6 ADMINISTRATIVE RULES

 

 

 

DE PARTMEN T OF CONSU MER AND INDUS TRY SER VIC ES BURE AU OF WORKERS ' DISABILITY COM PENS ATIO N WORKER'S COM PENS ATIO N HEALT H CARE SER VIC ES

Filed with th e Secretar y of Stat e on May 1, 2001 .

These ru les tak e effect 7 days after fili ng with th e Secretar y of Stat e

 

(By auth ority conferr ed on th e bur eau of worker's disability com pensat ion by sections 205 an d 315 of 1969 PA 317 , section 33 of 1969 PA 306 , Execut ive Reorgan izat ion Order No. 1982 -2, Execut ive Reorgan izat ion Order No. 1986 -3, an d Execut ive Reorgan izat ion Order No. 1990 -1, MCL 418 .205 , 418 .315 , 24.233 , 18.24, 418 .1, an d 418 .2)

 

R 418 .10107 , R 418 .10108 , R 418 .10207 , R 418 .10404 , an d R 418 .101501  of th e Michigan

Administrat ive Code, ar e am ended as follows:

 

PART 1.  GENER AL PROVISIONS

 

R 418 .10107   Sou rce  documents  .

Rule 107 . The followi ng docum ent s ar e  adopted by reference in th ese ru les an d ar e available  for  inspection  at ,  or   purcha se   from,   th e   bur eau   of   workers'   disability com pensat ion, health car e services division, P.O. Box 30016 , Lan sing, Michigan 48909 , at th e cos ts listed or from th e organizations listed:

(a)  "Curr ent Pr oced ura l Term inology, CPT 2001 ," stan dar d edi tion, revised 2000 , copyrig ht October 2000 , publis hed by th e American Medical

Associat ion, 515 N  Stat e Str eet, Chicago, IL 60610 , order # OP054101B EW, 1-800-621- 8335 . The publicat ion ma y be purcha sed at a cos t of $49 .95, plus $6.95 for shipping an d han dling, at th e time of adoption of th ese ru les. Perm ission to use th is publicat ion is on file in th e bur eau .

(b)  "Medicar e's Nat iona l Level II Codes, HCPCS, 2001 ," Mille nn ium Edition, copyrig ht November 2000 , publis hed by th e American Medical Associat ion,  P.O. Box  7046 , 515  N Stat e Str eet, Chicago, IL 60610 , order # OP096101B EW customer service 1-800-621-8335 . The publicat ion ma y be purcha sed at a cos t of $49 .95, plus $6.95 for shipping an d han dling, at th e time of adoption of th ese rules.

(c)  "RBRVS, Fee Sched ule: A Plain En glish Guide," 1999 edi tion, publis hed by Un ited Commun icat ions Group, 11300 Rockville Pike, Suite 1100 , Rockville, MD 20852 -3030 . Customer service 1-301-287-2700 . The han dbook ma y be purcha sed at  a cos t of $49 .95, at th e time of adoption of th ese rules.

 

(d)  “Medi car e RBRVS 2001 : The Ph ysician s’ Guide,” published by The American Medi cal Ass ociat ion, 515 North Stat e Str eet, Chicago Il, 60610 , order #OP 059601B EW,  1-800 -621 - 8335 .  The  publicat ion  ma y  be  pur cha sed  at  a  cost  of  $71 .95,plus  $8.95  shipping  an d han dling, as of th e t ime of adoption of th ese ru les.

(e)   "Int ernat iona l Classificat ion of Dise ases ," ninth revision,  copyr ight  2000 ,  American Medi cal  Ass ociat ion,  P.O.  Box  7046 ,  515  N   Stat e   Str eet,   Chicago,   IL   60610 , order #OP 068101B EW, 1-800 -621 -8335.  The  publicat ion  ma y  be  pur cha sed  at  a  cost  of

$59 .95, plus $8.95 shipping an d han dling, at th e t ime of adoption of th ese ru les.

(f)  "2001 Dru g Topics Red Book ," published by  Medi cal  E con omics  Compan y  Inc.,  Five Para gon  Drive,  Mont vale,  NJ   07645 -1742 ,  1-800 -678 -5689 .   The  publicat ion  ma y  be pur cha sed at a cost of $64 .95, plus $7.95 for shipping an d han dling, at th e t ime of adoption of th ese ru les.

(g)   "Michigan Un iform Billing Manua l," developed in cooperat ion with th e American Hospita l Ass ociat ion's Nat iona l Un iform Billing Comm itt ee, published by Michigan Health an d Hospita l Ass ociat ion, 6215 West St.J osep h Highway, Lan sing, MI  48917 , 517 -886 - 8366 . As of th e t ime of adoption of th ese ru les, th e cost of th e publicat ion is $135 .00, plus 6% sales ta x.

 

R 418 .10108   De finitio ns ; A to I.

Rule 108 . As used in th ese ru les:

(a)   “Act” mean s 1969 PA No. 317 , MCL 418 .101 et seq.

(b)     “Adju st” mean s that a carr ier or a carr ier’s agent reduces a health car e provider’s request for payment to th e ma ximum fee allowed by th ese ru les, to a provider’s usua l an d customar y char ge, or, when th e ma ximum fee is by report , to a reasona ble am ount . Adjust also  mean s  when   a   carr ier   re-codes   a   pr oced ur e,  or   reduces   payment   as   a   result   of pr ofessi ona l review.

(c)   “App ropriat e car e” mean s health car e that is suita ble for a part icular person, con dition, occa sion, or  place.

(d)     “BR” or “by report ” mean s that th e pr oced ur e is  not  assigned  a  relat ive  value  un it , (RVU) or a ma ximum  fee an d requires a writt en des cription.

(e)    “Bur eau ” mean s th e bur eau of work ers’ disability com pensat ion in  th e dep artm ent  of con sum er  an d industr y services.

(f)    “Carr ier” mean s an organ izat ion which tran sacts th e business of work ers’ disability compensat ion insuran ce in Michigan  an d which ma y be an y of th e following:

(i)   A privat e insur er.

(ii)   A self-in sur er.

(iii)    One of th e fun ds of cha pter 5 of th e act.

(g)    “Case” mean s a cover ed injur y or illness which occur s on a specific dat e an d which is ident ified by th e work er’s nam e an d dat e of injur y or illness .

(h)    “Case recor d” mean s th e com plete health car e recor d which is ma inta ined by a carr ier an d which perta ins to a cover ed injur y or illness  that  occur s on a specific dat e.

(i)   “Complete pr oced ur e” mean s a pr oced ur e that conta ins a series of steps that ar e not to be billed  sep arat ely.

(j)   “Covered injur y or illness ” mean s an injur y or  illness  for which  tr eatm ent  is man dat ed by section 315 of th e act.

 

(k)      “Curr ent pr oced ura l  term inology” (CPT) mean s a list ing of descriptive term s an d ident ifying codes an d provides a un iform nat iona lly a ccep ted nomenclatur e for report ing medical services an d pr oced ur es. “Curr ent pr oced ura l term inology” provides instru ct ions for codin g an d claims pr ocessi ng.

(l)   “Disp ut e” mean s a disagreement between a carr ier or a carr ier’s agent an d a health car e provider on th e applicat ion of th ese ru les.

(m)    “Dura ble medical equipment ” mean s specialized equipment which is des igned to stan d repe at ed use, which is used to serve a medical pur pose, an d which  is appropriat e for  home use.

(n)      “Em ergency con dition” mean s that a delay in tr eat ing a pat ient would lead to  a significant  increase in th e thr eat to th e pat ient ’s life or to a body part .

(o)   “Esta blished pat ient ” mean s a pat ient whose  medical an d administrat ive recor ds  for  a part icular  cover ed injur y or illness  ar e available to th e provider.

(p)   “Expendable medical supply” mean s a disposable art icle that is needed in quant ity on a daily or  month ly basis.

(q)     “Fa cility” mean s an ent ity licensed  by  th e  stat e  in  a ccor d  with  1978  PA 368 ,  MCL 333 .1101  et seq. The office of an  individua l pra ct it ioner is not con sidered a facility.

(r)    “F ocu sed review” mean s th e evaluat ion of a spe cific health car e service or  provider  to esta blish patt ern s of use an d dollar  expe nditur es.

(s)   “Follow-up days” mean s th e days of car e followin g a sur gical pr oced ur e that ar e included in  th e  pr oced ur e’s  ma ximum  allowable   payment ,   but   does   not   include   car e   for com plicat ions. If th e sur gical pr oced ur e lists “xxx” for th e follow-u p days, th en th e global concept does not apply. If “yyy” is listed for follow-u p days, th en th e carr ier sha ll set th e global period. If “zzz” is used , th en th e pr oced ur e code is part of an oth er service an d fa lls with in th e global period of th e oth er service.

(t)    ) “Health car e organ izat ion” mean s a group of pra ct it ioners or individua ls joined togeth er to provide health  car e services an d includes  an y of th e followin g:

(i)   A health ma int enan ce organ izat ion.

(ii)   An industr ia l or oth er clinic.

(iii)    An occupat iona l health car e cent er.

(iv)   A home health agency.

(v)   A visiting nur se associat ion.

(vi)   A laborat ory.

(vii)    A medical supply compan y.

(viii)    A commun ity menta l health boar d.

(u)   “Health car e review ” mean s th e review of a health car e case or bill, or both , by a carr ier, an d includes  techn ical health  car e review  an d pr ofessi ona l health  car e review .

(v)   “Incidenta l sur gery” mean s a sur gery which is per form ed thr ough th e sam e incision, on th e sam e day, by th e sam e doct or of denta l sur gery, doct or of medicine, doct or of osteopath y, or doct or of podiatr y an d which is not relat ed to diagnosis.

(w)    “Indepe ndent medical exam inat ion” mean s an exam inat ion an d evaluat ion which is requested by a carr ier or  an  employee  an d  which  is  con ducted  by  a  differ ent  pra ct it ioner than  th e pra ct it ioner who provides car e.

(x)   “Indepe ndent pr oced ur e” mean s a pr oced ur e that  ma y be carr ied out  by itself, separat e an d apart  from th e tota l service that  usua lly a ccom pan ies it .

 

(y)   “Insur ed employer” mean s an employer who pur cha ses work ers’ com pensat ion insuran ce from an  insuran ce com pan y that  is licensed to write insuran ce in th e stat e of Michigan .

 

P ART 2.  MED ICINE

 

R 418 .10207   Men tal hea lt h se rvices .

Rule 207 . (1) A psychiatr ist , only, sha ll use pr oced ur e codes 90805 ,

90807 ,  90809 ,  90811 ,  90813 ,  90815 ,  90817 ,  90819 ,  90822 ,  90824 ,  90827 ,  an d  90829  to

des cribe tr eatm ent of a menta l health con dition, an d sha ll not be billed in con jun ct ion with , 99201 -99499 , an evaluat ion an d mana gement service.

(2)     A psychiatr ist sha ll use pr oced ur e codes 90801 an d 90802 to des cribe a psychiatr ic diagnostic int erview. A psychiatr ic con sultat ion ma y  be report ed with pr oced ur e codes 99214 -99263 an d sha ll be limited to evaluat ion an d does not include psychiatr ic tr eatm ent .

(3)   An individua l per form ing psychological testing sha ll report th e services using pr oced ur e codes 96100 -96117 .

(4)    Menta l health providers sha ll use th e followin g modifiers to describe th e pra ct it ioner providing th e health services:

(a)   -AH , for services provided by a licensed psychologist.

(b)   -AL, for services provided by a limited licensed psychologist.

(c)  -AJ , for services provided by a cert ified socia l work er.

(d)   -LC, for services provided by a licensed pr ofessi ona l coun selor.

(e)   -CS, for services provided by a limited licensed coun selor.

(f)   -MF, for services provided by a licensed marr iage an d fam ily th era pist.

(g)   -ML, for services provided by a limited licensed marr iage an d fam ily th era pist.

 

P ART 4.  SUR GER Y

 

R 418 .10404   Fo llow -up ca re occu rri ng du ri ng globa l se rvice .

Rule 404 . (1) Follow-up car e for a diagnostic pr oced ur e sha ll refer only to th e days required to recover from th e diagnostic pr oced ur e an d not th e tr eatm ent of th e un derlying condition.

(2)     Follow-up car e for th era peut ic sur gical pr oced ur es includes  only  that  car e  which  is usua lly part of th e  sur gical  service.  Complicat ions,  exacerbat ions,  recurr ence,  or  th e prese nce of oth er com pensable diseases or injur ies requiring additiona l services should be report ed with  th e  ident ificat ion  of  appropriat e  pr oced ur es.  The  follow-u p  days  for  th e sur gical pr oced ur es ar e adopted from th e “Medi car e RBRVS 2001 : The Ph ysician s Guide” as referenced in R 418 .10107 (d). The follow-u p days  for  each  sur gical  pr oced ur e  ar e ident ified in  th e "global" column  in  th e manua l published  by th e bur eau  sep arat e from th ese ru les.

(a)     If a carr ier requests th e sur geon to see an injur ed work er dur ing th e global service period for th e pur pose of job restr ict ions, job adjustm ent s, or return to work , th en th e visit sha ll not be con sidered part of th e global sur gery packa ge.  If th e carr ier requests th e visit, th en th e carr ier sha ll prior auth orize th e visit assigning an auth orizat ion num ber. The provider sha ll bill th e visit using  pr oced ur e  99455  an d  modifier  –32 ,  including  th e auth orizat ion num ber in box 23 of th e HCFA 1500 form .  The carr ier sha ll not deny a prior

 

auth orized visit  an d  sha ll  reimbur se  th e  provider  for  th e  prior  auth orized  visit.  The ma ximum a llowable payment for 99455 -32 sha ll be listed in ta ble 1501 -a of th ese ru les.

(b)   The medical recor d sha ll reflect job adjustm ent s, job restr ict ions or limitat ions, or return to work dat e an d th e provider sha ll include th e medical recor d with th e bill.

(c)   If an insur ed employer requests th e sur geon to see an injur ed work er dur ing th e global sur gery period for th e pur pose of job adjustm ent s, restr ict ions, or return to work , th en th e employer sha ll obta in th e prior auth orizat ion num ber from th e carr ier for th e visit.

(3)   Hospita l follow-u p car e or a hospita l visit by th e pra ct it ioner resp onsible for th e sur gery sha ll be con sidered part of th e sur gical follow-u p days listed for th e pr oced ur e an d sha ll not be paid as an indepe ndent pr oced ur e.

 

P ART 15 . P ROCEDURE  CODES  AND RE IMBURSE MEN T TABLES

 

R 418 .101501      Tab les for hea lt h ca re se rvices  and  procedu res .

Rule 1501 . (1) Pr oced ur es that do not ha ve relat ive values assigned ar e referenced in th is ru le. The following ta bles ha ve assigned fees  developed  by  th e  bur eau  thr ough  ru le promu lgat ion an d sha ll be published as part of th ese ru les.

(a)      Miscellan eous medical an d sur gical pr oced ur es with out assigned relat ive values or specific payment meth odologies ar e listed in ta ble

1501 -A.

(b)   Laborat ory an d path ology pr oced ur e codes an d ma ximum a llowable payment s ar e listed in ta ble 1501 -B.

(c)   The orth otic an d prosth etic codes an d ma ximum allowable payment s listed  sha ll  be listed in ta ble 1501 -C.

(2)     The bur eau sha ll publish sep arat e from th ese ru les a manua l conta ining all of th e following:

(a)      Pr oced ur e codes an d relat ive value un it s for th e medical, sur gical, an d ra diology services.

(b)   Ancillar y services ident ified by codes from Medi car e's level II codes .

(c)  Maximum payment rat ios for hospita ls.

(d)   A copy of th e billing form s an d instru ct ions for com pletion.

 

Tab le 1501 -A
01999 -PA	Pat ient Contr olled Ana lgesia (See R 418 .10915 )	$137 .00
90471	Administrat ion of a single or combinat ion vaccine	$7.50
90472	Administrat ion of two or more vaccines or toxoid	$5.00
99000	Han dling or conveyan ce of spe cimen	$5.00
99025	Initial  new  pat ient  exam inat ion  perform ed  with  a  starr ed  sur gical procedur e	$55 .00
99050	Aft er hour office service Monday-Fr iday (R 418 .10202 )	$5.00
99052	Services between 10:00 PM an d 8:00AM	$5.00
99054	Wee kend, holiday after hour office service	$12 .00
99199	Carr ier arran ged missed appointm ent . (See R 418 .10111 )	BR
99199 -32	Carr ier or requested report , per page (See R 418 .10114 )	$25 .00
WC700	Pr escription Dru g dispe nse fee (R 418 .10912 (4)	$4.00
99455 -32	Carr ier requested visit for job evaluat ion (R 418 .10404 )	$70 .00

 

 

Tab le 1501 -A
RN001 -32	Reha bilitat ion or case mana ger visit (See R 418 .10121 )	$25 .00

 

 

Tab le  1501 -B P atho logy  and  Labo rato ry Se rvices NOTE:  Laborat ory  an d  path ology  procedur es  with   assigned    RVU’s   will   be   listed   in   th e  health   car e services  manua l  an d  sha ll  be  reimbur sed  as  a  medical  procedur e
Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP
80054		0	BR	80055		0	BR	80058		0	BR
80059		0	BR	80061		0	BR	80072		0	BR
80090		0	BR	80091		0	BR	80092		0	BR
80100		0	BR	80101		0	BR	80102		0	BR
80103		0	BR	80150		0	BR	80152		0	BR
80154		0	BR	80156		0	BR	80158		0	BR
80160		0	BR	80162		0	BR	80164		0	BR
80166		0	BR	80168		0	BR	80170		0	BR
80172		0	BR	80174		0	BR	80176		0	BR
80178		0	BR	80182		0	BR	80184		0	BR
80185		0	BR	80186		0	BR	80188		0	BR
80190		0	BR	80192		0	BR	80194		0	BR
80196		0	BR	80197		0	BR	80198		0	BR
80200		0	BR	80201		0	BR	80202		0	BR
80299		0	BR	80400		0	BR	80402		0	BR
80406		0	BR	80408		0	BR	80410		0	BR
80412		0	BR	80414		0	BR	80415		0	BR
80416		0	BR	80417		0	BR	80418		0	BR
80420		0	BR	80422		0	BR	80424		0	BR
80426		0	BR	80428		0	BR	80430		0	BR
80432		0	BR	80434		0	BR	80435		0	BR
80436		0	BR	80438		0	BR	80439		0	BR
80440		0	BR	81000		0	BR	81001		0	BR
81002		0	BR	81003		0	BR	81005		0	BR
81007		0	BR	81015		0	BR	81020		0	BR
81025		0	BR	81050		0	BR	81099		0	BR
82000		0	BR	82003		0	BR	82009		0	$3.30
82010		0	$24 .20	82013		0	BR	82016		0	BR
82017		0	BR	82024		0	BR	82030		0	BR
82040		0	BR	82042		0	$3.30	82043		0	BR
82044		0	BR	82055		0	$31 .00	82075		0	$35 .00
82085		0	BR	82088		0	BR	82101		0	BR
82103		0	BR	82104		0	BR	82105		0	BR
82106		0	BR	82108		0	BR	82127		0	BR
82128		0	BR	82131		0	BR	82135		0	BR
82136		0	BR	82139		0	BR	82140		0	$9.90
82143		0	BR	82145		0	$9.90	82150		0	$8.80
82154		0	BR	82157		0	BR	82160		0	BR
82163		0	BR	82164		0	BR	82172		0	BR
82175		0	$13 .20	82180		0	$16 .50	82190		0	BR

 

 

Tab le  1501 -B P atho logy  and  Labo rato ry Se rvices NOTE:  Laborat ory  an d  path ology  procedur es  with   assigned    RVU’s   will   be   listed   in   th e  health   car e services  manua l  an d  sha ll  be  reimbur sed  as  a  medical  procedur e
Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP
82205		0	$26 .00	82232		0	BR	82239		0	BR
82240		0	BR	82247		0	BR	82248		0	BR
82252		0	BR	82261		0	BR	82270		0	BR
82273		0	BR	82286		0	BR	82300		0	BR
82306		0	BR	82307		0	BR	82308		0	BR
82310		0	BR	82330		0	$23 .00	82331		0	BR
82340		0	$11 .00	82355		0	BR	82360		0	BR
82365		0	BR	82370		0	BR	82374		0	BR
82375		0	$19 .80	82376		0	BR	82378		0	BR
82379		0	BR	82380		0	BR	82382		0	BR
82383		0	BR	82384		0	BR	82387		0	BR
82390		0	BR	82397		0	BR	82415		0	BR
82435		0	BR	82436		0	$7.70	82438		0	BR
82441		0	BR	82465		0	BR	82480		0	BR
82482		0	$9.90	82485		0	BR	82486		0	$27 .00
82487		0	$9.63	82488		0	$9.63	82489		0	$9.63
82491		0	BR	82492		0	BR	82495		0	$16 .50
82507		0	$13 .20	82520		0	BR	82523		0	BR
82525		0	BR	82528		0	BR	82530		0	BR
82533		0	BR	82540		0	$19 .80	82541		0	BR
82542		0	BR	82543		0	BR	82544		0	BR
82550		0	$8.00	82552		0	$23 .25	82553		0	$20 .90
82554		0	BR	82565		0	BR	82570		0	BR
82575		0	BR	82585		0	BR	82595		0	BR
82600		0	$23 .10	82607		0	BR	82608		0	BR
82615		0	BR	82626		0	BR	82627		0	BR
82633		0	BR	82634		0	BR	82638		0	BR
82646		0	BR	82649		0	BR	82651		0	BR
82652		0	BR	82654		0	BR	82657		0	BR
82658		0	BR	82664		0	BR	82666		0	BR
82668		0	BR	82670		0	BR	82671		0	BR
82672		0	BR	82677		0	BR	82679		0	BR
82690		0	BR	82693		0	BR	82696		0	BR
82705		0	$13 .20	82710		0	$32 .18	82715		0	BR
82725		0	BR	82726		0	BR	82728		0	BR
82731		0	BR	82735		0	$16 .50	82742		0	BR
82746		0	BR	82747		0	BR	82757		0	BR
82759		0	BR	82760		0	BR	82775		0	BR
82776		0	BR	82784		0	BR	82785		0	BR
82787		0	BR	82800		0	$3.30	82803		0	$13 .20
82805		0	BR	82810		0	BR	82820		0	BR
82926		0	BR	82928		0	BR	82938		0	BR
82941		0	BR	82943		0	BR	82946		0	BR
82947		0	BR	82948		0	BR	82950		0	BR
82951		0	$19 .00	82952		0	BR	82953		0	BR

 

 

Tab le  1501 -B P atho logy  and  Labo rato ry Se rvices NOTE:  Laborat ory  an d  path ology  procedur es  with   assigned    RVU’s   will   be   listed   in   th e  health   car e services  manua l  an d  sha ll  be  reimbur sed  as  a  medical  procedur e
Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP
82955		0	BR	82960		0	BR	82962		0	BR
82963		0	BR	82965		0	BR	82975		0	BR
82977		0	BR	82978		0	BR	82979		0	BR
82980		0	BR	82985		0	BR	83001		0	BR
83002		0	BR	83003		0	BR	83008		0	BR
83010		0	BR	83012		0	BR	83013		0	BR
83014		0	BR	83015		0	$13 .20	83018		0	$5.00
83020		0	$25 .58	83021		0	BR	83026		0	BR
83030		0	BR	83033		0	BR	83036		0	BR
83045		0	BR	83050		0	$19 .80	83051		0	$13 .20
83055		0	$17 .60	83060		0	$19 .80	83065		0	BR
83068		0	BR	83069		0	$3.30	83070		0	$4.00
83071		0	$4.13	83080		0	BR	83088		0	BR
83150		0	BR	83491		0	BR	83497		0	BR
83498		0	BR	83499		0	BR	83500		0	BR
83505		0	BR	83516		0	BR	83518		0	BR
83519		0	BR	83520		0	BR	83525		0	BR
83527		0	BR	83528		0	BR	83540		0	$8.00
83550		0	$9.08	83570		0	BR	83582		0	BR
83586		0	BR	83593		0	BR	83605		0	BR
83615		0	BR	83625		0	BR	83632		0	BR
83633		0	BR	83634		0	BR	83655		0	$16 .50
83661		0	BR	83662		0	BR	83670		0	BR
83690		0	$9.90	83715		0	$24 .20	83716		0	BR
83718		0	$8.25	83719		0	$8.25	83721		0	$8.25
83727		0	BR	83735		0	BR	83775		0	BR
83785		0	$16 .50	83788		0	BR	83789		0	BR
83805		0	$25 .58	83825		0	$16 .50	83835		0	BR
83840		0	BR	83857		0	BR	83858		0	BR
83864		0	BR	83866		0	BR	83872		0	BR
83873		0	BR	83874		0	BR	83883		0	BR
83885		0	$13 .20	83887		0	BR	83890		0	BR
83891		0	BR	83892		0	BR	83893		0	BR
83894		0	BR	83896		0	BR	83897		0	BR
83898		0	BR	83901		0	BR	83902		0	BR
83903		0	BR	83904		0	BR	83905		0	BR
83906		0	BR	83912		0	BR	83915		0	BR
83916		0	BR	83918		0	BR	83919		0	BR
83925		0	$5.78	83930		0	$13 .20	83935		0	BR
83937		0	BR	83945		0	BR	83970		0	BR
83986		0	$3.30	83992		0	$17 .60	84022		0	BR
84030		0	BR	84035		0	BR	84060		0	BR
84061		0	BR	84066		0	BR	84075		0	BR
84078		0	$19 .80	84080		0	$27 .50	84081		0	BR
84085		0	BR	84087		0	BR	84100		0	BR

 

 

Tab le  1501 -B P atho logy  and  Labo rato ry Se rvices NOTE:  Laborat ory  an d  path ology  procedur es  with   assigned    RVU’s   will   be   listed   in   th e  health   car e services  manua l  an d  sha ll  be  reimbur sed  as  a  medical  procedur e
Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP
84105		0	BR	84106		0	$9.90	84110		0	$19 .80
84119		0	BR	84120		0	BR	84126		0	BR
84127		0	BR	84132		0	BR	84133		0	BR
84134		0	BR	84135		0	BR	84138		0	BR
84140		0	BR	84143		0	BR	84144		0	BR
84146		0	BR	84150		0	BR	84153		0	BR
84154		0	BR	84155		0	$3.00	84160		0	$4.00
84165		0	$25 .58	84181		0	BR	84182		0	BR
84202		0	BR	84203		0	BR	84206		0	BR
84207		0	BR	84210		0	BR	84220		0	BR
84228		0	BR	84233		0	BR	84234		0	BR
84235		0	BR	84238		0	BR	84244		0	BR
84252		0	BR	84255		0	$13 .20	84260		0	BR
84270		0	BR	84275		0	BR	84285		0	BR
84295		0	BR	84300		0	$7.98	84305		0	BR
84307		0	BR	84311		0	$6.88	84315		0	$3.30
84375		0	$9.63	84376		0	BR	84377		0	BR
84378		0	BR	84379		0	BR	84392		0	BR
84402		0	BR	84403		0	BR	84425		0	BR
84430		0	$25 .58	84432		0	BR	84436		0	BR
84437		0	BR	84439		0	BR	84442		0	BR
84443		0	BR	84445		0	BR	84446		0	BR
84449		0	BR	84450		0	BR	84460		0	BR
84466		0	BR	84478		0	$8.00	84479		0	BR
84480		0	BR	84481		0	BR	84482		0	BR
84484		0	BR	84485		0	BR	84488		0	BR
84490		0	BR	84510		0	BR	84512		0	BR
84520		0	BR	84525		0	BR	84540		0	$7.70
84545		0	$12 .10	84550		0	$11 .00	84560		0	BR
84577		0	BR	84578		0	BR	84580		0	BR
84583		0	BR	84585		0	BR	84586		0	BR
84588		0	BR	84590		0	BR	84597		0	BR
84600		0	$22 .55	84620		0	BR	84630		0	$13 .20
84681		0	BR	84702		0	BR	84703		0	BR
84830		0	BR	84999		0	BR	85002		0	$9.90
85007		0	$7.00	85008		0	$0.83	85009		0	$7.98
85013		0	$2.48	85014		0	$3.30	85018		0	$8.00
85021		0	$5.50	85022		0	$16 .00	85023		0	BR
85024		0	BR	85025		0	BR	85027		0	$6.88
85031		0	$12 .10	85041		0	$3.30	85044		0	BR
85045		0	BR	85046		0	BR	85048		0	$3.30
85130		0	BR	85170		0	$6.60	85175		0	$20 .90
85210		0	BR	85220		0	BR	85230		0	BR
85240		0	BR	85244		0	BR	85245		0	BR
85246		0	BR	85247		0	BR	85250		0	BR

 

 

Tab le  1501 -B P atho logy  and  Labo rato ry Se rvices NOTE:  Laborat ory  an d  path ology  procedur es  with   assigned    RVU’s   will   be   listed   in   th e  health   car e services  manua l  an d  sha ll  be  reimbur sed  as  a  medical  procedur e
Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP
85260		0	BR	85270		0	BR	85280		0	BR
85290		0	BR	85291		0	BR	85292		0	BR
85293		0	BR	85300		0	BR	85301		0	BR
85302		0	BR	85303		0	BR	85305		0	BR
85306		0	BR	85335		0	BR	85337		0	BR
85345		0	$9.90	85347		0	$9.90	85348		0	$9.90
85360		0	BR	85362		0	BR	85366		0	BR
85370		0	BR	85378		0	BR	85379		0	BR
85384		0	BR	85385		0	BR	85390		0	BR
85400		0	BR	85410		0	BR	85415		0	BR
85420		0	BR	85421		0	BR	85441		0	BR
85445		0	BR	85460		0	BR	85461		0	BR
85475		0	BR	85520		0	BR	85525		0	BR
85530		0	BR	85535		0	BR	85540		0	BR
85547		0	BR	85549		0	BR	85555		0	BR
85557		0	BR	85576		0	BR	85585		0	BR
85590		0	BR	85595		0	BR	85597		0	BR
85610		0	$7.70	85611		0	BR	85612		0	BR
85613		0	BR	85635		0	BR	85651		0	$8.00
85652		0	$8.00	85660		0	BR	85670		0	BR
85675		0	BR	85705		0	BR	85730		0	$9.90
85732		0	BR	85810		0	BR	85999		0	BR
86000		0	BR	86003		0	BR	86005		0	BR
86021		0	BR	86022		0	BR	86023		0	BR
86038		0	$26 .00	86039		0	$11 .55	86060		0	$7.98
86063		0	BR	86140		0	$6.60	86147		0	BR
86148		0	BR	86155		0	BR	86156		0	BR
86157		0	BR	86160		0	BR	86161		0	BR
86162		0	BR	86171		0	BR	86185		0	BR
86215		0	BR	86225		0	BR	86226		0	BR
86235		0	BR	86243		0	BR	86255		0	BR
86277		0	BR	86280		0	BR	86308		0	$6.33
86309		0	BR	86310		0	BR	86316		0	BR
86317		0	BR	86318		0	BR	86320		0	BR
86325		0	BR	86327		0	BR	86329		0	BR
86331		0	BR	86332		0	BR	86334		0	BR
86337		0	BR	86340		0	BR	86341		0	BR
86343		0	BR	86344		0	BR	86353		0	BR
86359		0	BR	86360		0	BR	86361		0	BR
86376		0	BR	86378		0	BR	86382		0	BR
86384		0	BR	86403		0	BR	86406		0	BR
86430		0	$6.60	86431		0	$6.60	86485		0	BR
86586		0	BR	86588		0	BR	86590		0	BR
86592		0	$6.33	86593		0	$6.33	86602		0	BR
86603		0	BR	86606		0	BR	86609		0	BR

 

 

Tab le  1501 -B P atho logy  and  Labo rato ry Se rvices NOTE:  Laborat ory  an d  path ology  procedur es  with   assigned    RVU’s   will   be   listed   in   th e  health   car e services  manua l  an d  sha ll  be  reimbur sed  as  a  medical  procedur e
Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP
86612		0	BR	86615		0	BR	86617		0	BR
86618		0	BR	86619		0	BR	86622		0	BR
86625		0	BR	86628		0	BR	86631		0	BR
86632		0	BR	86635		0	BR	86638		0	BR
86641		0	BR	86644		0	BR	86645		0	BR
86648		0	BR	86651		0	BR	86652		0	BR
86653		0	BR	86654		0	BR	86658		0	BR
86663		0	BR	86664		0	BR	86665		0	BR
86668		0	BR	86671		0	BR	86674		0	BR
86677		0	BR	86682		0	BR	86684		0	BR
86687		0	BR	86688		0	BR	86689		0	BR
86692		0	BR	86694		0	BR	86695		0	BR
86698		0	BR	86701		0	BR	86702		0	BR
86703		0	BR	86704		0	BR	86705		0	BR
86706		0	BR	86707		0	BR	86708		0	BR
86709		0	BR	86710		0	BR	86713		0	BR
86717		0	BR	86720		0	BR	86723		0	BR
86727		0	BR	86729		0	BR	86732		0	BR
86735		0	BR	86738		0	BR	86741		0	BR
86744		0	BR	86747		0	BR	86750		0	BR
86753		0	BR	86756		0	BR	86759		0	BR
86762		0	BR	86765		0	BR	86768		0	BR
86771		0	BR	86774		0	BR	86777		0	BR
86778		0	BR	86781		0	BR	86784		0	BR
86787		0	BR	86790		0	BR	86793		0	BR
86800		0	BR	86803		0	BR	86804		0	BR
86805		0	BR	86806		0	BR	86807		0	BR
86808		0	BR	86812		0	BR	86813		0	BR
86816		0	BR	86817		0	BR	86821		0	BR
86822		0	BR	86849		0	BR	86850		0	BR
86860		0	BR	86870		0	BR	86880		0	BR
86885		0	BR	86886		0	BR	86890		0	BR
86891		0	BR	86900		0	BR	86901		0	BR
86903		0	BR	86904		0	BR	86905		0	BR
86906		0	BR	86910		0	BR	86911		0	BR
86915		0	BR	86920		0	BR	86921		0	BR
86922		0	BR	86927		0	BR	86930		0	BR
86931		0	BR	86932		0	BR	86940		0	BR
86941		0	BR	86945		0	BR	86950		0	BR
86965		0	BR	86970		0	BR	86971		0	BR
86972		0	BR	86975		0	BR	86976		0	BR
86977		0	BR	86978		0	BR	86985		0	BR
86999		0	BR	87001		0	BR	87003		0	BR
87015		0	BR	87040		0	$15 .40	87045		0	BR
87070		0	BR	87075		0	$33 .00	87076		0	BR

 

 

Tab le  1501 -B P atho logy  and  Labo rato ry Se rvices NOTE:  Laborat ory  an d  path ology  procedur es  with   assigned    RVU’s   will   be   listed   in   th e  health   car e services  manua l  an d  sha ll  be  reimbur sed  as  a  medical  procedur e
Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP
87081		0	BR	87088		0	BR	87101		0	BR
87102		0	BR	87103		0	BR	87106		0	BR
87109		0	BR	87110		0	BR	87116		0	BR
87118		0	BR	87140		0	BR	87143		0	BR
87147		0	BR	87158		0	BR	87164		0	BR
87166		0	BR	87176		0	BR	87177		0	BR
87181		0	$3.30	87184		0	$0.00	87186		0	BR
87187		0	BR	87188		0	BR	87190		0	BR
87197		0	$15 .95	87205		0	$7.98	87206		0	$7.98
87207		0	$13 .20	87210		0	$7.98	87220		0	$7.98
87230		0	BR	87250		0	$73 .98	87252		0	BR
87253		0	BR	87260		0	BR	87265		0	BR
87270		0	BR	87272		0	BR	87274		0	BR
87276		0	BR	87278		0	BR	87280		0	BR
87285		0	BR	87290		0	BR	87299		0	BR
87301		0	BR	87320		0	BR	87324		0	BR
87328		0	BR	87332		0	BR	87335		0	BR
87340		0	BR	87350		0	BR	87380		0	BR
87385		0	BR	87390		0	BR	87391		0	BR
87420		0	BR	87425		0	BR	87430		0	BR
87449		0	BR	87450		0	BR	87470		0	BR
87471		0	BR	87472		0	BR	87475		0	BR
87476		0	BR	87477		0	BR	87480		0	BR
87481		0	BR	87482		0	BR	87485		0	BR
87486		0	BR	87487		0	BR	87490		0	BR
87491		0	BR	87492		0	BR	87495		0	BR
87496		0	BR	87497		0	BR	87510		0	BR
87511		0	BR	87512		0	BR	87515		0	BR
87516		0	BR	87517		0	BR	87520		0	BR
87521		0	BR	87522		0	BR	87525		0	BR
87526		0	BR	87527		0	BR	87528		0	BR
87529		0	BR	87530		0	BR	87531		0	BR
87532		0	BR	87533		0	BR	87534		0	BR
87535		0	BR	87536		0	BR	87537		0	BR
87538		0	BR	87539		0	BR	87540		0	BR
87541		0	BR	87542		0	BR	87550		0	BR
87551		0	BR	87552		0	BR	87555		0	BR
87556		0	BR	87557		0	BR	87560		0	BR
87561		0	BR	87562		0	BR	87580		0	BR
87581		0	BR	87582		0	BR	87590		0	BR
87591		0	BR	87592		0	BR	87620		0	BR
87621		0	BR	87622		0	BR	87650		0	BR
87651		0	BR	87652		0	BR	87797		0	BR
87798		0	BR	87799		0	BR	87810		0	BR
87850		0	BR	87880		0	BR	87899		0	BR

 

 

Tab le  1501 -B P atho logy  and  Labo rato ry Se rvices NOTE:  Laborat ory  an d  path ology  procedur es  with   assigned    RVU’s   will   be   listed   in   th e  health   car e services  manua l  an d  sha ll  be  reimbur sed  as  a  medical  procedur e
Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP	Code	Mo d	RV U	MAP
87999		0	BR	88000		0	BR	88005		0	BR
88007		0	BR	88012		0	BR	88014		0	BR
88016		0	BR	88020		0	BR	88025		0	BR
88027		0	BR	88028		0	BR	88029		0	BR
88036		0	BR	88037		0	BR	88040		0	BR
88045		0	BR	88099		0	BR	88130		0	BR
88140		0	BR	88142		0	BR	88143		0	BR
88144		0	BR	88145		0	BR	88147		0	BR
88148		0	BR	88150		0	BR	88152		0	BR
88153		0	BR	88154		0	BR	88155		0	BR
88164		0	BR	88165		0	BR	88166		0	BR
88167		0	BR	88199		0	BR	88199	TC	0	BR
88199	26	0	BR	88230		0	BR	88233		0	BR
88235		0	BR	88237		0	BR	88239		0	BR
88240		0	BR	88241		0	BR	88245		0	BR
88248		0	BR	88249		0	BR	88261		0	BR
88262		0	BR	88263		0	BR	88264		0	BR
88267		0	BR	88269		0	BR	88271		0	BR
88272		0	BR	88273		0	BR	88274		0	BR
88275		0	BR	88280		0	BR	88283		0	BR
88285		0	BR	88289		0	BR	88299		0	BR
88371		0	BR	88372		0	BR	88399		0	BR
88399	TC	0	BR	88399	26	0	BR	89050		0	BR
89051		0	BR	89060		0	BR	89125		0	BR
89160		0	BR	89190		0	BR	89250		0	BR
89251		0	BR	89252		0	BR	89253		0	BR
89254		0	BR	89255		0	BR	89256		0	BR
89257		0	BR	89258		0	BR	89259		0	BR
89260		0	BR	89261		0	BR	89264		0	BR
89300		0	BR	89310		0	BR	89320		0	BR
89325		0	BR	89329		0	BR	89330		0	BR
89355		0	BR	89365		0	BR	89399		0	BR
89399	TC	0	BR	89399	26	0	BR

 

 

Table 1501 -C Orth ot ics an d Pr osth et ics
Code	MAP	Code	MAP	Code	MAP
L0120   $17 .29		L0130   $117 .02		L0140   $42 .00
L0150   $74 .60		L0160   $119 .82		L0170   $796 .31
L0172   $110 .00		L0174   $194 .07		L0180   $314 .44
L0190   $407 .89		L0200   $430 .12		L0210   $28 .85
L0220   $90 .00		L0300   $124 .59		L0310   $242 .46
L0315   $213 .27		LO317  $255 .89		LO320  $336 .00
L0330   $476 .12		L0340   $567 .22		L0350   $696 .40

 

 

Table 1501 -C Orth ot ics an d Pr osth et ics
Code	MAP	Code	MAP	Code	MAP
L0360   $1,551 .72		L0370   $349 .60		L0380   $614 .95
L0390   $1,400 .30		L0400   $1,498 .32		L0410   $1 ,626.40
L0420   $1,886 .09		L0430   $1,062 .50		L0440   $899 .60
L0500   $99 .00		L0510   $214 .00		L0515   $176 .00
L0520   $358 .03		L0530   $359 .95		L0540   $387 .68
L0550   $1,273 .00		L0560   $1,590 .56		L0565   $902 .84
L0600   $60 .09		L0610   $224 .46		L0620   $367 .86
LO700  $1,779 .92		L0710   $1,882 .90		L0810   $2,371 .87
L0820   $1,876 .79		L0830   $2,829 .65		L0860   $960 .00
L0900   $104 .34		L0910   $302 .09		L0920   $110 .60
L0930   $328 .72		L0940   $103 .04		L0950   $299 .10
L0960   $60 .01		L0970   $99 .30		L0972   $89 .42
L0974   $155 .56		L0976   $138 .95		L0978   $167 .24
L0980   $15 .17		L0982   $14 .15		L0984   $47 .18
L1000   $1,763 .98		L1010   $58 .31		L1020   $75 .11
L1025   $108 .35		L1030   $55 .27		L1040   $67 .79
L1050   $72 .34		L1060   $83 .09		L1070   $78 .18
L1080   $48 .08		L1085   $133 .74		L1090   $79 .64
L1100   $138 .17		L1110   $221 .90		L1120   $34 .51
L1200   $1,424 .25		L1210   $227 .34		L1220   $192 .48
L1230   $493 .91		L1240   $67 .46		L1250   $62 .77
L1260   $65 .74		L1270   $67 .32		L1280   $74 .95
L1290   $68 .29		L1300   $1,451 .36		L1310   $1,493 .46
L1499   BR		L1500   $1,650 .36		L1510   $828 .93
L1520   $1,486 .64		L1685   $1,033 .49		L1686   $653 .04
L1800   $43 .34		L1810   $81 .00		L1815   $63 .13
L1820   $103 .00		L1825   $35 .83		L1830   $57 .01
L1832   $480 .05		L1834   $674 .46		L1840   $798 .89
L1844   $734 .88		L1845   $583 .78		L1850   $187 .57
L1855   $954 .77		L1858   $1,221 .93		L1860   $1,383 .48
L1870   $909 .28		L1880   $550 .82		L1900   $234 .40
L1902   $52 .02		L1904   $333 .00		L1906   $86 .17
L1910   $174 .27		L1920   $286 .29		L1930   $175 .57
L1940   $429 .68		L1945   $1,145 .70		L1950   $647 .18
L1960   $530 .36		L1970   $618 .24		L1980   $318 .88
L1990   $459 .09		L2000   $881 .27		L2010   $803 .35
L2020   $1,132 .33		L2030   $880 .19		L2036   $2,022 .35
L2037   $1,447 .16		L2038   $1,024 .83		L2040   $154 .26
L2050   $413 .88		L2060   $504 .44		L2070   $116 .84
L2080   $312 .50		L2090   $380 .99		L2102   $521 .09
L2104   $619 .81		L2106   $747 .33		L2108   $1,170 .03
L2112   $304 .03		L2114   $440 .38		L2116   $537 .16
L2122   $891 .10		L2124   $992 .94		L2126   $1,356 .79
L2128   $1,498 .50		L2132   $525 .66		L2134   $803 .12
L2136   $878 .87		L2180   $101 .75		L2182   $79 .63
L2184   $107 .63		L2186   $130 .80		L2188   $260 .22
L2190   $59 .45		L2192   $309 .80		L2200   $41 .30
L2210   $58 .40		L2220   $71 .16		L2230   $66 .67

 

 

Table 1501 -C Orth ot ics an d Pr osth et ics
Code	MAP	Code	MAP	Code	MAP
L2240   $72 .66		L2250   $308 .74		L2260   $174 .17
L2265   $102 .31		L2270   $46 .67		L2275   $103 .91
L2280   $393 .43		L2300   $233 .93		L2310   $106 .88
L2320   $178 .76		L2330   $341 .16		L2335   $197 .38
L2340   $388 .32		L2350   $774 .19		L2360   $44 .96
L2370   $223 .04		L2375   $99 .17		L2380   $106 .97
L2385   $116 .38		L2390   $95 .11		L2395   $101 .95
L2397   $87 .81		L2405   $44 .22		L2415   $159 .56
L2425   $158 .17		L2435   $143 .80		L2492   $88 .60
L2500   $274 .10		L2510   $631 .12		L2520   $374 .57
L2525   $873 .78		L2526   $595 .12		L2530   $204 .14
L2540   $367 .33		L2550   $249 .53		L2570   $413 .84
L2580   $403 .24		L2600   $178 .44		L2610   $211 .00
L2620   $232 .31		L2622   $266 .44		L2624   $287 .71
L2627   $1,489 .46		L2628   $1,455 .67		L2630   $215 .15
L2640   $291 .98		L2650   $104 .27		L2660   $161 .94
L2670   $148 .21		L2680   $135 .96		L2750   $72 .62
L2760   $52 .79		L2770   $53 .64		L2780   $58 .80
L2785   $27 .54		L2795   $57 .13		L2800   $92 .00
L2810   $67 .86		L2820   $75 .46		L2830   $81 .62
L2840   $30 .06		L2850   $42 .15		L2999   BR
L3000   $170 .00		L3001   BR		L3002   $99 .00
L3003   $99 .00		L3010   $135 .00		L3020   $99 .00
L3030   BR		L3040   BR		L3050   BR
L3060   BR		L3070   BR		L3080   BR
L3090   BR		L3100   BR		L3150   BR
L3215   $94 .18		L3216   $108 .00		L3217   $127 .00
L3218   $87 .00		L3219   $102 .87		L3221   $120 .00
L3222   $150 .00		L3223   $91 .00		L3230   $425 .00
L3250   $381 .00		L3251   $450 .00		L3252   $300 .00
L3253   $90 .00		L3254   $38 .00		L3257   $180 .00
L3260   $60 .00		L3265   $35 .00		L3300   $42 .00
L3310   $40 .00		L3320   BR		L3330   $275 .00
L3332   $18 .00		L3334   $25 .00		L3340   $70 .00
L3350   $13 .00		L3360   $15 .00		L3370   $22 .00
L3380   $32 .00		L3390   $15 .00		L3400   $56 .00
L3410   $64 .00		L3420   $32 .00		L3430   $44 .00
L3440   $35 .00		L3500   BR		L3510   BR
L3520   BR		L3530   BR		L3540   BR
L3550   BR		L3560   BR		L3570   BR
L3580   BR		L3590   BR		L3595   BR
L3650   $37 .82		L3660   $65 .54		L3670   $72 .11
L3700   $44 .51		L3710   $78 .83		L3720   $556 .10
L3730   $766 .44		L3740   $908 .66		L3800   $140 .00
L3805   $256 .00		L3810   $55 .09		L3815   $51 .16
L3820   $87 .86		L3825   $55 .14		L3830   $71 .98
L3835   $78 .02		L3840   $53 .45		L3845   $69.02
L3850   $98 .59		L3855   $99 .38		L3860   $136 .03

 

 

Table 1501 -C Orth ot ics an d Pr osth et ics
Code	MAP	Code	MAP	Code	MAP
L3900   $1,396 .48		L3901   $1,481 .20		L3902   $2,137 .19
L3904   $2,354 .94		L3906   $384 .00		L3907   $406 .00
L3908   $38 .21		L3910   $253 .61		L3912   $69 .00
L3914   $62 .00		L3916   $109 .00		L3918   $64 .00
L3920   $90 .00		L3922   $75 .02		L3924   $88 .95
L3926   $71 .96		L3928   $43 .89		L3930   $50 .94
L3932   $38 .12		L3934   $40 .91		L3936   $75 .73
L3938   $74 .25		L3940   $83 .41		L3942   $62 .14
L3944   $78 .52		L3946   $59 .28		L3948   $46 .85
L3950   $126 .68		L3952   $141 .50		L3954   $77 .63
L3960   $505 .85		L3962   $457 .52		L3963   $1,063 .83
L3964   $501 .52		L3965   $772 .40		L3966   $613 .07
L3968   $713 .05		L3969   $563 .81		L3970   $193 .93
L3972   $178 .22		L3974   $109 .98		L3980   $197 .13
L3982   $238 .05		L3984   $219 .47		L3985   $496 .93
L3986   $476 .56		L3995   $20 .85		L3999   BR
L4000   $1,107 .83		L4010   $942 .50		L4020   $748 .37
L4030   $438 .67		L4040   $354 .66		L4045   $285 .01
L4050   $358 .70		L4055   $232 .27		L4060   $276 .12
L4070   $244 .52		L4080   $87 .00		L4090   $78 .46
L4100   $90 .62		L4110   $73 .68		L4130   $431 .00
L4210   BR		L4350   $58 .25		L4360   $180 .43
L4370   $123 .02		L4380   $69 .99		L5000   $400 .00
L5010   $1,217 .00		L5020   $2,226 .00		L5050   $2,231 .00
L5060   $2,691 .00		L5100   $2,499 .00		L5105   $3,215 .69
L5150   $3,599 .00		L5160   $3,869 .00		L5200   $3,081 .00
L5210   $2,332 .00		L5220   $2,592 .00		L5230   $4,198 .00
L5250   $4,802 .00		L5270   $4,760 .75		L5280   $4,713 .13
L5300   $2,612 .75		L5310   $3,859 .00		L5320   $3,815 .00
L5330   $5,450 .14		L5340   $5,823 .31		L5400   $1,261 .00
L5410   $333 .00		L5420   $1,547 .71		L5430   $420 .12
L5450   $363 .27		L5460   $476 .46		L5500   $1,262 .00
L5505   $1,685 .00		L5510   $1,535 .00		L5520   $1,347 .00
L5530   $1,752 .00		L5535   $1,569 .73		L5540   $1 ,765.00
L5560   $1,829 .00		L5570   $1,840 .00		L5580   $2,352 .00
L5585   $2,696 .00		L5590   $2,225 .22		L5595   $3,727 .16
L5600   $4,115 .89		L5610   $1,916 .47		L5611   $1,491 .40
L5613   $2,268 .50		L5614   $3,508 .49		L5616   $1,257 .18
L5618   $654 .32		L5620   $533 .41		L5622   $729 .81
L5624   $635 .07		L5626   $777 .71		L5628   $775 .86
L5629   $220 .64		L5210   $2,332 .00		L5220   $2,592 .00
L5230   $4,198 .00		L5250   $4,802 .00		L5270   $4,760 .75
L5280   $4,713 .13		L5300   $2,612 .75		L5310   $3,859 .00
L5320   $3,815 .00		L5330   $5,450 .14		L5340   $5,823 .31
L5400   $1,261 .00		L5410   $333 .00		L5420   $1,547 .71
L5430   $420 .12		L5450   $363 .27		L5460   $476 .46
L5500   $1,262 .00		L5505   $1,685 .00		L5510   $1,535 .00
L5520   $1,347 .00		L5530   $1,752 .00		L5535   $1,569 .73

 

 

Table 1501 -C Orth ot ics an d Pr osth et ics
Code	MAP	Code	MAP	Code	MAP
L5540   $1,765 .00		L5560   $1,829 .00		L5570   $1,840 .00
L5580   $2,352 .00		L5585   $2,696 .00		L5590   $2,225 .22
L5595   $3,727 .16		L5600   $4,115 .89		L5610   $1,916 .47
L5611   $1,491 .40		L5613   $2,268 .50		L5614   $3,508 .49
L5616   $1,257 .18		L5618   $654 .32		L5620   $533 .41
L5622   $729 .81		L5624   $635 .07		L5626   $777 .71
L5628   $775 .86		L5629   $220 .64		L5682   $578 .90
L5684   $44 .54		L5686   $47 .29		L5688   $56 .53
L5690   $90 .58		L5692   $123 .00		L5694   $167 .93
L5695   $150 .96		L5696   $171 .28		L5697   $74 .32
L5698   $96 .56		L5699   $142 .40		L5700   $2,534 .95
L5701   $3,147 .36		L5702   $4,021 .66		L5704   $436 .72
L5705   $800 .64		L5706   $780 .94		L5707   $1,049 .19
L5710   $332 .93		L5711   $483.34		L5712   $398 .87
L5714   $387 .18		L5716   $674 .65		L5718   $843 .24
L5722   $835 .75		L5724   $1,397 .20		L5726   BR
L5728   $1,851 .35		L5780   $1,059 .79		L5785   $480 .92
L5790   $665 .57		L5795   $993 .86		L5810   $450 .67
L5811   $675 .10		L5812   $495 .00		L5816   $710 .00
L5818   $888 .94		L5822   $1,576 .30		L5824   $1,400 .00
L5828   $2,263 .39		L5830   $1,756 .46		L5840   $1,400 .00
L5850   $118 .42		L5855   $285 .88		L5910   $335 .26
L5920   $491 .14		L5925   $280 .00		L5940   $464 .30
L5950   BR		L5960   $892 .37		L5962   $490 .00
L5964   $798 .56		L5966   $1,035 .31		L5970   $187 .99
L5972   $326 .23		L5974   $215 .70		L5976   $451 .39
L5978   $270 .13		L5979   $2,090 .00		L5980   $2,917 .79
L5981   $2,382 .65		L5982   $535 .13		L5984   $527 .33
L5986   $586 .57		L5999   BR		L6000   $1,229 .90
L6010   $1,368 .70		L6020   $1,276 .09		L6050   $2,263 .00
L6055   $2,450 .75		L6100   $2,229 .00		L6110   $2 ,284.04
L6120   $2,202 .07		L6130   $2,396 .27		L6200   $2,982 .00
L6205   $3,370 .85		L6250   $3,267 .79		L6300   $3,448 .64
L6310   $2,809 .00		L6320   $1,581 .89		L6350   $3,625 .73
L6360   $2,948 .39		L6370   $1,880 .09		L6380   $1,130 .00
L6382   $1,520 .00		L6384   $1,764 .86		L6386   $371 .72
L6388   $406 .94		L6400   $2,147 .89		L6450   $2,853 .88
L6500   $2,856 .22		L6550   $3,529 .76		L6570   $4,051 .49
L6580   $1,446 .95		L6582   $1,273 .99		L6584   $1,894 .64
L6586   $1,734 .41		L6588   $2,616 .40		L6590   $2,435 .32
L6600   $173 .63		L6605   $171 .44		L6610   $154 .12
L6615   $160 .80		L6616   $60 .04		L6620   $280 .66
L6623   $593 .77		L6625   $492 .31		L6628   $443 .44
L6629   $135 .43		L6630   $529 .70		L6632   $60 .14
L6635   $185 .00		L6637   $339 .89		L6640   $259 .30
L6641   $148 .50		L6642   $201 .28		L6645   $295 .49
L6650   $313 .32		L6655   $69 .53		L6660   $84 .96
L6665   $42 .64		L6670   $44 .39		L6672   $156 .07

 

 

Table 1501 -C Orth ot ics an d Pr osth et ics
Code	MAP	Code	MAP	Code	MAP
L6675   $111 .16		L6676   $112 .26		L6680   $396 .63
L6682   $492 .52		L6684   $575 .62		L6686   $546 .47
L6687   $485 .00		L6688   $490 .36		L6689   $623 .71
L6690   $636 .49		L6691   $375 .00		L6692   $517 .66
L6700   $480 .17		L6705   $281 .90		L6710   $456 .45
L6715   $435 .00		L6720   $789 .68		L6725   $465 .24
L6730   $591 .50		L6735   $275 .82		L6740   $359 .60
L6745   $329 .03		L6750   $325 .22		L6755   $324 .30
L6765   $338 .82		L6770   $326 .63		L6775   $387 .01
L6780   $413 .69		L6790   $418 .27		L6795   $1,145 .60
L6800   $937 .88		L6805   $314 .94		L6806   $1,219 .79
L6809   $343 .46		L6810   $172 .66		L6825   $955 .02
L6830   $1,253 .51		L6835   $1,091 .93		L6840   $758 .59
L6845   $704 .22		L6850   $637 .78		L6855   $811 .19
L6860   $615 .22		L6865   $301 .42		L6875   $719 .47
L6880   $466 .76		L6890   $190 .00		L6895   $732 .76
L6900   $1,989 .50		L6905   $1,990 .23
L6910   $2,001 .88		L6915   $774.57		L6920   $6,434 .34
L6925   $6,874 .02		L6930   $6,197 .18		L6935   $6,841 .72
L6940   $8,002 .61		L6945   $8,927 .91		L6950   $7,987 .74
L6955   $9,263 .27		L6960   $9,744 .62		L6965   $11 ,544 .00
L6970   $12 ,356 .57		L6975   $13 ,619 .84		L7010   $3,174 .94
L7015   $5,611 .94		L7020   $3,466 .69		L7025   $3,428 .95
L7030   $5,488 .37		L7035   $3,648 .62		L7040   $2,609 .59
L7170   $5,427 .59		L7180   $29 ,891 .81		L7260   $1,821 .71
L7261   $3,610 .95		L7266   $916 .48		L7272   $1,812 .94
L7274   $5,621 .72		L7360   $240 .00		L7362   $242 .00
L7364   $392 .77		L7366   $540 .20		L7499   BR
L7500   $80 .00		L7510   BR		L8100   BR
L8110   BR		L8120   BR		L8130   BR
L8140   BR		L8150   BR		L8160   BR
L8170   BR		L8180   BR		L8190   BR
L8200   BR		L8210   BR		L8220   BR
L8300   $58 .56		L8310   $92 .46		L8320   $37 .11
L8330   $34 .27		L8400   $23 .02		L8410   $19 .18
L8415   $19 .84		L8420   $18 .01		L8430   $20 .50
L8435   $19 .46		L8440   $38 .71		L8460   $61 .69
L8465   $45 .16		L8470   $6.18		L8480   $8.52
L8485   $10 .17		L8490   $134 .87		L8499   BR
L8500   BR		L8501   BR		L8610   BR
L8699   BR