $75.56

31638 $247.96

31640 $260.18

31641 $253.79

31643 $173.07

31645 $165.36

31646 $143.33

31647 $223.85

31648 $215.05

31649 $69.91

31651 $78.94

31660 $214.70

31661 $226.27

31717 $129.00

31720 $50.74

31725 $93.35

Confidential








31730 $204.00

31750 $1,124.00

31755 $1,525.00

31760 $1,308.55

31766 $1,746.15

31770 $1,286.31

31775 $1,373.57

31780 $1,133.37

31781 $1,370.33

31785 $1,033.19

31786 $1,458.03

31800 $630.00

31805 $791.25

31820 $387.50

31825 $546.84

31830 $392.60

32035 $655.00

32036 $716.80

32096 $805.98

32097 $805.98

32098 $757.67

32100 $828.24

32110 $1,319.00

32120 $817.60

32124 $869.19

32140 $930.71

32141 $1,087.00

32150 $935.86

32151 $931.56

32160 $701.77

32200 $1,042.91

32215 $763.90

32220 $1,499.00

32225 $937.10

32310 $870.63

32320 $1,513.97

32400 $139.00

32405 $95.13

32440 $1,540.84

32442 $1,664.00

32445 $1,649.93

32480 $1,452.59

32482 $1,545.56

32484 $1,396.83

32486 $1,606.00

32488 $1,782.00

Confidential








32491 $1,433.88

32501 $241.05

32503 $1,791.41

32504 $2,040.99

32505 $931.06

32506 $155.47

32507 $155.47

32540 $1,086.00

32550 $749.00

32551 $151.99

32552 $180.33

32553 $572.50

32554 $201.87

32555 $301.70

32556 $547.71

32557 $581.23

32560 $249.66

32561 $94.37

32562 $83.88

32601 $303.04

32604 $473.64

32606 $455.74

32607 $307.92

32608 $377.75

32609 $261.33

32650 $671.15

32651 $914.00

32652 $1,186.00

32653 $916.00

32654 $821.00

32655 $896.04

32656 $805.99

32658 $725.93

32659 $736.36

32661 $807.74

32662 $907.21

32663 $1,312.00

32664 $850.92

32665 $995.56

32666 $870.88

32667 $155.47

32668 $156.28

32669 $1,337.05

32670 $1,594.51

32671 $1,766.99

32672 $1,512.96

Confidential








32673 $1,198.79

32674 $213.27

32701 $214.82

32800 $886.12

32810 $862.92

32815 $1,608.00

32820 $1,321.16

32850 $3,000.00

32851 $2,601.47

32852 $2,930.90

32853 $3,109.26

32854 $3,361.78

32855 $376.89

32856 $471.11

32900 $1,288.00

32905 $1,290.84

32906 $1,597.87

32940 $1,186.15

32960 $124.00

32997 $329.50

32998 $2,750.00

33010 $114.60

33011 $116.48

33015 $457.00

33020 $831.97

33025 $772.72

33030 $1,227.88

33031 $1,363.82

33050 $933.24

33120 $1,505.18

33130 $1,314.22

33140 $1,299.83

33141 $135.08

33202 $750.00

33203 $769.51

33206 $448.62

33207 $494.78

33208 $489.93

33210 $172.85

33211 $178.46

33212 $335.93

33213 $350.96

33214 $482.18

33215 $307.45

33216 $379.15

33217 $375.00

Confidential








33218 $389.88

33220 $392.56

33221 $351.18

33222 $352.17

33223 $420.61

33224 $495.20

33225 $440.21

33226 $477.63

33227 $335.21

33228 $349.44

33229 $363.66

33230 $377.52

33231 $391.75

33233 $243.69

33234 $445.00

33235 $516.00

33236 $683.55

33237 $827.23

33238 $912.56

33240 $381.88

33241 $225.00

33243 $1,277.84

33244 $830.00

33249 $887.38

33250 $1,385.81

33251 $1,543.07

33254 $1,309.03

33255 $1,575.35

33256 $1,880.62

33257 $507.83

33258 $573.06

33259 $749.93

33261 $1,543.63

33262 $364.00

33263 $378.22

33264 $392.45

33265 $1,309.03

33266 $1,789.55

33282 $240.08

33284 $163.00

33300 $1,841.00

33305 $2,206.00

33310 $1,146.68

33315 $1,423.93

33320 $1,028.17

33321 $1,194.30

Confidential








33322 $1,328.49

33330 $1,353.60

33332 $1,318.89

33335 $1,799.21

33361 $1,313.56

33362 $1,437.09

33363 $1,487.94

33364 $1,584.30

33365 $1,729.80

33366 $1,950.50

33367 $606.47

33368 $734.90

33369 $970.28

33400 $2,164.39

33401 $1,446.38

33403 $1,510.00

33404 $1,761.62

33405 $2,277.66

33406 $2,725.00

33410 $1,938.00

33411 $3,070.20

33412 $2,473.00

33413 $3,079.80

33414 $2,063.90

33415 $1,894.40

33416 $1,931.31

33417 $1,654.04

33420 $1,310.18

33422 $1,668.32

33425 $2,405.45

33426 $2,307.36

33427 $2,460.45

33430 $2,604.49

33460 $2,062.59

33463 $2,513.00

33464 $2,221.31

33465 $2,438.30

33468 $1,811.70

33470 $1,163.73

33471 $1,257.22

33472 $1,321.66

33474 $1,722.00

33475 $2,219.62

33476 $1,448.59

33478 $1,558.26

33496 $1,642.14

Confidential








33500 $1,527.32

33501 $1,053.95

33502 $1,258.48

33503 $1,213.13

33504 $1,424.47

33505 $1,888.41

33506 $2,030.00

33507 $1,725.56

33508 $15.93

33510 $1,950.39

33511 $2,108.67

33512 $2,335.79

33513 $2,401.53

33514 $2,506.92

33516 $2,607.72

33517 $172.78

33518 $366.91

33519 $494.41

33521 $606.08

33522 $699.30

33523 $804.73

33530 $464.00

33533 $1,913.19

33534 $2,186.37

33535 $2,393.16

33536 $2,547.64

33542 $2,349.74

33545 $2,788.14

33548 $2,389.02

33572 $229.52

33600 $1,670.21

33602 $1,625.41

33606 $1,741.83

33608 $1,790.20

33610 $1,732.55

33611 $1,900.57

33612 $1,998.86

33615 $1,879.12

33617 $2,154.33

33619 $2,670.38

33620 $1,485.44

33621 $894.97

33622 $3,520.43

33641 $1,508.69

33645 $1,538.54

33647 $1,641.59

Confidential








33660 $1,745.93

33665 $1,789.00

33670 $1,916.54

33675 $2,017.54

33676 $2,123.00

33677 $2,207.00

33681 $1,788.00

33684 $1,859.00

33688 $1,738.00

33690 $1,140.00

33692 $1,726.99

33694 $1,909.17

33697 $2,072.40

33702 $1,532.41

33710 $1,708.78

33720 $1,526.90

33722 $1,530.48

33724 $1,491.52

33726 $1,964.99

33730 $1,947.10

33732 $1,646.76

33735 $1,174.95

33736 $1,383.34

33737 $1,268.16

33750 $1,205.73

33755 $1,212.80

33762 $1,241.67

33764 $1,259.38

33766 $1,351.25

33767 $1,425.12

33768 $414.26

33770 $2,064.20

33771 $2,049.41

33774 $1,792.57

33775 $1,830.68

33776 $1,947.18

33777 $1,901.88

33778 $2,312.76

33779 $2,108.50

33780 $2,300.96

33781 $2,141.17

33782 $3,217.36

33783 $3,477.31

33786 $2,224.43

33788 $1,514.62

33800 $932.95

Confidential








33802 $1,044.97

33803 $1,161.94

33813 $1,238.96

33814 $1,506.17

33820 $974.63

33822 $1,014.31

33824 $1,161.71

33840 $1,188.56

33845 $1,314.21

33851 $1,257.08

33852 $1,333.84

33853 $1,820.43

33860 $2,913.61

33863 $2,978.87

33864 $2,704.23

33870 $2,498.22

33875 $1,928.63

33877 $3,255.24

33880 $1,772.79

33881 $1,530.58

33883 $1,127.43

33884 $405.56

33886 $978.78

33889 $811.84

33891 $1,005.36

33910 $1,527.19

33915 $1,251.14

33916 $1,531.76

33917 $1,443.55

33920 $1,779.55

33922 $1,360.88

33924 $289.50

33925 $1,742.47

33926 $2,399.06

33930 $4,500.00

33933 $617.50

33935 $3,487.29

33940 $3,000.00

33944 $356.00

33945 $2,682.50

33960 $952.44

33961 $538.84

33967 $255.78

33968 $33.85

33970 $350.51

33971 $685.00

Confidential








33973 $511.97

33974 $876.73

33975 $1,071.59

33976 $1,196.04

33977 $1,154.69

33978 $1,328.48

33979 $1,997.53

33980 $1,826.73

33981 $857.61

33982 $2,004.41

33983 $2,362.14

33990 $427.37

33991 $622.72

33992 $202.83

33993 $178.11

34001 $857.00

34051 $949.03

34101 $618.71

34111 $619.15

34151 $1,375.00

34201 $683.00

34203 $938.00

34401 $1,096.00

34421 $735.00

34451 $1,497.95

34471 $642.18

34490 $620.65

34501 $935.00

34502 $1,542.14

34510 $1,103.37

34520 $1,031.60

34530 $996.57

34800 $1,159.04

34802 $1,257.70

34803 $1,294.33

34804 $1,256.32

34805 $1,195.57

34808 $212.15

34812 $348.48

34813 $244.78

34820 $503.33

34825 $708.97

34826 $207.55

34830 $1,837.90

34831 $1,924.94

34832 $1,976.47

Confidential








34833 $629.98

34834 $283.24

34900 $922.34

35001 $1,158.12

35002 $1,168.77

35005 $1,049.75

35011 $1,016.33

35013 $1,257.17

35021 $1,214.24

35022 $1,365.89

35045 $981.07

35081 $1,723.35

35082 $2,197.24

35091 $1,862.38

35092 $2,444.00

35102 $1,873.84

35103 $2,278.57

35111 $1,404.31

35112 $1,702.74

35121 $1,685.98

35122 $1,977.14

35131 $1,430.71

35132 $1,695.81

35141 $1,141.75

35142 $1,356.51

35151 $1,287.58

35152 $1,291.00

35180 $807.66

35182 $1,718.47

35184 $1,006.00

35188 $833.00

35189 $1,585.66

35190 $758.56

35201 $903.00

35206 $778.94

35207 $701.44

35211 $1,356.75

35216 $1,169.38

35221 $1,345.00

35226 $864.27

35231 $1,136.00

35236 $991.23

35241 $1,414.99

35246 $1,546.61

35251 $1,671.71

35256 $1,048.24

Confidential








35261 $1,025.00

35266 $871.47

35271 $1,348.46

35276 $1,420.56

35281 $1,598.10

35286 $962.14

35301 $1,073.71

35302 $1,108.72

35303 $1,217.92

35304 $1,267.09

35305 $1,217.92

35306 $455.63

35311 $1,488.42

35321 $916.06

35331 $1,492.03

35341 $1,423.14

35351 $1,312.25

35355 $1,068.29

35361 $1,587.79

35363 $1,721.93

35371 $850.90

35372 $1,019.76

35390 $164.40

35400 $153.95

35450 $522.38

35452 $353.27

35458 $497.75

35460 $318.56

35471 $537.70

35472 $366.76

35475 $349.79

35476 $279.09

35500 $327.96

35501 $1,373.00

35506 $1,230.20

35508 $1,191.46

35509 $1,319.00

35510 $1,278.39

35511 $1,200.87

35512 $1,253.40

35515 $1,182.10

35516 $953.00

35518 $1,192.29

35521 $1,280.18

35522 $1,220.36

35523 $1,108.30

Confidential








35525 $1,155.82

35526 $1,746.03

35531 $2,050.00

35533 $1,544.00

35535 $1,798.17

35536 $1,763.09

35537 $2,141.26

35538 $2,391.76

35539 $2,248.04

35540 $2,505.46

35556 $1,388.80

35558 $1,247.69

35560 $1,777.79

35563 $1,234.00

35565 $1,305.00

35566 $1,666.66

35570 $1,442.12

35571 $1,385.41

35572 $350.73

35583 $1,438.79

35585 $1,698.87

35587 $1,426.73

35600 $256.40

35601 $1,284.00

35606 $1,196.14

35612 $935.81

35616 $1,000.61

35621 $1,124.00

35623 $1,330.00

35626 $1,583.83

35631 $1,859.00

35632 $1,707.81

35633 $1,908.76

35634 $1,671.04

35636 $1,663.27

35637 $1,705.30

35638 $1,732.16

35642 $1,029.96

35645 $1,025.92

35646 $1,764.07

35647 $1,583.00

35650 $1,090.74

35654 $1,411.33

35656 $1,113.80

35661 $1,116.99

35663 $1,291.71

Confidential








35665 $1,213.44

35666 $1,309.30

35671 $1,152.50

35681 $82.20

35682 $367.86

35683 $426.09

35685 $207.20

35686 $166.73

35691 $986.24

35693 $871.81

35694 $1,029.57

35695 $1,069.02

35697 $153.53

35700 $158.36

35701 $510.00

35721 $463.15

35741 $507.63

35761 $376.26

35800 $480.50

35820 $787.00

35840 $612.00

35860 $407.94

35870 $1,298.34

35875 $606.40

35876 $968.64

35879 $939.00

35881 $1,057.00

35883 $1,235.50

35884 $1,294.09

35901 $490.78

35903 $587.56

35905 $1,751.96

35907 $1,964.02

36000 $25.00

36002 $165.67

36005 $30.02

36010 $124.20

36011 $160.95

36012 $209.00

36013 $177.64

36014 $179.00

36015 $208.00

36100 $212.00

36120 $131.00

36140 $105.05

36147 $749.50

Confidential








36148 $236.00

36160 $174.00

36200 $155.84

36215 $247.90

36216 $283.17

36217 $339.87

36218 $53.99

36221 $1,143.64

36222 $1,446.92

36223 $321.92

36224 $1,732.57

36225 $1,560.22

36226 $1,767.56

36227 $253.20

36228 $1,202.71

36245 $261.76

36246 $274.87

36247 $328.63

36248 $59.00

36251 $1,250.00

36252 $1,375.00

36253 $1,890.00

36254 $1,965.00

36260 $569.78

36261 $351.48

36262 $256.00

36400 $17.00

36405 $22.17

36406 $17.68

36410 $17.16

36415 $2.70

36416 $2.70

36420 $47.28

36425 $36.58

36430 $34.56

36440 $51.75

36450 $110.31

36455 $115.48

36460 $334.48

36468 $104.71

36469 $67.00

36470 $142.85

36471 $99.00

36475 $363.38

36476 $178.15

36478 $360.31

Confidential








36479 $177.46

36481 $354.22

36500 $160.00

36510 $64.00

36511 $89.16

36512 $89.93

36513 $91.77

36514 $96.00

36515 $96.00

36516 $96.00

36522 $104.04

36555 $260.93

36556 $123.94

36557 $332.00

36558 $286.14

36560 $373.01

36561 $363.92

36563 $385.21

36565 $1,006.09

36566 $1,311.00

36568 $100.78

36569 $94.32

36570 $1,215.77

36571 $329.98

36575 $164.00

36576 $373.44

36578 $530.50

36580 $69.02

36581 $202.54

36582 $1,133.63

36583 $415.00

36584 $208.92

36585 $1,186.14

36589 $168.32

36590 $261.50

36591 $15.70

36592 $17.27

36593 $30.00

36595 $596.27

36596 $137.59

36597 $129.10

36598 $30.45

36600 $21.11

36620 $50.33

36625 $101.61

36640 $118.51

Confidential








36660 $67.67

36680 $60.77

36800 $127.81

36810 $213.34

36815 $146.21

36818 $690.63

36819 $757.88

36820 $797.27

36821 $530.08

36822 $380.00

36823 $1,239.83

36825 $577.91

36830 $661.50

36831 $447.74

36832 $583.85

36833 $658.86

36835 $451.50

36838 $1,185.73

36860 $156.57

36861 $133.59

36870 $310.09

37140 $1,322.78

37145 $1,412.03

37160 $1,214.00

37180 $1,397.63

37181 $1,497.22

37182 $843.47

37183 $403.09

37184 $2,318.74

37185 $742.97

37186 $1,427.24

37187 $416.24

37188 $1,833.14

37191 $2,536.30

37192 $1,569.02

37193 $1,639.50

37195 $300.00

37197 $1,558.84

37200 $222.27

37202 $308.06

37211 $398.16

37212 $351.48

37213 $245.33

37214 $144.74

37215 $1,072.65

37216 $1,043.27

Confidential








37217 $1,142.40

37220 $2,995.20

37221 $520.39

37222 $865.80

37223 $219.75

37224 $471.83

37225 $636.18

37226 $525.75

37227 $7,000.00

37228 $575.08

37229 $6,115.50

37230 $7,115.50

37231 $8,283.00

37232 $1,151.80

37233 $1,411.80

37234 $3,654.30

37235 $3,907.80

37236 $2,866.00

37237 $1,188.00

37238 $4,108.00

37239 $1,975.00

37241 $457.79

37242 $511.13

37243 $609.37

37244 $710.83

37250 $109.23

37251 $81.96

37500 $700.15

37565 $640.50

37600 $507.00

37605 $578.00

37606 $464.90

37607 $374.85

37609 $254.00

37615 $424.00

37616 $1,039.84

37617 $1,227.00

37618 $364.68

37619 $1,613.85

37650 $472.00

37660 $1,149.00

37700 $251.62

37718 $399.34

37722 $471.69

37735 $626.46

37760 $615.11

Confidential








37761 $567.85

37765 $447.59

37766 $540.21

37780 $257.77

37785 $242.00

37788 $1,256.67

37790 $484.67

38100 $915.00

38101 $906.00

38102 $246.15

38115 $898.00

38120 $941.06

38200 $88.00

38205 $78.84

38206 $78.84

38220 $153.50

38221 $168.84

38230 $212.27

38232 $181.44

38240 $119.79

38241 $120.17

38242 $90.50

38243 $115.39

38300 $112.00

38305 $338.00

38308 $402.92

38380 $522.52

38381 $779.17

38382 $605.29

38500 $244.00

38505 $121.35

38510 $357.00

38520 $420.70

38525 $374.30

38530 $489.17

38542 $375.00

38550 $402.00

38555 $850.00

38562 $639.54

38564 $635.70

38570 $511.65

38571 $776.01

38572 $910.08

38700 $700.04

38720 $1,150.72

38724 $1,226.00

Confidential








38740 $474.00

38745 $714.46

38746 $219.19

38747 $250.33

38760 $646.76

38765 $1,172.75

38770 $762.48

38780 $983.83

38790 $50.09

38792 $37.41

38794 $273.08

38900 $133.89

39000 $464.73

39010 $788.60

39200 $865.08

39220 $1,102.75

39400 $464.00

39501 $782.48

39503 $3,202.00

39540 $794.96

39541 $855.02

39545 $852.32

39560 $736.21

39561 $1,123.61

Confidential





reimbursement by procedure codes 30000 - 39999 … · reimbursement by procedure codes 30000 -...

Documents