DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
7 CCR 1101-3
WORKERS’ COMPENSATION RULES OF PROCEDURE
Rule 18	MEDICAL FEE SCHEDULE
18-1	STATEMENT OF PURPOSE
Pursuant to § 8-42-101(3)(a)(I) C.R.S. and  § 8-47-107, C.R.S., the Director promulgates this Medical Fee Schedule to review and establish maximum allowable fees for health care services falling within the purview of the Act.  The Director adopts and hereby incorporates by reference as modified herein the 2014 edition of the Relative Values for Physicians (RVP©), developed by Relative Value Studies, Inc., published by OPTUMINSIGHT (Ingenix®), the Current Procedural Terminology CPT® 2014, Professional Edition, published by the American Medical Association (AMA) and Medicare Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual, Version 32.0 developed and published by 3M Health Information Systems using MS-DRGs effective after October 1, 2014.  The incorporation is limited to the specific editions named and does not include later revisions or additions.  For information about inspecting or obtaining copies of the incorporated materials, contact the Medical Policy Unit Supervisor, 633 17th Street, Suite 400, Denver, Colorado 80202-3626.  These materials may be examined at any state publications depository library.  All guidelines and instructions are adopted as set forth in the RVP©, CPT® and MS-DRGs, and all CPT® modifiers, unless otherwise specified in this Rule.
This Rule applies to all services rendered on or after January 1, 2015.  All other bills shall be reimbursed in accordance with the fee schedule in effect at the time service was rendered.
18-2	STANDARD TERMINOLOGY FOR THIS RULE
(A)	CPT® - Current Procedural Terminology CPT® 2014, copyrighted and distributed by the AMA and incorporated by reference in 18-1.
(B)        DoWC Zxxxx – Colorado Division of Workers’ Compensation created codes.
(C)        MS-DRGs – version 32.0 incorporated by reference in 18-1.
(D)        RVP© – the 2014 edition incorporated by reference in 18-1.
(E)        For other terms, see Rule 16, Utilization Standards.
18-3      HOW TO OBTAIN COPIES
All users are responsible for the timely purchase and use of Rule 18 and its supporting documentation as referenced herein.  The Division shall make available for public review and inspection copies of all materials incorporated by reference in Rule 18.  Copies of the RVP© may be purchased from Ingenix® OptumInsight, the Current Procedural Terminology, 2014  Edition may be purchased from the AMA, the MS-DRGs Definitions Manual may be purchased from 3M Health Information Systems, and the Colorado Workers' Compensation Rules of Procedures with Treatment Guidelines, 7 CCR 1101-3, may be purchased from LexisNexis Matthew Bender & Co., Inc., Albany, NY.  Interpretive Bulletins and unofficial copies of all rules, including Rule 18, are available on the Colorado Department of Labor and Employment web site.  An official copy of the rules is available on the Secretary of State’s webpage.

18-4      CONVERSION FACTORS (CF)
The following CFs shall be used to determine the maximum allowed fee.  The maximum fee is determined by multiplying the following section CFs by the established relative value unit(s) (RVU) found in the corresponding RVP© sections:
RVP© SECTION		CF
Anesthesia	$ 53.73/RVU
Surgery	$ 99.83/RVU
Radiology	$ 18.41/RVU
Pathology	$ 13.72/RVU
Medicine	$   8.33/RVU
Physical Medicine	$   6.23/RVU
(Physical Medicine and Rehabilitation,
Medical Nutrition Therapy and Acupuncture)
Evaluation & Management (E&M)	$ 10.16/RVU
18-5	INSTRUCTIONS AND/OR MODIFICATIONS TO THE DOCUMENTS INCORPORATED BY REFERENCE IN RULE 18-1 
(A)	Maximum allowance for all providers under Rule 16-5 is 100% of the RVP© value or as defined in this Rule. 
(B)	Unless modified herein, the RVP© is adopted for RVUs and reimbursement.  Interim relative value procedures (marked by an “I” in the left-hand margin of the RVP©) are accepted as a basis of payment for services; however deleted CPT® codes (marked by an “M” in the RVP©) are not, unless otherwise advised by this Rule.  Division created codes (Zxxxx) and values supersede CPT® or RVP© codes and reimbursement levels. Those codes listed with RVUs of “BR” (by report) and “RNE” (relativity not established) require prior authorization as explained in Rule 16.  The CPT® 2014 is adopted for codes, descriptions, parenthetical notes and coding guidelines, unless modified in this Rule. 
	Any billed CPT® code identified as a “separate procedure” in CPT® shall have an appropriate modifier appended to the code for the payer to allow separate payment (i.e., modifier -59). 
	No code listed in CPT® identified as an “add-on” code is payable unless an appropriate primary code is billed with the “add-on” code in the same episode of care. 
(C)	CPT® Category III codes listed in the RVP© may be used for billing with agreement of the payer as to reimbursement.  Payment shall be in compliance with Rule 16-6(C).

(D)	Surgery/Anesthesia
(1)	Anesthesia Section:
(a)	All anesthesia base values shall be established by the use of the codes as set forth in the RVP©, Anesthesia Section.  Anesthesia services are only reimbursable if the anesthesia is administered by a physician, a Certified Registered Nurse Anesthetist (CRNA), or an anesthesiologist assistant (AA) who remains in constant attendance during the procedure for the sole purpose of rendering anesthesia.
When anesthesia is administered by a CRNA or AA:
1)	CRNAs not under the medical direction of an anesthesiologist, reimbursement shall be 90% of the maximum anesthesia value;
2)	If billed separately, CRNAs and AAs, under the medical direction of an anesthesiologist, shall be reimbursed 50% of the maximum anesthesia value.  The other 50% is payable to the anesthesiologist providing the medical direction to the CRNA or AA;
3)	Medical direction for administering the anesthesia includes performing the following activities:
a)	Performs a pre-anesthesia examination and evaluation,
b)	Prescribes the anesthesia plan,
c)	Personally participates in the most demanding procedures in the anesthesia plan including induction and emergence,
d)	Ensures that any procedure in the anesthesia plan that s/he does not perform is performed by a qualified anesthetist,
e)	Monitors the course of anesthesia administration at frequent intervals,
f)	Remains physically present and available for immediate diagnosis and treatment of emergencies, and
g)	Provides indicated post-anesthesia care.
(b)	Anesthesia physical status modifiers and qualifying circumstances are reimbursed using the anesthesia CF and unit values found in the RVP©, Anesthesia section’s Guidelines XI “Physical Status Modifiers” and XII, “Qualifying Circumstances.”  
(c)	The following modifiers are to be used when billing for anesthesia services:
AA – anesthesia services performed personally by the anesthesiologist
AD – greater than four (4) concurrent (occurring at the same time) anesthesia service cases being supervised by an anesthesiologist
QK – anesthesiologist providing direction to qualified individuals of two (2) to four (4) concurrent anesthesia cases
QX – CRNA or AA service; with medical direction by a physician
QZ – CRNA service; without medical direction by a physician
QY – Medical direction of one CRNA or AA by an anesthesiologist
QS – Monitored anesthesia care service (MAC)
G8 – Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive surgical procedure 
G9 – Monitored anesthesia care (MAC) of a patient who has a history of severe cardiopulmonary disease
(d)	The supervision of AAs shall be limited in accordance with the Medical Practice Act.	
(e)	Physical status modifiers are reimbursed as follows, using the anesthesia conversion factor:
	P-1	Healthy patient					0 RVUs
	P-2	Patient with mild systemic disease		0 RVUs
	P-3	Patient with severe systemic disease		1 RVU

	P-4	Patient with severe systemic disease that is a 
		constant threat to life				2 RVUs
	P-5	A moribund patient who is not expected to
		survive without the operation			3 RVUs
	P-6	A declared brain-dead patient			0 RVUs
(f)	Qualifying circumstance codes are reimbursed using the medicine conversion factor: 
	Anesthesia complicated by extreme age; 
	under 1 year old or > 70 years old			1 RVU
	Anesthesia complicated by utilization of 	
	total body hypothermia					5 RVUs
	Anesthesia complicated by utilization of
	controlled hypotension					5 RVUs
	Anesthesia complicated by emergency
	conditions (specify) 					2 RVUs

(g)	When more than one surgical procedure is performed during a single episode, only the highest valued base anesthesia procedure value is billed with the total anesthesia time for all procedures.  

(h) 	Anesthesia time begins when the anesthesiologist prepares the patient for the induction of anesthesia and ends when the anesthesiologist is no longer in personal attendance and the patient is placed under postoperative supervision.  Total minutes are reported for reimbursement.  Each 15-minutes of anesthesia time equals 1 additional RVU.  Five minutes or more is considered significant time and adds 1 RVU to the payment calculation. 
 (i)	Calculation of Maximum Fees for Anesthesia
	Base Anesthesia value from the RVP© Anesthesia Guidelines

			+1 Unit/15 minutes of anesthesia time
					+Any physical status modifier units
			Total Relative Value Anesthesia Units
			Multiplied by the Anesthesia CF in section 18-4
			Total Maximum Anesthesia Fees

“Qualifying circumstance” codes are reimbursed under section 18-5(D)(1)(f) of this Rule.
(j)	Non-time based Anesthesia Procedures 
Modifier -47 shall be used by surgeons performing non-time based anesthesia.
The relative value units are located in the RVP© Anesthesia Guidelines, Paragraph XIV 
(2)	Surgical Section: 
(a)	The use of assistant surgeons shall be limited according to the American College Of Surgeons'  Physicians as Assistants at Surgery:  2013 Study (January 2013), available from the American College of Surgeons, Chicago, IL, or from their web page.  The incorporation is limited to the edition named and does not include later revisions or additions.  Copies of the material incorporated by reference may be inspected at any State publications depository library.  For information about inspecting or obtaining copies of the incorporated material, contact the Medical Policy Unit Supervisor, 633 17th Street, Suite 400, Denver, Colorado, 80202-3626.
Where the publication restricts use of such assistants to "almost never" or a procedure is not referenced in the publication, prior authorization for payment (see Rule 16-9) is required.
(b)	Incidental procedures are commonly performed as an integral part of a total service and do not warrant a separate benefit.  
(c)	No payment shall be made for more than one (1) assistant surgeon or minimum assistant surgeon without prior authorization for payment (see Rule 16-9) unless a trauma team was activated due to the emergency nature of the injury(ies).
(d)	The payer may use available billing information such as provider credential(s) and clinical record(s) to determine if an appropriate modifier should be used on the bill.  To modify a billed code refer to Rule 16-11(B)(4).
(e)	When an operation requires two primary surgeons performing two distinct portions of the operation, modifier -62 is used with the procedure in question and reimbursement is increased to 125% of the value, apportioned in relation to the responsibilities and work of each surgeon or 50% of the total increased maximum fee to each surgeon.
	Surgical team reimbursement requires prior authorization and the use of modifier - 66 on the surgical codes.
	Assistant Surgeon, indicated by modifier -80 has a maximum allowance of 20 % of the surgeon’s fees.
Assistant Surgeon (when qualified resident surgeon is not available), indicated by modifier -82, is also reimbursed at 20% of the surgeon’s fees.
Minimum Assistant Surgeon, such as a physician’s assistant, a nurse practitioner, or a clinical nurse specialist, is indicated by modifier -81 and reimbursed at 10% of the surgeon’s fees.
 (f)	Global Period   
	1) All surgical procedures include the following:
a)	Local infiltration, metacarpal/metatarsal/digital block or typical anesthesia;
b)	One related E&M encounter on the date immediately prior to or on the date of the procedure (including history and physical);
c)	Intraoperative services that are normally a usual and necessary part of a surgical procedure; 
d)	Immediate postoperative care, including dictating operative notes, talking with the family and other physicians;
e)	Evaluating the patient in the post-anesthesia recovery room;
f)	Post-surgical pain management by the surgeon;
g)	Typical postoperative follow-up care during the global period of the surgery that is related to recovery from the surgery as identified in RVP© as global:
•	000 –are endoscopies or some minor surgical procedures, typically a 0 day postoperative period. Visits on the same day of procedures are generally included in the allowance for the procedure, unless a separately identifiable service is performed and billed with the appropriate modifier. 
•	010 - are other minor procedures, 10 day postoperative period. 
•	090 - are major surgeries, 90 day postoperative period.
•	XXX – does not apply
•	ZZZ – are covered under another procedure’s global days 
•	MMM – global service day’s concept does not apply.  (See Medicare’s Global Maternity Care reporting rule.)
•	Global period, defined RVP©, begins the day after surgery and continues for the defined period.
h)	Supplies – Except for those identified as exclusions;
i)	Miscellaneous Services – Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts and splints; insertion, irrigation and removal of urinary catheters, routine peripheral IV lines, nasograstric and rectal tubes; changes and removal of tracheostomy tubes;
j)	Applicable Surgical Modifiers:
•	24 - Unrelated E&M service by the same physician during a postoperative period.
•	25 - Significant and separately identifiable E&M service on the same day of the procedure within the global period of minor surgical procedures (0 or 10 days). 
•	54 - Surgical Care only.  Fee is 60% of the billed surgery code Maximum Fee Schedule value.
•	55 - Postoperative management only.  Fee is 30% of the billed surgery code Maximum Fee Schedule value.
•	56 - Preoperative management only. Fee is 10% of the billed surgery code Maximum Fee Schedule value.
•	57 - Decision for surgery.
•	58 - Staged or related procedure or service by the same physician during the postoperative period.
•	76 - Repeat procedure or service by the same physician.
•	78 - Unplanned Return to the Operating/Procedure Room by the same physician following initial procedure for a related procedure during the postoperative period.
•	79 - Un-related procedure or service by the same physician during the postoperative period.
 2)	The following services performed during a global period would warrant separate billing if documentation demonstrates significant identifiable services were involved, such as:
a)	E&M services unrelated to the primary surgical procedure.
b)	Services necessary to stabilize the patient for the primary surgical procedure.
c)	Services not considered part of the surgical procedure, including an E&M visit by an authorized treating physician for disability management.  The E&M service shall have an appropriate modifier appended to the E&M level of the service code when the surgeon is performing services during the global period.  If at all possible, an appropriate identifying diagnosis code shall identify the E&M service as unrelated to the surgical global period.  In addition, the reasonableness and necessity for an E&M service that is separate and identifiable from the surgical global period shall be clearly documented in the medical record.  
d)	Disability management of an injured worker for the same diagnosis requires the managing physician to clearly identify in the medical record the specific disability management detail that was performed during that visit.  The definitions of what is considered disability counseling can be located under 18-5(I)(1) and in Exhibit #7 of this Rule. 
e)	Unusual circumstances, complications, exacerbations, or recurrences.
f)	Unrelated diseases or injuries.
g)	If a patient is seen for the first time or an established patient is seen for a new problem and the “decision for surgery” is made the day of the procedure or the day before the procedure is performed, then the surgeon can bill both the procedure code and an E&M code, using a --57 modifier or -25 modifier on the E&M code.
3)	Separate identifiable services shall use an appropriate CPT®/RVP© modifier in conjunction with the billed service.
(g)	Multiple Procedures (modifier -51) and Bilateral Procedures (modifier -50)
Multiple procedure guidelines do not apply to codes specifically identified as add-on procedures or to those specifically identified as exempt from modifier -51.
Bilateral procedures shall be billed on one line with one (1) unit and the modifier -50 appended to the CPT® code.  The maximum fee is calculated at 150% of the Maximum Fee Schedule value. 
When multiple procedures are performed by the same surgeon during the same surgical setting, modifier -51 shall be appended to the lower valued procedure(s). When multiple surgical procedures are performed in a single surgical setting, the highest valued or primary procedure is allowed 100% of the maximum fee and all other valued procedures, appended with a modifier -51, are allowed at 50% of the maximum fee.  
(h)	The “Services with Significant Direct Costs” section of the RVP© is not adopted.  Supplies shall be reimbursed as set out in section 18-6(H).
(i)	If a surgical arthroscopic procedure is converted to the same surgical open procedure on the same joint, only the open procedure is payable.  If an arthroscopic procedure and open procedure are performed on different joints, the two (2) procedures may be separately payable with anatomic modifiers or modifier -50.
(j)	Use code G0289 to report any combination of surgical knee arthroscopies for removal of loose body, foreign body, and/or debridement/shaving of articular cartilage.  G0289 is 11.8 RVUs and is paid using the surgical conversion factor.
G0289 shall not be paid when reported in conjunction with other knee arthroscopy codes in the same compartment of the same knee.
G0289 shall be paid when reported in conjunction with other knee arthroscopy codes in a different compartment of the knee.  G0289 is subject to the 50% multiple surgical reduction guidelines.
(k)	Relative value units listed in the 2014 RVP© Surgery Section listed below shall be replaced as follows:
1)	Epidural for blood or clot patch injection = 1.9 
2)	Epidurals diagnostic or therapeutic injections substance(s) including anesthetic antispasmodic, opioid, steroid, other solutions (NOT neurolytic substances) for subarachnoid
	a)	Cervical or thoracic level = 2.0
	b)	Lumbar or sacral (caudal) = 1.65
3)	Epidurals (including indwelling catheter placement), for continuous infusion or intermittent bolus of diagnostic or therapeutic substance(s) including anesthetic, antispasmodic, opioid, steroid, other solutions (NOT neurolytic  substances) for subarachnoid 
a)	Cervical or thoracic level =1.85
b)	Lumbar or sacral (caudal) = 1.77
				4)     	Somatic nerve injections: 
a)	Greater occipital nerve= 1.5 
b)	Spinal accessory nerve = 1.5 
c)	Injection brachial plexus, continuous infusion by catheter (including catheter placement) = 1.0 
d)	Regional block (intercostal) = 1.7 
e)	Sciatic nerve, continuous infusion = 1.3 
f)	Femoral nerve, single = 1.5 
g)	Injection, femoral nerve, continuous infusion by catheter (including catheter placement) = 1.2 
h)	Lumbar plexus, posterior approach, continuous infusion = 2.0 
i)	Other peripheral nerve or branch = 1.25 
				5)	Paravertebral facet joint injections:
a)	Single level cervical/thoracic levels = 2.0
b)	Second levels at cervical/thoracic = 1.25 
c)	Third and any additional levels at cervical/thoracic = 1.10 
				6)	Paravertebral facet joint injections:
a)	Single level lumbar/sacral levels = 1.75
b)	Second levels at lumbar/sacral = 1.0
c)	Third and any additional levels at lumbar/sacral = 1.0 
				7)	Autonomic nerve injection
a)	Anesthetic agent, superior hypogastric plexus = 1.3
b)	Anesthetic agent, lumbar or thoracic (paravertebral sympathetic) = 2.0 
				8)	Destruction of nerve by neurolytic agent:
a)	Trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch, second and third division branches at foramen ovale = 5.5 
b)	Intercostal nerve = 3.0
c)	Pudendal nerve = 3.0
d)	Paravertebral facet joints at cervical and thoracic single level = 4.4 
e)	Paravertebral facet joints at cervical and thoracic each additional level = 2.0
f)	Paravertebral facet joints at lumbar or sacral single level = 4.2 
g)	Paravertebral facet joints at lumbar or sacral single each additional level = 1.8 
h)	Other peripheral nerve or branch = 1.6 
i)	Celiac plexus = 2.9 
				9)	Functional Assessments related to spinal or sacroiliac joint injections shall be reimbursed in accordance with 18-6(G)(6). 
				10)	Tympanic Membrane surgery:		
a)	Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch = 11.7
			(l)	Venipuncture for clinical laboratory testing maximum fee allowance is covered under Exhibit #8 of this Rule. 
 (E)	Radiology Section:
(1)	General
(a)	The cost of dyes and contrast shall be reimbursed in accordance with 18-6(K)(2)c)4).
(b)	Copying charges for x-rays and MRIs shall be $15.00/film regardless of the size of the film.
(c)	The payer may use available billing information such as provider credential(s) and clinical record(s) to determine if an appropriate RVP© modifier should have been used on the bill.  To modify a billed code, refer to Rule 16-11(B)(4).
(d)	In billing radiology services, the applicable radiology procedure code shall be billed using the appropriate modifier to bill either the professional component (26) or the technical component (TC).  If a physician bills the total or professional component, a separate written interpretive report is required.  
If a physician interprets the same radiological image more than once, or if multiple physicians interpret the same radiological image, only one (1) interpretation shall be reimbursed.
The time a physician spends reviewing and/or interpreting an existing radiological image is considered a part of the physician’s evaluation and management service code.
(2)	Thermography
(a)	The provider supervising and interpreting the thermographic evaluation shall be board certified by the examining board of one (1) of the following national organizations and follow their recognized protocols:
American Academy of Thermology;
American Chiropractic College of Infrared Imaging. 
(b)	Indications for diagnostic thermographic evaluation must be one (1) of the following:
Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy (CRPS/RSD);
Sympathetically Maintained Pain (SMP);
Autonomic neuropathy;
(c)	General Protocols for Stress Testing
	Cold Water Autonomic Functional Stress Testing – Baseline infrared images are obtained in a 68º F +/- 1 degree steady state environment following equilibration for 15 minutes.  After the quantitative and qualitative baseline images are captured, cold water autonomic functional stress testing is performed by submersing the asymptomatic extremity in 68º F +/- 1 degree cold water bath for 5 minutes while imaging and evaluating the autonomic response.
	Whole Body Autonomic Stress Testing – Refer to the thermogram discussion section found in the Complex Regional Pain Syndrome Medical Treatment Guidelines.
(d)	Thermography Billing Codes:
DoWC Z0200  Upper body w/ Autonomic Stress Testing     $865.37
DoWC Z0201  Lower body w/Autonomic Stress Testing      $865.37
(e)	Prior authorization for payment (see Rule 16-9) is required for thermography services only if the requested study does not meet the indicators for thermography as outlined in this radiology section.  The billing shall include a report supplying the thermographic evaluation and reflecting compliance with 18-5(E)(2).
		(3)	Urea breath test C-14 (Isotopic); acquisition for analysis and the analysis maximum fees are listed under Exhibit #8 of this Rule. 
 (F)	Pathology Section:
Laboratories with a CLIA certificate of waiver may perform only those tests cleared by the Food and Drug Administration (FDA) as waived tests. Laboratories with a CLIA certificate of waiver shall bill using the QW modifier. 
Laboratories with a CLIA certificate of compliance or accreditation may perform non-waived tests. Laboratories with a CLIA certificate of compliance or accreditation do not append the QW modifier to claim lines. 
(1)	All clinical pathology laboratory tests, except as allowed by this rule, are reimbursed at the total component dollar value listed under Exhibit #8 of this Rule or billed charges, whichever is less.  No separate technical or professional component maximum dollar split is separately payable by the payer.  However the technical and professional component billing parties may agree upon a dollar value split of the total maximum fees listed in Exhibit #8 of this Rule.
	When a physician clinical pathologist is required for consultation and interpretation, and a separate written report is created, the maximum fee is determined by using the RVP© values and the pathology conversion factors.  Maximum Fee Schedule value is determined by the Pathology Conversion Factor when the Pathology CPT® code description includes “interpretation” and “report” or the following Pathology CPT® code description is from: 
•	physician blood bank services, 
•	cytopathology and cell marker study interpretations, 
•	cytogenics or molecular cytogenics interpretation and report, 
•	surgical pathology gross and microscopic and special stain groups 1 and 2 and histochemical stain, blood or bone marrow interpretations, and
•	Skin tests for “unlisted antigen each, coccidoidomycosis, histoplasmosis, TB intradermal.
When ordering automated laboratory tests, the ordering physician may seek verbal consultation with the pathologist in charge of the laboratory’s policy, procedures and staff qualifications.  The consultation with the ordering physician is not payable unless the ordering physician requested additional medical interpretation and judgment and requested a separate written report.  Upon such a request, the pathologist may bill using the proper CPT® code and values from the RVP©, not DoWC Z0755.
(2)	Drug Testing Codes and Values
(a)	G0434 (Drug screen, other than chromatographic; any number of drug classes, by Clinical Laboratory Improvement Amendments (CLIA) waived test or moderate complexity test, per patient encounter) will be used to report very simple testing methods, such as dipsticks, cups, cassettes, and cards, that are interpreted visually, with the assistance of a scanner, or are read utilizing a moderately complex reader device outside the instrumented laboratory setting (i.e., non-instrumented devices). This code is also used to report any other type of drug screen testing using test(s) that are classified as CLIA moderate complexity test(s), keeping the following points in mind: 
G0434 includes qualitative drug screen tests that are waived under CLIA as well as dipsticks, cups, cards, cassettes, etc. that are not CLIA waived. 
(b)	Only one (1) unit of service for code G0434 can be billed per patient encounter regardless of the number of drug classes tested and irrespective of the use or presence of the QW modifier on claim lines. 
(c)	G0431 (Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter) will be used to report more complex testing methods, such as multi-channel chemistry analyzers, where a more complex instrumented device is required to perform some or all of the screening tests for the patient. This code may only be reported if the drug screen test(s) is classified as CLIA high complexity test(s) with the following restrictions: 
G0431 may only be reported when tests are performed using instrumented systems (i.e., durable systems capable of withstanding repeated use). 
CLIA waived tests and comparable non-waived tests may not be reported under test code G0431; they must be reported under test code G0434. 
CLIA moderate complexity tests should be reported under test code G0434 with one (1) Unit of Service (UOS). 
G0431 may only be reported once per patient encounter. 
Laboratories billing G0431 must not append the QW modifier to claim lines. 
Maximum Fee Schedule values are listed under Exhibit #8 of this Rule.
 (d)	Drug testing shall be done prior to the initial long-term drug prescription being implemented and randomly repeated at least annually.
While the injured worker is receiving chronic opioid management, additional drug screens with documented justification may be conducted.  Examples of documented justification include the following:
(1)	Concern regarding the functional status of the patient
(2)	Abnormal results on previous testing
(3)	Change in management of dosage or pain
(4)	Chronic daily opioid dosage above 150 mg of morphine or equivalent
(e)	Qualitative testing must meet one of the following criteria before performing a quantitative review:
(1)	The results of the qualitative screen are presumptively positive; or
(2)	Results of the qualitative screen are negative and this negative finding is inconsistent with the patient’s medical history.
(f)	Codes G0431 and G0434 in section 18-5(F)(2) are to be billed and used to determine Maximum Fee Schedule values instead of the codes listed under the “Drug Testing” subsection in the “Pathology and Laboratory Section” of CPT® and RVP©.  Specific quantitative drug testing codes listed under other sections of the “Pathology and Laboratory Section” of CPT® and RVP© are still recognized.
(G)	Medicine Section: 
(1)	Medicine home therapy services in the RVP© are not adopted.  For appropriate codes see section 18-6(L), Home Therapy.
(2)	Anesthesia qualifying circumstance values are reimbursed in accordance with the section 18-5(D)(1).
(3)	Biofeedback
Prior authorization for payment (see Rule 16-9) shall be required from the payer for any treatment exceeding the treatment guidelines.  A licensed physician or psychologist shall prescribe all services and include the number of sessions.  Session notes shall be periodically reviewed by the prescribing physician or psychologist to determine the continued need for the service.  All services shall be provided or supervised by an appropriate recognized provider as listed under Rule 16-5.  Supervision shall be as defined in Rule 17, Medical Treatment Guidelines.  Persons providing biofeedback shall be certified by the Biofeedback Certification International Alliance (BCIA), or be a licensed physician or psychologist, as listed under Rule 16-5(A)(1)(a) and (b) with evidence of equivalent biofeedback training.  Providers who are performing Individual Psychophysiological therapy that incorporates Biofeedback with psychotherapy must be appropriately licensed by DORA to perform psychotherapy.
Maximum Fee Schedule values for biofeedback services shall be consistent with the values published in the RVP Errata Quarter 2 2014 as follows: 
			Biofeedback training by any modality		0.3/min
			Biofeedback peri/uro/rectal			0.3/min
 (4)	Appendix J of the 2014 CPT® identifies mixed, motor and sensory nerve conduction studies and their appropriate billing.  
(5)	Manipulation -- Chiropractic (DC), Medical (MD) and Osteopathic (DO):
(a)	Prior authorization for payment (see Rule 16-9) shall be obtained before billing for more than four body regions in one (1) visit.  Manipulative therapy is limited to the maximum allowed in Rule 17, Medical Treatment Guidelines.  The provider's medical records shall reflect medical necessity and prior authorization for payment (see Rule 16-9) if treatment exceeds these limitations.
(b)	An office visit may be billed on the same day as manipulation codes when the documentation meets the E&M requirement and an appropriate modifier is used.
(6)	Psychiatric/Psychological Services:  
(a)	A licensed psychologist (PsyD, PhD, EdD) is reimbursed a maximum of 100% of the medical fee listed in the RVP©.  Other non-physician providers performing psychological/psychiatric services shall be paid at 75% of the fee allowed for physicians.  
(b)	Prior authorization for payment (see Rule 16-9) is required any time the following limitations are exceeded on a single day:
Psychiatric diagnostic evaluation, with or without medical services, per episode					limit:  2 hours (bill the appropriate CPT® code for each hour.)
Central Nervous System (CNS) Assessments/Tests, (neuro-cognitive, mental status, speech) requiring more than six (6) hours require prior authorization.
Most initial evaluations for delayed recovery, exclusive of testing, can be completed in two (2) hours.  
(c)	Psychotherapy services                      	limit: 60 min. per visit
Prior authorization for payment (see Rule 16-9) is required any time the 60 minutes per visit limitation is exceeded.
Psychotherapy for work-related conditions requiring more than 20 visits or continuing for more than three (3) months after the initiation of therapy, whichever comes first, requires prior authorization for payment (see Rule 16-9) except where specifically addressed in Rule 17, Medical Treatment Guidelines.
(d)	When billing an evaluation and management (E&M) code in addition to psychotherapy:
(1)	Both services must be separately identifiable;
(2)	The level of E&M is based on history, exam and medical decision making;
(3)	Time may not be used as the basis for the E&M code selection; and 
(4)	Add-on psychotherapy codes are to be used by psychiatrists to indicate both services were provided.
Non-medical disciplines cannot bill most E&M codes.
 (7)	Hyperbaric Oxygen Therapy Services
The maximum unit value shall be 24 units per session, instead of 14 units as listed in the RVP©.
(8)	Qualified Non-Physician Provider Telephone or On-Line Services
Reimbursement to qualified non-physician providers for coordination of care with professionals shall be based upon the telephone codes for qualified non-physician providers found in the RVP© Medicine Section.  Coordination of care reimbursement is limited to telephone calls made to professionals outside of the non-physician provider’s employment facility(ies) and/or to the injured worker or their family.
(9)	Quantitative Autonomic Testing Battery (ATB) and Autonomic Nervous System Testing.
(a)	Quantitative Sudomotor Axon Reflex Test (QSART) is a diagnostic test used to diagnose Complex Regional Pain Syndrome.  This test is performed on a minimum of two (2) extremities, and encompasses the following components:
1)	Resting Sweat Test
2)	Stimulated Sweat Test
3)	Resting Skin Temperature Test
4)	Interpretation of clinical laboratory scores.  Physician must evaluate the patient specific clinical information generated from the test and quantify it into a numerical scale.  The data from the test and a separate report interpreting the results of the test must be documented.
(b)	Maximum fee when all of the services outlined in 18-5(G)(9)(a) are completed and documented.
QSART Billing Code 
DoWC Z0401	QSART		$1,007.00
Z0401 may only be billed once per workers’ compensation claim, regardless of the number limbs tested.
(10)	Intra-Operative Monitoring (IOM)
IOM is used to identify compromise to the nervous system during certain surgical procedures.  Evoked responses are constantly monitored for changes that could imply damage to the nervous system. 
(a)	Clinical Services for IOM: Technical and Professional
1)	Technical staff:  A qualified specifically trained technician shall setup the monitoring equipment in the operating room and is expected to be in constant attendance in the operating room with the physical or electronic capacity for real-time communication with the supervising neurologist or other physician trained in neurophysiology.  The technician shall be specifically trained/registered with:
The American Society of Neurophysiologic Monitoring; or
The American Society of Electrodiagnostic Technologists
2)	Professional/Supervisory /Interpretive
A specifically neurophysiology trained Colorado licensed physician shall monitor the patient’s nervous system throughout the surgical procedure.  The monitoring physician’s time is billed based upon the actual time the physician devotes to the individual patient, even if the monitoring physician is monitoring more than one (1) patient.  The monitoring physician’s time does not have to be continuous for each patient and may be cumulative.  The monitoring physician shall not monitor more than three (3) surgical patients at one time.  The monitoring physician shall provide constant neuromonitoring at critical points during the surgical procedure as indicated by the surgeon or any unanticipated testing responses.  There must be a neurophysiology trained Colorado licensed physician backup available to continue monitoring the other two patients if one of the patients being monitored has complications and/or requires the monitoring physician’s undivided attention for any reason.  There is no additional payment for the back-up neuromonitoring physician, unless he/she is utilized in a specific case.
3)	Technical Electronic Capacity for Real-time Communication requirements
The electronic communication equipment shall use a 16-channel monitoring and minimum real-time auditory system, with the possible addition of video connectivity between monitoring staff, operating surgeon and anesthesia.  The equipment must also provide for all of the monitoring modalities that may be applied with the IOM procedure code.
(b)	Procedures and Time Reporting
Physicians shall include an interpretive written report for all primary billed procedures.
 (11)	Speech Therapy/Evaluation and Treatment
Reimbursement shall be according to the unit values as listed in the RVP© multiplied by their section’s respective CF.
(12)	Vaccine and Toxoids
Shall be billed using the appropriate J code or CPT® code listed in the Medicare Part B Drug Average Sale Price (ASP), or at cost to the billing provider if no dollar value is listed in ASP.
(13)	IV Infusions Performed in Physicians’ Offices or Sent Home with Patient
IV infusion therapy performed in a physician’s office shall be billed under the “Therapeutic, Prophylactic, and Diagnostic Injections and Infusions” and the “Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration” in the Medicine Section of CPT®.  The appropriate CPT®/RVP© code units multiplied by the Medicine conversion factor is the Maximum Fee Schedule value for the infusion service. The infused therapeutic drugs are payable at cost to the provider’s office.
		Maximum fees for supplies and medications provided by a physician's office for self-administered home care infusion therapy is covered under section 18-6(L)(1).
(H)	Physical Medicine and Rehabilitation: 
Restorative services are an integral part of the healing process for a variety of injured workers.
(1)	Prior authorization for payment (see Rule 16-9) is required for medical nutrition therapy.  
(2)	For recommendations on the use of the physical medicine and rehabilitation procedures, modalities, and testing, see Rule 17, Medical Treatment Guidelines.
(3)	Special Note to All Physical Medicine and Rehabilitation Providers:
	The authorized treating provider shall obtain prior authorization for payment (see Rule 16-9) from the payer for any physical medicine or rehabilitation treatment not listed in or exceeding the frequency or duration recommendations in Rule 17, Medical Treatment Guidelines.
	The injured worker shall be re-evaluated by the prescribing physician within 30 calendar days from the initiation of the prescribed treatment and at least once every month while that treatment continues to establish achievement of functional goals.  Prior authorization for payment (see Rule 16-9) shall be required for treatment of a condition not covered under Rule 17, Medical Treatment Guidelines and exceeding 60 calendar days from the initiation of treatment.  
(4)	Interdisciplinary Rehabilitation Programs – Requires Prior Authorization for Payment (see Rule 16-9).
	An interdisciplinary rehabilitation program is one that provides focused, coordinated, and goal-oriented services using a team of professionals from varying disciplines to deliver care.  These programs can benefit persons who have limitations that interfere with their physical, psychological, social, and/or vocational functioning.  As defined in Rule 17, Medical Treatment Guidelines, interdisciplinary rehabilitation programs may include, but are not limited to:  chronic pain, spinal cord, or brain injury programs.
		Billing Restrictions: All billing providers shall detail to the payer the services, frequency of services, duration of the program and their proposed fees for the entire program and all professionals.  The billing provider and payer shall attempt to mutually agree upon billing code(s) and fee(s) for each interdisciplinary rehabilitation program.
	If there is a single billing provider for the entire interdisciplinary rehabilitation program and a daily per diem rate is mutually agreed upon, use billing code Z0500.
	If the individual interdisciplinary rehabilitation professionals bill separately for their participation in an interdisciplinary rehabilitation program, the applicable CPT® codes shall be used to bill for their services.  Demonstrated participation in an interdisciplinary rehabilitation program allows the use of the frequencies and durations listed in the relevant Medical Treatment Guideline’s recommendations.
(5)	Procedures (therapeutic exercises, neuromuscular re-education, aquatic therapy, gait training, massage, acupuncture, dry needling of trigger points, manual therapy techniques, therapeutic activities, cognitive development, sensory integrative techniques and any unlisted physical medicine procedures.)
	The provider’s medical records shall reflect the medical necessity and the provider shall obtain prior authorization for payment (see Rule 16-9) if the procedures are not recommended or the frequency and duration exceeds the recommendations of the Rule 17, Medical Treatment Guidelines.  The maximum amount of time allowed is one (1) hour of procedures per day, per discipline; unless medical necessity is documented and prior authorization is obtained from the payer.
Aquatic Therapy Services 
		The maximum unit value shall be 5 units per 15-minutes instead of the 4.5 units as listed in the RVP©.
Dry Needling of Trigger Points, Single or multiple needles, 
DoWC Z0501 -	initial 15 minutes of dry needling		5.4 RVUs  
DoWC Z0502 - each add’l 15 minutes of dry needling 	4.5 RVUs
(6)	Modalities
RVP© Timed and Non-timed Modalities 
Billing Restrictions:  There is a total limit of two (2) modalities (whether timed or non-timed) per visit, per discipline, per day.
NOTE:  Instruction and application of a transcutaneous electric nerve stimulation (TENS) unit for the patient's independent use shall be billed using the education code in the Medicine section of the RVP©.  Rental or purchase of a TENS unit requires prior authorization for payment (see Rule 16-9).  For Maximum Fee Schedule value, see 18-6(H).
 (7)	Evaluation Services for Therapists:  Physical Therapy (PT), Occupational Therapy (OT) and Athletic Trainers (ATC).
(a)	All evaluation services must be supported by the appropriate history, physical examination documentation, treatment goals and treatment plan or re-evaluation of the treatment plan.  The provider shall clearly state the reason for the evaluation, the nature and results of the physical examination of the patient, and the reasoning for recommending the continuation or adjustment of the treatment protocol.  Without appropriate supporting documentation, the payer may deny payment.  The re-evaluation codes shall not be billed for routine pre-treatment patient assessment.
If a new problem or abnormality is encountered that requires a new evaluation and treatment plan, the professional may perform and bill for another initial evaluation.  A new problem or abnormality may be caused by a surgical procedure being performed after the initial evaluation has been completed.
(b)	Payers are only required to pay for evaluation services directly performed by a PT, OT, or ATC.  All evaluation notes or reports must be written and signed by the PT, OT or ATC.  Physicians shall bill the appropriate E&M code from the E&M section of the RVP©.
(c)	A patient may be seen by more than one (1) health care professional on the same day.  An evaluation service with appropriate documentation may be charged by each professional per patient, per day.
(d)	Reimbursement to PTs, OTs, speech language pathologists and audiologists for coordination of care with professionals shall be based upon the telephone codes for qualified non-physician providers found in the RVP© Medicine Section.  Coordination of care reimbursement is limited to telephone calls made to professionals outside of the therapist’s/pathologist’s/ audiologist’s employment facility(ies) and/or to the injured worker or their family.
(e)	All interdisciplinary team conferences shall be billed in compliance with section18-5(I)(5).
(8)	Special Tests 
The following respective tests are considered special tests: 
•	Job Site Evaluation 
•	Functional Capacity Evaluation
•	Assistive Technology Assessment
•	Speech
•	Computer Enhanced Evaluation (DoWC Z0503)
•	Work Tolerance Screening (DoWC Z0504)
(a)	Billing Restrictions:
1)	Job Site Evaluations require prior authorization for payment (see Rule 16-9) if exceeding two (2) hours. Computer-Enhanced Evaluations and Work Tolerance Screenings require prior authorization for payment for more than four (4) hours per test or more than three (3) tests per claim.  Functional Capacity Evaluations require prior authorization for payment for more than four (4) hours per test or two (2) tests per claim.
2)	The provider shall specify the time required to perform the test in 15-minute increments.
3)	The value for the analysis and the written report is included in the code’s value.
4)	No E&M services or PT, OT, or acupuncture evaluations shall be charged separately for these tests.
5)	Data from computerized equipment shall always include the supporting analysis developed by the physical medicine professional before it is payable as a special test.
(b)	Provider Restrictions: all special tests must be fully supervised by a physician, PT, OT, speech language pathologist/therapist or audiologist.  Final reports must be written and signed by the physician, PT, OT, speech language pathologist/therapist or audiologist.
(9)	Supplies 
Physical medicine supplies are reimbursed in accordance with section18-6(H).
(10)	Unattended Treatment
When a patient uses a facility or its equipment for unattended procedures, in an individual or a group setting, bill:
DoWC Z0505     fixed fee per day                        1.5 RVU
(11)	Non-Medical Facility
Fees, such as gyms, pools, etc., and training or supervision by non-medical providers require prior authorization for payment (see Rule 16-9) and a written negotiated fee.
(12)	Unlisted Service Physical Medicine
All unlisted services or procedures require a report.
(13)	Work Conditioning, Work Hardening, Work Simulation
(a)	Work conditioning is a non-interdisciplinary program that is focused on the individual needs of the patient to return to work.  Usually one (1) discipline oversees the patient in meeting goals to return to work.  Refer to Rule 17, Medical Treatment Guidelines.
Restriction:  Maximum daily time is two (2) hours per day without additional prior authorization for payment (see Rule 16-9).
(b)	Work Hardening is an interdisciplinary program that uses a team of disciplines to meet the goal of employability and return to work.  This type of program entails a progressive increase in the number of hours a day that an individual completes work tasks until they can tolerate a full workday.  In order to do this, the program must address the medical, psychological, behavioral, physical, functional and vocational components of employability and return to work.  Refer to Rule 17, Medical Treatment Guidelines.
Restriction:  Maximum daily time is six (6) hours per day without additional prior authorization for payment (see Rule 16-9).  
(c)	Work Simulation is a program where an individual completes specific work-related tasks for a particular job and return to work.  Use of this program is appropriate when modified duty can only be partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient requires more structured supervision.  The need for work simulation should be based upon the results of a functional capacity evaluation and/or job analysis.  Refer to Rule 17, Medical Treatment Guidelines.
(d)	For Work Conditioning, Work Hardening, or Work Simulation, the following apply:
1)	The provider shall submit a treatment plan including expected frequency and duration of treatment.  If requested by the provider, the payer will prior authorize payment for the treatment plan services or shall identify any concerns including those based on the reasonableness or necessity of care.
2)	If the frequency and duration is expected to exceed the Medical Treatment Guidelines’ recommendation, prior authorization for payment is required (see Rule 16-9).
3)	Provider Restrictions:  All procedures must be performed by or under the onsite supervision of a physician, psychologist, PT, OT, speech language pathologist or audiologist.

(I)	Evaluation and Management Section (E&M)
(1)	Evaluation and management codes may be billed by medical providers as defined in Rule 16-5(A)(1)(a) as well as nurse practitioners (NP) and physician assistants (PA).  Medical record documentation shall encompass the “E&M Documentation Guidelines” criteria as adopted in Exhibit #7 of this Rule, to justify the billed level of E&M service.  If 50% of the time spent for an E&M visit is shared decision making, disability counseling or coordination of care, then time can determine the level of E&M service.  Documented telephonic or on-line communication time with the patient or other healthcare providers one (1) day prior or seven (7) days following the scheduled E&M visit, may be included in the calculation of total time.
Disability counseling should be an integral part of managing workers’ compensation injuries.  The counseling shall be completely documented in the medical records, including, but not limited to, the amount of time spent with the injured worker and the specifics of the discussion as it relates to the individual patient.  Disability counseling shall include, but not be limited to, return to work, temporary and permanent work restrictions, self-management of symptoms while working, correct posture/mechanics to perform work functions, job task exercises for muscle strengthening and stretching, and appropriate tool and equipment use to prevent re-injury and/or worsening of the existing injury.
(2)	New or Established Patients
An E&M visit shall be billed as a “new” patient service for each “new injury” even though the provider has seen the patient within the last three (3) years.  Any subsequent E&M visits are to be billed as an “established patient” and reflect the level of service indicated by the documentation when addressing all of the current injuries. 
(3)	Number of Office Visits
All providers are limited to one (1) office visit per patient, per day, per workers’ compensation claim, unless prior authorization for payment is obtained (see Rule 16-9).  The E&M Guideline criteria as specified in the RVP© E&M Section shall be used in all office visits to determine the appropriate level.
(4)	Treating Physician Telephone or On-line Services
Telephone or on-line services may be billed if: 
(a)	The service is performed more than one (1) day prior to a related E&M office visit, or
(b)	The service is performed more than seven (7) days following a related E&M office visit, and 
(c)	The medical records/documentation specifies all the following:
1)	The amount of time and date;
2)	The patient, family member, or healthcare provider talked to; and
3)	The specifics of the discussion and/or decision made during the communication. 
(5)	Face-to-Face or Telephonic Treating Physician or Qualified Non-physician Medical Team Conferences
A medical team conference can only be billed if all of the criteria are met under CPT®.   A medical team conference shall consist of medical professionals caring for the injured worker. 
The billing statement shall be prepared in accordance with Rule 16, Utilization Standards.
(6)	Face -to-face or telephonic meeting by a non-treating physician with the employer, claim representatives or any attorney in order to provide a medical opinion on a specific workers’ compensation case, which is not accompanied by a specific report or written record. 
Billing Code DoWC Z0601:	$65.00 per 15 minutes billed to the requesting party.
(7)	Face-to-face or telephonic meeting by a non-treating physician with the employer, claim representatives or any attorney in order to provide a medical opinion on a specific workers’ compensation case, which is accompanied by a report or written record, shall be billed as a special report (see section 18-6(G)(4)).
(8)	A consultation occurs when a treating physician seeks an opinion from another physician regarding a patient’s diagnosis or treatment and meets the CPT® requirements for a consultation.  An independent medical exam (IME) occurs when a physician is requested to evaluate a patient by any party or party’s representative and is billed in accordance with section 18-6(G).
(9)	When billing for prolonged services, either face-to-face or non-face-to-face, the provider shall provide a report that documents time distinguishable from the E&M visit.
(J)	Telehealth 
(1)         Closely associated with telemedicine is the term “telehealth”, which is often used to encompass a broader definition of remote health care that does not always involve clinical services.  Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs and continuing medical education are all considered part of telemedicine and telehealth. 
             Telemental Health is a broad term that refers to providing mental healthcare from a distance.  Video conferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs and continuing medical education are all considered part of telemental health.
             Services provided via telecommunications technologies are not covered if the client has access to a comparable service within 30 miles of his/her place of residence.
(2)	Telehealth facilities can bill for the originating fee only if the patient’s originating site is located in a:
(a)	County outside of a Metropolitan Statistical Area (MSA), or
(b)	A Health Professional Shortage Area, either located outside of an MSA or in a rural census tract, as determined by the office of Rural Health Policy within the Health Resources and Services Administration (HRSA). 
Telehealth originating site facility fee: 
	Q3014 		 $35.00 /per 15 minutes
(3)	HIPAA privacy and electronic security standards are required for both the originating site and the rendering providers. 
(a)	Protecting patient health information, and patient / client decision making and consent are vital.
(b)	Policies and procedures need to be in place to protect the electronic security of data, and the physical security of telehealth equipment so that patient health information is protected. 
(c)	Compliance with accreditation requirements, regulations, and relevant legislation is necessary. 
(d)	Health professionals providing telehealth services shall be fully licensed, registered, and credentialed by the appropriate governing agency.
(4)	All telehealth procedures are required to be at an originating site that is deemed appropriate with the appropriate HIPAA privacy and electronic security standards in place.  Authorized originating sites are:
(a)	The office of a physician or practitioner
(b)	A hospital (inpatient or outpatient)
(c)	A critical access hospital (CAH)
(d)	A rural health clinic (RHC)
(e)	A federally qualified health center (FQHC)
(f)	A hospital based or critical access hospital based renal dialysis center (including satellites)
(g)	A skilled nursing facility (SNF)
(h)	A community mental health center (CMHC)
 (5)	The physician-patient / psychologist-patient relationship needs to be established.
(a)	This relationship is established through assessment, diagnosis and treatment of the patient.  Two way live audio / video services is acceptable to ‘establish' a patient relationship.
(b)	Physicians / psychologists need to meet standard of care.

(c)         The patient is required to provide the appropriate consent for treatment.
(6)	Communication Protocol
(a)	Video conferencing is an advanced communication technology that may be used for telehealth. 
(b)	It is the originating site’s required responsibility to establish provider and patient identity verification.
(7)	Payment for telehealth services
(a)	Telehealth consultations, emergency department or initial inpatient; 30 minutes communicating via telehealth
	G0425		$187.95
(b)	Telehealth consultations, emergency department or initial inpatient; 50 minutes communicating via telehealth
	G0426		$256.69
(c)	Telehealth consultations, emergency department or initial inpatient; 70 minutes communicating via telehealth
	G0427		$375.88
(d)	Follow up inpatient telehealth consultations;
	G0406	Follow up inpatient, limited (typically 15 min.) 		$54.81
	G0407	Follow up inpatient, intermediate (typically 25 min.)	$97.45
	G0408	Follow up inpatient, complex (typically 35 min.) 	           $140.09
	Subsequent inpatient hospital care services are limited to one telehealth visit every 3 days.
             Subsequent nursing facility care services are limited to one telehealth visit every 30 days.

 (e)        For all other physician / psychologist telehealth services, the physician / psychologist shall bill the appropriate RVP© CPT® code with the GT modifier.  Reimbursement is the RVU value for the CPT® code times the appropriate CF + $5.00 when modifier GT is appended to the appropriate CPT® code(s).
GT –     Attached to the distance (rendering) physician / psychologist billed CPT® or HCPCS indicates the service was performed via interactive audio and video telecommunication systems.  Using the modifier certifies that the patient was present at an eligible originating site when the telehealth service was furnished. 
18-6	DIVISION ESTABLISHED CODES AND VALUES 
(A)	Face-to-face or telephonic meeting by a treating physician with the employer, claim representatives, or any attorney, and with or without the injured worker.  Claim representatives may include physicians or qualified medical personnel performing payer-initiated medical treatment reviews, but this code does not apply to requests initiated by a provider for prior authorization for payment (see Rule 16-9).
Before the meeting is separately payable, the following must be met:
(1)	Each meeting shall be at a minimum 15 minutes.  
(2)	A report or written record signed by the physician is required and shall include the following:
(a)	Who was present at the meeting and their role at the meeting;
(b)	Purpose of the meeting;
(c)	A brief statement of recommendations and actions at the conclusion of the meeting;
(d)	Documented time (both start and end times); and
(e)	Billing code DoWC Z0701. 
$75.00 per 15 minutes for time attending the meeting and preparing the report (no travel time or mileage is separately payable).  The fee includes the cost of the report for all parties, including the injured worker.
(B)	Cancellation Fees for Payer Made Appointments
(1)	A cancellation fee is payable only when a payer schedules an appointment the injured worker fails to keep, and the payer has not canceled three (3) business days prior to the appointment.  The payer shall pay:
One-half of the usual fee for the scheduled services, or $150.00, whichever is less.
Cancellation Fee Billing Code:     DoWC Z0720 
(2)	Missed Appointments:
When claimants fail to keep scheduled appointments, the provider should contact the payer within two (2) business days.  Upon reporting the missed appointment, the provider may request whether the payer wishes to reschedule the appointment for the claimant.  If the claimant fails to keep the payer’s rescheduled appointment, the provider may bill for a cancellation fee according to section 18-6(B).
(C)	Copying Fees
The payer, payer's representative, injured worker and injured worker's representative shall pay a reasonable fee for the reproduction of the injured worker's medical record.  Reasonable cost for paper copies shall not exceed $18.53 for the first 10 or fewer pages, $0.85 per page for pages 11-40, and $0.57 per page thereafter. Actual postage or shipping costs and applicable sales tax, if any, may also be charged.  The per-page fee for records copied from microfilm shall be $1.50 per page.
If the requester and provider agree, the copy may be provided on a disc.  The fee will not exceed $14.00 per disc.  
If the requester and provider agree and appropriate security is in place, including, but not limited to, compatible encryption, the copies may be submitted electronically.  Requester and provider should attempt to agree on a reasonable fee.  Absent an agreement to the contrary, the fee shall be $0.10 per page.
Copying charges do not apply for the initial submission of records that are part of the required documentation for billing.
Copying Fee Billing Code:           DoWC Z0721 
(D)	Deposition and Testimony Fees
(1)	When requesting deposition or testimony from physicians or any other type of provider, guidance should be obtained from the Interprofessional Code, as prepared by the Colorado Bar Association, the Denver Bar Association, the Colorado Medical Society and the Denver Medical Society.  If the parties cannot agree upon lesser fees for the deposition or testimony services, or cancellation time frames and/or fees, the following deposition and testimony rules and fees shall be used.
If, in an individual case, a party can show good cause to an Administrative Law Judge (ALJ) for exceeding the Maximum Fee Schedule value, that ALJ may allow a greater fee than listed in section 18-6(D) for that case.
(2)	By prior agreement, the provider may charge for preparation time for a deposition, for reviewing and signing the deposition or for preparation time for testimony.
Preparation Time: 
Treating or Non-treating Provider: DoWC Z0730		$325.00 per hour
(3)	Deposition:
Payment for a treating or non-treating provider’s testimony at a deposition shall not exceed $325.00 per hour, billed in half-hour increments.  Calculation of the provider’s time shall be "portal to portal."
If requested, the provider is entitled to a full hour deposit in advance in order to schedule the deposition.
If the provider is notified of the cancellation of the deposition at least seven (7) business days prior to the scheduled deposition, the provider shall be paid the number of hours s/he has reasonably spent in preparation and shall refund to the deposing party any portion of an advance payment in excess of time actually spent preparing and/or testifying. Bill using code DoWC Z0731.
If the provider is notified of the cancellation of the deposition at least five (5) business days but less than seven (7) business days prior to the scheduled deposition, the provider shall be paid the number of hours s/he has reasonably spent in preparation and one-half the time scheduled for the deposition. Bill using code DoWC Z0732.
If the provider is notified less than five (5) business days in advance of a cancellation, or the deposition is shorter than the time scheduled, the provider shall be paid the number of hours s/he has reasonably spent in preparation and has scheduled for the deposition. Bill using code DoWC Z0733.
Deposition: 
Treating or Non-treating provider:  DoWC Z0734		$325.00 per hr.
Billed in half-hour increments
(4)	Testimony:
Calculation of the provider’s time shall be "portal to portal” (includes travel time and mileage in both directions).
For testifying at a hearing, if requested,	 the provider is entitled to a four (4) hour deposit in advance in order to schedule the testimony.
If the provider is notified of the cancellation of the testimony at least seven (7) business days prior to the scheduled testimony, the provider shall be paid the number of hours s/he has reasonably spent in preparation and shall refund any portion of an advance payment in excess of time actually spent preparing and/or testifying. Bill using code DoWC Z0735.
If the provider is notified of the cancellation of the testimony at least  five (5) business days but less than seven (7) business days prior to the scheduled testimony, the provider shall be paid the number of hours s/he has reasonably spent in preparation and one-half the time scheduled for the testimony. Bill using code DoWC Z0736.
If the provider is notified of a cancellation less than five (5) business days prior to the date of the testimony or the testimony is shorter than the time scheduled, the provider shall be paid the number of hours s/he has reasonably spent in preparation and has scheduled for the testimony. Bill using code DoWC Z0737.
Testimony:                    
Treating or Non-treating provider:    DoWC Z0738  	$450.00 per hour
(E)	Injured Worker Travel Expenses
The payer shall pay an injured worker for reasonable and necessary expenses for travel to and from medical appointments and reasonable mileage to obtain prescribed medications.  The rate for mileage shall be 53 cents per mile.  The injured worker shall submit a request to the payer showing the date(s) of travel and mileage, with an explanation for any other reasonable and necessary travel expenses incurred or anticipated.
Mileage Expense Billing Code:    DoWC Z0723
Other Travel Expenses Billing Code:  DoWC Z0724
(F)	Permanent Impairment Rating
(1)	The payer is only required to pay for one (1) combined whole-person permanent impairment rating per claim, except as otherwise provided in the Workers' Compensation Rules of Procedures.  Exceptions that may require payment for an additional impairment rating include, but are not limited to, reopened cases, as ordered by the Director or an Administrative Law Judge, or a subsequent request to review apportionment.  The authorized treating provider is required to submit in writing all permanent restrictions and future maintenance care related to the injury or occupational disease.
(2)	Provider Restrictions
The permanent impairment rating shall be determined by the Level II Accredited Authorized Treating Physician (see Rule 5-5(D)).
(3)	Maximum Medical Improvement (MMI) Determined Without any Permanent Impairment
When physicians determine the injured worker is at MMI and has no permanent impairment, the physicians should be reimbursed an appropriate level of E&M service. The authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient should complete the Physician’s Report of Workers’ Compensation Injury (Closing Report), WC164 (see section 18-6(G)(2)).  Reimbursement for the appropriate level of E&M service is only applicable if the physician examines the injured worker and meets the criteria as defined in the RVP©.
(4)	MMI Determined with a Calculated Permanent Impairment Rating
(a)	Calculated Impairment:  The total fee includes the office visit, a complete physical examination, complete history, review of all medical records except when the amount of medical records is extensive (see below), determining MMI, completing all required measurements, referencing all tables used to determine the rating, using all report forms from the AMA's Guide to the Evaluation of Permanent Impairment, Third Edition (Revised), (AMA Guides), and completing the Division form, titled Physician's Report of Workers’ Compensation Injury (Closing Report) WC164.
Extensive medical records take longer than one (1) hour to review and a separate report is created.  The separate report must document each record reviewed, specific details of the record reviewed and the dates represented by the record(s) reviewed.  The separate record review can be billed under special reports for written reports only and requires prior authorization and agreement from the payer for the separate record review fees.
(b)	Use the appropriate DoWC code:
1)	Fee for the Level II Accredited Authorized Treating Physician Providing Primary Care:
Bill DoWC Z0759 $355.00.
2)	Fee for the Referral, Level II Accredited Authorized Physician:
Bill DoWC Z0760 $575.00.
(3)	A return visit for a range of motion (ROM) validation shall be reimbursed using the appropriate separate procedure CPT® code in the medicine section of the RVP©.
4)	Fee for a Multiple Impairment Evaluation Requiring More Than One (1) Level II Accredited Physician:
All physicians providing consulting services for the completion of a whole person impairment rating shall bill using the appropriate E&M consultation code and shall forward their portion of the rating to the authorized physician determining the combined whole person rating.
(G)	Report Preparation
(1)	Routine Reports
Providers shall submit routine reports free of charge as directed in Rule 16-7(E) and by statute.  Requests for additional copies of routine reports and for reports not in Rule 16-7(E) or in statute are reimbursable under the copying fee section of this Rule. Routine reports include:

•	Diagnostic testing 
•	Procedure reports
•	Progress notes
•	Office notes 
•	Operative reports
•	Supply invoices, if requested by the payer
 (2)	Completion of the Physician’s Report of Workers’ Compensation Injury (WC164)
(a)	Initial Report
The authorized treating physician (generally the designated or selected physician)  managing the total workers’ compensation claim of the patient completes the initial WC164 and submits it to the payer and to the injured worker after the first visit with the injured worker.  When applicable, the emergency room or urgent care authorized treating physician for this workers’ compensation injury may also create a WC164 initial report.  Unless requested or prior authorized by the payer in a specific workers’ compensation claim, no other authorized physician should complete and bill for the initial WC164 form. This form shall include completion of items 1-7 and 10.  Note that certain information in Item 2 (such as Insurer Claim #) may be omitted if not known by the provider.
(b)	Closing Report
The WC164 closing report is required from the authorized treating physician (generally the designated or selected physician)  managing the total workers’ compensation claim of the patient when the injured worker is at maximum medical improvement for all injuries or diseases covered under this workers’ compensation claim, with or without a permanent impairment.  The form requires the completion of items 1-5, 6 b-c, 7, 8 and 10.  If the injured worker has sustained a permanent impairment, then item 9 must be completed and the following additional information shall be attached to the bill at the time MMI is determined:
1)	All necessary permanent impairment rating reports when the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is Level II Accredited, or
2)	The name of the Level II Accredited Physician requested to perform the permanent impairment rating when a rating is necessary and the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is not determining the permanent impairment rating.
(c)	Payer Requested WC164 Report 
If the payer requests a provider complete the WC164 report, the payer shall pay the provider for the completion and submission of the completed WC164 report.
(d)	Provider Initiated WC164 Report 
If a provider wants to use the WC164 report as a progress report or for any purpose other than those designated in section18-6(G)(2)(a), (b) or (c), and seeks reimbursement for completion of the form, the provider shall get prior approval from the payer.
(e)	Billing Codes and Maximum Allowance for completion and submission of WC164 report 
Maximum allowance for the completion and submission of the WC164 report is:
DoWC Z0750  	$47.00	Initial Report
DoWC Z0751	$47.00	Progress Report (Payer Requested or Provider Initiated)
DoWC Z0752	$47.00	Closing Report
DoWC Z0753	$47.00	Initial and Closing Reports are completed on the
		same form for the same date of service
(3)	Request for physicians to complete additional forms sent to them by a payer or employer shall be paid by the requesting party.  A form requiring 15 minutes or less of a physician’s time shall be billed pursuant to (a) and (b) below.  Forms requiring more than 15 minutes shall be paid as a special report.
(a)	Billing Code Z0754 
(b)	Maximum fee is $47.00 per form completion
(4)	Special Reports
Description:  The term special reports includes reports not otherwise addressed under Rule 16, Utilization Standards, Rule 17, Medical Treatment Guidelines and Rule 18, including any form, questionnaire or letter with variable content.  This includes, but is not limited to, independent medical evaluations (Z0756) or reviews when the physician is requested to review files and examine the patient to provide an opinion for the requesting party,  performed outside C.R.S. §8-42-107.2 (the Division IME process) and treating or non-treating medical reviewers or evaluators producing written reports pertaining to injured workers not otherwise addressed.  Special reports also include payment for meeting, reviewing another’s written record, and amending or signing that record (see section 18-5(I)(7)).  Reimbursement for preparation of special reports or records shall require prior agreement with the requesting party.  
Billable Hours:  Because narrative reports may have variable content, the content and total payment shall be agreed upon by the provider and the report's requester before the provider begins the report.
Advance Payment:  If requested, the provider is entitled to a two (2) hour deposit in advance in order to schedule any patient exam associated with a special report.    
Cancellation:
Written Reports Only:  In cases of cancellation for those special reports not requiring a scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation up to the date of cancellation.  Bill the cancellation using DoWC code Z0761.
IME/report with patient exam:  In cases of special reports requiring a scheduled patient exam, if the provider is notified of a cancellation at least seven (7) business days prior to the scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation and shall refund to the party requesting the special report any portion of an advance payment in excess of time actually spent preparing.  Bill the cancellation using DoWC code Z0762.
In cases of special reports requiring a scheduled patient exam, if the provider is notified of a cancellation at least five (5) business days but less than seven (7) business days prior to the scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation and one-half the time scheduled for the patient exam.  Any portion of a deposit in excess of this amount shall be refunded.  Bill the cancellation using DoWC code Z0763.
In cases of special reports requiring a scheduled patient exam, if the provider is notified of a cancellation less than five (5) business days prior to the scheduled patient exam, the provider shall be paid for the time s/he has reasonably spent in preparation and has scheduled for the patient exam. Bill the cancellation using DoWC code Z0764.
Billing Codes:
Written Report Only 		DoWC Code:	Z0755
IME/Report with patient exam	DoWC Code:	Z0756
Lengthy Form Completion	DoWC Code:	Z0757
18-5(I)(7) meeting and report
with Non-treating Physician	DoWC Code:	Z0758
Special Report Maximum Fees: 	$325.00 per hour billed in 15- minute increments.
CRS 8-43-404 IME Audio Recording	DoWC Code:	Z0766
					$30.00 per exam
CRS 8-43-404 IME Audio copying fee	DoWC Code:	Z0767
					$20.00 per copy
(5)	Chronic Opioid Management Report 
(a)	When the authorized treating physician prescribes long-term opioid treatment, s/he shall use the Division of Workers’ Compensation Chronic Pain Disorder Medical Treatment Guidelines and also review the Colorado State Board of Medical Examiners’ Policy #10-14, “Guidelines for the Use of Controlled Substances for the Treatment of Pain.”  Urine drug tests for chronic opioid management shall employ testing methodologies that meet or exceed industry standards for sensitivity, specificity and accuracy.  The test methodology must be capable of identifying and quantifying the parent compound and relevant metabolites of the opioid prescribed.  In-office screening tests designed to screen for drugs of abuse are not appropriate for chronic opioid compliance monitoring.
1)	Drug testing shall be done prior to the initial long-term drug prescription being implemented and randomly repeated at least annually.
2)	When drug screen tests are ordered, the authorized treating physician shall utilize the Colorado Prescription Drug Monitoring Program (PDMP).
3)	While the injured worker is receiving chronic opioid management, additional drug screens with documented justification may be conducted.  Examples of documented justification include the following:
a)	Concern regarding the functional status of the patient
b)	Abnormal results on previous testing
c)	Change in management of dosage or pain
d)	Chronic daily opioid dosage above 150 mg of morphine or equivalent
4)	The opioids prescribed for long-term treatment (opioids being prescribed for >30 days for non-surgical cases and >30 days post procedure for surgical cases) shall be provided through a pharmacy.
5)	The prescribing authorized treating physician shall review and integrate the screening results, PDMP, and the injured worker’s past and current functional status on the prescribed levels of medications.  A written report will document the treating physician’s assessment of the patient’s past and current functional status of work, leisure activities and activities of daily living competencies.
(b)	Codes and maximum fees for the authorized treating physician for a written report with all the following review services completed and documented:
1)	Ordering and reviewing drug tests
2)	Ordering and reviewing PDMP results
3)	Reviewing the medical records
4)	Reviewing the injured workers’ current functional status
5)	Determining what actions, if any, need to be taken
6)	Appropriate chronic pain diagnostic code (International Classification of Diseases (ICD))
Bill using code DoWC Z0765	$75.00 per 15 minutes
– maximum of 30 minutes per report
NOTE:  This code is not to be used for acute or subacute pain management.
		(6) 	Functional Assessments 
(a) 	Pre-and post-injection assessments by a trained physician, nurse, physician’s assistant, occupational therapist, physical therapist, or a medical assistant may be billed with spinal or sacroiliac (SI) joint injection codes. The following 3 elements are required:
	1) 	A brief commentary on the procedures, including the anesthesia used in the injection and verification of the needle placement by fluoroscopy, CT or MRI. 
	2)	Pre-and post-injection procedure shall have at least 3 objective, diagnostically appropriate, functional measures identified, measured and documented.  These may include spinal range of motion; tolerance and time limits for sitting, walking and lifting; straight leg raises for herniated discs; a variety of provocative SI joint maneuvers such as Patrick’s sign, Gaeslen, distraction or gapping and compression tests.  Objective descriptions, preferably with measurements, shall be provided initially and post procedure at the appropriate time for medication effect, usually 30 minutes post procedure.  
	3)	There shall be a trained physician or trained non-physician health care professional detailed report with a pre- and post-procedure pain diagram, normally using a 0-10 point scale.   The patient(s) should be instructed to keep a post injection pain diary that details the patient’s pain level for all pertinent body parts, including any affected limbs.  The patient pain diary should be kept for at least 8 hours post injection and preferably up to seven (7) days.  The patient should be encouraged to also report any changes in activity level post injection.
(b)	If all three elements are documented, the billing code and maximum fee is 
	as follows:
	DoWC Z0770	$91.44 per episode of care; pre-and post, functional assessment related to spinal or SI joint injections.	
(H)	Supplies, Durable Medical Equipment (DME), Orthotics and Prostheses
(1)	Supplies necessary to perform a service or procedure are considered inclusive and not separately reimbursable.  Only supplies that are not an integral part of a service or procedure are considered to be over and above those usually included in the service or procedure.
(2)	Unless other limitations exist in this Rule, medical professionals shall bill supplies, including “Supply et al.,” orthotics, prostheses, DME or drugs, including injectables, using Medicare’s HCPCS Level II codes, when one exists, as established in the January 2014 Durable Medical Equipment, Prosthetics,  Orthotics and Supplies (DMEPOS) schedule or Medicare’s Part B Drug Average Sale Price (ASP). Otherwise, the billing provider shall identify their cost by submitting a copy of their invoice with their bill. The DMEPOS schedule can be found at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html (last checked 08/14/14). The Medicare Part B Drug Average Sale Price (ASP) fees can be found at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html.
(3)	Payers shall pay medical professionals using Medicare’s January 2014 DMEPOS Colorado HCPCS Level II maximum fee values or Medicare’s Part B Drug ASP values listed for the codes billed. If no code exists, the payer shall pay 120% of the cost for the item as indicated on the provider’s invoice.
(4)	Unless other limitations exist in this Rule, DMEPOS suppliers shall be reimbursed using Medicare’s HCPCS Level II codes, when one exists, as established in the January 2014 DMEPOS schedule. Otherwise, the supplier shall be reimbursed at 100% of Colorado Medicaid’s July 2014 fee schedule. The Colorado Medicaid Fee Schedule can be found at: https://www.colorado.gov/hcpf/provider-rates-fee-schedule. If no Medicare or Medicaid fee schedule value exists, payers shall reimburse Suppliers the published Manufactures Suggested Retail Price (MSRP), the item will be reimbursed at MSRP less 20%. If there is no established fee schedule value or MSRP, reimbursement shall be based on 120% of the cost of the item as indicated on the supplier’s invoice.
(5) 	Reimbursement of supplies to facilities shall be in compliance with sections 18-6 (I) – (N).
(6)      	Payment for professional services associated with the fabrication and/or modification of orthotics, custom splints, adaptive equipment, and/or adaptation and programming of communication systems and devices shall be paid in accordance with the Colorado Medicare HCPCS Level II values.
(7)	Take home exercise supplies with a total cost of $50 or less may be billed without an invoice at a maximum fee of actual billed charges; however, payers reserve the right to request an invoice, at any time, to validate the provider’s cost. Home exercise supplies can include, but are not limited to the following items: therabands, theratubes, band/tube straps, theraputty, bow-tie tubing, fitness cables/trainers, overhead pulleys, exercise balls, cuff weights, dumbbells, ankle weight bands, wrist weight bands, hand squeeze balls, flexbars, digiflex hand exercisers, power webs, plyoballs, spring hand grippers, hand helper rubber band units, ankle stretchers, rocker boards, balance paws, and aqua weights.
(8) 	Complex Rehabilitation Technology dispensed and billed by Non-Physician DMEPOS Suppliers
(a)  	Complex rehabilitation technology (CRT) items, including products such as complex rehabilitation power wheelchairs, highly configurable manual wheelchairs, adaptive seating and positioning systems, and other specialized equipment, such as standing frames and gait trainers, enable individuals to maximize their function and minimize the extent and costs of their medical care.
(b)  	Complex Rehabilitation Technology products must be provided by suppliers who are specifically accredited by a Center for Medicare and Medicaid Services (CMS) deemed accreditation organization as a supplier of CRT and licensed as a DMEPOS Supplier with the Colorado Secretary of State.
(c)   	The maximum fee schedule allowance for CRT is 100% of Medicare’s January 2014 DMEPOS Colorado HCPCS Level II listed fee values.  The DMEPOS schedule can be found at:http://www.cms.gov/Medicare/Medicare-Fee-For-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html 
(d)   	If no Medicare fee schedule value exists for the billed CRT HCPCS code, the Maximum Fee Schedule value is the published Manufacturer’s Suggested Retail Price (MSRP), less 20%.
(I)	Inpatient Hospital Facility Fees
(1)	Provider Restrictions
All non-emergency, inpatient admissions require prior authorization for payment (see Rule 16-9).
(2)	Bills for Services
(a)	Inpatient hospital facility fees shall be billed on the UB-04 and require summary level billing by revenue code.  The provider must submit itemized bills along with the UB-04.
(b)	The maximum inpatient facility fee is determined by applying the Center for Medicare and Medicaid Services (CMS) “Medicare Severity Diagnosis Related Groups” (MS-DRGs) classification system in effect at the time of discharge.  Exhibit #1 of this Rule shows the relative weights per MS-DRGs that are used in calculating the maximum allowance.
The hospital shall indicate the MS-DRG code number FL 71 of the UB-04 billing form and maintain documentation on file showing how the MS-DRG was determined. The hospital shall determine the MS-DRG using the MS-DRGs Definitions Manual in effect at the time of discharge.  The attending physician shall not be required to certify this documentation unless a dispute arises between the hospital and the payer regarding MS-DRG assignment.  The payer may deny payment for services until the appropriate MS-DRG code is supplied.
(c)	Exhibit #1 of this Rule establishes the maximum length of stay (LOS) using the “arithmetic mean LOS”.  However, no additional allowance for exceeding this LOS, other than through the cost outlier criteria under section18-6(I)(3)(d) is allowed.
(d)	Any inpatient admission requiring the use of both an acute care hospital (admission/discharge) and its Medicare certified rehabilitation facility (admission/discharge) is considered as one (1) admission and MS-DRG.  This does not apply to long term care and licensed rehabilitation facilities.
(3)	Inpatient Facility Reimbursement:
(a)	The following types of inpatient facilities are reimbursed at 100% of billed inpatient charges:
1)	Children’s hospitals
2)	Veterans’ Administration hospitals
3)	State psychiatric hospitals
(b)	The following types of inpatient facilities are reimbursed at 80% of billed inpatient charges:
1)	Medicare certified Critical Access Hospitals (CAH) (listed in Exhibit #3 of this Rule) 
2)	Medicare certified long-term care hospitals
3)	Colorado Department of Public Health and Environment (CDPHE) licensed rehabilitation facilities, 
4)	CDPHE licensed psychiatric facilities that are privately owned.
5)	CDPHE licensed skilled nursing facilities (SNF).
(c)	All other inpatient facilities are reimbursed as follows:
Retrieve the relative weights for the assigned MS-DRG from the MS-DRG table in effect at the time of discharge in Exhibit #1 of this Rule and locate the hospital’s base rate in Exhibit #2 of this Rule.
The “Maximum Fee Allowance” is determined by calculating:
1)	(MS-DRG Relative Wt x Specific hospital base rate x 185%) + (trauma center activation allowance) + (organ acquisition, when appropriate).
2)	For trauma center activation allowance, (revenue codes 680-685) see section18-6(J)(6)(b)5).
3)	For organ acquisition allowance, (revenue codes 810-819) see section 18-6(I)(3)(h).
(d)	Outliers are admissions with extraordinary cost warranting additional reimbursement beyond the maximum allowance under section 18-6(I)(3)(c).  To calculate the additional reimbursement, if any:
1)	Determine the “Hospital’s Cost”: 
Total billed charges (excluding any trauma center activation or organ acquisition billed charges) multiplied by the hospital’s cost-to-charge ratio.
2)	Each hospital’s cost-to-charge ratio is given in Exhibit #2 of this Rule.
3)	The “Difference” = “Hospital’s Cost” – “Maximum Fee Allowance” excluding any trauma center activation or organ acquisition allowance (see (c) above).
4)	If the “Difference” is greater than $25,799.00, additional reimbursement is warranted.  The additional reimbursement is determined by the following equation: 
“Difference” x .80 = additional fee allowance
(e)	Inpatient combined with Emergency Room Department (ERD), Trauma Center or organ acquisition reimbursement
1)	If an injured worker is admitted to the hospital, the ERD reimbursement is included in the inpatient reimbursement under section 18-6 (I)(3),
2)	Trauma Center activation fees (see section 18-6(J)(6)(b)5)) and organ acquisition allowance (see section 18-6(I)(3)(h)) are paid in addition to inpatient fees (see sections 18-6(I)(3)(c-d)).
(f)	If an injured worker is admitted to one hospital and is subsequently transferred to another hospital, the payment to the transferring hospital will be based upon a per diem value of the MS-DRG maximum value.  The per diem value is calculated based upon the transferring hospital’s MS-DRG relative weight multiplied by the hospital’s specific base rate (Exhibit #2 of this Rule) divided by the MS-DRG geometric mean length of stay (Exhibit #1 of this Rule).  This per diem amount is multiplied by the actual LOS.  If the patient is admitted and transferred on the same day, the actual LOS equals one (1).  The receiving hospital shall receive the appropriate MS-DRG maximum value.
(g)	To comply with Rule 16-6(B), the payer shall compare each billed charge type:
•	The MS-DRG adjusted billed charges to the MS-DRG allowance (including any outlier allowance);
•	The trauma center activation billed charge to the trauma center activation allowance; and  
•	The organ acquisition charges to the organ acquisition maximum fees under section 18-6(I)(3)(h).
The MS-DRG adjusted billed charges are determined by subtracting the trauma center activation billed charges and the organ acquisition billed charges from the total billed charges.  The final payment is the sum of the lesser of each of these comparisons.
(h)	The organ acquisition allowance will be calculated using the most recent filed computation of organ acquisition costs and charges for hospitals which are certified transplant centers (CMS Worksheet D-4 or subsequent form) plus 20%.
(J)	Outpatient Hospital Facility Fees
(1)	Provider Restrictions
(a)	All non-emergency outpatient surgeries require prior authorization for payment (see Rule 16-9).
(b)	A separate facility fee is only payable if the facility is licensed as a hospital by the Colorado Department of Public Health and Environment (CDPHE) or applicable out of state governing agency and statute.
(2)	Types of Bills for Service
(a)	Outpatient facility fees shall be billed on the UB-04 and require summary level billing by revenue code.  The provider must submit itemized bills along with the UB-04.
(b)	All professional charges (professional services include, but are not limited to, PT/OT, anesthesia,  speech therapy,  etc.) are subject to the RVP© and Dental Fee Schedules as incorporated by this Rule and applicable to all facilities regardless of whether the facility fees are based upon Exhibit #4 of this Rule or a percentage of billed charges.
(c)	Outpatient hospital facility bills include all outpatient surgery, ERD, Clinics, Urgent Care (UC) and diagnostic testing in the Radiology, Pathology or Medicine section of CPT®/RVP©.
 (3)	Outpatient Facility Reimbursement:
(a)	The following types of outpatient facilities are reimbursed at 100% of billed outpatient charges, except for any associated professional fees (see (J)(2)(b) above):
1)	Children’s hospitals
2)	Veterans’ Administration hospitals
3)	State psychiatric hospitals
(b)	The following types of outpatient facilities are reimbursed at 80% of billed outpatient clinic facility charges only, except for any associated professional fees:
1)	CAH facilities listed in Exhibit #3 of this Rule.
 (c)	Exhibit #4 to this Rule
Hospital reimbursement is based upon Medicare’s 2014 Outpatient Prospective Payment System (OPPS) as modified in Exhibit #4 of this Rule. Exhibit #4 lists Medicare’s Outpatient Hospital Ambulatory Prospective Payment (APC) Codes and the Division’s established rates for hospitals and other types of providers as follows:
•	Column 1 lists the APC code number.
•	Column 2 lists APC code description.
•	Column 3 is used to determine maximum fees for all Outpatient Hospital Emergency Room Departments (ERDs).
•	Column 4 is used to determine maximum fees for all hospital facilities not listed under sections18-6(J)(3)(a) and (b).
•	Column 5 is used to determine maximum fees for all Ambulatory Surgery Centers (ASC) when outpatient surgery is performed in an ASC.
To identify which APC grouper is aligned with an Exhibit #4 APC code # and dollar value, use Medicare’s 2014 Addendum B. Grouper code 210 in Exhibit #4 was created by the Division to reimburse RVP© spinal fusion codes not listed in Medicare’s Hospital Outpatient Prospective Payment System, Addendum B. 
(4)	The APC Exhibit #4 values include the following packaged revenue codes inclusive of the following services and may not be billed separately (all surgically implanted items that remain in the body post-surgery are separately payable at cost to the facility):      
	(a)	nursing, technician, and related services;
	(b)	use of the facility where the surgical procedure(s) was performed;
	(c)	drugs and biologicals for which separate payment is not allowed;
	(d)	medical and surgical supplies, durable medical equipment and orthotics not listed as a “pass through”;
	(e)	surgical dressings;
	(f)	equipment;
	(g)	splints, casts and related devices;
	(h)	radiology services when not allowed under Exhibit #4;
	(i)	administrative, record keeping and housekeeping items and services;
	(j)	materials, including supplies and equipment for the administration and monitoring of anesthesia;
	(k)	supervision of the services of an anesthetist by the operating surgeon; and
	(l)	post-operative pain blocks.

Packaged Services	
Revenue Code	Description	
0250	Pharmacy; General Classification	
0251	Pharmacy; Generic Drugs	
0252	Pharmacy; Non-Generic Drugs	
0254	Pharmacy; Drugs Incident to Other Diagnostic Services	
0255	Pharmacy; Drugs Incident to Radiology	
0257	Pharmacy; Non-Prescription	
0258	Pharmacy; IV Solutions	
0259	Pharmacy; Other Pharmacy	
0260	IV Therapy; General Classification	
0261	IV Therapy; Infusion Pump	
0262	IV Therapy; IV Therapy/Pharmacy Services	
0263	IV Therapy; IV Therapy/Drug/Supply Delivery	
0264	IV Therapy; IV Therapy/Supplies	
0269	IV Therapy;  Other IV Therapy	
0270	Medical/Surgical Supplies and Devices; General Classification	
0271	Medical/Surgical Supplies and Devices; Non-sterile Supply	
0272	Medical/Surgical Supplies and Devices; Sterile Supply	
0275	Medical/Surgical Supplies and Devices; Pacemaker	
0276	Medical/Surgical Supplies and Devices; Intraocular Lens	
0278	Medical/Surgical Supplies and Devices; except surgically implanted items 	
0279	Medical/Surgical Supplies and Devices; except surgically implanted items 	
0280	Oncology; General Classification	
0289	Oncology; Other Oncology	
0343	Nuclear Medicine; Diagnostic Radiopharmaceuticals	
0344	Nuclear Medicine; Therapeutic Radiopharmaceuticals	
0370	Anesthesia; General Classification	
0371	Anesthesia; Anesthesia Incident to Radiology	
0372	Anesthesia; Anesthesia Incident to Other DX Services	
0379	Anesthesia; Other Anesthesia	
0390	Administration, Processing and Storage for Blood and Blood Components; General Classification	
0392	Administration, Processing and Storage for Blood and Blood Components; Processing and Storage	
0399	Administration, Processing and Storage for Blood and Blood Components; Other Blood Handling	
0621	Medical Surgical Supplies - Extension of 027X; Supplies Incident to Radiology	
0622	Medical Surgical Supplies - Extension of 027X; Supplies Incident to Other DX Services	
0623	Medical Supplies - Extension of 027X, Surgical Dressings	
0624	Medical Surgical Supplies - Extension of 027X; FDA Investigational Devices	
0630	Pharmacy - Extension of 025X; Reserved	
0631	Pharmacy - Extension of 025X; Single Source Drug	
0632	Pharmacy - Extension of 025X; Multiple Source Drug	
0633	Pharmacy - Extension of 025X; Restrictive Prescription	
0700	Cast Room; General Classification	
0710	Recovery Room; General Classification	
0720	Labor Room/Delivery; General Classification	
0721	Labor Room/Delivery; Labor	
0732	EKG/ECG (Electrocardiogram); Telemetry	
0821	Hemodialysis-Outpatient or Home; Hemodialysis Composite or Other Rate	
0824	Hemodialysis-Outpatient or Home; Maintenance - 100%	
0825	Hemodialysis-Outpatient or Home; Support Services	
0829	Hemodialysis-Outpatient or Home; Other OP Hemodialysis	
0942	Other Therapeutic Services (also see 095X, an extension of 094x); Education/Training	
0943	Other Therapeutic Services (also see 095X, an extension of 094X), Cardiac Rehabilitation	
0948	Other Therapeutic Services (also see 095X, an extension of 094X), Pulmonary Rehabilitation	
(5)	Recognized Status Indicators from Medicare’s Addendum B are applied as follows:
(a)	“A” means use another fee schedule instead of Exhibit #4, i.e., 18-4 Conversion Factors or 18-6(Q) Ambulance Fee Schedule. 
(b)	“B” means it is not recognized by Medicare for Outpatient Hospital services Part B bill type (12x and 130x) and therefore is not separately payable unless separate fees are applicable under another section of this Rule, such as home health.
(c)	“C” means recognized by Medicare as inpatient only procedures; however, the Division does recognize these procedures can be done outpatient if prior authorization is obtained per Rule 16-9.
(d)	“F” means corneal tissue acquisition, certain CRNA services and Hepatitis A vaccines are allowed at a reasonable cost to the facility.  The facility must provide a separate invoice identifying their cost.
(e)	“G” means “Pass-Through Drugs and Biologicals” that are separately payable under Exhibit #4 as an APC.
(f)	“H” means a “Pass-Through Device” that is separately payable under Exhibit #4 based upon cost to the facility.  Any surgically implanted items are allowed at “cost” to the facility.
(g)	“K” means a separately payable “Pass-Through Drug or Biological or Device,” for therapeutic radiopharmaceuticals, brachytherapy sources, blood and blood products as listed under Exhibit #4.
(h)	“L” represents Influenza Vaccine and therefore, is generally not considered workers’ compensation related. 
(i)	Any “Packaged Codes” with Q1, Q2, Q3, or STVX combinations are not recognized unless the payer and provider make a prior agreement.
(j)	“M” means not separately payable unless separate fees are applicable under another section of this Rule, such as home health.
(k)	“N” means the service is bundled and is not separately payable.
(l)	“P” means partial hospitalization and is paid based upon observation fees as outlined in section 18-6(J).
(m)	“R” means separate payment for blood and blood products.
(n)	“S” and “T” mean there are multiple procedures, the highest valued code allowed at 100% of the Exhibit #4 value and up to three (3) additional codes allowed at 50% of the Exhibit #4 value, per episode of care. 
 (o)	“V” represents a clinic or ERD visit and is separately payable for hospitals as specified in section18-6(J). 
(p)	“X” represents Ancillary Services and is separately payable. 
(q)	“Y” represents non-implantable Durable Medical Equipment and is paid according to Medicare’s Durable Medical Equipment Regional Carrier (DMERC) fee schedule for Colorado.
(6)	Total maximum facility value for an outpatient hospital episode of care includes:
(a)	The highest valued CPT® code aligned to APC code per Exhibit #4 plus 50% of any lesser-valued CPT® code aligned APC code values.
Facility fee reimbursement is limited to a maximum of four (4) CPT® procedure codes per episode, with a maximum of only one (1) procedure reimbursed at 100% of the allowed  Exhibit #4 value for the type of facility:
•	Hospital Outpatient ERD bills are reimbursed based upon Column 3;
•	Hospitals are reimbursed based upon Column 4.
•	ASCs are reimbursed based upon Column 5.
(b)	Fees in addition to section 18-6(J)(6) and requirements necessary to be reimbursed under Column 3 from Exhibit #4 for an Outpatient Hospital ERD Column:
1)	Outpatient ERDs within Colorado must be physically located within a hospital licensed by the CDPHE as a general hospital; or 
2)	Free-standing ERD, must have equivalent operations as a licensed ERD; or 
3)	Meets the out-of-state facility’s state’s licensure requirements.
4)	The ERD “Level of Care” is identified based upon one (1) of five (5) levels of care.  The level of care is defined by CPT® E&M definitions and internal level of care guidelines developed by the hospital in compliance with Medicare regulations.  The hospital’s guidelines should establish an appropriate graduation of hospital resources (ERD staff and other resources) as the level of service increases.  Upon request the provider shall supply a copy of their level of care guidelines to the payer. (Only the higher one (1) of any ERD levels or critical care codes shall be paid).
5)	Trauma Center fees are not paid for alerts.  Trauma activation fees are as follows: 
•	Revenue Code 681		$3,000.00
•	Revenue Code 682		$2,500.00
•	Revenue Code 683		$1,000.00
•	Revenue Code 684		            $0
a)	These fees are in addition to ERD and inpatient fees.
b)	Activation fees mean a trauma team has been activated, not just alerted. 
c)	The level of trauma activation shall be determined by CDPHE’s assigned hospital trauma level designation.
6)	The hospital shall be paid an outlier threshold payment if the hospital’s cost is greater than its maximum fee per billed line by $500.00.  The outlier calculation is as follows:
•	“Cost” is calculated by taking the individual hospital’s “CCR” rate listed in Exhibit #2 of this Rule and multiplying it by the hospital’s line charge.
•	“Difference” is equal to the Hospital’s line cost subtracted from the line maximum fee.
•	If the line “difference” is greater than $500.00, then the maximum outlier dollar is 80% of the difference.  If the difference is equal to or less than $500.00 then no additional outlier dollars are warranted.
7)	For the purposes of Rule 16-6 (B), the sum of all outpatient ERD fees charged, less any amounts charged for professional fees found on the same bill, is to be compared to the maximum reimbursement allowed by the calculated value of seciton18-6(J)(6)(b).  The lesser of the two (2) amounts shall be the maximum facility allowance for the ERD episode of care.  A line by line comparison is not appropriate.
8)	If an injured worker is admitted to the hospital through that hospital’s ERD, the ERD reimbursement is included in the inpatient reimbursement under section 18-6(I)(3).
(c)	Multiple APCs identified by multiple CPT® codes are to be indicated by the use of modifiers –51 and –50, respectively.  The 50% reduction applies to all lower valued procedures, even if they are identified in the RVP© as modifier -51 exempt.  The reduction also applies to the second "primary" procedure of bilateral procedures.
1)	All surgical procedures performed in one (1) operating room, regardless of the number of surgeons, are considered one (1) outpatient surgical episode of care for purposes of facility fee reimbursement.
2)	If an arthroscopic procedure is converted to an open procedure on the same joint, only the open procedure is payable.  If an arthroscopic procedure and open procedure are performed on different joints, the two (2) procedures may be separately payable with anatomic modifiers.  
3)	When reported in conjunction with other knee arthroscopy codes, any combination of surgical knee arthroscopies for removal of loose body, foreign body, and/or debridement/shaving of articular cartilage shall be paid only if performed in a different compartment of the knee using G0289.
4)	Discontinued surgeries require the use of modifier -73 (discontinued prior to administration of anesthesia) or modifier -74 (discontinued after administration of anesthesia).  Modifier -73 results in a reimbursement of 50% of the APC value for the primary procedure only.  Modifier -74 allows reimbursement of 100% of the primary procedure value only.
5)	In compliance with Rule 16-6(B), the sum of section 18-6(J)(3)(c) Columns 1-5 is compared to the total facility fee billed charges.  The lesser of the two amounts shall be the maximum facility allowance for the surgical episode of care.  A line by line comparison of billed charges to the calculated maximum fee schedule allowance of section 18-6(J)(3)(c) is not appropriate.
(d)	Any diagnostic testing clinical labs or therapies with a status indicator (SI) of “A” may be reimbursed using Exhibit #8 of this Rule or the appropriate CF to the unit values for the specific CPT® code as listed in the RVP©.
(e)	Observation room Maximum Fee Schedule value is limited to six (6) hours without prior authorization for payment (see Rule 16-9). Documentation should support the medical necessity for observation or convalescent care.  Observation time begins when the patient is placed in a bed for the purpose of initiating observation care in accordance with the physician’s order.  Observation or daily outpatient convalescence time ends when the patient is actually discharged from the hospital or ASC or admitted into a licensed facility for an inpatient stay.  Observation time would not include the time patients remain in the observation area after treatment is finished for reasons such as waiting for transportation home.  Hospital or convalescence licensure is required for billing observation or convalescence time beyond 23 hours.
Billing Codes:
G0378 Observation/Convalescence rate:  $45.00 per hour,
				  round to the nearest hour.
(f)	Professional fees are reimbursed according to the fee schedule times the appropriate conversion factor regardless of the facility type.  Additional reimbursement is payable for the following services not included in the values found in Exhibit #4 of this Rule:
•	ambulance services (Revenue Code 540), see section18-6(Q)
•	blood, blood plasma, platelets (Revenue Codes 380X)
•	Physician or physician assistant services
•	Nurse practitioner services 
•	Licensed clinical psychologist
•	Licensed social workers
•	Rehabilitation services (PT, OT, Respiratory or Speech/Language, Revenue Codes 420, 430,440) are paid based upon the RVP© unit value multiplied by the applicable conversion factor.
(g)	Any prescription for a drug supply to be used longer than a 24 hour period, filled at any clinic, shall fall under the requirements of and be reimbursed as a pharmacy fee, see section 18-6(M).
(h)	Outpatient Hospital Clinic and Urgent Care (Form Locator (FL) 4 are 07xx and revenue codes 51x-53x) Facility Fees  
Clinic Visit fees are limited for all facilities in accordance with the following:
1)	No separate facility fees are allowed for follow-up care visits.  Subsequent care for an initial diagnosis does not qualify for a separate facility fee.  To receive another facility fee, any subsequent diagnosis shall be a new acute care situation entirely different from the initial diagnosis.
2)	No facility fee is appropriate when the injured worker is sent to the employer’s designated provider for a non-urgent episode of care during regular business hours of 8 am to 5 pm, Monday through Friday.
3)	Any specialty care clinic (wound/infections) that require expensive drugs/supplies that are typically not provided by a physician’s office may be allowed a separate clinic fee with prior approval from the payer as outlined in Exhibit #4.
4)	Clinics designated as critical access hospitals (CAH) as listed in Exhibit #3 or rural health facilities as listed in Exhibit #5 (FL4 071x) of this Rule, may be reimbursed a separate clinic fee at 80% of billed charges regardless of whether the clinic is designated by the employer or the time of day or urgency of the episode of care.
Clinic fees are paid based upon Exhibit #4 and as outlined in this Rule.
 (i)	IV Infusions Performed in Outpatient Hospital Facilities
IV infusion therapy performed in an outpatient hospital facility is reimbursed per section18-6(J). 
(K)	Freestanding (Not Affiliated with a Hospital) Outpatient Diagnostic Testing or Treatment Facilities
(1)	Types of facilities
(a)	Ambulatory Surgery Centers licensed by the CDPHE 
(b)	Physician offices 
(c)	Freestanding Radiology Imaging Cardiovascular Testing and Procedure Centers 
(d)	Freestanding Clinical Laboratory Centers
(e)	Urgent Care - facility fees are only payable if the facility qualifies as an Urgent Care facility. Facilities licensed by the CDPHE as a Community Clinic (CC) or a Community Clinic and Emergency Center (CCEC) under 6 CCR 1011-1, Chapter IX should still provide evidence of these qualifications to be reimbursed as an Urgent Care facility.  The facility shall meet all of the following criteria to be eligible for a separate Urgent Care facility fee:
1)	Separate facility dedicated to providing initial walk-in urgent care;
2)	Access without appointment during all operating hours;
3)	State licensed physician on-site at all times exclusively to evaluate walk-in patients;
4)	Support staff dedicated to urgent walk-in visits with certifications in Basic Life Support (BLS);
5)	Advanced Cardiac Life Support (ACLS) certified life support capabilities to stabilize emergencies including, but not limited to, EKG, defibrillator, oxygen and respiratory support equipment (full crash cart), etc.;
6)	Ambulance access;
7)	Professional staff on-site at the facility certified in ACLS;
8)	Extended hours including evening and some weekend hours;
9)	Basic x-ray availability on-site during all operating hours;
10)	Clinical Laboratory Improvement Amendments (CLIA) certified laboratory on-site for basic diagnostic labs or ability to obtain basic laboratory results within 1 hour;
11)	Capabilities include, but are not limited to, suturing, minor procedures, splinting, IV medications and hydration; and
12)	Written procedures exist for the facility’s stabilization and transport processes.
(2)	Billing and Maximum Fees
(a)	ASCs are reimbursed in accordance with section18-6(J) and Column 5 from Exhibit #4 of this Rule. 
(b)	Maximum reimbursement for physicians performing diagnostic testing in their offices during the course of their care shall be based upon the appropriate RVP© unit value multiplied by the applicable 18-4 conversion factor. 
(c)	Maximum Fees for all Freestanding Diagnostic Testing Facilities: 
1)	All providers should indicate whether they are billing for the professional component only (26 modifier) or technical component only (TC modifier) for any diagnostic test or procedure by listing the appropriate RVP© modifier on the required billing form CMS-1500.
2)	Shall be based upon the appropriate RVP© unit value multiplied by the applicable 18-4 conversion factor.
3)	All radiology and cardiovascular codes are reimbursed at 90% of the modified or not modified RVP© unit value multiplied by the radiology 18-4 conversion factor.  A maximum of four (4) radiology codes may be used in one (1) episode of outpatient diagnostic testing.  The highest valued radiology code is allowed at 100% of the maximum value and the remaining three (3) lower valued codes are allowed at 50% of the maximum radiology value.
 4)	Diagnostic testing dyes, contrasts, supplies and drugs are not separately payable.
5)	Fluoroscopy is generally considered incidental when used for guidance when performing higher valued radiology tests.  Refer to CPT® for specific billing instructions.
6)	The maximum fees for all clinical laboratory testing shall be reimbursed according the fees as outlined under Pathology, section 18-5(F).
7)	All observation services must be prior approved by the payer if time is greater than three (3) hours. 
	G0378 Observation rate: $45.00 per hour
(d)	Urgent Care Facility Reimbursement
1)	The total maximum value for an urgent care episode of care includes:
a)	An Urgent Care facility fee maximum allowance of $75.00; and
b)	Prior agreement or authorization is recommended for all facilities billing a separate Urgent Care fee.  Facilities must provide documentation of the required Urgent Care facility criteria as listed in section 18-6(K) if requested by the payer.
c)	All other services/procedures provided in an Urgent Care facility are reimbursed according the appropriate CPT® code relative weight from RVP© multiplied by the appropriate 18-4 conversion factor.
d)	The Observation Room allowance shall not exceed a rate of $45.00 per hour and is limited to a maximum of three (3) hours without prior authorization for payment (see Rule 16-9).
	G0378 Observation rate: $45.00 per hour
e)	All supplies are included in the facility fee for Urgent Care facilities.
g)	Any prescription for a drug supply to be used longer than a 24 hour period, filled at any clinic, shall fall under the requirements of and be reimbursed as a pharmacy fee.  See section18-6(M).
2)	No separate facility fees are allowed for follow-up care.  Subsequent care for an initial diagnosis does not qualify for a separate facility fee.  To receive another facility fee any subsequent diagnosis shall be a new acute care situation entirely different from the initial diagnosis.
3)	No facility fee is appropriate when the injured worker is sent to the employer's designated provider for a non-urgent episode of care during regular business hours of 8 am to 5 pm, Monday through Friday.
(L)	Home Care Services
Prior authorization for payment (see Rule 16-9) is required for all home care services. All skilled home care service providers shall be licensed by the Colorado Department of Public Health and Environment (CDPHE) as Type A providers. The payer and the home health entity should agree in writing on the type of care, the type and skill level of provider, frequency of care and duration of care at each visit, and any financial arrangements to prevent disputes.
(1)        Home Infusion Therapy
The per day or refill rates for home infusion therapy shall include all reasonable and necessary products, equipment, IV administration sets, supplies, supply management, and delivery services necessary to perform the infusion therapy.  Per diem rates are only payable when licensed professionals (RNs) are providing “reasonable and necessary” skilled assessment and evaluation services in the patient’s home.
Skilled Nursing fees are separately payable when the nurse travels to the injured workers home to perform initial and subsequent patient evaluation(s), education, and coordination of care.  Skilled nursing fees are billed and payable as indicated under section 18-6(L)(2).
 (a)	Parenteral Nutrition:
S9364  <1 Liter			$160.00/ day
S9365  1 liter			$174.00/ day
S9366  1.1 - 2.0 liter		$200.00/ day
S9367  2.1 - 3.0 liter		$227.00/ day
S9368  > 3.0 liter		$254.00/ day
The per day rates include the standard total parenteral nutrition (TPN) formula.  Lipids, specialty amino acid formulas, and drugs other than in standard formula are separately payable under section 18-6(M).
(b)	Antibiotic Therapy per day rate by professional + drug cost at Medicare’s Average Sale Price (ASP).  If ASP is not available, bill using the drug cost at Average Wholesale Price (AWP).
S9494 hourly				$158.00/ day
S9497 once every 3 hours		$152.00/ day
S9500 every 24 hours			  $97.00/ day
S9501 once every 12 hours		$110.00/ day
S9502 once every 8 hours		$122.00/ day
S9503 once every 6 hours		$134.00/ day
S9504 once every 4 hours		$146.00/ day
(c)	Chemotherapy per day rate + drug cost at Medicare’s Average Sale Price (ASP).  If ASP is not available, bill using the drug cost at Average Wholesale Price (AWP).
S9329	Administrative Services				$  0.00/ day
S9330	Continuous (24 hrs. or more) chemotherapy	$91.00/ day
S9331	Intermittent (less than 24 hrs.)		           $103.00/ day
(d)	Enteral nutrition (enteral formula and nursing services separately billable):
S9341	Via Gravity			$44.09/ day
S9342	Via Pump			$24.23/ day
S9343	Via Bolus			$24.23/ day
(e)	Pain Management per day or refill + drug cost at Medicare’s Average Sale Price (ASP).  If ASP is not available, bill using the drug cost at Average Wholesale Price (AWP).
S9326	Continuous (24 hrs. or more)			$  79.00/ day
S9327	Intermittent (less than 24 hrs.)			$103.00/ day
S9328	Implanted pump				            $116.00/ refill (No separate daily rate is applicable when the patient has an implanted pain pump.)
(f)	Fluid Replacement per day rate + drug cost at Medicare’s Average Sale Price (ASP).  If ASP is not available, bill using the drug cost at Average Wholesale Price (AWP).
S9373  < 1 liter per day			$61.00/ day
S9374   1 liter per day			$85.00/ day
S9375  >1 but <2 liters per day		$85.00/ day
S9376  >2 liters but <3 liters		$85.00/ day
S9377  >3 liters per day 		$85.00/ day
(g)	Multiple Therapies:
Highest cost per day or refill only + drug cost at Medicare’s Average Sale Price (ASP).  If ASP is not available, bill using the drug cost at Average Wholesale Price (AWP).
Medication/Drug Restrictions - the payment for drugs may be based upon Medicare’s Average Sale Price (ASP).  If ASP is not available, bill using the drug cost at Average Wholesale Price (AWP).
AWP (see section 18-6(M)) of the drug is determined through the use of industry publications such as the monthly Price Alert, First Databank, Inc.
(2)	Nursing Services
(a)	Skilled Nursing (LPN & RN)
S9123 RN 		$111.00/hr.
S9124 LPN		$   89.00/hr.
There is a limit of two (2) hours without prior authorization for payment (see Rule 16-9).
(b)	Certified Nurse Assistant (CNA):
S9122 CNA 		$ 45.00/hr. 
The amount of time spent with the injured worker must be specified in the medical records and on the bill.
(3)	Physical Medicine
Physical medicine procedures are payable at the same rate as provided in section 185(H), Physical Medicine and Rehabilitation.
(4)	Mileage
Travel allowances should be agreed upon with the payer and the mileage rate should not exceed $0.53 per mile, portal to portal.
DoWC code:	Z0772
(5)	Travel Time
Travel is typically included in the fees listed.  Travel time greater than one (1) hour one-way shall be reimbursed.  The fee shall be agreed upon at the time of prior authorization for payment (see Rule 16-9) and shall not exceed $30.00 per hour.
DoWC code:	Z0773 
(M)	Drugs and Medications	
(1)	Drugs (brand name or generic) shall be reported on bills using the applicable identifier from the National Drug Code (NDC) Directory as published by the Food and Drug Administration (FDA) 
(2)	Average Wholesale Price (AWP)
(a)	AWP for brand name and generic pharmaceuticals may be determined through the use of such monthly publications as Price Alert, Red Book, or Medispan.  In case of a dispute on AWP values, the parties should take the average of their referenced published values.
(b)	If published AWP data becomes unavailable, substitute Wholesale Acquisition Cost (WAC) + 20% for AWP everywhere it is found in this Rule.
(3)	Reimbursement for Drugs & Medications 
(a)	For prescriptions, except compounded topical prescriptions, written within 30 days from the date of injury, reimbursement shall be AWP + $4.00.
(b)	For prescriptions, except compounded topical prescriptions, written after 30 days from the date of injury, reimbursement shall be AWP + $4.00.  If drugs have been repackaged, use the original AWP and NDC that was assigned by the source of the repackaged drugs to determine reimbursement. 
(c)	Drugs administered in the course of the provider’s direct care (injectables) shall be reimbursed at the provider’s actual cost incurred or Medicare’s Part B Drug Average Sale Price (ASP). 
(d)	Over-the-counter medications, drugs that are safe and effective for use by the general public without a prescription, are reimbursed at NDC/AWP and are not eligible for dispensing fees.
(4)	Compounded Drugs
All prescriptions shall be billed using the DoWC Z code corresponding with the applicable category for compounded topical products, including prepackaged compounded medications, as follows:
Category I	Z0790	Fee $ 75.00	per 30 day supply
Any anti-inflammatory medication or any local anesthetic single agent.
Category II	Z0791	Fee $150.00	per 30 day supply
Any anti-inflammatory agent or agents in combination with any local anesthetic agent or agents.
Category III	Z0792	Fee $250.00	per 30 day supply
Any single agent other than anti-inflammatory agent or local anesthetic, either alone, or in combination with anti-inflammatory or local anesthetic agents.
Category IV	Z0793	Fee $350.00	per 30 day supply
Two (2) or more agents that are not anti-inflammatory or local anesthetic agents, either alone or in combination with other anti-inflammatory or local anesthetic agents.
All ingredient materials must be listed by quantity used per prescription.  Category fees include materials, shipping and handling, and time.  Regardless of how many ingredients or what type, compounded drugs cannot be reimbursed higher than the Category IV fee.  The 30 day Maximum Fee Schedule value shall be fractioned down to the prescribed and dispensed amount given to the injured worker. 
(5)	Injured Worker Reimbursement
In the event the injured worker has directly paid for authorized prescriptions, the payer shall reimburse the injured worker for the amounts actually paid for authorized prescriptions or authorized over-the-counter drugs within 30 days after submission of the injured worker’s receipt.  See Rule 16-11(G).
(6)	Dietary Supplements, Vitamins and Herbal Medicines
Reimbursement for outpatient dietary supplements, vitamins and herbal medicines dispensed in conjunction with acupuncture and complementary alternative medicine are authorized only by prior agreement of the payer, except if specifically provided for in Rule 17, Medical Treatment Guidelines.
(7)	Prescription Writing
(a)	Physicians shall indicate on the prescription form that the medication is related to a workers’ compensation claim.
(b)	All prescriptions shall be filled with bio-equivalent generic drugs unless the physician indicates "Dispense As Written" (DAW) on the prescription.
(c)	The provider shall prescribe no more than a 60-day supply per prescription.
(8)	Required Billing Forms
(a)	All parties shall use one (1) of the following forms:
1)	CMS-1500 – the dispensing provider shall bill by using the metric quantity and NDC number of the drug being dispensed; or, if one does not exist, the RVP© supply code; or
2)	WC-M4 form or equivalent – each item on the form shall be completed; or
3)	With the agreement of the payer, the National Council for Prescription Drug Programs (NCPDP) or ANSI ASC 837 (American National Standards Institute Accredited Standards Committee) electronic billing transaction containing the same information as in (1) or (2) in this sub-section may be used for billing.
	NCPDP Workers’ Compensation/Property and Casualty (P&C) Universal Claim Form, version 1.1, for prescription drugs billed on paper shall be used by dispensing pharmacies and pharmacy benefit managers (PBMs).  Physicians may use the CMS- 1500 billing form as described in Rule 16-7(B)(1).  
	Physicians shall list the “repackaged” and the “original” NDC numbers in field 24 of the CMS-1500.  List the “repackaged” NDC number first and the “original” NDC number second, with the prefix ‘ORIG’ appended.
(b)	Items prescribed for the work-related injury that do not have an NDC code shall be billed as a supply, using the RVP© supply code (see section18-6(H)).
(c)	The payer may return any prescription billing form if the information is incomplete.
(d)	A signature shall be kept on file indicating that the patient or his/her authorized representative has received the prescription.
(9)	A line-by-line itemization of each drug billed and the payment for that drug shall be made on the payment voucher by the payer.
(N)	Complementary Alternative Medicine (CAM)
CAM is a term used to describe a broad range of treatment modalities, some of which are generally accepted in the medical community and others that remain outside the accepted practice of conventional western medicine.  Non-physician providers of CAM may be both licensed and non-licensed health practitioners with training in one (1) or more forms of therapy and certified by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) in acupuncture and/or Chinese herbology. CAM requires prior authorization for payment (see Rule 16-9). Refer to Rule 17, Medical Treatment Guidelines for the specific types of CAM modalities.
(O)	Acupuncture
Acupuncture is an accepted procedure for the relief of pain and tissue inflammation.  While commonly used for treatment of pain, it may also be used as an adjunct to physical rehabilitation and/or surgery to hasten return of functional recovery.  Acupuncture may be performed with or without the use of electrical current on the needles at the acupuncture site.
(1)	Provider Restrictions
All non-physician providers must be a Licensed Acupuncturist (LAc) by the Colorado Department of Regulatory Agencies as provided in Rule 16, Utilization Standards.  All physician and non-physician providers must provide evidence of training, and licensure upon request of the payer.
(2)	Billing Restrictions
(a)	For treatment frequencies exceeding the maximum allowed in Rule 17, Medical Treatment Guidelines, the provider must obtain prior authorization for payment (see Rule 16-9).
(b)	Unless the provider’s medical records reflect medical necessity and the provider obtains prior authorization for payment (see Rule 16-9), the maximum amount of time allowed for acupuncture and procedures is one (1) hour of procedures, per day, per discipline.

(3)	Billing Codes:
(a)	Reimburse acupuncture, including or not including electrical stimulation, as listed in the RVP©.
(b)	Non-Physician evaluation services
1)	New or established patient services are reimbursable only if the medical record specifies the appropriate history, physical examination, treatment plan or evaluation of the treatment plan.  Payers are only required to pay for evaluation services directly performed by an LAc.  All evaluation notes or reports must be written and signed by the LAc.  Without appropriate supporting documentation, the payer may deny payment.  (See Rule 16-11)
2)	LAc new patient visit:		DOWC Z0800
					Maximum value $99.68 
3)	LAc established patient visit:	DOWC Z0801    
					Maximum value $67.28
(c)	Herbs require prior authorization for payment (see Rule 16-9) and fee agreements as per section18-6(M)(6).
(d)	See the appropriate Physical Medicine and Rehabilitation section of the RVP© for other billing codes and limitations (see also section18-5(H)). 
(e)	Acupuncture supplies are reimbursed in accordance with section 18-6(H).
(P)	Use of an Interpreter
Rates and terms shall be negotiated.  Prior authorization for payment (see Rule 16-9) is required except for emergency treatment.  Use DoWC Z0722 to bill.
(Q)	Ambulance Fee Schedule
(1)	Billing Requirements: 
Payment under the fee schedule for ambulance services is comprised of a base rate payment plus a payment for mileage. Both the transport of the injured worker to the nearest facility and all items and services associated with such transport are considered inclusive with the base rate and mileage rate.
(2)	General Claims Submission:
(a)	All hospitals billing for ground or air ambulance services shall bill on the UB-04 and all other ambulance providers shall bill on the CMS-1500.
(b)	Use the appropriate HCPCS code plus the HCPCS origin/destination modifier.
(c)	The transporting supplier’s name, complete address and provider number should be listed in Item 33 (CMS-1500).
(d)	The zip code for the origin (point of pickup) must be in Item 23 (CMS-1500). If billing on the UB-04 use FL 39-41 with an “AO” and the point of pick up zip code. If billing for multiple trips and the zip code for each origin is the same, services can be submitted on the same claim. If the zip codes are different, a separate claim must be submitted for each trip.
(3)	Ground and Air Ambulance Vehicle and Crew Requirements
As required by the Colorado Department of Public Health and Environment.
(4)	HCPCS Procedure Codes and Maximum Allowances for Ambulance Services:
(a)	Ground (both water and land) Ambulance Base Rates and Mileage
The selection of the base code is based upon the condition of the injured worker at the time of transport, not the vehicle used and includes services and supplies used during the transport.

		Urban	Rural  (R = Zip Code) First 17 miles or > if not a Super Rural	Super Rural (B =Zip code)	
Ground Ambulance 	HCPCS Code Description	Medicare Rate *250%	Medicare Rate *250%	Medicare Rate *250%	
A0425	Ground mileage, per statue mile	$  17.90	$  18.08	$  18.08	
A0426	Ambulance service, advanced life support, non-emergency transport, level 1 (ALS1- Non-Emergency)	$ 671.89	$ 678.48	$ 831.82	
A0427	Ambulance service, advanced life support, emergency transport, level 1 (ALS1-Emergency)	$1,063.83	$1,074.26	$1,317.04	
A0428	Ambulance service, basic life support, non-emergency transport (BLS)	$  559.91	$565.40	$  693.18	
A0429	Ambulance service, basic life support, emergency transport (BLS-Emergency)	$  895.86	$  904.64	$1,109.09	
A0433	Advanced life support, level 2 (ALS2)	$1,539.75	$1,554.85	$1,906.25	
A0434	Specialty care transport (SCT)	$1,819.71	$1,837.55	$2,252.84	
A0432	Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers. 	$  979.84	$  989.45	$  989.45	
The “urban” base rate(s) and mileage rate(s) as indicated in section 18-6(Q) shall be applied to all relevant/applicable ambulance services unless the zip code range area is “Rural” or “Super Rural.”  Medicare MSA zip code grouping is listed on Medicare’s webpage with an “R” indicator for “Rural” and “B” indicator for “Super Rural.”  See Medicare’s Zip Code to Carrier Locality File- Updated 08/27/2014.
(5)	Modifiers
Modifiers identify place of origin and destination of the ambulance trip.  The modifier is to be placed next to the HCPCS code billed. The following is a list of current ambulance modifiers.  Each of the modifiers may be utilized to make up the first and/or second half of a two-letter modifier.  The first letter must describe the origin of the transport, and the second letter must describe the destination (Example: if a patient is picked up at his/her home and transported to the hospital, the modifier to describe the origin and destination would be – RH).
Code 	Description
D	Diagnostic or therapeutic site other than “P” or “H”
E	Residential, domiciliary, custodial facility, nursing home other than SNF (other than 1819 facility)
G	Hospital-based dialysis facility (hospital or hospital-related) which includes:
		- Hospital administered/Hospital located
		- Non-Hospital administered/Hospital located
H	Hospital
I	Site of transfer (e.g., airport, ferry, or helicopter pad) between modes of ambulance transport
J	Non-hospital-based dialysis facility
		- Non-Hospital administered/Non-Hospital located
		- Hospital administered/Non-Hospital located
N	Skilled Nursing Facility (SNF) (1819 Facility)
P	Physician’s Office (includes HMO non-hospital facility, clinic, etc.)
R	Residence
S	Scene of Accident or Acute Event
X	Destination Code Only (Intermediate stop at physician’s office enroute to the hospital, includes HMO non-hospital facility, clinic, etc.)
(6)	Mileage
Charges for mileage must be based on loaded mileage only, i.e., from the pickup of a patient to his/her arrival at the destination. Payment is allowed for all medically necessary mileage.  If mileage is billed, the miles must be in whole numbers. If a trip has a fraction of a mile, round up to the nearest whole number.  Use code “1” as the mileage for trips of less than a mile.
18-7	DENTAL FEE SCHEDULE
The dental fee schedule is adopted using the American Dental Association’s Current Dental Terminology, 2014 (CDT-2014).  However, surgical treatment for dental trauma and subsequent, related procedures may be billed using medical codes from the RVP©.  If billed using medical codes as listed in the RVP©, reimbursement shall be in accordance with the Surgery/Anesthesia section of the RVP© and its corresponding conversion factor.  All dental billing and reimbursement shall be in accordance with the Division's Rule 16, Utilization Standards, and Rule 17, Medical Treatment Guidelines.  See Exhibit #6 of this Rule for the listing and Maximum Fee Schedule value for CDT-2014 dental codes.
Regarding prosthetic appliances, the provider may bill and be reimbursed for 50% of the allowed fee at the time the master casts are prepared for removable prosthodontics or the final impressions are taken for fixed prosthodontics.  The remaining 50% may be billed on insertion of the final prosthesis.

Exhibit #1	
For Hospital Inpatient Discharges Dates of Service on and After 1/1/2015	
MS-DRG 	MDC	TYPE	MS-DRG Title	Weights	Geometric mean LOS	Arithmetic mean LOS	
1	PRE	SURG	HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC	25.3920	28.2	36.1	
2	PRE	SURG	HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC	15.6820	15.8	18.7	
3	PRE	SURG	ECMO OR TRACH W MV 96+ HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.	17.6399	26.2	32.0	
4	PRE	SURG	TRACH W MV 96+ HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.	10.8533	20.2	24.5	
5	PRE	SURG	LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT	10.4973	15.1	20.5	
6	PRE	SURG	LIVER TRANSPLANT W/O MCC	4.7461	7.9	8.8	
7	PRE	SURG	LUNG TRANSPLANT	9.2986	15.8	18.3	
8	PRE	SURG	SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT	5.3302	9.8	11.4	
10	PRE	SURG	PANCREAS TRANSPLANT	4.0849	7.9	9.7	
11	PRE	SURG	TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES W MCC	4.7380	11.3	14.1	
12	PRE	SURG	TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES W CC	3.3293	8.3	10.0	
13	PRE	SURG	TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES W/O CC/MCC	2.1357	5.8	6.6	
14	PRE	SURG	ALLOGENEIC BONE MARROW TRANSPLANT	10.9883	19.7	24.8	
16	PRE	SURG	AUTOLOGOUS BONE MARROW TRANSPLANT W CC/MCC	5.8780	17.5	19.1	
17	PRE	SURG	AUTOLOGOUS BONE MARROW TRANSPLANT W/O CC/MCC	4.1603	8.8	12.3	
20	1	SURG	INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W MCC	9.4423	13.9	16.7	
21	1	SURG	INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W CC	7.1555	11.9	13.4	
22	1	SURG	INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC	4.4934	6.4	7.9	
23	1	SURG	CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT	5.2939	7.9	11.0	
24	1	SURG	CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC	3.7461	4.4	6.3	
25	1	SURG	CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC	4.3374	7.4	9.7	
26	1	SURG	CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC	3.0011	4.7	6.1	
27	1	SURG	CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC	2.2824	2.5	3.3	
28	1	SURG	SPINAL PROCEDURES W MCC	5.3968	9.5	12.2	
29	1	SURG	SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS	3.1573	4.8	6.4	
30	1	SURG	SPINAL PROCEDURES W/O CC/MCC	1.7835	2.6	3.3	
31	1	SURG	VENTRICULAR SHUNT PROCEDURES W MCC	4.1493	7.7	10.9	
32	1	SURG	VENTRICULAR SHUNT PROCEDURES W CC	2.0325	3.3	4.6	
33	1	SURG	VENTRICULAR SHUNT PROCEDURES W/O CC/MCC	1.5602	2.0	2.5	
34	1	SURG	CAROTID ARTERY STENT PROCEDURE W MCC	3.7008	4.5	6.7	
35	1	SURG	CAROTID ARTERY STENT PROCEDURE W CC	2.2109	2.0	2.9	
36	1	SURG	CAROTID ARTERY STENT PROCEDURE W/O CC/MCC	1.7313	1.3	1.5	
37	1	SURG	EXTRACRANIAL PROCEDURES W MCC	3.1459	5.5	8.0	
38	1	SURG	EXTRACRANIAL PROCEDURES W CC	1.5870	2.3	3.4	
39	1	SURG	EXTRACRANIAL PROCEDURES W/O CC/MCC	1.0582	1.3	1.6	
40	1	SURG	PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W MCC	3.7960	8.1	11.0	
41	1	SURG	PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM	2.1267	4.7	6.1	
42	1	SURG	PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC	1.8586	2.5	3.3	
52	1	MED	SPINAL DISORDERS & INJURIES W CC/MCC	1.5813	4.2	5.7	
53	1	MED	SPINAL DISORDERS & INJURIES W/O CC/MCC	0.9294	2.7	3.5	
54	1	MED	NERVOUS SYSTEM NEOPLASMS W MCC	1.3048	3.9	5.3	
55	1	MED	NERVOUS SYSTEM NEOPLASMS W/O MCC	1.0191	3.0	4.1	
56	1	MED	DEGENERATIVE NERVOUS SYSTEM DISORDERS W MCC	1.7615	5.2	7.0	
57	1	MED	DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC	1.0099	3.5	4.8	
58	1	MED	MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W MCC	1.6336	5.2	7.0	
59	1	MED	MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W CC	1.0290	3.8	4.6	
60	1	MED	MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W/O CC/MCC	0.7867	3.0	3.5	
61	1	MED	ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W MCC	2.7571	5.7	7.4	
62	1	MED	ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W CC	1.8555	4.1	4.8	
63	1	MED	ACUTE ISCHEMIC STROKE W USE OF THROMBOLYTIC AGENT W/O CC/MCC	1.5098	3.0	3.4	
64	1	MED	INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC	1.7381	4.6	6.2	
65	1	MED	INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS	1.0643	3.4	4.2	
66	1	MED	INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC	0.7530	2.4	2.8	
67	1	MED	NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W MCC	1.4527	4.0	5.3	
68	1	MED	NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W/O MCC	0.8395	2.3	2.9	
69	1	MED	TRANSIENT ISCHEMIA	0.6985	2.0	2.5	
70	1	MED	NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC	1.6438	4.8	6.5	
71	1	MED	NONSPECIFIC CEREBROVASCULAR DISORDERS W CC	0.9748	3.4	4.4	
72	1	MED	NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC/MCC	0.6947	2.2	2.8	
73	1	MED	CRANIAL & PERIPHERAL NERVE DISORDERS W MCC	1.3290	3.9	5.3	
74	1	MED	CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC	0.8847	2.9	3.7	
75	1	MED	VIRAL MENINGITIS W CC/MCC	1.6595	5.2	6.6	
76	1	MED	VIRAL MENINGITIS W/O CC/MCC	0.8629	3.2	3.7	
77	1	MED	HYPERTENSIVE ENCEPHALOPATHY W MCC	1.6245	4.6	5.9	
78	1	MED	HYPERTENSIVE ENCEPHALOPATHY W CC	0.9361	3.2	4.0	
79	1	MED	HYPERTENSIVE ENCEPHALOPATHY W/O CC/MCC	0.6677	2.2	2.7	
80	1	MED	NONTRAUMATIC STUPOR & COMA W MCC	1.2790	3.7	5.1	
81	1	MED	NONTRAUMATIC STUPOR & COMA W/O MCC	0.7850	2.6	3.5	
82	1	MED	TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC	1.9142	3.2	5.4	
83	1	MED	TRAUMATIC STUPOR & COMA, COMA >1 HR W CC	1.2401	3.3	4.2	
84	1	MED	TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC	0.8592	2.1	2.6	
85	1	MED	TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC	1.9770	4.7	6.5	
86	1	MED	TRAUMATIC STUPOR & COMA, COMA <1 HR W CC	1.1181	3.2	4.1	
87	1	MED	TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC	0.7460	2.1	2.6	
88	1	MED	CONCUSSION W MCC	1.5708	3.7	5.2	
89	1	MED	CONCUSSION W CC	0.9588	2.6	3.2	
90	1	MED	CONCUSSION W/O CC/MCC	0.7353	1.8	2.2	
91	1	MED	OTHER DISORDERS OF NERVOUS SYSTEM W MCC	1.5978	4.2	5.8	
92	1	MED	OTHER DISORDERS OF NERVOUS SYSTEM W CC	0.8989	3.0	3.8	
93	1	MED	OTHER DISORDERS OF NERVOUS SYSTEM W/O CC/MCC	0.6783	2.1	2.6	
94	1	MED	BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W MCC	3.3357	8.2	10.7	
95	1	MED	BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W CC	2.3844	5.9	7.6	
96	1	MED	BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W/O CC/MCC	2.0726	4.5	5.3	
97	1	MED	NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W MCC	3.1625	8.5	10.9	
98	1	MED	NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W CC	1.7189	5.4	6.9	
99	1	MED	NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W/O CC/MCC	1.1609	3.8	4.7	
100	1	MED	SEIZURES W MCC	1.5304	4.1	5.6	
101	1	MED	SEIZURES W/O MCC	0.7567	2.5	3.2	
102	1	MED	HEADACHES W MCC	1.0073	2.9	3.9	
103	1	MED	HEADACHES W/O MCC	0.6915	2.2	2.8	
113	2	SURG	ORBITAL PROCEDURES W CC/MCC	1.8611	3.7	5.1	
114	2	SURG	ORBITAL PROCEDURES W/O CC/MCC	1.1568	2.2	2.9	
115	2	SURG	EXTRAOCULAR PROCEDURES EXCEPT ORBIT	1.2780	3.3	4.4	
116	2	SURG	INTRAOCULAR PROCEDURES W CC/MCC	1.4005	3.2	4.5	
117	2	SURG	INTRAOCULAR PROCEDURES W/O CC/MCC	0.8239	1.7	2.1	
121	2	MED	ACUTE MAJOR EYE INFECTIONS W CC/MCC	1.0635	3.9	5.0	
122	2	MED	ACUTE MAJOR EYE INFECTIONS W/O CC/MCC	0.6352	3.1	3.8	
123	2	MED	NEUROLOGICAL EYE DISORDERS	0.6732	2.0	2.4	
124	2	MED	OTHER DISORDERS OF THE EYE W MCC	1.1432	3.4	4.6	
125	2	MED	OTHER DISORDERS OF THE EYE W/O MCC	0.6852	2.4	3.1	
129	3	SURG	MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE	2.3284	3.8	5.3	
130	3	SURG	MAJOR HEAD & NECK PROCEDURES W/O CC/MCC	1.2599	2.2	2.7	
131	3	SURG	CRANIAL/FACIAL PROCEDURES W CC/MCC	2.3703	4.0	5.6	
132	3	SURG	CRANIAL/FACIAL PROCEDURES W/O CC/MCC	1.4248	2.0	2.6	
133	3	SURG	OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W CC/MCC	1.8644	3.6	5.3	
134	3	SURG	OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC	1.0083	1.7	2.2	
135	3	SURG	SINUS & MASTOID PROCEDURES W CC/MCC	1.9150	4.2	5.7	
136	3	SURG	SINUS & MASTOID PROCEDURES W/O CC/MCC	1.0509	1.6	2.2	
137	3	SURG	MOUTH PROCEDURES W CC/MCC	1.3735	3.6	4.8	
138	3	SURG	MOUTH PROCEDURES W/O CC/MCC	0.7888	1.8	2.3	
139	3	SURG	SALIVARY GLAND PROCEDURES	0.9856	1.4	1.8	
146	3	MED	EAR, NOSE, MOUTH & THROAT MALIGNANCY W MCC	1.9749	5.8	8.2	
147	3	MED	EAR, NOSE, MOUTH & THROAT MALIGNANCY W CC	1.2869	3.8	5.3	
148	3	MED	EAR, NOSE, MOUTH & THROAT MALIGNANCY W/O CC/MCC	0.8205	2.2	2.9	
149	3	MED	DYSEQUILIBRIUM	0.6342	2.0	2.4	
150	3	MED	EPISTAXIS W MCC	1.2943	3.6	4.8	
151	3	MED	EPISTAXIS W/O MCC	0.6690	2.2	2.7	
152	3	MED	OTITIS MEDIA & URI W MCC	1.0162	3.5	4.4	
153	3	MED	OTITIS MEDIA & URI W/O MCC	0.6884	2.6	3.2	
154	3	MED	OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W MCC	1.3703	4.0	5.4	
155	3	MED	OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W CC	0.8848	3.1	3.9	
156	3	MED	OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W/O CC/MCC	0.6516	2.2	2.8	
157	3	MED	DENTAL & ORAL DISEASES W MCC	1.5814	4.6	6.3	
158	3	MED	DENTAL & ORAL DISEASES W CC	0.8519	2.9	3.8	
159	3	MED	DENTAL & ORAL DISEASES W/O CC/MCC	0.5935	2.0	2.5	
163	4	SURG	MAJOR CHEST PROCEDURES W MCC	5.0332	10.7	13.1	
164	4	SURG	MAJOR CHEST PROCEDURES W CC	2.6010	5.4	6.6	
165	4	SURG	MAJOR CHEST PROCEDURES W/O CC/MCC	1.8220	3.2	3.9	
166	4	SURG	OTHER RESP SYSTEM O.R. PROCEDURES W MCC	3.6610	8.7	11.1	
167	4	SURG	OTHER RESP SYSTEM O.R. PROCEDURES W CC	1.9818	5.1	6.5	
168	4	SURG	OTHER RESP SYSTEM O.R. PROCEDURES W/O CC/MCC	1.3291	2.9	3.8	
175	4	MED	PULMONARY EMBOLISM W MCC	1.5271	5.2	6.3	
176	4	MED	PULMONARY EMBOLISM W/O MCC	0.9670	3.5	4.2	
177	4	MED	RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC	1.9492	6.2	7.7	
178	4	MED	RESPIRATORY INFECTIONS & INFLAMMATIONS W CC	1.3909	5.0	6.0	
179	4	MED	RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC	0.9693	3.6	4.4	
180	4	MED	RESPIRATORY NEOPLASMS W MCC	1.6869	5.3	6.9	
181	4	MED	RESPIRATORY NEOPLASMS W CC	1.1582	3.7	4.8	
182	4	MED	RESPIRATORY NEOPLASMS W/O CC/MCC	0.8088	2.4	3.1	
183	4	MED	MAJOR CHEST TRAUMA W MCC	1.5101	4.8	6.0	
184	4	MED	MAJOR CHEST TRAUMA W CC	0.9889	3.3	4.0	
185	4	MED	MAJOR CHEST TRAUMA W/O CC/MCC	0.6628	2.4	2.8	
186	4	MED	PLEURAL EFFUSION W MCC	1.5452	4.8	6.2	
187	4	MED	PLEURAL EFFUSION W CC	1.0691	3.5	4.5	
188	4	MED	PLEURAL EFFUSION W/O CC/MCC	0.7609	2.5	3.2	
189	4	MED	PULMONARY EDEMA & RESPIRATORY FAILURE	1.2136	3.9	5.0	
190	4	MED	CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC	1.1743	4.2	5.1	
191	4	MED	CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC	0.9370	3.4	4.2	
192	4	MED	CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC	0.7190	2.7	3.3	
193	4	MED	SIMPLE PNEUMONIA & PLEURISY W MCC	1.4491	4.9	6.0	
194	4	MED	SIMPLE PNEUMONIA & PLEURISY W CC	0.9688	3.8	4.5	
195	4	MED	SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC	0.7044	2.9	3.4	
196	4	MED	INTERSTITIAL LUNG DISEASE W MCC	1.6635	5.4	6.9	
197	4	MED	INTERSTITIAL LUNG DISEASE W CC	1.0615	3.7	4.6	
198	4	MED	INTERSTITIAL LUNG DISEASE W/O CC/MCC	0.8054	2.7	3.3	
199	4	MED	PNEUMOTHORAX W MCC	1.8345	5.8	7.5	
200	4	MED	PNEUMOTHORAX W CC	1.0084	3.4	4.3	
201	4	MED	PNEUMOTHORAX W/O CC/MCC	0.7096	2.5	3.2	
202	4	MED	BRONCHITIS & ASTHMA W CC/MCC	0.8775	3.2	3.9	
203	4	MED	BRONCHITIS & ASTHMA W/O CC/MCC	0.6535	2.5	3.0	
204	4	MED	RESPIRATORY SIGNS & SYMPTOMS	0.7041	2.1	2.7	
205	4	MED	OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC	1.3999	4.0	5.3	
206	4	MED	OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC	0.7942	2.4	3.1	
207	4	MED	RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS	5.3425	12.4	14.4	
208	4	MED	RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <96 HOURS	2.2969	5.0	6.9	
215	5	SURG	OTHER HEART ASSIST SYSTEM IMPLANT	15.4348	11.3	17.3	
216	5	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W MCC	9.5238	13.0	15.8	
217	5	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W CC	6.3291	8.7	9.9	
218	5	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W/O CC/MCC	5.5693	6.4	7.3	
219	5	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W MCC	7.7067	9.8	11.9	
220	5	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC	5.2056	6.6	7.3	
221	5	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W/O CC/MCC	4.6347	4.9	5.4	
222	5	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W MCC	8.6570	9.9	11.9	
223	5	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W/O MCC	6.2924	4.4	6.0	
224	5	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W MCC	7.6733	7.9	9.8	
225	5	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W/O MCC	5.8610	4.1	4.9	
226	5	SURG	CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC	6.9573	6.3	8.7	
227	5	SURG	CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC	5.4493	2.2	3.3	
228	5	SURG	OTHER CARDIOTHORACIC PROCEDURES W MCC	7.3113	11.2	13.5	
229	5	SURG	OTHER CARDIOTHORACIC PROCEDURES W CC	4.4606	6.5	7.4	
230	5	SURG	OTHER CARDIOTHORACIC PROCEDURES W/O CC/MCC	4.0755	4.3	4.9	
231	5	SURG	CORONARY BYPASS W PTCA W MCC	7.7247	10.6	12.5	
232	5	SURG	CORONARY BYPASS W PTCA W/O MCC	5.5976	7.9	8.6	
233	5	SURG	CORONARY BYPASS W CARDIAC CATH W MCC	7.3493	11.8	13.3	
234	5	SURG	CORONARY BYPASS W CARDIAC CATH W/O MCC	4.8816	8.0	8.6	
235	5	SURG	CORONARY BYPASS W/O CARDIAC CATH W MCC	5.7089	9.0	10.3	
236	5	SURG	CORONARY BYPASS W/O CARDIAC CATH W/O MCC	3.7952	6.0	6.5	
237	5	SURG	MAJOR CARDIOVASC PROCEDURES W MCC	5.0843	6.7	9.6	
238	5	SURG	MAJOR CARDIOVASC PROCEDURES W/O MCC	3.4241	2.6	3.7	
239	5	SURG	AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC	4.7590	10.6	13.5	
240	5	SURG	AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC	2.7594	7.2	8.8	
241	5	SURG	AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W/O CC/MCC	1.4111	4.4	5.2	
242	5	SURG	PERMANENT CARDIAC PACEMAKER IMPLANT W MCC	3.7242	5.8	7.4	
243	5	SURG	PERMANENT CARDIAC PACEMAKER IMPLANT W CC	2.6695	3.6	4.5	
244	5	SURG	PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC	2.1555	2.4	2.9	
245	5	SURG	AICD GENERATOR PROCEDURES	4.6485	3.2	4.6	
246	5	SURG	PERC CARDIOVASC PROC W DRUG-ELUTING STENT W MCC OR 4+ VESSELS/STENTS	3.2368	3.9	5.3	
247	5	SURG	PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC	2.0586	2.0	2.4	
248	5	SURG	PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W MCC OR 4+ VES/STENTS	3.0411	4.8	6.4	
249	5	SURG	PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC	1.8808	2.4	2.9	
250	5	SURG	PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC	2.9885	5.0	6.9	
251	5	SURG	PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC	2.0399	2.1	2.8	
252	5	SURG	OTHER VASCULAR PROCEDURES W MCC	3.2646	5.3	7.8	
253	5	SURG	OTHER VASCULAR PROCEDURES W CC	2.5532	3.9	5.4	
254	5	SURG	OTHER VASCULAR PROCEDURES W/O CC/MCC	1.7304	2.1	2.7	
255	5	SURG	UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W MCC	2.6051	6.5	8.4	
256	5	SURG	UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W CC	1.6986	5.3	6.5	
257	5	SURG	UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W/O CC/MCC	1.0558	3.0	3.9	
258	5	SURG	CARDIAC PACEMAKER DEVICE REPLACEMENT W MCC	2.7613	4.9	6.2	
259	5	SURG	CARDIAC PACEMAKER DEVICE REPLACEMENT W/O MCC	1.9924	2.6	3.4	
260	5	SURG	CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W MCC	3.7456	7.9	10.6	
261	5	SURG	CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W CC	1.8552	3.4	4.5	
262	5	SURG	CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W/O CC/MCC	1.3978	2.3	2.9	
263	5	SURG	VEIN LIGATION & STRIPPING	1.8664	3.4	5.3	
264	5	SURG	OTHER CIRCULATORY SYSTEM O.R. PROCEDURES	2.8292	5.4	8.1	
265	5	SURG	AICD LEAD PROCEDURES	2.8641	2.7	4.1	
266	5	SURG	ENDOVASCULAR CARDIAC VALVE REPLACEMENT W MCC	8.9920	8.4	10.6	
267	5	SURG	ENDOVASCULAR CARDIAC VALVE REPLACEMENT W/O MCC	6.7517	5.0	5.8	
280	5	MED	ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC	1.7289	4.7	6.0	
281	5	MED	ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC	1.0247	3.0	3.7	
282	5	MED	ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC	0.7562	2.0	2.4	
283	5	MED	ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC	1.6753	3.0	4.7	
284	5	MED	ACUTE MYOCARDIAL INFARCTION, EXPIRED W CC	0.7703	1.8	2.4	
285	5	MED	ACUTE MYOCARDIAL INFARCTION, EXPIRED W/O CC/MCC	0.5065	1.3	1.6	
286	5	MED	CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC	2.1240	5.0	6.7	
287	5	MED	CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC	1.1290	2.3	3.1	
288	5	MED	ACUTE & SUBACUTE ENDOCARDITIS W MCC	2.7138	7.6	9.4	
289	5	MED	ACUTE & SUBACUTE ENDOCARDITIS W CC	1.6991	5.8	7.0	
290	5	MED	ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC	1.2476	3.9	4.9	
291	5	MED	HEART FAILURE & SHOCK W MCC	1.5097	4.6	5.9	
292	5	MED	HEART FAILURE & SHOCK W CC	0.9824	3.6	4.4	
293	5	MED	HEART FAILURE & SHOCK W/O CC/MCC	0.6762	2.6	3.1	
294	5	MED	DEEP VEIN THROMBOPHLEBITIS W CC/MCC	1.0480	4.1	5.0	
295	5	MED	DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC	0.6926	3.1	3.7	
296	5	MED	CARDIAC ARREST, UNEXPLAINED W MCC	1.2347	1.8	2.8	
297	5	MED	CARDIAC ARREST, UNEXPLAINED W CC	0.6475	1.3	1.6	
298	5	MED	CARDIAC ARREST, UNEXPLAINED W/O CC/MCC	0.4227	1.1	1.2	
299	5	MED	PERIPHERAL VASCULAR DISORDERS W MCC	1.4094	4.4	5.7	
300	5	MED	PERIPHERAL VASCULAR DISORDERS W CC	0.9770	3.5	4.4	
301	5	MED	PERIPHERAL VASCULAR DISORDERS W/O CC/MCC	0.6776	2.6	3.2	
302	5	MED	ATHEROSCLEROSIS W MCC	1.0311	2.8	3.9	
303	5	MED	ATHEROSCLEROSIS W/O MCC	0.6101	1.8	2.3	
304	5	MED	HYPERTENSION W MCC	1.0016	3.2	4.2	
305	5	MED	HYPERTENSION W/O MCC	0.6272	2.1	2.5	
306	5	MED	CARDIAC CONGENITAL & VALVULAR DISORDERS W MCC	1.3687	3.9	5.1	
307	5	MED	CARDIAC CONGENITAL & VALVULAR DISORDERS W/O MCC	0.7698	2.4	3.1	
308	5	MED	CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC	1.2107	3.8	4.9	
309	5	MED	CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC	0.7865	2.6	3.3	
310	5	MED	CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC	0.5493	1.9	2.2	
311	5	MED	ANGINA PECTORIS	0.5662	1.8	2.2	
312	5	MED	SYNCOPE & COLLAPSE	0.7423	2.3	2.8	
313	5	MED	CHEST PAIN	0.6138	1.6	2.0	
314	5	MED	OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC	1.9195	4.9	6.7	
315	5	MED	OTHER CIRCULATORY SYSTEM DIAGNOSES W CC	0.9613	3.0	3.9	
316	5	MED	OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC/MCC	0.6210	1.9	2.4	
326	6	SURG	STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC	5.3847	11.2	14.5	
327	6	SURG	STOMACH, ESOPHAGEAL & DUODENAL PROC W CC	2.6532	5.8	7.7	
328	6	SURG	STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC	1.4949	2.4	3.2	
329	6	SURG	MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC	5.0776	11.7	14.4	
330	6	SURG	MAJOR SMALL & LARGE BOWEL PROCEDURES W CC	2.5491	7.1	8.4	
331	6	SURG	MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC	1.6580	4.3	4.8	
332	6	SURG	RECTAL RESECTION W MCC	4.7048	10.5	12.8	
333	6	SURG	RECTAL RESECTION W CC	2.4728	6.3	7.3	
334	6	SURG	RECTAL RESECTION W/O CC/MCC	1.6032	3.6	4.2	
335	6	SURG	PERITONEAL ADHESIOLYSIS W MCC	4.2881	10.9	13.1	
336	6	SURG	PERITONEAL ADHESIOLYSIS W CC	2.3539	6.8	8.3	
337	6	SURG	PERITONEAL ADHESIOLYSIS W/O CC/MCC	1.5596	3.9	4.8	
338	6	SURG	APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W MCC	3.0701	7.5	9.2	
339	6	SURG	APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC	1.7340	5.0	5.9	
340	6	SURG	APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC	1.2137	2.9	3.4	
341	6	SURG	APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W MCC	2.2862	4.7	6.4	
342	6	SURG	APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC	1.3112	2.6	3.4	
343	6	SURG	APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC	0.9404	1.6	1.8	
344	6	SURG	MINOR SMALL & LARGE BOWEL PROCEDURES W MCC	3.3079	8.7	11.2	
345	6	SURG	MINOR SMALL & LARGE BOWEL PROCEDURES W CC	1.7107	5.4	6.4	
346	6	SURG	MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC	1.1991	3.8	4.3	
347	6	SURG	ANAL & STOMAL PROCEDURES W MCC	2.6226	6.3	8.7	
348	6	SURG	ANAL & STOMAL PROCEDURES W CC	1.3825	3.9	5.0	
349	6	SURG	ANAL & STOMAL PROCEDURES W/O CC/MCC	0.9078	2.3	2.9	
350	6	SURG	INGUINAL & FEMORAL HERNIA PROCEDURES W MCC	2.4665	5.5	7.5	
351	6	SURG	INGUINAL & FEMORAL HERNIA PROCEDURES W CC	1.4024	3.4	4.3	
352	6	SURG	INGUINAL & FEMORAL HERNIA PROCEDURES W/O CC/MCC	0.9288	1.9	2.3	
353	6	SURG	HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W MCC	2.9077	6.2	8.2	
354	6	SURG	HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC	1.6915	3.9	4.8	
355	6	SURG	HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC	1.2521	2.4	2.9	
356	6	SURG	OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC	3.8573	8.4	11.3	
357	6	SURG	OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC	2.1072	5.1	6.6	
358	6	SURG	OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC/MCC	1.3737	2.9	3.8	
368	6	MED	MAJOR ESOPHAGEAL DISORDERS W MCC	1.8641	4.9	6.4	
369	6	MED	MAJOR ESOPHAGEAL DISORDERS W CC	1.0703	3.4	4.1	
370	6	MED	MAJOR ESOPHAGEAL DISORDERS W/O CC/MCC	0.7390	2.3	2.8	
371	6	MED	MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC	1.8633	6.0	7.8	
372	6	MED	MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC	1.1343	4.6	5.6	
373	6	MED	MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W/O CC/MCC	0.8013	3.4	4.1	
374	6	MED	DIGESTIVE MALIGNANCY W MCC	2.0182	6.0	7.9	
375	6	MED	DIGESTIVE MALIGNANCY W CC	1.2429	4.1	5.2	
376	6	MED	DIGESTIVE MALIGNANCY W/O CC/MCC	0.9021	2.7	3.4	
377	6	MED	G.I. HEMORRHAGE W MCC	1.7775	4.7	6.1	
378	6	MED	G.I. HEMORRHAGE W CC	1.0021	3.2	3.8	
379	6	MED	G.I. HEMORRHAGE W/O CC/MCC	0.6776	2.3	2.7	
380	6	MED	COMPLICATED PEPTIC ULCER W MCC	1.9265	5.4	7.0	
381	6	MED	COMPLICATED PEPTIC ULCER W CC	1.0875	3.5	4.3	
382	6	MED	COMPLICATED PEPTIC ULCER W/O CC/MCC	0.7591	2.6	3.1	
383	6	MED	UNCOMPLICATED PEPTIC ULCER W MCC	1.3215	4.2	5.2	
384	6	MED	UNCOMPLICATED PEPTIC ULCER W/O MCC	0.8510	2.8	3.4	
385	6	MED	INFLAMMATORY BOWEL DISEASE W MCC	1.7649	5.9	7.8	
386	6	MED	INFLAMMATORY BOWEL DISEASE W CC	1.0040	3.9	4.8	
387	6	MED	INFLAMMATORY BOWEL DISEASE W/O CC/MCC	0.7449	2.9	3.6	
388	6	MED	G.I. OBSTRUCTION W MCC	1.6100	5.3	6.9	
389	6	MED	G.I. OBSTRUCTION W CC	0.8717	3.5	4.4	
390	6	MED	G.I. OBSTRUCTION W/O CC/MCC	0.6034	2.6	3.1	
391	6	MED	ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC	1.1976	3.7	5.0	
392	6	MED	ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC	0.7388	2.7	3.3	
393	6	MED	OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC	1.6893	4.6	6.5	
394	6	MED	OTHER DIGESTIVE SYSTEM DIAGNOSES W CC	0.9448	3.3	4.2	
395	6	MED	OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC	0.6574	2.3	2.9	
405	7	SURG	PANCREAS, LIVER & SHUNT PROCEDURES W MCC	5.5387	10.7	14.3	
406	7	SURG	PANCREAS, LIVER & SHUNT PROCEDURES W CC	2.8067	5.9	7.5	
407	7	SURG	PANCREAS, LIVER & SHUNT PROCEDURES W/O CC/MCC	1.9472	3.9	4.8	
408	7	SURG	BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W MCC	3.8967	10.0	12.2	
409	7	SURG	BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC	2.2218	6.3	7.5	
410	7	SURG	BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC	1.6206	4.4	5.1	
411	7	SURG	CHOLECYSTECTOMY W C.D.E. W MCC	3.6261	9.4	11.6	
412	7	SURG	CHOLECYSTECTOMY W C.D.E. W CC	2.4166	6.3	7.4	
413	7	SURG	CHOLECYSTECTOMY W C.D.E. W/O CC/MCC	1.7708	4.2	5.1	
414	7	SURG	CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W MCC	3.5545	8.7	10.6	
415	7	SURG	CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC	2.0267	5.6	6.5	
416	7	SURG	CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC	1.3465	3.6	4.1	
417	7	SURG	LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC	2.4353	5.8	7.3	
418	7	SURG	LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC	1.6600	3.9	4.7	
419	7	SURG	LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC	1.2316	2.4	2.9	
420	7	SURG	HEPATOBILIARY DIAGNOSTIC PROCEDURES W MCC	3.4621	8.0	11.3	
421	7	SURG	HEPATOBILIARY DIAGNOSTIC PROCEDURES W CC	1.7699	3.9	5.4	
422	7	SURG	HEPATOBILIARY DIAGNOSTIC PROCEDURES W/O CC/MCC	1.2352	2.7	3.2	
423	7	SURG	OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W MCC	4.1961	9.8	13.1	
424	7	SURG	OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W CC	2.2993	6.1	7.8	
425	7	SURG	OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC	1.3793	3.7	4.4	
432	7	MED	CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC	1.6710	4.7	6.1	
433	7	MED	CIRRHOSIS & ALCOHOLIC HEPATITIS W CC	0.9173	3.3	4.0	
434	7	MED	CIRRHOSIS & ALCOHOLIC HEPATITIS W/O CC/MCC	0.6229	2.3	2.8	
435	7	MED	MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC	1.7524	5.1	6.7	
436	7	MED	MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC	1.1640	3.8	4.9	
437	7	MED	MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W/O CC/MCC	0.8971	2.6	3.4	
438	7	MED	DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC	1.7023	5.0	6.8	
439	7	MED	DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC	0.9071	3.5	4.4	
440	7	MED	DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC	0.6423	2.7	3.2	
441	7	MED	DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W MCC	1.8835	4.9	6.8	
442	7	MED	DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC	0.9266	3.3	4.2	
443	7	MED	DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC/MCC	0.6512	2.5	3.0	
444	7	MED	DISORDERS OF THE BILIARY TRACT W MCC	1.6212	4.6	6.1	
445	7	MED	DISORDERS OF THE BILIARY TRACT W CC	1.0654	3.3	4.2	
446	7	MED	DISORDERS OF THE BILIARY TRACT W/O CC/MCC	0.7569	2.3	2.8	
453	8	SURG	COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC	11.1637	9.4	11.6	
454	8	SURG	COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC	8.0184	4.9	5.8	
455	8	SURG	COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC	6.2503	3.1	3.5	
456	8	SURG	SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR 9+ FUS W MCC	9.4039	9.9	12.0	
457	8	SURG	SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR 9+ FUS W CC	6.9074	5.5	6.5	
458	8	SURG	SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR 9+ FUS W/O CC/MCC	5.2637	3.4	3.8	
459	8	SURG	SPINAL FUSION EXCEPT CERVICAL W MCC	6.6686	6.8	8.5	
460	8	SURG	SPINAL FUSION EXCEPT CERVICAL W/O MCC	3.9998	3.0	3.5	
461	8	SURG	BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W MCC	5.0202	6.3	7.6	
462	8	SURG	BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC	3.4905	3.4	3.7	
463	8	SURG	WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W MCC	5.3345	10.6	14.1	
464	8	SURG	WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC	3.0085	6.2	7.8	
465	8	SURG	WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W/O CC/MCC	1.9463	3.7	4.7	
466	8	SURG	REVISION OF HIP OR KNEE REPLACEMENT W MCC	5.1513	6.7	8.2	
467	8	SURG	REVISION OF HIP OR KNEE REPLACEMENT W CC	3.4231	3.8	4.3	
468	8	SURG	REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC	2.7652	2.9	3.1	
469	8	SURG	MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC	3.3905	6.1	7.2	
470	8	SURG	MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC	2.1137	3.0	3.2	
471	8	SURG	CERVICAL SPINAL FUSION W MCC	4.8737	6.3	8.6	
472	8	SURG	CERVICAL SPINAL FUSION W CC	2.9166	2.4	3.4	
473	8	SURG	CERVICAL SPINAL FUSION W/O CC/MCC	2.2655	1.5	1.8	
474	8	SURG	AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W MCC	3.5943	8.5	10.9	
475	8	SURG	AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W CC	2.0504	5.8	7.2	
476	8	SURG	AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W/O CC/MCC	1.1187	3.1	3.9	
477	8	SURG	BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC	3.1638	8.5	10.4	
478	8	SURG	BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC	2.2441	5.4	6.6	
479	8	SURG	BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC	1.7312	3.2	4.0	
480	8	SURG	HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC	3.0052	6.9	8.0	
481	8	SURG	HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC	1.9776	4.7	5.1	
482	8	SURG	HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC	1.6243	3.8	4.1	
483	8	SURG	MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES	2.4205	2.0	2.4	
485	8	SURG	KNEE PROCEDURES W PDX OF INFECTION W MCC	3.0949	7.9	9.5	
486	8	SURG	KNEE PROCEDURES W PDX OF INFECTION W CC	2.0656	5.5	6.2	
487	8	SURG	KNEE PROCEDURES W PDX OF INFECTION W/O CC/MCC	1.5630	3.9	4.6	
488	8	SURG	KNEE PROCEDURES W/O PDX OF INFECTION W CC/MCC	1.7225	3.4	4.1	
489	8	SURG	KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC	1.3186	2.3	2.6	
492	8	SURG	LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W MCC	3.1873	6.4	7.9	
493	8	SURG	LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W CC	2.0354	3.9	4.6	
494	8	SURG	LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W/O CC/MCC	1.5397	2.6	3.0	
495	8	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W MCC	3.0476	7.2	9.5	
496	8	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W CC	1.7289	3.9	5.0	
497	8	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W/O CC/MCC	1.2230	2.0	2.5	
498	8	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W CC/MCC	2.1416	5.2	7.0	
499	8	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W/O CC/MCC	1.0753	2.0	2.5	
500	8	SURG	SOFT TISSUE PROCEDURES W MCC	3.2420	7.6	10.1	
501	8	SURG	SOFT TISSUE PROCEDURES W CC	1.6474	4.2	5.4	
502	8	SURG	SOFT TISSUE PROCEDURES W/O CC/MCC	1.1597	2.3	2.8	
503	8	SURG	FOOT PROCEDURES W MCC	2.3338	6.8	8.4	
504	8	SURG	FOOT PROCEDURES W CC	1.5691	4.8	5.8	
505	8	SURG	FOOT PROCEDURES W/O CC/MCC	1.2474	2.6	3.3	
506	8	SURG	MAJOR THUMB OR JOINT PROCEDURES	1.2881	3.2	4.1	
507	8	SURG	MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC	1.9154	4.1	5.1	
508	8	SURG	MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC	1.5198	1.9	2.4	
509	8	SURG	ARTHROSCOPY	1.5494	3.1	4.1	
510	8	SURG	SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W MCC	2.2857	4.7	5.8	
511	8	SURG	SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W CC	1.6509	3.2	3.8	
512	8	SURG	SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W/O CC/MCC	1.2963	1.9	2.3	
513	8	SURG	HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC	1.4462	3.5	4.7	
514	8	SURG	HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC	0.8996	2.1	2.6	
515	8	SURG	OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC	3.2235	7.1	9.1	
516	8	SURG	OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC	2.0434	4.3	5.3	
517	8	SURG	OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC	1.7251	2.6	3.2	
518	8	SURG	BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM	3.0628	4.2	6.5	
519	8	SURG	BACK & NECK PROC EXC SPINAL FUSION W CC 	1.6468	3.0	3.9	
520	8	SURG	BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC	1.1396	1.7	2.1	
533	8	MED	FRACTURES OF FEMUR W MCC	1.4495	4.3	5.7	
534	8	MED	FRACTURES OF FEMUR W/O MCC	0.7594	2.9	3.5	
535	8	MED	FRACTURES OF HIP & PELVIS W MCC	1.2410	4.1	5.2	
536	8	MED	FRACTURES OF HIP & PELVIS W/O MCC	0.7201	3.0	3.5	
537	8	MED	SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH W CC/MCC	0.8975	3.3	4.0	
538	8	MED	SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH W/O CC/MCC	0.6917	2.5	3.0	
539	8	MED	OSTEOMYELITIS W MCC	1.8276	6.1	8.1	
540	8	MED	OSTEOMYELITIS W CC	1.2967	4.7	5.9	
541	8	MED	OSTEOMYELITIS W/O CC/MCC	0.9218	3.5	4.4	
542	8	MED	PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W MCC	1.9472	6.0	7.8	
543	8	MED	PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC	1.1227	4.0	5.1	
544	8	MED	PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W/O CC/MCC	0.7936	3.1	3.6	
545	8	MED	CONNECTIVE TISSUE DISORDERS W MCC	2.5341	6.0	8.4	
546	8	MED	CONNECTIVE TISSUE DISORDERS W CC	1.1711	3.9	4.9	
547	8	MED	CONNECTIVE TISSUE DISORDERS W/O CC/MCC	0.7985	2.8	3.4	
548	8	MED	SEPTIC ARTHRITIS W MCC	1.9123	6.1	7.7	
549	8	MED	SEPTIC ARTHRITIS W CC	1.1514	4.4	5.5	
550	8	MED	SEPTIC ARTHRITIS W/O CC/MCC	0.8390	3.1	3.8	
551	8	MED	MEDICAL BACK PROBLEMS W MCC	1.5556	4.7	6.1	
552	8	MED	MEDICAL BACK PROBLEMS W/O MCC	0.8698	3.0	3.7	
553	8	MED	BONE DISEASES & ARTHROPATHIES W MCC	1.2187	4.1	5.3	
554	8	MED	BONE DISEASES & ARTHROPATHIES W/O MCC	0.7274	2.8	3.4	
555	8	MED	SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W MCC	1.2636	3.8	5.0	
556	8	MED	SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC	0.7183	2.5	3.1	
557	8	MED	TENDONITIS, MYOSITIS & BURSITIS W MCC	1.4269	5.0	6.1	
558	8	MED	TENDONITIS, MYOSITIS & BURSITIS W/O MCC	0.8522	3.4	4.0	
559	8	MED	AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC	1.8555	4.9	6.7	
560	8	MED	AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC	1.0756	3.4	4.3	
561	8	MED	AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC	0.6688	2.0	2.4	
562	8	MED	FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W MCC	1.3706	4.3	5.5	
563	8	MED	FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC	0.7756	2.9	3.5	
564	8	MED	OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W MCC	1.5036	4.7	6.2	
565	8	MED	OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC	0.9398	3.5	4.3	
566	8	MED	OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W/O CC/MCC	0.6871	2.4	3.0	
570	9	SURG	SKIN DEBRIDEMENT W MCC	2.3952	7.1	9.2	
571	9	SURG	SKIN DEBRIDEMENT W CC	1.4664	5.1	6.2	
572	9	SURG	SKIN DEBRIDEMENT W/O CC/MCC	0.9919	3.7	4.3	
573	9	SURG	SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W MCC	3.7074	8.5	12.7	
574	9	SURG	SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W CC	2.6298	7.0	9.3	
575	9	SURG	SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC	1.4926	4.2	5.4	
576	9	SURG	SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W MCC	4.1423	7.6	11.3	
577	9	SURG	SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W CC	1.9812	3.7	5.4	
578	9	SURG	SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W/O CC/MCC	1.3162	2.3	3.1	
579	9	SURG	OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC	2.7263	6.9	9.1	
580	9	SURG	OTHER SKIN, SUBCUT TISS & BREAST PROC W CC	1.5727	3.8	5.1	
581	9	SURG	OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC	1.1338	2.0	2.5	
582	9	SURG	MASTECTOMY FOR MALIGNANCY W CC/MCC	1.3003	2.0	2.6	
583	9	SURG	MASTECTOMY FOR MALIGNANCY W/O CC/MCC	1.0932	1.5	1.7	
584	9	SURG	BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W CC/MCC	1.7682	3.5	4.9	
585	9	SURG	BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC	1.3752	1.9	2.3	
592	9	MED	SKIN ULCERS W MCC	1.4249	5.1	6.6	
593	9	MED	SKIN ULCERS W CC	1.0196	4.2	5.1	
594	9	MED	SKIN ULCERS W/O CC/MCC	0.7124	3.0	3.8	
595	9	MED	MAJOR SKIN DISORDERS W MCC	1.9629	5.5	7.5	
596	9	MED	MAJOR SKIN DISORDERS W/O MCC	0.9527	3.5	4.5	
597	9	MED	MALIGNANT BREAST DISORDERS W MCC	1.6758	5.3	7.1	
598	9	MED	MALIGNANT BREAST DISORDERS W CC	1.1235	3.7	5.1	
599	9	MED	MALIGNANT BREAST DISORDERS W/O CC/MCC	0.7259	2.4	3.0	
600	9	MED	NON-MALIGNANT BREAST DISORDERS W CC/MCC	0.9803	3.8	4.7	
601	9	MED	NON-MALIGNANT BREAST DISORDERS W/O CC/MCC	0.6314	2.6	3.2	
602	9	MED	CELLULITIS W MCC	1.4557	5.0	6.2	
603	9	MED	CELLULITIS W/O MCC	0.8447	3.5	4.2	
604	9	MED	TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W MCC	1.2624	3.8	5.0	
605	9	MED	TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC	0.7664	2.5	3.1	
606	9	MED	MINOR SKIN DISORDERS W MCC	1.3664	4.1	5.7	
607	9	MED	MINOR SKIN DISORDERS W/O MCC	0.7296	2.7	3.5	
614	10	SURG	ADRENAL & PITUITARY PROCEDURES W CC/MCC	2.4642	4.1	5.6	
615	10	SURG	ADRENAL & PITUITARY PROCEDURES W/O CC/MCC	1.4243	2.2	2.6	
616	10	SURG	AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W MCC	4.1611	10.7	13.1	
617	10	SURG	AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W CC	1.9956	6.0	7.1	
618	10	SURG	AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W/O CC/MCC	1.3512	4.0	5.0	
619	10	SURG	O.R. PROCEDURES FOR OBESITY W MCC	3.2890	4.2	6.4	
620	10	SURG	O.R. PROCEDURES FOR OBESITY W CC	1.8470	2.5	3.1	
621	10	SURG	O.R. PROCEDURES FOR OBESITY W/O CC/MCC	1.5434	1.8	2.0	
622	10	SURG	SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W MCC	3.8047	9.1	12.5	
623	10	SURG	SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC	1.8308	5.6	6.9	
624	10	SURG	SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W/O CC/MCC	1.1314	3.6	4.3	
625	10	SURG	THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W MCC	2.4896	4.5	7.1	
626	10	SURG	THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W CC	1.3080	2.1	3.0	
627	10	SURG	THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W/O CC/MCC	0.8663	1.3	1.4	
628	10	SURG	OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W MCC	3.2935	6.6	9.4	
629	10	SURG	OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC	2.2471	6.1	7.4	
630	10	SURG	OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC/MCC	1.4305	3.1	4.0	
637	10	MED	DIABETES W MCC	1.3944	4.1	5.5	
638	10	MED	DIABETES W CC	0.8261	3.0	3.7	
639	10	MED	DIABETES W/O CC/MCC	0.6068	2.2	2.6	
640	10	MED	MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC	1.1044	3.2	4.4	
641	10	MED	MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC	0.7051	2.6	3.3	
642	10	MED	INBORN AND OTHER DISORDERS OF METABOLISM	1.1429	3.3	4.6	
643	10	MED	ENDOCRINE DISORDERS W MCC	1.6460	5.4	6.8	
644	10	MED	ENDOCRINE DISORDERS W CC	1.0199	3.8	4.6	
645	10	MED	ENDOCRINE DISORDERS W/O CC/MCC	0.7180	2.7	3.3	
652	11	SURG	KIDNEY TRANSPLANT	3.1502	5.7	6.6	
653	11	SURG	MAJOR BLADDER PROCEDURES W MCC	5.7958	12.1	15.0	
654	11	SURG	MAJOR BLADDER PROCEDURES W CC	3.0973	7.6	8.7	
655	11	SURG	MAJOR BLADDER PROCEDURES W/O CC/MCC	2.2590	4.8	5.5	
656	11	SURG	KIDNEY & URETER PROCEDURES FOR NEOPLASM W MCC	3.4517	6.9	9.0	
657	11	SURG	KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC	2.0111	4.3	5.2	
658	11	SURG	KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC	1.5299	2.6	3.0	
659	11	SURG	KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC	3.3813	7.5	10.0	
660	11	SURG	KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC	1.8888	4.1	5.4	
661	11	SURG	KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC	1.3494	2.2	2.6	
662	11	SURG	MINOR BLADDER PROCEDURES W MCC	3.0042	7.7	10.2	
663	11	SURG	MINOR BLADDER PROCEDURES W CC	1.5285	3.8	5.0	
664	11	SURG	MINOR BLADDER PROCEDURES W/O CC/MCC	1.2406	1.8	2.3	
665	11	SURG	PROSTATECTOMY W MCC	3.1585	9.1	11.7	
666	11	SURG	PROSTATECTOMY W CC	1.7512	4.5	6.1	
667	11	SURG	PROSTATECTOMY W/O CC/MCC	0.9690	2.0	2.6	
668	11	SURG	TRANSURETHRAL PROCEDURES W MCC	2.4989	6.4	8.6	
669	11	SURG	TRANSURETHRAL PROCEDURES W CC	1.2662	2.9	4.0	
670	11	SURG	TRANSURETHRAL PROCEDURES W/O CC/MCC	0.8957	1.9	2.4	
671	11	SURG	URETHRAL PROCEDURES W CC/MCC	1.6170	4.0	5.7	
672	11	SURG	URETHRAL PROCEDURES W/O CC/MCC	0.8496	1.8	2.2	
673	11	SURG	OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC	3.5023	6.8	10.2	
674	11	SURG	OTHER KIDNEY & URINARY TRACT PROCEDURES W CC	2.2600	5.1	6.9	
675	11	SURG	OTHER KIDNEY & URINARY TRACT PROCEDURES W/O CC/MCC	1.4443	2.0	2.7	
682	11	MED	RENAL FAILURE W MCC	1.5194	4.6	6.1	
683	11	MED	RENAL FAILURE W CC	0.9512	3.5	4.4	
684	11	MED	RENAL FAILURE W/O CC/MCC	0.6085	2.4	2.9	
685	11	MED	ADMIT FOR RENAL DIALYSIS	1.0025	2.5	3.4	
686	11	MED	KIDNEY & URINARY TRACT NEOPLASMS W MCC	1.7637	5.2	7.0	
687	11	MED	KIDNEY & URINARY TRACT NEOPLASMS W CC	1.0054	3.5	4.5	
688	11	MED	KIDNEY & URINARY TRACT NEOPLASMS W/O CC/MCC	0.6911	2.0	2.5	
689	11	MED	KIDNEY & URINARY TRACT INFECTIONS W MCC	1.1172	4.2	5.1	
690	11	MED	KIDNEY & URINARY TRACT INFECTIONS W/O MCC	0.7794	3.1	3.8	
691	11	MED	URINARY STONES W ESW LITHOTRIPSY W CC/MCC	1.6238	2.8	3.7	
692	11	MED	URINARY STONES W ESW LITHOTRIPSY W/O CC/MCC	1.1286	1.6	2.0	
693	11	MED	URINARY STONES W/O ESW LITHOTRIPSY W MCC	1.3433	3.8	5.1	
694	11	MED	URINARY STONES W/O ESW LITHOTRIPSY W/O MCC	0.6859	1.9	2.3	
695	11	MED	KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W MCC	1.2450	4.0	5.3	
696	11	MED	KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC	0.6619	2.4	3.0	
697	11	MED	URETHRAL STRICTURE	0.9229	2.5	3.3	
698	11	MED	OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC	1.5625	5.1	6.4	
699	11	MED	OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC	1.0170	3.5	4.4	
700	11	MED	OTHER KIDNEY & URINARY TRACT DIAGNOSES W/O CC/MCC	0.7110	2.6	3.2	
707	12	SURG	MAJOR MALE PELVIC PROCEDURES W CC/MCC	1.8155	2.9	3.9	
708	12	SURG	MAJOR MALE PELVIC PROCEDURES W/O CC/MCC	1.3262	1.4	1.6	
709	12	SURG	PENIS PROCEDURES W CC/MCC	2.1341	4.0	6.7	
710	12	SURG	PENIS PROCEDURES W/O CC/MCC	1.2949	1.5	1.8	
711	12	SURG	TESTES PROCEDURES W CC/MCC	2.2547	5.7	8.1	
712	12	SURG	TESTES PROCEDURES W/O CC/MCC	1.0632	2.3	3.4	
713	12	SURG	TRANSURETHRAL PROSTATECTOMY W CC/MCC	1.4828	3.2	4.5	
714	12	SURG	TRANSURETHRAL PROSTATECTOMY W/O CC/MCC	0.7933	1.6	1.9	
715	12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC FOR MALIGNANCY W CC/MCC	2.0051	4.6	6.4	
716	12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC FOR MALIGNANCY W/O CC/MCC	1.1857	1.5	1.7	
717	12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W CC/MCC	1.7717	4.6	6.5	
718	12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W/O CC/MCC	1.0099	2.2	2.8	
722	12	MED	MALIGNANCY, MALE REPRODUCTIVE SYSTEM W MCC	1.7569	5.6	7.4	
723	12	MED	MALIGNANCY, MALE REPRODUCTIVE SYSTEM W CC	1.0635	3.8	4.9	
724	12	MED	MALIGNANCY, MALE REPRODUCTIVE SYSTEM W/O CC/MCC	0.6412	2.1	2.8	
725	12	MED	BENIGN PROSTATIC HYPERTROPHY W MCC	1.1790	4.3	5.6	
726	12	MED	BENIGN PROSTATIC HYPERTROPHY W/O MCC	0.7029	2.6	3.2	
727	12	MED	INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W MCC	1.4195	4.9	6.2	
728	12	MED	INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC	0.8006	3.2	3.8	
729	12	MED	OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W CC/MCC	1.0390	3.4	4.5	
730	12	MED	OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W/O CC/MCC	0.6660	2.2	2.9	
734	13	SURG	PELVIC EVISCERATION, RAD HYSTERECTOMY & RAD VULVECTOMY W CC/MCC	2.5704	4.5	6.5	
735	13	SURG	PELVIC EVISCERATION, RAD HYSTERECTOMY & RAD VULVECTOMY W/O CC/MCC	1.2265	1.8	2.2	
736	13	SURG	UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W MCC	4.4341	10.1	12.5	
737	13	SURG	UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W CC	2.0198	5.2	6.1	
738	13	SURG	UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC	1.2746	2.9	3.3	
739	13	SURG	UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC	3.3133	6.6	9.1	
740	13	SURG	UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC	1.6069	3.0	3.9	
741	13	SURG	UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC/MCC	1.1846	1.7	2.0	
742	13	SURG	UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC	1.5436	2.9	3.9	
743	13	SURG	UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC	0.9954	1.7	1.9	
744	13	SURG	D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W CC/MCC	1.7484	4.1	5.7	
745	13	SURG	D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W/O CC/MCC	0.9553	1.8	2.3	
746	13	SURG	VAGINA, CERVIX & VULVA PROCEDURES W CC/MCC	1.4219	3.1	4.5	
747	13	SURG	VAGINA, CERVIX & VULVA PROCEDURES W/O CC/MCC	0.8892	1.5	1.8	
748	13	SURG	FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES	1.0845	1.5	1.8	
749	13	SURG	OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES W CC/MCC	2.5541	6.0	8.3	
750	13	SURG	OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES W/O CC/MCC	1.1904	2.1	2.6	
754	13	MED	MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W MCC	1.9626	5.9	8.2	
755	13	MED	MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC	1.1066	3.6	4.9	
756	13	MED	MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC	0.6652	2.1	2.8	
757	13	MED	INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W MCC	1.5397	5.7	7.1	
758	13	MED	INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W CC	1.0518	4.3	5.3	
759	13	MED	INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC	0.6931	3.0	3.7	
760	13	MED	MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W CC/MCC	0.8399	2.7	3.5	
761	13	MED	MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W/O CC/MCC	0.4988	1.7	2.1	
765	14	SURG	CESAREAN SECTION W CC/MCC	1.0924	3.8	4.7	
766	14	SURG	CESAREAN SECTION W/O CC/MCC	0.7562	2.9	3.0	
767	14	SURG	VAGINAL DELIVERY W STERILIZATION &/OR D&C	0.8513	2.7	3.4	
768	14	SURG	VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C	1.1184	4.7	5.8	
769	14	SURG	POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE	1.8930	3.5	5.7	
770	14	SURG	ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY	0.8029	1.7	2.2	
774	14	MED	VAGINAL DELIVERY W COMPLICATING DIAGNOSES	0.7168	2.6	3.1	
775	14	MED	VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES	0.5643	2.1	2.3	
776	14	MED	POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE	0.8117	2.7	3.6	
777	14	MED	ECTOPIC PREGNANCY	1.0145	1.7	2.2	
778	14	MED	THREATENED ABORTION	0.5638	2.1	3.2	
779	14	MED	ABORTION W/O D&C	0.6389	1.5	2.0	
780	14	MED	FALSE LABOR	0.2880	1.2	1.3	
781	14	MED	OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS	0.7546	2.6	3.9	
782	14	MED	OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS	0.4057	1.7	2.2	
789	15	MED	NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY	1.5547	1.8	1.8	
790	15	MED	EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE	5.1268	17.9	17.9	
791	15	MED	PREMATURITY W MAJOR PROBLEMS	3.5015	13.3	13.3	
792	15	MED	PREMATURITY W/O MAJOR PROBLEMS	2.1127	8.6	8.6	
793	15	MED	FULL TERM NEONATE W MAJOR PROBLEMS	3.5968	4.7	4.7	
794	15	MED	NEONATE W OTHER SIGNIFICANT PROBLEMS	1.2731	3.4	3.4	
795	15	MED	NORMAL NEWBORN	0.1724	3.1	3.1	
799	16	SURG	SPLENECTOMY W MCC	5.0131	9.4	12.2	
800	16	SURG	SPLENECTOMY W CC	2.6403	5.5	7.0	
801	16	SURG	SPLENECTOMY W/O CC/MCC	1.5477	2.7	3.4	
802	16	SURG	OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W MCC	3.3601	7.9	10.8	
803	16	SURG	OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W CC	1.8440	4.4	5.9	
804	16	SURG	OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W/O CC/MCC	1.2265	2.3	3.0	
808	16	MED	MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC	2.2260	6.0	8.0	
809	16	MED	MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC	1.2037	3.7	4.7	
810	16	MED	MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W/O CC/MCC	0.8409	2.6	3.2	
811	16	MED	RED BLOOD CELL DISORDERS W MCC	1.2829	3.6	4.9	
812	16	MED	RED BLOOD CELL DISORDERS W/O MCC	0.8162	2.6	3.4	
813	16	MED	COAGULATION DISORDERS	1.6534	3.5	4.9	
814	16	MED	RETICULOENDOTHELIAL & IMMUNITY DISORDERS W MCC	1.7048	4.9	6.8	
815	16	MED	RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC	0.9948	3.3	4.2	
816	16	MED	RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC	0.6882	2.3	2.9	
820	17	SURG	LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W MCC	5.5226	11.6	15.3	
821	17	SURG	LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W CC	2.3064	4.5	6.3	
822	17	SURG	LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W/O CC/MCC	1.2805	2.1	2.8	
823	17	SURG	LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W MCC	4.4622	11.4	14.6	
824	17	SURG	LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC	2.2951	5.8	7.6	
825	17	SURG	LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC/MCC	1.3803	2.7	3.7	
826	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W MCC	5.0900	10.4	13.8	
827	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W CC	2.3214	5.1	6.7	
828	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W/O CC/MCC	1.5321	2.8	3.4	
829	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R. PROC W CC/MCC	3.4231	6.7	10.3	
830	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R. PROC W/O CC/MCC	1.2523	2.2	2.9	
834	17	MED	ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC	5.2735	10.1	16.5	
835	17	MED	ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC	2.1042	4.7	7.6	
836	17	MED	ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W/O CC/MCC	1.1693	2.7	4.0	
837	17	MED	CHEMO W ACUTE LEUKEMIA AS SDX OR W HIGH DOSE CHEMO AGENT W MCC	6.4631	16.3	22.2	
838	17	MED	CHEMO W ACUTE LEUKEMIA AS SDX W CC OR HIGH DOSE CHEMO AGENT	2.7923	6.8	9.9	
839	17	MED	CHEMO W ACUTE LEUKEMIA AS SDX W/O CC/MCC	1.2525	4.9	5.7	
840	17	MED	LYMPHOMA & NON-ACUTE LEUKEMIA W MCC	3.1058	7.6	10.5	
841	17	MED	LYMPHOMA & NON-ACUTE LEUKEMIA W CC	1.6226	4.7	6.1	
842	17	MED	LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC/MCC	1.0777	2.9	3.8	
843	17	MED	OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W MCC	1.7902	5.5	7.4	
844	17	MED	OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC	1.2058	4.1	5.4	
845	17	MED	OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC/MCC	0.8551	2.9	3.7	
846	17	MED	CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W MCC	2.3264	5.5	7.7	
847	17	MED	CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC	1.1569	2.9	3.5	
848	17	MED	CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W/O CC/MCC	0.8454	2.4	2.9	
849	17	MED	RADIOTHERAPY	1.4657	4.4	5.7	
853	18	SURG	INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC	5.2068	10.8	13.9	
854	18	SURG	INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC	2.3877	6.7	8.1	
855	18	SURG	INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W/O CC/MCC	1.7057	3.3	4.7	
856	18	SURG	POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC	4.8177	10.0	13.3	
857	18	SURG	POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC	2.0500	5.6	7.0	
858	18	SURG	POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC	1.3390	3.7	4.6	
862	18	MED	POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC	1.8506	5.5	7.2	
863	18	MED	POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC	0.9836	3.7	4.5	
864	18	MED	FEVER	0.8419	2.8	3.5	
865	18	MED	VIRAL ILLNESS W MCC	1.5131	4.2	5.8	
866	18	MED	VIRAL ILLNESS W/O MCC	0.7425	2.7	3.4	
867	18	MED	OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W MCC	2.7245	7.0	9.5	
868	18	MED	OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W CC	1.0897	3.9	4.9	
869	18	MED	OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W/O CC/MCC	0.6877	2.7	3.2	
870	18	MED	SEPTICEMIA OR SEVERE SEPSIS W MV 96+ HOURS	5.8698	12.6	14.7	
871	18	MED	SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W MCC	1.8072	5.1	6.6	
872	18	MED	SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W/O MCC	1.0528	4.0	4.7	
876	19	SURG	O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS	3.3533	7.4	14.9	
880	19	MED	ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION	0.6704	2.2	3.0	
881	19	MED	DEPRESSIVE NEUROSES	0.6464	3.3	4.4	
882	19	MED	NEUROSES EXCEPT DEPRESSIVE	0.6935	3.2	4.5	
883	19	MED	DISORDERS OF PERSONALITY & IMPULSE CONTROL	1.3062	4.4	8.2	
884	19	MED	ORGANIC DISTURBANCES & MENTAL RETARDATION	1.0783	4.1	5.9	
885	19	MED	PSYCHOSES	1.0217	5.4	7.4	
886	19	MED	BEHAVIORAL & DEVELOPMENTAL DISORDERS	0.8288	3.8	6.1	
887	19	MED	OTHER MENTAL DISORDER DIAGNOSES	0.9329	3.0	4.7	
894	20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA	0.4450	2.1	2.9	
895	20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY	1.2152	9.6	12.3	
896	20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC	1.5244	4.7	6.5	
897	20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC	0.6905	3.2	4.0	
901	21	SURG	WOUND DEBRIDEMENTS FOR INJURIES W MCC	3.9929	8.9	13.2	
902	21	SURG	WOUND DEBRIDEMENTS FOR INJURIES W CC	1.7433	4.9	6.8	
903	21	SURG	WOUND DEBRIDEMENTS FOR INJURIES W/O CC/MCC	1.1280	3.0	4.1	
904	21	SURG	SKIN GRAFTS FOR INJURIES W CC/MCC	3.3637	7.0	10.6	
905	21	SURG	SKIN GRAFTS FOR INJURIES W/O CC/MCC	1.3889	3.3	4.4	
906	21	SURG	HAND PROCEDURES FOR INJURIES	1.1789	2.3	3.3	
907	21	SURG	OTHER O.R. PROCEDURES FOR INJURIES W MCC	3.7873	7.4	10.2	
908	21	SURG	OTHER O.R. PROCEDURES FOR INJURIES W CC	1.9575	4.2	5.6	
909	21	SURG	OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC	1.2556	2.5	3.2	
913	21	MED	TRAUMATIC INJURY W MCC	1.1410	3.4	4.7	
914	21	MED	TRAUMATIC INJURY W/O MCC	0.7009	2.3	2.9	
915	21	MED	ALLERGIC REACTIONS W MCC	1.5381	3.6	5.0	
916	21	MED	ALLERGIC REACTIONS W/O MCC	0.5137	1.7	2.0	
917	21	MED	POISONING & TOXIC EFFECTS OF DRUGS W MCC	1.4051	3.4	4.8	
918	21	MED	POISONING & TOXIC EFFECTS OF DRUGS W/O MCC	0.6412	2.1	2.7	
919	21	MED	COMPLICATIONS OF TREATMENT W MCC	1.6750	4.3	6.0	
920	21	MED	COMPLICATIONS OF TREATMENT W CC	0.9850	3.0	3.9	
921	21	MED	COMPLICATIONS OF TREATMENT W/O CC/MCC	0.6602	2.1	2.7	
922	21	MED	OTHER INJURY, POISONING & TOXIC EFFECT DIAG W MCC	1.4953	3.8	5.6	
923	21	MED	OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O MCC	0.7348	2.2	3.3	
927	22	SURG	EXTENSIVE BURNS OR FULL THICKNESS BURNS W MV 96+ HRS W SKIN GRAFT	15.5499	23.0	29.0	
928	22	SURG	FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC/MCC	5.3820	11.0	15.0	
929	22	SURG	FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W/O CC/MCC	2.3344	5.4	7.1	
933	22	MED	EXTENSIVE BURNS OR FULL THICKNESS BURNS W MV 96+ HRS W/O SKIN GRAFT	2.7557	2.3	5.5	
934	22	MED	FULL THICKNESS BURN W/O SKIN GRFT OR INHAL INJ	1.5748	4.0	5.7	
935	22	MED	NON-EXTENSIVE BURNS	1.4717	3.2	4.9	
939	23	SURG	O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W MCC	2.7647	6.0	8.8	
940	23	SURG	O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W CC	1.8274	3.5	5.0	
941	23	SURG	O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC	1.3531	2.1	2.7	
945	23	MED	REHABILITATION W CC/MCC	1.2709	8.5	10.4	
946	23	MED	REHABILITATION W/O CC/MCC	1.0662	6.5	7.6	
947	23	MED	SIGNS & SYMPTOMS W MCC	1.1368	3.5	4.7	
948	23	MED	SIGNS & SYMPTOMS W/O MCC	0.7131	2.6	3.2	
949	23	MED	AFTERCARE W CC/MCC	1.0525	2.9	4.4	
950	23	MED	AFTERCARE W/O CC/MCC	0.5508	2.3	3.1	
951	23	MED	OTHER FACTORS INFLUENCING HEALTH STATUS	0.9188	2.4	5.3	
955	24	SURG	CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA	5.5727	8.0	11.6	
956	24	SURG	LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA	3.6692	6.6	8.0	
957	24	SURG	OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC	6.8453	10.0	14.0	
958	24	SURG	OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC	3.8602	7.3	8.9	
959	24	SURG	OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC	2.5447	4.6	5.7	
963	24	MED	OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC	2.7071	5.6	8.3	
964	24	MED	OTHER MULTIPLE SIGNIFICANT TRAUMA W CC	1.4769	4.2	5.2	
965	24	MED	OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC	0.9418	2.9	3.6	
969	25	SURG	HIV W EXTENSIVE O.R. PROCEDURE W MCC	6.0815	12.3	16.9	
970	25	SURG	HIV W EXTENSIVE O.R. PROCEDURE W/O MCC	2.2085	5.4	7.1	
974	25	MED	HIV W MAJOR RELATED CONDITION W MCC	2.6849	6.7	9.3	
975	25	MED	HIV W MAJOR RELATED CONDITION W CC	1.3047	4.5	5.8	
976	25	MED	HIV W MAJOR RELATED CONDITION W/O CC/MCC	0.8774	3.1	3.9	
977	25	MED	HIV W OR W/O OTHER RELATED CONDITION	1.1305	3.5	4.7	
981	 	SURG	EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC	4.9968	9.9	13.1	
982	 	SURG	EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC	2.8150	5.7	7.4	
983	 	SURG	EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC	1.8039	2.7	3.6	
984	 	SURG	PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC	3.4344	9.4	12.9	
985	 	SURG	PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC	1.8509	5.0	6.9	
986	 	SURG	PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC	1.0453	2.4	3.2	
987	 	SURG	NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC	3.3008	8.3	11.1	
988	 	SURG	NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC	1.7643	4.7	6.3	
989	 	SURG	NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC	1.0454	2.2	3.0	
998	 	**	PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS	 	 	 	
999	 	**	UNGROUPABLE	 	 	 	
Exhibit #2	
Hospital Base Rates and Cost to Charge Ratio’s (CCR)	
Effective for In-Patient Hospital Discharges Occurring on and after January 1, 2015	
Provider Number	Provider Name	Base Rate	CCR	
60001	NORTH COLORADO MEDICAL CENTER	 $6,437.87 	0.266	
60003	LONGMONT UNITED HOSPITAL	 $5,986.39 	0.343	
60004	PLATTE VALLEY MEDICAL CENTER	 $6,126.47 	0.392	
60006	MONTROSE MEMORIAL HOSPITAL	 $5,798.58 	0.412	
60008	SAN LUIS VALLEY REGIONAL MEDICAL CENTER	 $5,809.45 	0.426	
60009	EXEMPLA LUTHERAN MEDICAL CENTER	 $6,116.57 	0.229	
60010	POUDRE VALLEY HOSPITAL	 $5,991.95 	0.352	
60011	DENVER HEALTH MEDICAL CENTER	 $7,848.87 	0.309	
60012	CENTURA HEALTH-ST MARY CORWIN MEDICAL CENTER	 $6,184.18 	0.245	
60013	MERCY REGIONAL MEDICAL CENTER	 $7,596.82 	0.382	
60014	PRESBYTERIAN ST LUKES MEDICAL CENTER	 $6,591.12 	0.199	
60015	CENTURA HEALTH-ST ANTHONY HOSPITAL	 $6,062.53 	0.228	
60016	CENTURA HEALTH-ST THOMAS MORE HOSPITAL	 $6,645.33 	0.412	
60020	PARKVIEW MEDICAL CENTER INC	 $5,857.10 	0.186	
60022	UNIVERSITY COLO HEALTH MEMORIAL HOSPITAL CENTRAL	 $5,829.41 	0.291	
60023	ST MARYS HOSPITAL AND MEDICAL CENTER	 $6,617.45 	0.354	
60024	UNIVERSITY OF COLORADO HOSPITAL ANSCHUTZ INPATIENT	 $8,288.06 	0.197	
60027	BOULDER COMMUNITY HOSPITAL	 $5,895.14 	0.255	
60028	EXEMPLA SAINT JOSEPH HOSPITAL	 $6,671.47 	0.222	
60030	MCKEE MEDICAL CENTER	 $5,756.16 	0.349	
60031	CENTURA HEALTH-PENROSE ST FRANCIS HEALTH SERVICES	 $6,004.53 	0.242	
60032	ROSE MEDICAL CENTER	 $6,508.14 	0.18	
60034	SWEDISH MEDICAL CENTER	 $6,204.04 	0.173	
60036	ARKANSAS VALLEY REGIONAL MEDICAL CENTER	 $5,809.45 	0.477	
60043	KEEFE MEMORIAL HOSPITAL	 $15,160.85 	0.409	
60044	COLORADO PLAINS MEDICAL CENTER	 $6,264.58 	0.294	
60049	YAMPA VALLEY MEDICAL CENTER	 $9,176.20 	0.596	
60054	COMMUNITY HOSPITAL	 $5,725.76 	0.439	
60064	CENTURA HEALTH-PORTER ADVENTIST HOSPITAL	 $5,972.04 	0.215	
60065	NORTH SUBURBAN MEDICAL CENTER	 $6,225.30 	0.161	
60071	DELTA COUNTY MEMORIAL HOSPITAL	 $5,714.48 	0.474	
60075	VALLEY VIEW HOSPITAL ASSOCIATION	 $7,852.40 	0.491	
60076	STERLING REGIONAL MEDCENTER	 $7,449.71 	0.54	
60096	VAIL VALLEY MEDICAL CENTER	 $11,497.98 	0.475	
60100	MEDICAL CENTER OF AURORA, THE	 $6,097.05 	0.19	
60103	CENTURA HEALTH-AVISTA ADVENTIST HOSPITAL	 $6,160.21 	0.289	
60104	CENTURA HEALTH-ST ANTHONY NORTH HOSPITAL	 $6,729.17 	0.245	
60107	NATIONAL JEWISH HEALTH	 $6,126.47 	0.249	
60112	SKY RIDGE MEDICAL CENTER	 $5,971.87 	0.156	
60113	CENTURA HEALTH-LITTLETON ADVENTIST HOSPITAL	 $5,970.33 	0.198	
60114	PARKER ADVENTIST HOSPITAL	 $5,972.14 	0.216	
60116	EXEMPLA GOOD SAMARITAN MEDICAL CENTER LLC	 $5,888.91 	0.202	
60117	ANIMAS SURGICAL HOSPITAL, LLC	 $5,652.38 	0.392	
60118	ST ANTHONY SUMMIT MEDICAL CENTER	 $5,992.00 	0.329	
60119	MEDICAL CENTER OF THE ROCKIES	 $5,671.58 	0.331	
60124	ORTHOCOLORADO HOSPITAL AT ST ANTHONY MED CAMPUS	 $5,960.88 	0.235	
60125	CASTLE ROCK ADVENTIST HOSPITAL	 $5,960.88 	0.249	
69999	Any New Hospital	 $5,884.64 	0.29426	

Exhibit #3	
Effective January 1, 2015 	
Critical Access Hospitals	
Name	Location in Colorado 	
Aspen Valley Hospital	Aspen	
East Morgan County Hospital	Brush	
Estes Park Medical Center	Estes Park	
Family Health West	Fruita	
Grand River Hospital District	Rifle	
Gunnison Valley Hospital	Gunnison	
Haxtun Hospital District	Haxtun	
Heart of the Rockies Regional Medical Center	Salida	
Kit Carson County Memorial Hospital	Burlington	
Lincoln Community Hospital 	Hugo	
Melissa Memorial Hospital	Holyoke	
Middle Park Medical Center	Kremmling/Granby	
Mt. San Rafael Hospital	Trinidad	
Pagosa Springs Medical Center	Pagosa Springs	
Pikes Peak Regional Hospital	Woodland Park	
Pioneers Medical Center	Meeker	
Prowers Medical Center	Lamar	
Rangeley District Hospital	Rangely	
Rio Grande Hospital	Del Norte	
San Luis Valley Health	La Jara	
Sedgwick County Health Center	Julesburg	
Southeast Colorado Hospital District	Springfield	
Southwest Memorial Hospital	Cortez	
Spanish Peaks Regional Health Center	Walsenburg	
St. Vincent General Hospital District	Leadville	
The Memorial Hospital at Craig	Craig	
Weisbrod Memorial County Hospital 	Eads	
Wray Community District Hospital	Wray	
Yuma District Hospital	Yuma	

Exhibit #4	
Effective for Dates of Service on and After 1/1/2015	
Col#1
APC	Column #2
APC Code Description	Column #3
Outpatient Emergency Room Department  Facility Payment Rate *260%	Column #4
Outpatient Hospital  Facility Payment Rate *170%	Column #5
Outpatient ASC Facility: 85% of OP Hospital Facility Payment Rate (Col #4)	
1	Level I Photochemotherapy	 $                98.98 	 $         64.72 	 $              55.01 	
4	Level I Needle Biopsy/ Aspiration Except Bone Marrow	 $             1,069.22 	 $       697.50 	 $            592.88 	
5	Level II Needle Biopsy/Aspiration Except Bone Marrow	 $             1,825.41 	 $   1,142.21 	 $            970.88 	
6	Level I Incision & Drainage	 $                 415.12 	 $       270.17 	 $            229.65 	
7	Level II Incision & Drainage	 $             2,195.83 	 $   1,421.81 	 $        1,208.54 	
8	Level III Incision and Drainage	 $             4,080.65 	 $   2,650.51 	 $        2,252.93 	
12	Level I Debridement & Destruction	 $                 158.16 	 $       103.41 	 $              87.90 	
13	Level II Debridement & Destruction	 $                 217.70 	 $       142.34 	 $            120.99 	
15	Level III Debridement & Destruction	 $                 383.21 	 $       250.51 	 $            212.94 	
16	Level IV Debridement & Destruction	 $                 714.51 	 $       467.04 	 $            396.98 	
17	Level V Debridement & Destruction	 $             3,928.81 	 $   2,561.90 	 $        2,177.62 	
19	Level I Excision/ Biopsy	 $                 828.85 	 $       541.62 	 $            460.38 	
20	Level II Excision/ Biopsy	 $             1,666.37 	 $   1,086.28 	 $            923.34 	
21	Level III Excision/ Biopsy	 $             2,980.48 	 $   1,941.76 	 $        1,650.50 	
22	Level IV Excision/ Biopsy	 $             4,514.98 	 $   2,930.55 	 $        2,490.97 	
28	Level I Breast and Skin Surgery	 $             5,133.08 	 $   3,345.17 	 $        2,843.39 	
29	Level II Breast and Skin Surgery	 $             6,904.48 	 $   4,450.36 	 $        3,782.81 	
30	Level III Breast and Skin Surgery	 $             9,325.65 	 $   5,741.45 	 $        4,880.23 	
31	Level I Health and Behavior Services	 $                   62.19 	 $         40.66 	0	
35	Vascular Puncture and Minor Diagnostic Procedures	 $                   57.49 	 $         37.59 	 $              31.95 	
37	Level IV Needle Biopsy/Aspiration Except Bone Marrow	 $             3,180.45 	 $   1,978.88 	 $        1,682.04 	
39	Level I Implantation of Neurostimulator Generator	 $           44,805.54 	 $   4,028.19 	 $        3,423.96 	
40	Level I Implantation/Revision/Replacement of Neurostimulator Electrodes 	 $           12,028.90 	 $   3,550.28 	 $        3,017.74 	
41	Level I Arthroscopy	 $             5,604.74 	 $   3,652.91 	 $        3,104.98 	
42	Level II Arthroscopy	 $           11,073.43 	 $   6,200.61 	 $        5,270.52 	
45	Bone/Joint Manipulation Under Anesthesia	 $             3,001.57 	 $   1,957.85 	 $        1,664.18 	
47	Arthroplasty without Prosthesis	 $             8,118.37 	 $   4,330.40 	 $        3,680.84 	
48	Level I Arthroplasty or Implantation with Prosthesis	 $           12,061.11 	 $   4,512.43 	 $        3,835.57 	
49	Level I Musculoskeletal Procedures Except Hand and Foot	 $             4,261.58 	 $   2,768.86 	 $        2,353.53 	
50	Level II Musculoskeletal Procedures Except Hand and Foot	 $             6,697.34 	 $   3,939.81 	 $        3,348.84 	
51	Level III Musculoskeletal Procedures Except Hand and Foot	 $             9,832.26 	 $   5,131.46 	 $        4,361.74 	
52	Level IV Musculoskeletal Procedures Except Hand and Foot	 $           16,918.10 	 $   8,234.43 	 $        6,999.26 	
53	Level I Hand Musculoskeletal Procedures	 $             3,251.59 	 $   2,118.38 	 $        1,800.63 	
54	Level II Hand Musculoskeletal Procedures	 $             5,794.75 	 $   3,546.01 	 $        3,014.11 	
55	Level I Foot Musculoskeletal Procedures	 $             4,377.75 	 $   2,774.50 	 $        2,358.33 	
56	Level II Foot Musculoskeletal Procedures	 $           12,660.15 	 $   5,143.82 	 $        4,372.25 	
57	Bunion Procedures	 $             6,796.74 	 $   3,727.64 	 $        3,168.50 	
58	Level I Cast Application	 $                 260.55 	 $       170.34 	 $            144.79 	
59	Level I Strapping	 $                 145.21 	 $         94.95 	 $              80.70 	
60	Manipulation Therapy	 $                   45.76 	 $         29.92 	 $              25.43 	
61	Level II Implantation/Revision/Replacement of Neurostimulator Electrodes 	 $           19,303.67 	 $   4,286.31 	 $        3,643.36 	
62	Level I Treatment Fracture/Dislocation	 $             5,231.69 	 $   3,185.04 	 $        2,707.28 	
63	Level II Treatment Fracture/Dislocation	 $           10,724.53 	 $   5,155.37 	 $        4,382.06 	
64	Level III Treatment Fracture/Dislocation	 $           13,997.46 	 $   5,221.32 	 $        4,438.12 	
65	IORT, MRgFUS, and MEG	 $             3,245.53 	 $   2,114.86 	 $        1,797.63 	
66	Level I Stereotactic Radiosurgery	 $             4,995.38 	 $   3,266.21 	 $        2,776.28 	
67	Level II Stereotactic Radiosurgery	 $             9,338.29 	 $   6,105.81 	 $        5,189.93 	
69	Thoracoscopy	 $             6,864.31 	 $   4,463.97 	 $        3,794.37 	
70	Thoracentesis/Lavage Procedures	 $             1,261.49 	 $       798.59 	 $            678.80 	
71	Level I Endoscopy Upper Airway	 $                 391.09 	 $       255.64 	 $            217.29 	
72	Level II Endoscopy Upper Airway	 $                 960.88 	 $       626.26 	 $            532.32 	
73	Level III Endoscopy Upper Airway	 $             3,162.38 	 $   2,026.36 	 $        1,722.40 	
74	Level IV Endoscopy Upper Airway	 $             4,889.12 	 $   3,127.04 	 $        2,657.99 	
75	Level V Endoscopy Upper Airway	 $             7,934.58 	 $   4,751.16 	 $        4,038.49 	
76	Level I Endoscopy Lower Airway	 $             2,474.21 	 $   1,614.68 	 $        1,372.48 	
77	Level I Pulmonary Treatment	 $                 102.31 	 $         66.90 	 $              56.86 	
78	Level III Pulmonary Treatment	 $                 352.04 	 $       230.13 	 $            195.61 	
79	Ventilation Initiation and Management	 $                 907.95 	 $       591.64 	 $            502.89 	
80	Diagnostic Cardiac Catheterization	 $             6,726.15 	 $   3,870.12 	 $        3,289.60 	
82	Coronary or Non-Coronary Atherectomy	 $           22,990.92 	 $ 10,985.77 	 $        9,337.90 	
83	Coronary Angioplasty, Valvuloplasty, and Level I Endovascular Revascularization of the Lower Extremity 	 $           11,467.07 	 $   5,501.81 	 $        4,676.54 	
84	Level I Electrophysiologic Procedures	 $             1,961.18 	 $   1,270.64 	 $        1,080.04 	
85	Level II Electrophysiologic Procedures	 $           11,005.15 	 $   4,850.60 	 $        4,123.01 	
88	Thrombectomy	 $             8,506.06 	 $   5,028.29 	 $        4,274.05 	
89	Insertion/Replacement of Permanent Pacemaker and Electrodes	 $           22,854.78 	 $   4,616.05 	 $        3,923.64 	
90	Level I Insertion/Replacement of Permanent Pacemaker 	 $           19,118.09 	 $   4,117.59 	 $        3,499.96 	
93	Vascular Reconstruction/Fistula Repair 	 $             7,401.39 	 $   3,128.65 	 $        2,659.36 	
94	Level I Resuscitation and Cardioversion	 $                 415.09 	 $       271.30 	 $            230.60 	
95	Cardiac Rehabilitation	 $                 268.55 	 $       175.59 	 $            149.25 	
96	Level II Noninvasive Physiologic Studies	 $                 340.76 	 $       222.74 	 $            189.32 	
97	Level I Noninvasive Physiologic Studies	 $                 182.47 	 $       119.31 	 $            101.41 	
99	Electrocardiograms/Cardiography	 $                   70.51 	 $         46.10 	 $              39.19 	
100	Cardiac Stress Tests	 $                 634.95 	 $       415.16 	 $            352.88 	
101	Tilt Table Evaluation	 $                 844.17 	 $       551.79 	0	
102	Level II Pulmonary Treatment	 $                 203.29 	 $       132.80 	 $            112.88 	
103	Miscellaneous Vascular Procedures	 $             3,962.74 	 $   2,504.48 	 $        2,128.81 	
104	Transcatheter Placement of Intracoronary Stents	 $           16,545.75 	 $   5,330.21 	 $        4,530.68 	
105	Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices	 $             6,026.02 	 $   2,727.72 	 $        2,318.57 	
106	Insertion/Replacement/Repair of Pacemaker Generator, Leads, and/or Electrodes	 $           11,965.15 	 $   4,133.08 	 $        3,513.12 	
107	Level I Implantation of Cardioverter-Defibrillators (ICDs)	 $           65,047.27 	 $   8,114.90 	 $        6,897.66 	
108	Level II Implantation of Cardioverter-Defibrillators (ICDs)	 $           83,576.87 	 $   9,666.95 	 $        8,216.91 	
110	Transfusion	 $                 741.44 	 $       484.64 	 $            411.95 	
111	Blood Product Exchange	 $             2,821.94 	 $   1,844.93 	 $        1,568.19 	
112	Apheresis and Stem Cell Procedures	 $             7,970.77 	 $   5,209.57 	 $        4,428.14 	
113	Excision Lymphatic System	 $             5,270.07 	 $   3,433.41 	 $        2,918.40 	
114	Thyroid/Lymphadenectomy Procedures	 $           10,330.92 	 $   6,702.14 	 $        5,696.82 	
115	Cannula/Access Device Procedures	 $             7,390.16 	 $   3,766.08 	 $        3,201.17 	
121	Level I Tube or Catheter Changes or Repositioning	 $             1,212.87 	 $       752.11 	 $            639.30 	
126	Level I Urinary and Anal Procedures	 $                 206.13 	 $       134.72 	 $            114.51 	
129	Level I Closed Treatment Fracture	 $                 281.24 	 $       183.83 	 $            156.26 	
130	Level I Laparoscopy	 $             7,620.57 	 $   4,710.13 	 $        4,003.61 	
131	Level II Laparoscopy	 $             9,486.07 	 $   5,995.89 	 $        5,096.51 	
132	Level III Laparoscopy	 $           13,950.09 	 $   7,403.69 	 $        6,293.14 	
138	Level II Closed Treatment Fracture 	 $                 451.00 	 $       294.35 	 $            250.20 	
139	Level III Closed Treatment Fracture 	 $             1,167.19 	 $       753.17 	 $            640.19 	
141	Level I Upper GI Procedures	 $             1,743.22 	 $   1,136.04 	 $            965.63 	
142	Level I Small Intestine Endoscopy	 $             2,176.67 	 $   1,396.31 	 $        1,186.86 	
143	Lower GI Endoscopy	 $             1,915.78 	 $   1,250.75 	 $        1,063.14 	
146	Level I Sigmoidoscopy and Anoscopy	 $             1,198.60 	 $       782.45 	 $            665.08 	
147	Level II Sigmoidoscopy and Anoscopy	 $             2,026.31 	 $   1,289.79 	 $        1,096.32 	
148	Level I Anal/Rectal Procedures	 $             1,229.44 	 $       800.73 	 $            680.62 	
149	Level III Anal/Rectal Procedures	 $             4,963.97 	 $   3,231.39 	 $        2,746.68 	
150	Level IV Anal/Rectal Procedures	 $             6,503.41 	 $   4,091.92 	 $        3,478.13 	
151	Endoscopic Retrograde Cholangio-Pancreatography (ERCP)	 $             5,027.59 	 $   2,945.73 	 $        2,503.87 	
152	Level I Percutaneous Abdominal and Biliary Procedures	 $             4,649.74 	 $   2,463.48 	 $        2,093.96 	
153	Peritoneal and Abdominal Procedures	 $             4,774.61 	 $   3,045.38 	 $        2,588.57 	
154	Hernia/Hydrocele Procedures	 $             6,759.06 	 $   3,857.68 	 $        3,279.03 	
155	Level II Anal/Rectal Procedures	 $             3,691.82 	 $   2,408.33 	 $        2,047.08 	
156	Level III Urinary and Anal Procedures	 $             1,089.82 	 $       706.37 	 $            600.42 	
157	Colorectal Cancer Screening: Barium Enema	 $                 753.90 	 $       492.93 	 $            418.99 	
158	Colorectal Cancer Screening: Colonoscopy	 $             1,681.50 	 $   1,099.33 	 $            934.43 	
159	Colorectal Cancer Screening: Flexible Sigmoidoscopy	 $             1,198.94 	 $       783.53 	 $            666.00 	
160	Level I Cystourethroscopy and other Genitourinary Procedures	 $             1,401.43 	 $       913.29 	 $            776.30 	
161	Level II Cystourethroscopy and other Genitourinary Procedures	 $             3,132.48 	 $   1,992.86 	 $        1,693.93 	
162	Level III Cystourethroscopy and other Genitourinary Procedures	 $             5,219.03 	 $   3,250.35 	 $        2,762.80 	
163	Level IV Cystourethroscopy and other Genitourinary Procedures	 $             7,553.03 	 $   4,830.36 	 $        4,105.81 	
164	Level II Urinary and Anal Procedures	 $                 548.86 	 $       355.14 	 $            301.87 	
165	Level IV Urinary and Anal Procedures	 $             3,689.43 	 $   2,243.45 	 $        1,906.94 	
166	Level I Urethral Procedures	 $             3,975.89 	 $   2,587.14 	 $        2,199.07 	
168	Level II Urethral Procedures	 $             6,592.09 	 $   2,792.59 	 $        2,373.70 	
169	Lithotripsy	 $             7,776.96 	 $   5,073.24 	 $        4,312.26 	
170	Dialysis	 $             1,586.68 	 $   1,034.12 	 $            879.00 	
174	Level IV Laparoscopy	 $           22,342.84 	 $ 11,692.87 	 $        9,938.94 	
177	Level I Echocardiogram with Contrast	 $             1,301.48 	 $       850.54 	 $            722.96 	
178	Level II Echocardiogram with Contrast	 $             1,701.05 	 $   1,112.11 	 $            945.30 	
181	Level II Male Genital Procedures	 $             5,655.81 	 $   3,675.10 	 $        3,123.83 	
183	Level I Male Genital Procedures	 $             4,511.75 	 $   2,943.80 	 $        2,502.23 	
184	Prostate Biopsy	 $             2,761.17 	 $   1,801.59 	 $        1,531.35 	
188	Level II Female Reproductive Proc	 $                 329.34 	 $       214.91 	 $            182.67 	
189	Level III Female Reproductive Proc	 $                 492.52 	 $       321.77 	 $            273.51 	
190	Level I Hysteroscopy	 $             4,584.76 	 $   2,978.54 	 $        2,531.76 	
191	Level I Female Reproductive Proc	 $                   26.86 	 $         17.56 	 $              14.93 	
192	Level IV Female Reproductive Proc	 $                 959.82 	 $       627.51 	 $            533.38 	
193	Level V Female Reproductive Proc	 $             3,575.52 	 $   2,330.59 	 $        1,981.00 	
195	Level VI Female Reproductive Procedures	 $             6,558.71 	 $   4,027.22 	 $        3,423.14 	
202	Level VII Female Reproductive Procedures	 $             9,279.14 	 $   3,798.02 	 $        3,228.32 	
203	Level IV Nerve Injections	 $             4,017.18 	 $   2,622.42 	 $        2,229.05 	
204	Level I Nerve Injections	 $                 525.75 	 $       343.72 	 $            292.16 	
205	Level III Male Genital Procedures	 $             9,238.94 	 $   4,954.10 	 $        4,210.98 	
206	Level II Nerve Injections	 $                 920.37 	 $       601.42 	 $            511.21 	
207	Level III Nerve Injections	 $             1,741.77 	 $   1,137.71 	 $            967.05 	
208	Laminotomies and Laminectomies	 $           10,408.61 	 $   6,591.25 	 $        5,602.56 	
209	Level II Extended EEG, Sleep, and Cardiovascular Studies	 $             1,144.31 	 $       748.20 	 $            635.97 	
210	Spinal Fusions	 $           10,408.61 	 $   6,591.25 	 $        5,602.56 	
213	Level I Extended EEG, Sleep, and Cardiovascular Studies	 $                 472.16 	 $       308.69 	 $            262.39 	
215	Level I Nerve and Muscle Services	 $                 130.78 	 $         85.51 	 $              72.68 	
216	Level III Nerve and Muscle Services	 $                 563.65 	 $       367.55 	 $            312.42 	
218	Level II Nerve and Muscle Services	 $                 332.15 	 $       217.15 	 $            184.58 	
219	Vascular Ligation 	 $             5,561.63 	 $   3,307.72 	 $        2,811.56 	
220	Level I Nerve Procedures	 $             3,598.11 	 $   2,346.50 	 $        1,994.52 	
221	Level II Nerve Procedures	 $             7,445.80 	 $   4,246.23 	 $        3,609.29 	
224	Implantation of Catheter/Reservoir/Shunt	 $             8,880.69 	 $   4,167.40 	 $        3,542.29 	
227	Implantation of Drug Infusion Device	 $           38,089.40 	 $   4,679.58 	 $        3,977.64 	
229	Level II Endovascular Revascularization of the Lower Extremity 	 $           23,711.22 	 $   8,564.13 	 $        7,279.51 	
230	Level I Eye Tests & Treatments	 $                 134.03 	 $         87.64 	 $              74.49 	
231	Level III Eye Tests & Treatments	 $                 472.97 	 $       309.22 	 $            262.83 	
232	Level I Anterior Segment Eye Procedures	 $                 448.19 	 $       292.93 	 $            248.99 	
233	Level III Anterior Segment Eye Procedures	 $             3,102.22 	 $   1,984.76 	 $        1,687.05 	
234	Level IV Anterior Segment Eye Procedures	 $             4,547.27 	 $   2,787.39 	 $        2,369.28 	
235	Level I Posterior Segment Eye Procedures	 $             1,116.93 	 $       730.23 	 $            620.70 	
237	Level II Posterior Segment Eye Procedures	 $             4,458.71 	 $   2,820.86 	 $        2,397.73 	
238	Level I Repair and Plastic Eye Procedures	 $                 663.94 	 $       433.68 	 $            368.63 	
239	Level II Repair and Plastic Eye Procedures	 $             1,673.65 	 $   1,085.01 	 $            922.25 	
240	Level III Repair and Plastic Eye Procedures	 $             3,769.79 	 $   2,445.39 	 $        2,078.58 	
241	Level IV Repair and Plastic Eye Procedures	 $             5,165.94 	 $   3,241.95 	 $        2,755.65 	
242	Level V Repair and Plastic Eye Procedures	 $             8,119.67 	 $   4,548.23 	 $        3,866.00 	
243	Strabismus/Muscle Procedures	 $             5,062.49 	 $   3,307.77 	 $        2,811.60 	
244	Corneal and Amniotic Membrane Transplant	 $             8,393.22 	 $   4,476.46 	 $        3,804.99 	
246	Cataract Procedures with IOL Insert	 $             4,591.63 	 $   2,544.08 	 $        2,162.47 	
247	Laser Eye Procedures	 $             1,113.42 	 $       727.35 	 $            618.25 	
249	Cataract Procedures without IOL Insert	 $             5,601.31 	 $   3,483.30 	 $        2,960.81 	
250	Level I ENT Procedures	 $                 218.71 	 $       142.93 	 $            121.49 	
251	Level II ENT Procedures	 $                 678.83 	 $       443.54 	 $            377.01 	
252	Level III ENT Procedures	 $             1,417.36 	 $       920.53 	 $            782.45 	
253	Level IV ENT Procedures	 $             3,166.36 	 $   2,039.05 	 $        1,733.19 	
254	Level V ENT Procedures	 $             4,834.13 	 $   3,131.70 	 $        2,661.94 	
255	Level II Anterior Segment Eye Procedures	 $             1,939.29 	 $   1,255.32 	 $        1,067.02 	
256	Level VI ENT Procedures	 $             9,268.19 	 $   5,872.11 	 $        4,991.30 	
259	Level VII ENT Procedures	 $           79,979.85 	 $   8,215.47 	 $        6,983.15 	
260	Level I Plain Film Except Teeth	 $                 149.11 	 $         97.50 	 $              82.87 	
261	Level II Plain Film Except Teeth Including Bone Density Measurement	 $                 236.31 	 $       154.51 	 $            131.34 	
262	Plain Film of Teeth	 $                 110.84 	 $         72.47 	 $              61.60 	
263	Level I Miscellaneous Radiology Procedures	 $                 826.57 	 $       527.04 	 $            447.99 	
265	Level I Diagnostic and Screening Ultrasound	 $                 234.13 	 $       153.09 	 $            130.12 	
266	Level II Diagnostic and Screening Ultrasound	 $                 349.88 	 $       228.75 	 $            194.43 	
267	Level III Diagnostic and Screening Ultrasound	 $                 496.18 	 $       324.40 	 $            275.74 	
269	Level II Echocardiogram Without Contrast 	 $             1,110.90 	 $       726.36 	 $            617.41 	
270	Level III Echocardiogram Without Contrast 	 $             1,545.47 	 $   1,009.89 	 $            858.41 	
272	Fluoroscopy	 $                 407.34 	 $       244.53 	 $            207.85 	
274	Myelography	 $             1,553.27 	 $   1,015.29 	 $            863.00 	
275	Arthrography	 $                 882.26 	 $       576.80 	 $            490.28 	
276	Level I Digestive Radiology	 $                 264.78 	 $       173.13 	 $            147.16 	
277	Level II Digestive Radiology	 $                 393.20 	 $       256.83 	 $            218.31 	
278	Diagnostic Urography	 $                 669.76 	 $       432.97 	 $            368.03 	
279	Level II Angiography and Venography	 $             6,698.74 	 $   3,661.20 	 $        3,112.02 	
280	Level III Angiography and Venography	 $           11,735.41 	 $   6,824.50 	 $        5,800.83 	
282	Miscellaneous Computed Axial Tomography	 $                 206.86 	 $       135.14 	 $            114.87 	
283	Computed Tomography with Contrast	 $                 647.40 	 $       423.26 	 $            359.77 	
284	Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast	 $             1,108.87 	 $       724.96 	 $            616.22 	
288	Bone Density:Axial Skeleton	 $                 234.42 	 $       153.27 	 $            130.28 	
293	Level VI Anterior Segment Eye Procedures	 $           20,014.59 	 $   4,628.68 	 $        3,934.38 	
299	Hyperthermia and Radiation Treatment Procedures	 $             1,074.37 	 $       702.47 	 $            597.10 	
300	Level I Radiation Therapy	 $                 271.08 	 $       177.24 	 $            150.66 	
301	Level II Radiation Therapy	 $                 499.93 	 $       326.88 	 $            277.84 	
303	Treatment Device Construction	 $                 555.07 	 $       362.90 	 $            308.46 	
304	Level I Therapeutic Radiation Treatment Preparation	 $                 298.09 	 $       194.91 	 $            165.67 	
305	Level II Therapeutic Radiation Treatment Preparation	 $                 809.56 	 $       529.33 	 $            449.93 	
308	Positron Emission Tomography (PET) imaging	 $             3,407.56 	 $   2,227.80 	 $        1,893.63 	
310	Level III Therapeutic Radiation Treatment Preparation	 $             2,694.61 	 $   1,749.00 	 $        1,486.65 	
312	Radioelement Applications	 $                 939.35 	 $       610.88 	 $            519.24 	
313	Brachytherapy	 $             1,907.88 	 $   1,247.21 	 $        1,060.13 	
315	Level II Implantation of Neurostimulator Generator 	 $           60,042.35 	 $   4,758.12 	 $        4,044.41 	
317	Level II Miscellaneous Radiology Procedures	 $             1,920.59 	 $   1,198.26 	 $        1,018.52 	
318	Implantation of Neurostimulator Pulse Generator and Electrode 	 $           71,837.09 	 $   6,031.00 	 $        5,126.35 	
319	Level III Endovascular Revascularization of the Lower Extremity	 $          40,325.97 	 $ 12,669.34 	 $      10,768.94 	
320	Electroconvulsive Therapy	 $             1,132.33 	 $       740.37 	 $            629.31 	
322	Brief Individual Psychotherapy	 $                 219.41 	 $       143.46 	 $            121.94 	
323	Extended Individual Psychotherapy	 $                 298.66 	 $       195.28 	 $            165.99 	
324	Family Psychotherapy	 $                 336.02 	 $       219.71 	 $            186.75 	
325	Group Psychotherapy	 $                 180.28 	 $       117.88 	 $            100.20 	
326	Level I Skin Repair	 $                 517.48 	 $       338.22 	 $            287.48 	
327	Level II Skin Repair	 $             1,064.47 	 $       695.23 	 $            590.95 	
328	Level III Skin Repair	 $             3,565.09 	 $   2,326.59 	 $        1,977.60 	
329	Level IV Skin Repair	 $             5,877.20 	 $   3,797.05 	 $        3,227.49 	
330	Dental Procedures	 $             1,181.91 	 $       772.55 	 $            656.67 	
331	Combined Abdomen and Pelvis CT without Contrast 	 $                 628.65 	 $       410.92 	 $            349.28 	
332	Computed Tomography without Contrast	 $                 328.82 	 $       214.98 	 $            182.73 	
333	Computed Tomography without Contrast followed by Contrast	 $                 729.04 	 $       476.63 	 $            405.14 	
334	Combined Abdomen and Pelvis CT with Contrast 	 $             1,014.34 	 $       663.15 	 $            563.68 	
336	Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast	 $                 766.43 	 $       501.13 	 $            425.96 	
337	Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast followed by Contrast	 $             1,281.59 	 $       837.55 	 $            711.91 	
340	Level I Minor Procedures	 $                 138.94 	 $         90.81 	 $              77.19 	
341	Skin Tests	 $                   32.50 	 $         21.25 	 $              18.06 	
342	Level I Pathology	 $                   51.58 	 $         33.73 	 $              28.67 	
343	Level III Pathology	 $                 159.82 	 $       104.50 	 $              88.82 	
344	Level IV Pathology	 $                 467.14 	 $       303.58 	 $            258.04 	
345	Level I Transfusion Laboratory Procedures	 $                   31.51 	 $         20.60 	 $              17.51 	
346	Level II Transfusion Laboratory Procedures	 $                   82.08 	 $         53.65 	 $              45.60 	
347	Level III Transfusion Laboratory Procedures	 $                 157.20 	 $       102.47 	 $              87.10 	
351	Level VII Anterior Segment Eye Procedures	 $           40,433.20 	 $   4,002.58 	 $        3,402.19 	
360	Level I Alimentary Tests	 $                 377.39 	 $       246.71 	 $            209.70 	
361	Level II Alimentary Tests	 $                 840.61 	 $       545.72 	 $            463.87 	
363	Level I Otorhinolaryngologic Function Tests	 $                 193.47 	 $       126.50 	 $            107.52 	
364	Level I Audiometry	 $                   85.59 	 $         55.96 	 $              47.57 	
365	Level II Audiometry	 $                 199.55 	 $       130.48 	 $            110.90 	
366	Level III Audiometry	 $                 305.81 	 $       199.95 	 $            169.96 	
367	Level I Pulmonary Test	 $                 149.16 	 $         97.02 	 $              82.47 	
368	Level II Pulmonary Tests	 $                 230.72 	 $       150.84 	 $            128.22 	
369	Level III Pulmonary Tests	 $                 633.65 	 $       413.52 	 $            351.49 	
370	Multiple Allergy Tests	 $                 107.46 	 $         70.26 	 $              59.72 	
373	Level I Neuropsychological Testing	 $                 284.88 	 $       186.25 	 $            158.31 	
377	Level II Cardiac Imaging	 $             2,999.41 	 $   1,961.15 	 $        1,666.98 	
378	Level II Pulmonary Imaging	 $             1,120.26 	 $       732.33 	 $            622.48 	
381	Single Allergy Tests	 $                   90.90 	 $         59.43 	 $              50.52 	
382	Level II Neuropsychological Testing	 $                 530.97 	 $       347.17 	 $            295.10 	
383	Cardiac Computed Tomographic Imaging	 $                 577.23 	 $       377.23 	 $            320.64 	
384	GI Procedures with Stents	 $             6,165.64 	 $   2,791.33 	 $        2,372.63 	
385	Level I Prosthetic Urological Procedures	 $           21,573.08 	 $   5,166.84 	 $        4,391.81 	
386	Level II Prosthetic Urological Procedures	 $           35,158.68 	 $   6,882.72 	 $        5,850.31 	
387	Level II Hysteroscopy	 $             7,325.68 	 $   4,555.64 	 $        3,872.30 	
388	Discography	 $             7,178.63 	 $   4,682.92 	 $        3,980.48 	
389	Level I Non-imaging Nuclear Medicine	 $                 365.01 	 $       238.66 	 $            202.86 	
390	Level I Endocrine Imaging	 $                 476.84 	 $       311.78 	 $            265.01 	
391	Level II Endocrine Imaging	 $                 746.04 	 $       487.80 	 $            414.63 	
392	Level II Non-imaging Nuclear Medicine	 $                 669.32 	 $       437.19 	 $            371.61 	
393	Hematologic Processing & Studies	 $             1,471.47 	 $       961.25 	 $            817.06 	
394	Hepatobiliary Imaging	 $                 968.68 	 $       633.31 	 $            538.31 	
395	GI Tract Imaging	 $                 841.83 	 $       550.37 	 $            467.82 	
396	Bone Imaging	 $                 842.24 	 $       550.70 	 $            468.09 	
398	Level I Cardiac Imaging	 $                 996.06 	 $       651.14 	 $            553.47 	
400	Hematopoietic Imaging	 $                 900.48 	 $       588.07 	 $            499.86 	
401	Level I Pulmonary Imaging	 $                 795.63 	 $       519.49 	 $            441.57 	
402	Level II Nervous System Imaging	 $             1,386.27 	 $       906.41 	 $            770.45 	
403	Level I Nervous System Imaging	 $                 422.97 	 $       276.56 	 $            235.07 	
404	Renal and Genitourinary Studies	 $             1,084.25 	 $       708.79 	 $            602.47 	
406	Level I Tumor/Infection Imaging	 $                 995.20 	 $       650.71 	 $            553.10 	
407	Level I Radionuclide Therapy	 $                 665.11 	 $       434.75 	 $            369.53 	
408	Level III Tumor/Infection Imaging	 $             3,009.29 	 $   1,967.61 	 $        1,672.47 	
412	Level III Radiation Therapy	 $             1,327.20 	 $       867.78 	 $            737.61 	
413	Level II Radionuclide Therapy	 $                 927.37 	 $       604.48 	 $            513.80 	
414	Level II Tumor/Infection Imaging	 $             1,708.12 	 $   1,116.74 	 $            949.23 	
415	Level II Endoscopy Lower Airway	 $             5,201.01 	 $   3,285.04 	 $        2,792.28 	
419	Level II Upper GI Procedures 	 $             2,633.93 	 $   1,588.37 	 $        1,350.12 	
420	Level II Minor Procedures	 $                 255.45 	 $       166.59 	 $            141.60 	
422	Level III Upper GI Procedures	 $             5,118.75 	 $   2,506.47 	 $        2,130.50 	
423	Level II Percutaneous Abdominal and Biliary Procedures	 $           10,676.09 	 $   5,209.56 	 $        4,428.13 	
424	Level II Small Intestine Endoscopy 	 $             3,205.90 	 $   2,044.81 	 $        1,738.09 	
425	Level II Arthroplasty or Implantation with Prosthesis	 $           25,303.38 	 $   6,629.39 	 $        5,634.98 	
426	Level II Strapping and Cast Application	 $                 359.61 	 $       235.13 	 $            199.86 	
427	Level II Tube or Catheter Changes or Repositioning	 $             3,396.09 	 $   1,712.91 	 $        1,455.97 	
428	Level III Sigmoidoscopy and Anoscopy	 $             4,308.54 	 $   2,795.43 	 $        2,376.11 	
429	Level V Cystourethroscopy and other Genitourinary Procedures	 $             8,591.15 	 $   5,558.87 	 $        4,725.04 	
431	Level IV Closed Treatment Fracture	 $             3,255.59 	 $   1,985.61 	 $        1,687.77 	
432	Level II Health and Behavior Services	 $                 127.71 	 $         83.50 	 $              70.98 	
433	Level II Pathology	 $                   94.98 	 $         62.10 	 $              52.79 	
434	Cardiac Defect Repair	 $           33,247.89 	 $   7,171.70 	 $        6,095.94 	
435	Level III Extended EEG, Sleep, and Cardiovascular Studies	 $             2,242.53 	 $   1,466.27 	 $        1,246.33 	
436	Level I Drug Administration	 $                   76.70 	 $         50.15 	 $              42.63 	
437	Level II Drug Administration	 $                 113.83 	 $         74.43 	 $              63.26 	
438	Level III Drug Administration	 $                 275.34 	 $       179.96 	 $            152.96 	
439	Level IV Drug Administration	 $                 447.67 	 $       292.62 	 $            248.73 	
440	Level V Drug Administration	 $                 778.78 	 $       509.10 	 $            432.73 	
442	Dosimetric Drug Administration	 $             4,738.08 	 $   3,097.98 	 $        2,633.28 	
609	Level 1 Type A Emergency Visits	 $                 144.69 	 0 	 0 	
613	Level 2 Type A Emergency Visits	 $                 262.37 	0	 0 	
614	Level 3 Type A Emergency Visits	 $                 432.77 	 0 	0	
615	Level 4 Type A Emergency Visits	 $                 763.65 	 0 	 0 	
616	Level 5 Type A Emergency Visits	 $             1,185.42 	 0 	0	
617	Critical Care	 $             1,650.84 	 0 	 0 	
618	Trauma Response with Critical Care	0	0	0	
621	Level I Vascular Access Procedures	 $             2,209.25 	 $   1,241.26 	 $        1,055.08 	
622	Level II Vascular Access Procedures	 $             5,002.35 	 $   2,165.25 	 $        1,840.46 	
623	Level III Vascular Access Procedures	 $             6,100.74 	 $   2,848.51 	 $        2,421.23 	
624	Phlebotomy and Minor Vascular Access Device Procedures	 $                 210.55 	 $       137.60 	 $            116.96 	
626	Level 1 Type B Emergency Visits	 $                 134.99 	 $         88.26 	 $              75.02 	
627	Level 2 Type B Emergency Visits	 $                 160.34 	 $       104.84 	 $              89.11 	
628	Level 3 Type B Emergency Visits	 $                 238.45 	 $       155.91 	 $            132.52 	
629	Level 4 Type B Emergency Visits	 $                 424.50 	 $       277.56 	 $            235.93 	
630	Level 5 Type B Emergency Visits	 $                 812.32 	 $       531.08 	 $            451.42 	
631	Level 1 Examinations & Related Services 	 $                 196.53 	 $       128.50 	 $            109.23 	
632	Level 2 Examinations & Related Services 	 $                 250.98 	 $       164.08 	 $            139.47 	
633	Level 3 Examinations & Related Services 	 $                 852.41 	 $       556.62 	 $            473.13 	
634	Hospital Clinic Visits	 $                 240.58 	 $       157.29 	 $            133.69 	
648	Level IV Breast and Skin Surgery	 $           12,601.45 	 $   4,371.01 	 $        3,715.35 	
651	Complex Interstitial Radiation Source Application	 $             2,594.54 	 $   1,556.64 	 $        1,323.15 	
652	Insertion of Intraperitoneal and Pleural Catheters	 $             6,283.84 	 $   3,444.29 	 $        2,927.65 	
653	Vascular Reconstruction/Fistula Repair with Device	 $             8,015.44 	 $   4,085.25 	 $        3,472.46 	
654	Level II Insertion/Replacement of Permanent Pacemaker 	 $           21,807.58 	 $   4,299.03 	 $        3,654.17 	
655	Insertion/Replacement/Conversion of a Permanent Dual Chamber Pacemaker or Pacing Electrode	 $           27,529.84 	 $   4,948.28 	 $        4,206.04 	
656	Transcatheter Placement of Intracoronary Drug-Eluting Stents	 $           20,056.45 	 $   5,305.86 	 $        4,509.98 	
659	Hyperbaric Oxygen	 $                 288.42 	 $       188.58 	 $            160.29 	
660	Level II Otorhinolaryngologic Function Tests	 $                 359.76 	 $       235.23 	 $            199.94 	
661	Level V Pathology	 $                 723.40 	 $       472.66 	 $            401.76 	
662	CT Angiography	 $                 759.10 	 $       496.03 	 $            421.63 	
664	Level I Proton Beam Radiation Therapy	 $             2,268.16 	 $   1,483.03 	 $        1,260.57 	
665	Bone Density:AppendicularSkeleton	 $                 133.15 	 $         87.06 	 $              74.00 	
667	Level II Proton Beam Radiation Therapy	 $             3,133.70 	 $   2,048.96 	 $        1,741.62 	
668	Level I Angiography and Venography	 $             2,150.07 	 $   1,214.48 	 $        1,032.31 	
672	Level III Posterior Segment Eye Procedures	 $             7,956.86 	 $   5,106.83 	 $        4,340.81 	
673	Level V Anterior Segment Eye Procedures	 $             7,897.16 	 $   3,590.72 	 $        3,052.11 	
674	Prostate Cryoablation	 $           21,329.65 	 $   6,008.07 	 $        5,106.86 	
676	Thrombolysis and Other Device Revisions 	 $                 477.78 	 $       307.24 	 $            261.15 	
678	External Counterpulsation	 $                 282.20 	 $       184.52 	 $            156.84 	
679	Level II Resuscitation and Cardioversion	 $             1,147.72 	 $       749.68 	 $            637.23 	
680	Insertion of Patient Activated Event Recorders	 $           16,178.58 	 $   2,753.53 	 $        2,340.50 	
683	Level II Photochemotherapy	 $                 558.82 	 $       365.38 	 $            310.57 	
685	Level III Needle Biopsy/Aspiration Except Bone Marrow	 $             1,970.18 	 $   1,282.91 	 $        1,090.47 	
687	Revision/Removal of Neurostimulator Electrodes	 $             4,448.00 	 $   2,846.36 	 $        2,419.41 	
688	Revision/Removal of Neurostimulator Pulse Generator Receiver	 $             5,777.64 	 $   3,623.56 	 $        3,080.03 	
690	Level I Electronic Analysis of Devices	 $                   93.99 	 $         61.46 	 $              52.24 	
691	Level III Electronic Analysis of Devices	 $                 717.29 	 $       468.67 	 $            398.37 	
692	Level II Electronic Analysis of Devices	 $                 301.13 	 $       196.56 	 $            167.08 	
694	Mohs Surgery	 $             1,134.15 	 $       741.56 	 $            630.32 	
697	Level I Echocardiogram Without Contrast 	 $                 651.74 	 $       425.88 	 $            362.00 	
698	Level II Eye Tests & Treatments	 $                 201.47 	 $       131.73 	 $            111.97 	
699	Level IV Eye Tests & Treatments	 $             3,111.08 	 $   2,011.59 	 $        1,709.85 	
701	Sr89 strontium	 $             2,868.61 	 $                -   	 $                     -   	
726	Dexrazoxane HCl injection	 $                 352.87 	 $                -   	 $                     -   	
731	Sargramostim injection	 $                   77.30 	 $                -   	 $                     -   	
736	Amphotericin b liposome inj	 $                   42.09 	 $                -   	 $                     -   	
738	Rasburicase	 $                 557.41 	 $                -   	 $                     -   	
747	Chlorothiazide sodium inj	 $                 394.52 	 $                -   	 $                     -   	
751	Mechlorethamine hcl inj	 $                 402.22 	 $                -   	 $                     -   	
752	Dactinomycin injection	 $             1,678.95 	 $                -   	 $                     -   	
759	Naltrexone, depot form	 $                     7.15 	 $                -   	 $                     -   	
800	Leuprolide acetate	 $             1,946.15 	 $                -   	 $                     -   	
802	Etoposide oral	 $                 152.85 	 $                -   	 $                     -   	
807	Aldesleukin injection	 $             4,345.09 	 $                -   	 $                     -   	
809	Bcg live intravesical vac	 $                 310.49 	 $                -   	 $                     -   	
810	Goserelin acetate implant	 $                 505.49 	 $                -   	 $                     -   	
812	Carmustine injection	 $             3,703.08 	 $                -   	 $                     -   	
814	Asparaginase, NOS	 $                 167.88 	 $                -   	 $                     -   	
820	Daunorubicin injection	 $                   67.91 	 $                -   	 $                     -   	
821	Daunorubicin citrate inj	 $                 633.88 	 $                -   	 $                     -   	
823	Docetaxel injection	 $                   10.35 	 $                -   	 $                     -   	
825	Nelarabine injection	 $                 340.00 	 $                -   	 $                     -   	
827	Floxuridine injection	 $                 180.41 	 $                -   	 $                     -   	
831	Ifosfamide injection	 $                   93.11 	 $                -   	 $                     -   	
832	Idarubicin hcl injection	 $                   92.77 	 $                -   	 $                     -   	
835	Cosyntropin injection NOS	 $                 264.37 	 $                -   	 $                     -   	
836	Interferon alfa-2b inj	 $                   53.69 	 $                -   	 $                     -   	
838	Interferon gamma 1-b inj	 $             7,005.88 	 $                -   	 $                     -   	
840	Inj melphalan hydrochl	 $             3,246.72 	 $                -   	 $                     -   	
842	Fludarabine phosphate inj	 $                 184.81 	 $                -   	 $                     -   	
843	Pegaspargase injection	 $           15,619.19 	 $                -   	 $                     -   	
844	Pentostatin injection	 $             3,700.35 	 $                -   	 $                     -   	
849	Rituximab injection	 $             1,802.74 	 $                -   	 $                     -   	
850	Streptozocin injection	 $                 723.94 	 $                -   	 $                     -   	
851	Thiotepa injection	 $             1,639.82 	 $                -   	 $                     -   	
856	Porfimer sodium injection	 $           50,247.03 	 $                -   	 $                     -   	
858	Inj cladribine	 $                   57.88 	 $                -   	 $                     -   	
861	Leuprolide acetate injeciton	 $                   22.78 	 $                -   	 $                     -   	
864	Mitoxantrone hydrochl	 $                   87.65 	 $                -   	 $                     -   	
868	Oral aprepitant	 $                   17.63 	 $                -   	 $                     -   	
873	Hyalgan/supartz inj per dose	 $                 237.43 	 $                -   	 $                     -   	
874	Synvisc or synvisc-one	 $                   33.44 	 $                -   	 $                     -   	
875	Euflexxa inj per dose	 $                 395.25 	 $                -   	 $                     -   	
877	Orthovisc inj per dose	 $                 459.29 	 $                -   	 $                     -   	
887	Azathioprine parenteral	 $                 564.98 	 $                -   	 $                     -   	
890	Lymphocyte immune globulin	 $             1,917.34 	 $                -   	 $                     -   	
901	Alpha 1 proteinase inhibitor	 $                   10.48 	 $                -   	 $                     -   	
902	Injection,onabotulinumtoxinA	 $                   14.14 	 $                -   	 $                     -   	
903	Cytomegalovirus imm IV /vial	 $             2,636.06 	 $                -   	 $                     -   	
910	Interferon beta-1b / .25 MG	 $                 755.38 	 $                -   	 $                     -   	
913	Ganciclovir long act implant	 $           44,096.00 	 $                -   	 $                     -   	
925	Factor viii	 $                     2.44 	 $                -   	 $                     -   	
927	Factor viii recombinant	 $                     2.96 	 $                -   	 $                     -   	
928	Factor ix complex	 $                     2.86 	 $                -   	 $                     -   	
929	Anti-inhibitor	 $                     4.26 	 $                -   	 $                     -   	
931	Factor IX non-recombinant	 $                     2.52 	 $                -   	 $                     -   	
932	Factor IX recombinant	 $                     3.46 	 $                -   	 $                     -   	
933	Gamma globulin > 10 CC inj	 $                 623.51 	 $                -   	 $                     -   	
934	Capecitabine, oral	 $                   86.71 	 $                -   	 $                     -   	
943	Octagam injection	 $                   79.61 	 $                -   	 $                     -   	
944	Gammagard liquid injection	 $                 102.28 	 $                -   	 $                     -   	
945	Rhophylac injection	 $                   12.27 	 $                -   	 $                     -   	
946	Hepagam b im injection	 $                 133.35 	 $                -   	 $                     -   	
947	Flebogamma injection	 $                   93.76 	 $                -   	 $                     -   	
948	Gamunex-C/Gammaked	 $                 103.40 	 $                -   	 $                     -   	
949	Frozen plasma, pooled, sd	 $                 186.16 	 $                -   	 $                     -   	
950	Whole blood for transfusion	 $                 508.69 	 $                -   	 $                     -   	
952	Cryoprecipitate each unit	 $                 170.38 	 $                -   	 $                     -   	
954	RBC leukocytes reduced	 $                 495.85 	 $                -   	 $                     -   	
955	Plasma, frz between 8-24hour	 $                 180.99 	 $                -   	 $                     -   	
956	Plasma protein fract,5%,50ml	 $                   43.60 	 $                -   	 $                     -   	
957	Platelets, each unit	 $                 305.89 	 $                -   	 $                     -   	
958	Plaelet rich plasma unit	 $                 431.44 	 $                -   	 $                     -   	
959	Red blood cells unit	 $                 393.87 	 $                -   	 $                     -   	
960	Washed red blood cells unit	 $                 752.47 	 $                -   	 $                     -   	
961	Albumin (human),5%, 50ml	 $                   54.44 	 $                -   	 $                     -   	
963	Albumin (human), 5%, 250 ml	 $                 177.37 	 $                -   	 $                     -   	
964	Albumin (human), 25%, 20 ml	 $                   88.74 	 $                -   	 $                     -   	
965	Albumin (human), 25%, 50ml	 $                 180.88 	 $                -   	 $                     -   	
966	Plasmaprotein fract,5%,250ml	 $                   96.28 	 $                -   	 $                     -   	
967	Blood split unit	 $                 264.32 	 $                -   	 $                     -   	
968	Platelets leukoreduced irrad	 $                 418.16 	 $                -   	 $                     -   	
969	RBC leukoreduced irradiated	 $                 723.87 	 $                -   	 $                     -   	
1009	Cryoprecipitatereducedplasma	 $                 223.60 	 $                -   	 $                     -   	
1010	Blood, l/r, cmv-neg	 $                 441.45 	 $                -   	 $                     -   	
1011	Platelets, hla-m, l/r, unit	 $             2,032.63 	 $                -   	 $                     -   	
1013	Platelets leukocytes reduced	 $                 307.50 	 $                -   	 $                     -   	
1015	Injection glatiramer acetate	 $                 393.67 	 $                -   	 $                     -   	
1016	Blood, l/r, froz/degly/wash	 $                 589.71 	 $                -   	 $                     -   	
1017	Plt, aph/pher, l/r, cmv-neg	 $             1,124.66 	 $                -   	 $                     -   	
1018	Blood, l/r, irradiated	 $                 429.88 	 $                -   	 $                     -   	
1019	Plate pheres leukoredu irrad	 $             1,741.14 	 $                -   	 $                     -   	
1020	Plt, pher, l/r cmv-neg, irr	 $             1,821.09 	 $                -   	 $                     -   	
1021	RBC, frz/deg/wsh, l/r, irrad	 $             1,129.91 	 $                -   	 $                     -   	
1022	RBC, l/r, cmv-neg, irrad	 $                 754.88 	 $                -   	 $                     -   	
1023	Pralidoxime chloride inj	 $                 232.86 	 $                -   	 $                     -   	
1052	Injection, voriconazole	 $                   10.66 	 $                -   	 $                     -   	
1064	I131 iodide cap, rx	 $                   48.15 	 $                -   	 $                     -   	
1083	Adalimumab injection	 $             1,480.10 	 $                -   	 $                     -   	
1084	Denileukin diftitox inj	 $             4,280.07 	 $                -   	 $                     -   	
1086	Temozolomide	 $                   25.19 	 $                -   	 $                     -   	
1138	Hepagam b intravenous, inj	 $                 133.35 	 $                -   	 $                     -   	
1139	Protein c concentrate	 $                   37.08 	 $                -   	 $                     -   	
1142	Supprelin LA implant	 $           43,243.28 	 $                -   	 $                     -   	
1150	I131 iodide sol, rx	 $                   28.08 	 $                -   	 $                     -   	
1166	Cytarabine liposome inj	 $             1,415.80 	 $                -   	 $                     -   	
1168	Inj, temsirolimus	 $                 148.23 	 $                -   	 $                     -   	
1178	Busulfan injection	 $                   66.48 	 $                -   	 $                     -   	
1203	Verteporfin injection	 $                   27.64 	 $                -   	 $                     -   	
1207	Octreotide injection, depot	 $                 356.93 	 $                -   	 $                     -   	
1213	Antihemophilic viii/vwf comp	 $                     2.44 	 $                -   	 $                     -   	
1214	Inj IVIG privigen 500 mg	 $                   95.50 	 $                -   	 $                     -   	
1232	Mitomycin injection	 $                   61.26 	 $                -   	 $                     -   	
1235	Valrubicin injection	 $             2,756.18 	 $                -   	 $                     -   	
1236	Levoleucovorin injection	 $                     4.55 	 $                -   	 $                     -   	
1237	Inj iron dextran	 $                   31.30 	 $                -   	 $                     -   	
1238	Topotecan oral	 $                 232.21 	 $                -   	 $                     -   	
1253	Triamcinolone A inj PRS-free	 $                     9.62 	 $                -   	 $                     -   	
1263	Antithrombin iii injection	 $                     8.14 	 $                -   	 $                     -   	
1268	Xyntha inj	 $                     2.96 	 $                -   	 $                     -   	
1272	Acetylcysteine injection	 $                     6.86 	 $                -   	 $                     -   	
1274	Edetate calcium disodium inj	 $                 523.64 	 $                -   	 $                     -   	
1280	Corticotropin injection	 $             8,230.35 	 $                -   	 $                     -   	
1281	Bevacizumab injection	 $                     4.26 	 $                -   	 $                     -   	
1289	AbobotulinumtoxinA	 $                   19.55 	 $                -   	 $                     -   	
1291	Rilonacept injection	 $                   62.63 	 $                -   	 $                     -   	
1295	Sm 153 lexidronam	 $           20,590.08 	 $                -   	 $                     -   	
1296	Degarelix injection	 $                     9.15 	 $                -   	 $                     -   	
1297	Ferumoxytol, non-esrd	 $                     1.79 	 $                -   	 $                     -   	
1311	Canakinumab injection	 $                 236.63 	 $                -   	 $                     -   	
1312	Hizentra injection	 $                   19.89 	 $                -   	 $                     -   	
1327	Imiglucerase injection	 $                 109.20 	 $                -   	 $                     -   	
1331	Olanzapine long-acting inj	 $                     7.15 	 $                -   	 $                     -   	
1332	Antithrombin recombinant	 $                 268.71 	 $                -   	 $                     -   	
1338	Methyl aminolevulinate, top	 $                 217.59 	 $                -   	 $                     -   	
1340	Collagenase, clost hist inj	 $                   99.35 	 $                -   	 $                     -   	
1341	Amobarbital 125 MG inj	 $                 467.66 	 $                -   	 $                     -   	
1343	Ganciclovir sodium injection	 $                 187.46 	 $                -   	 $                     -   	
1350	Topotecan injection	 $                     6.16 	 $                -   	 $                     -   	
1352	Wilate injection	 $                     2.34 	 $                -   	 $                     -   	
1353	Belimumab injection	 $                 100.88 	 $                -   	 $                     -   	
1354	Hydroxyprogesterone caproate	 $                     7.02 	 $                -   	 $                     -   	
1356	Zoledronic Acid 1mg	 $                 274.09 	 $                -   	 $                     -   	
1361	Enfuvirtide injection	 $                     1.43 	 $                -   	 $                     -   	
1408	Cyclophosphamide 100 MG inj	 $                 136.40 	 $                -   	 $                     -   	
1413	Lumizyme injection	 $                 399.36 	 $                -   	 $                     -   	
1415	Glassia injection	 $                   10.43 	 $                -   	 $                     -   	
1416	Factor XIII anti-hem factor	 $                   17.52 	 $                -   	 $                     -   	
1417	Gel-one	 $             1,445.57 	 $                -   	 $                     -   	
1419	Dermacell	 $                 198.07 	 $                -   	 $                     -   	
1420	Aflibercept injection	 $             2,549.30 	 $                -   	 $                     -   	
1421	Imported lipodox inj	 $             1,295.48 	 $                -   	 $                     -   	
1422	Anthrax vaccine sc or im	 $                 244.53 	 $                -   	 $                     -   	
1424	Nabilone oral	 $                   70.38 	 $                -   	 $                     -   	
1426	Eribulin mesylate injection	 $                 255.42 	 $                -   	 $                     -   	
1431	Centruroides immune f(ab)	 $             9,501.88 	 $                -   	 $                     -   	
1433	Calcitonin salmon injection	 $                 179.61 	 $                -   	 $                     -   	
1439	Aprotonin, 10,000 kiu	 $                     8.89 	 $                -   	 $                     -   	
1440	Inj desmopressin acetate	 $                   13.78 	 $                -   	 $                     -   	
1442	Non-HEU TC-99M add-on/dose	 $                   26.00 	 $                -   	 $                     -   	
1443	Icatibant injection	 $                 662.77 	 $                -   	 $                     -   	
1445	Methylnaltrexone injection	 $                     1.22 	 $                -   	 $                     -   	
1448	Opthalmic mitomycin	 $                 986.62 	 $                -   	 $                     -   	
1449	Talymed	 $                   35.83 	 $                -   	 $                     -   	
1454	Mumps vaccine sc	 $                 422.08 	 $                -   	 $                     -   	
1455	Foscarnet sodium injection	 $                   34.63 	 $                -   	 $                     -   	
1456	Pentobarbital sodium inj	 $                   83.82 	 $                -   	 $                     -   	
1457	Totazoline hcl injection	 $                 104.03 	 $                -   	 $                     -   	
1458	Phentolaine mesylate inj	 $                 301.81 	 $                -   	 $                     -   	
1459	Urea injection	 $                 318.24 	 $                -   	 $                     -   	
1460	Interferon alfa-2a inj	 $                 139.52 	 $                -   	 $                     -   	
1463	Tc99 Tilmanocept diag 0.5mci	 $                 624.00 	 $                -   	 $                     -   	
1464	Factor VIII (porcine)	 $                     0.52 	 $                -   	 $                     -   	
1465	Tacrolimus ex rel oral 0.1mg	 $                     1.09 	 $                -   	 $                     -   	
1466	Inj, vincristine sul lip 1mg	 $             5,374.20 	 $                -   	 $                     -   	
1467	Factor IX recombinant	 $                     3.30 	 $                -   	 $                     -   	
1468	Inj Aripiprazole Ext Rel 1mg	 $                     9.80 	 $                -   	 $                     -   	
1469	Inj, Filgrastim G-CSF 1mcg	 $                     2.57 	 $                -   	 $                     -   	
1471	Injection, Pertuzumab, 1 mg	 $                   26.55 	 $                -   	 $                     -   	
1472	Inj beta interferon im 1 mcg	 $                   85.36 	 $                -   	 $                     -   	
1473	Interferon alfa-n3 inj	 $                   82.68 	 $                -   	 $                     -   	
1474	Certolizumab pegol inj 1mg	 $                   13.34 	 $                -   	 $                     -   	
1475	Golimumab for iv use 1mg	 $                   63.39 	 $                -   	 $                     -   	
1605	Abciximab injection	 $             1,777.07 	 $                -   	 $                     -   	
1607	Eptifibatide injection	 $                   72.12 	 $                -   	 $                     -   	
1608	Etanercept injection	 $                 696.62 	 $                -   	 $                     -   	
1609	Rho(D) immune globulin h, sd	 $                   49.11 	 $                -   	 $                     -   	
1612	Daclizumab, parenteral	 $             1,368.48 	 $                -   	 $                     -   	
1613	Trastuzumab injection	 $                 209.53 	 $                -   	 $                     -   	
1630	Hep b ig, im	 $                 292.86 	 $                -   	 $                     -   	
1631	Baclofen intrathecal trial	 $                 197.18 	 $                -   	 $                     -   	
1633	Alefacept	 $                 108.26 	 $                -   	 $                     -   	
1643	Y90 ibritumomab, rx	 $         109,479.14 	 $                -   	 $                     -   	
1645	#N/A	 $           78,490.26 	 $                -   	 $                     -   	
1670	Tetanus immune globulin inj	 $                 713.49 	 $                -   	 $                     -   	
1675	P32 Na phosphate	 $                 579.98 	 $                -   	 $                     -   	
1676	P32 chromic phosphate	 $                 821.78 	 $                -   	 $                     -   	
1683	Basiliximab	 $             6,418.39 	 $                -   	 $                     -   	
1684	Corticorelin ovine triflutal	 $                   20.20 	 $                -   	 $                     -   	
1685	Darbepoetin alfa, non-esrd	 $                     9.57 	 $                -   	 $                     -   	
1686	Epoetin alfa, non-esrd	 $                   29.59 	 $                -   	 $                     -   	
1687	Digoxin immune fab (ovine)	 $             3,257.67 	 $                -   	 $                     -   	
1688	Ethanolamine oleate	 $                 779.84 	 $                -   	 $                     -   	
1689	Fomepizole	 $                   18.10 	 $                -   	 $                     -   	
1690	Hemin	 $                   42.87 	 $                -   	 $                     -   	
1693	Lepirudin	 $                 667.50 	 $                -   	 $                     -   	
1694	Ziconotide injection	 $                   17.16 	 $                -   	 $                     -   	
1695	Nesiritide injection	 $                 157.59 	 $                -   	 $                     -   	
1696	Palifermin injection	 $                   37.47 	 $                -   	 $                     -   	
1697	Pegaptanib sodium injection	 $             2,675.32 	 $                -   	 $                     -   	
1700	Inj secretin synthetic human	 $                   71.47 	 $                -   	 $                     -   	
1701	Treprostinil injection	 $                 159.22 	 $                -   	 $                     -   	
1704	Humate-P, inj	 $                     2.34 	 $                -   	 $                     -   	
1705	Factor viia	 $                     4.37 	 $                -   	 $                     -   	
1709	Azacitidine injection	 $                   14.14 	 $                -   	 $                     -   	
1710	Clofarabine injection	 $                 337.01 	 $                -   	 $                     -   	
1711	Vantas implant	 $             7,648.78 	 $                -   	 $                     -   	
1712	Paclitaxel protein bound	 $                   24.75 	 $                -   	 $                     -   	
1716	Brachytx, non-str, Gold-198	 $                 120.41 	 $                -   	 $                     -   	
1717	Brachytx, non-str, HDR Ir-192	 $                 723.45 	 $                -   	 $                     -   	
1719	Brachytx, NS, Non-HDRIr-192	 $                   87.20 	 $                -   	 $                     -   	
1738	Oxaliplatin	 $                     0.70 	 $                -   	 $                     -   	
1739	Pegademase bovine, 25 iu	 $                 717.29 	 $                -   	 $                     -   	
1741	Urofollitropin, 75 iu	 $                 179.24 	 $                -   	 $                     -   	
1841	Retinal prosth int/ext comp      	 $                          -   			
2616	Brachytx, non-str,Yttrium-90	 $           43,755.74 	 $                -   	 $                     -   	
2632	Iodine I-125 sodium iodide	 $                   49.32 	 $                -   	 $                     -   	
2634	Brachytx, non-str, HA, I-125	 $                 192.74 	 $                -   	 $                     -   	
2635	Brachytx, non-str, HA, P-103	 $                   69.32 	 $                -   	 $                     -   	
2636	Brachy linear, non-str,P-103	 $                 104.88 	 $                -   	 $                     -   	
2638	Brachytx, stranded, I-125	 $                 125.89 	 $                -   	 $                     -   	
2639	Brachytx, non-stranded,I-125	 $                 105.33 	 $                -   	 $                     -   	
2640	Brachytx, stranded, P-103	 $                 186.78 	 $                -   	 $                     -   	
2641	Brachytx, non-stranded,P-103	 $                 178.75 	 $                -   	 $                     -   	
2642	Brachytx, stranded, C-131	 $                 361.43 	 $                -   	 $                     -   	
2643	Brachytx, non-stranded,C-131	 $                 163.85 	 $                -   	 $                     -   	
2698	Brachytx, stranded, NOS	 $                 125.89 	 $                -   	 $                     -   	
2699	Brachytx, non-stranded, NOS	 $                   69.32 	 $                -   	 $                     -   	
2731	Immune globulin, powder	 $                   95.81 	 $                -   	 $                     -   	
2770	Quinupristin/dalfopristin	 $                 516.36 	 $                -   	 $                     -   	
3041	Bivalirudin	 $                     8.35 	 $                -   	 $                     -   	
3043	Gamma globulin 1 CC inj	 $                   62.35 	 $                -   	 $                     -   	
7000	Amifostine	 $                 781.77 	 $                -   	 $                     -   	
7011	Oprelvekin injection	 $                 719.34 	 $                -   	 $                     -   	
7035	Teniposide	 $                 902.07 	 $                -   	 $                     -   	
7038	Monoclonal antibodies	 $                   17.21 	 $                -   	 $                     -   	
7041	Tirofiban HCl	 $                   23.35 	 $                -   	 $                     -   	
7042	Capecitabine, oral	 $                   26.05 	 $                -   	 $                     -   	
7043	Infliximab injection	 $                 182.29 	 $                -   	 $                     -   	
7046	Doxorubicin inj 10mg	 $             1,335.05 	 $                -   	 $                     -   	
7048	Alteplase recombinant	 $                 155.01 	 $                -   	 $                     -   	
7308	Aminolevulinic acid hcl top	 $                 647.66 	 $                -   	 $                     -   	
8000	Cardiac Electrophysiologic Evaluation and Ablation Composite	 $           34,099.16 	 $ 14,541.19 	 $      12,360.01 	
9001	Linezolid injection	 $                 105.59 	 $                -   	 $                     -   	
9002	Tenecteplase injection	 $                 205.45 	 $                -   	 $                     -   	
9003	Palivizumab	 $             3,401.84 	 $                -   	 $                     -   	
9004	Gemtuzumab ozogamicin inj	 $             7,130.73 	 $                -   	 $                     -   	
9005	Reteplase injection	 $             5,984.97 	 $                -   	 $                     -   	
9006	Tacrolimus injection	 $                 354.02 	 $                -   	 $                     -   	
9012	Arsenic trioxide injection	 $                 128.02 	 $                -   	 $                     -   	
9018	Inj, rimabotulinumtoxinB	 $                   29.09 	 $                -   	 $                     -   	
9019	Caspofungin acetate	 $                   33.20 	 $                -   	 $                     -   	
9024	Amphotericin b lipid complex	 $                   27.22 	 $                -   	 $                     -   	
9032	Baclofen 10 MG injection	 $                 432.93 	 $                -   	 $                     -   	
9033	Cidofovir injection	 $             1,698.29 	 $                -   	 $                     -   	
9038	Inj estrogen conjugate	 $                 424.22 	 $                -   	 $                     -   	
9042	Glucagon hydrochloride	 $                 345.83 	 $                -   	 $                     -   	
9044	Ibutilide fumarate injection	 $                 227.50 	 $                -   	 $                     -   	
9104	Antithymocyte globuln rabbit	 $             1,484.78 	 $                -   	 $                     -   	
9108	Thyrotropin injection	 $             3,146.44 	 $                -   	 $                     -   	
9110	Alemtuzumab injection	 $             1,513.98 	 $                -   	 $                     -   	
9119	Injection, pegfilgrastim 6mg	 $             8,388.48 	 $                -   	 $                     -   	
9120	Injection, Fulvestrant	 $                 233.09 	 $                -   	 $                     -   	
9121	Injection, argatroban	 $                   46.67 	 $                -   	 $                     -   	
9122	Triptorelin pamoate	 $                 482.92 	 $                -   	 $                     -   	
9124	Daptomycin injection	 $                     1.66 	 $                -   	 $                     -   	
9125	Risperidone, long acting	 $                   15.44 	 $                -   	 $                     -   	
9126	Natalizumab injection	 $                   36.37 	 $                -   	 $                     -   	
9130	Inj, Imm Glob Bivigam, 500mg	 $                 100.46 	 $                -   	 $                     -   	
9131	Inj, Ado-trastuzumab Emt 1mg	 $                   75.84 	 $                -   	 $                     -   	
9132	Kcentra, per i.u.	 $                     4.00 	 $                -   	 $                     -   	
9133	Rabies ig, im/sc	 $                 568.91 	 $                -   	 $                     -   	
9134	Rabies ig, heat treated	 $                 555.49 	 $                -   	 $                     -   	
9135	Varicella-zoster ig, im	 $             1,755.57 	 $                -   	 $                     -   	
9137	Bcg vaccine, percut	 $                 310.49 	 $                -   	 $                     -   	
9139	Rabies vaccine, im	 $                 613.65 	 $                -   	 $                     -   	
9140	Rabies vaccine, id	 $                 411.89 	 $                -   	 $                     -   	
9143	Meningococcal vaccine, sc	 $                 276.87 	 $                -   	 $                     -   	
9144	Encephalitis vaccine, sc	 $                 270.74 	 $                -   	 $                     -   	
9145	Meningococcal vaccine, im	 $                 253.68 	 $                -   	 $                     -   	
9207	Bortezomib injection	 $                 118.48 	 $                -   	 $                     -   	
9208	Agalsidase beta injection	 $                 380.09 	 $                -   	 $                     -   	
9209	Laronidase injection	 $                   73.61 	 $                -   	 $                     -   	
9210	Palonosetron hcl	 $                   50.31 	 $                -   	 $                     -   	
9213	Pemetrexed injection	 $                 156.18 	 $                -   	 $                     -   	
9214	Bevacizumab injection	 $                 170.72 	 $                -   	 $                     -   	
9215	Cetuximab injection	 $                 136.60 	 $                -   	 $                     -   	
9217	Leuprolide acetate suspnsion	 $                 543.63 	 $                -   	 $                     -   	
9224	Galsulfase injection	 $                 936.75 	 $                -   	 $                     -   	
9225	Fluocinolone acetonide implt	 $           50,297.00 	 $                -   	 $                     -   	
9227	Micafungin sodium injection	 $                     2.52 	 $                -   	 $                     -   	
9228	Tigecycline injection	 $                     4.60 	 $                -   	 $                     -   	
9229	Ibandronate sodium injection	 $                 410.62 	 $                -   	 $                     -   	
9230	Abatacept injection	 $                   60.92 	 $                -   	 $                     -   	
9231	Decitabine injection	 $                   83.82 	 $                -   	 $                     -   	
9232	Idursulfase injection	 $             1,219.63 	 $                -   	 $                     -   	
9233	Ranibizumab injection	 $             1,032.72 	 $                -   	 $                     -   	
9234	Alglucosidase alfa injection	 $                 537.24 	 $                -   	 $                     -   	
9235	Panitumumab injection	 $                 237.20 	 $                -   	 $                     -   	
9236	Eculizumab injection	 $                 532.01 	 $                -   	 $                     -   	
9237	Inj, lanreotide acetate	 $                   98.51 	 $                -   	 $                     -   	
9240	Injection, ixabepilone	 $                 178.49 	 $                -   	 $                     -   	
9242	Injection, fosaprepitant	 $                     4.47 	 $                -   	 $                     -   	
9243	Bendamustine injection	 $                   55.51 	 $                -   	 $                     -   	
9245	Romiplostim injection	 $                 134.19 	 $                -   	 $                     -   	
9250	Artiss fibrin sealant	 $                 111.46 	 $                -   	 $                     -   	
9251	C1 esterase inhibitor inj	 $                 127.97 	 $                -   	 $                     -   	
9252	Plerixafor injection	 $                 776.83 	 $                -   	 $                     -   	
9253	Temozolomide injection	 $                   13.36 	 $                -   	 $                     -   	
9255	Paliperidone palmitate inj	 $                   19.89 	 $                -   	 $                     -   	
9256	Dexamethasone intra implant	 $                 509.26 	 $                -   	 $                     -   	
9258	Telavancin injection	 $                   10.69 	 $                -   	 $                     -   	
9259	Pralatrexate injection	 $                 498.29 	 $                -   	 $                     -   	
9260	Ofatumumab injection	 $                 122.67 	 $                -   	 $                     -   	
9261	Ustekinumab injection	 $                 384.46 	 $                -   	 $                     -   	
9263	Ecallantide injection	 $                 924.14 	 $                -   	 $                     -   	
9264	Tocilizumab injection	 $                     9.62 	 $                -   	 $                     -   	
9265	Romidepsin injection	 $                 677.69 	 $                -   	 $                     -   	
9268	Capsaicin 8% patch	 $                   66.43 	 $                -   	 $                     -   	
9269	C-1 esterase, berinert	 $                   85.02 	 $                -   	 $                     -   	
9270	Gammaplex IVIG	 $                   97.16 	 $                -   	 $                     -   	
9271	Velaglucerase alfa	 $                 923.34 	 $                -   	 $                     -   	
9272	Inj, denosumab	 $                   37.15 	 $                -   	 $                     -   	
9273	Sipuleucel-T auto CD54+	 $           87,050.42 	 $                -   	 $                     -   	
9274	Crotalidae Poly Immune Fab	 $             6,148.27 	 $                -   	 $                     -   	
9276	Cabazitaxel injection	 $                 361.50 	 $                -   	 $                     -   	
9278	Incobotulinumtoxin A	 $                   11.65 	 $                -   	 $                     -   	
9281	Injection, pegloticase	 $             1,482.00 	 $                -   	 $                     -   	
9284	Ipilimumab injection	 $                 335.32 	 $                -   	 $                     -   	
9286	Belatacept injection	 $                     9.88 	 $                -   	 $                     -   	
9287	Brentuximab vedotin inj	 $                 277.84 	 $                -   	 $                     -   	
9289	Erwinaze injection	 $                 895.39 	 $                -   	 $                     -   	
9290	Inj, bupivacaine liposome	 $                     2.86 	 $                -   	 $                     -   	
9293	Injection, glucarpidase 	 $                 638.09 	 $                -   	 $                     -   	
9294	Inj, Taliglucerace Alfa 10 u	 $                   80.34 	 $                -   	 $                     -   	
9295	Injection, Carfilzomib, 1 mg	 $                   76.15 	 $                -   	 $                     -   	
9296	Inj, ziv-aflibercept, 1mg	 $                   24.36 	 $                -   	 $                     -   	
9297	Inj, Omacetaxine Mep, 0.01mg	 $                     6.45 	 $                -   	 $                     -   	
9298	Inj, Ocriplasmin, 0.125 mg	 $             2,721.55 	 $                -   	 $                     -   	
9300	Omalizumab injection	 $                   66.61 	 $                -   	 $                     -   	
9366	Epifix	 $                 554.32 	 $                -   	 $                     -   	
9368	Grafix core	 $                 333.22 	 $                -   	 $                     -   	
9369	Grafix prime	 $                 299.49 	 $                -   	 $                     -   	
9441	Inj, ferric carboxymaltose	 $                     2.76 	 $                -   	 $                     -   	
9497	Loxapine, inhalation powder	 $                 399.62 	 $                -   	 $                     -   	
9500	Platelets, irradiated	 $                 437.89 	 $                -   	 $                     -   	
9501	Platelet pheres leukoreduced	 $             1,299.17 	 $                -   	 $                     -   	
9502	Platelet pheresis irradiated	 $             1,518.84 	 $                -   	 $                     -   	
9503	Fr frz plasma donor retested	 $                 158.68 	 $                -   	 $                     -   	
9504	RBC deglycerolized	 $                 987.61 	 $                -   	 $                     -   	
9505	RBC irradiated	 $                 570.28 	 $                -   	 $                     -   	
9506	Granulocytes, pheresis unit	 $             4,906.64 	 $                -   	 $                     -   	
9507	Platelets, pheresis	 $             1,045.77 	 $                -   	 $                     -   	
9508	Plasma 1 donor frz w/in 8 hr	 $                 205.82 	 $                -   	 $                     -   	

Exhibit #5	
Effective January 1, 2015 	
Rural Health Facilities	
 	
Akron Clinic	
82 Main	
Akron, CO  80720 – Washington County	
Telephone:  (970) 345-6336, Fax:  (970) 345-6576	
 	
Arkansas Valley Family Practice, LLC	
2317 San Juan Avenue	
La Junta, CO  81050 – Otero County	
Telephone:  (719) 383-2325, Fax:  (719) 383-2327	
 	
Basin Clinic	
421 West Adams Road	
Naturita, CO  81422 – Montrose County	
Telephone:  (970) 865-2665, Fax:  (970) 825-2674	
 	
Brush Family Clinic	
2400 W Edison	
Brush, CO 80723 - Morgan County	
Telephone: (970) 842-2833, Fax: (970) 842-6241	
 	
Buena Vista Health Center	
28374 County Road 317	
Buena Vista, CO 81211 - Chaffee County	
Telephone: (719) 395-9048, Fax: (719) 395-9064	
 	
Button Family Practice	
715 South 9th Street 	
Cannon City, CO 81212 – Fremont County	
Telephone:  (719) 269-8820, Fax:  (719) 204-0230	
 	
Centennial Family Health Center	
319 Main Street	
Ordway, CO 81063 – Crowley County	
Telephone:  (719) 267-3503, Fax:  (719) 267-4153	

Cortez Primary Care Clinic 	
118 North Chestnut	
Cortez, CO 81321 – Montezuma County	
Telephone: (970) 564-9777, Fax: (970) 564-8833	
	
Creed Family Practice Of Rio Grande Hospital	
802 Rio Grande Avenue	
Creed, CO 81130 – Mineral County	
Telephone:  (719) 658-0929, Fax: (719) 657-2851	
 	
Custer County Medical Clinic	
704 Edwards	
Westcliffe, CO 81252 - Custer County	
Telephone: (719) 783-2380, Fax: (719) 783-2377	
 	
Dolores Medical Center	
507 Central Avenue	
Dolores, CO 81323 - Montezuma County	
Telephone: (970) 882-7221, Fax: (970) 882-4243	
 	
Eads Medical Clinic	
1211 Luther Street	
Eads, CO 81036 - Kiowa County	
Telephone: (719) 438-2251, Fax: (719) 438-2254	
 	
Eastern Plains Medical Clinic Of Calhan	
560 Crystola Street	
Calhan, CO 80808 - El Paso County	
Telephone: (719) 347-0100, Fax: (719) 347-0551	
 	
Family Care Clinic	
615 Fairhurst	
Sterling, CO 80751 - Logan County	
Telephone: (970) 521-3223, Fax: (970) 521-3266	

	
Family Practice Of Holyoke	
1001 East Johnson Street	
Holyoke, CO 80734 - Phillips County	
Telephone: (970) 854-2500, Fax: (970) 854-3440	
 	
Florence Medical Center	
501 W 5th St	
Florence, CO 81226 - Fremont County	
Telephone: (719) 784-4816, Fax: (719) 784-6014	
 	
Fort Morgan Pediatric Clinic, PC	
1000 Lincoln Street, Ste. 202	
Fort Morgan, CO  80701 – Morgan County	
Telephone:  (970) 542-9187, Fax:  (970) 867-9187	
 	
Grand River Health Clinic West	
201 Sipperelle Drive 	
Parachute, CO 81635 – Garfield County	
Telephone: (970) 285-7046, Fax: (970) 285-6064	
 	
Grand River Primary Care	
501 Airport Road	
Rifle, CO 81650 - Garfield County	
Telephone: (970) 625-1100, Fax: (970) 625-0725	
 	
Kit Carson Clinic	
102 East 2nd Avenue	
Kit Carson, CO 80825 - Cheyenne County	
Telephone: (719) 962-3501, Fax: (719) 962-3403	
 	
Lake City Area Medical Center	
700 N Henson Street	
Lake City, CO 81235 - Hinsdale County	
Telephone: (970) 944-2331, Fax: (970) 944-2320	

	
Lamar Medical Clinic	
403 Kendall Drive	
Lamar, CO  81052 – Prowers County	
Telephone:  (719) 336-6767; Fax:  (719) 336-7217	
 	
Las Animas Family Practice	
304 Carson Avenue	
Las Animas, CO  81054 – Bent County	
Telephone:  (719) 456-6000; Fax:  (719) 456-9701	
	
Mancos Valley Health Center	
111 Railroad Aveneu	
Mancos, CO 81328 – Montezuma County	
Telephone: (970) 564-2104, Fax: (970) 564-2134	
 	
Meeker Family Health Center	
345 Cleveland Street	
Meeker, CO 81641 - Rio Blanco County	
Telephone: (970) 878-4014, Fax: (970) 878-3285	
 	
Mountain Medical Center Of Buena Vista, P.C	
36 Oak St	
Buena Vista, CO 81211 - Chaffee County	
Telephone: (719) 395-8632, Fax: (719) 395-4971	
 	
Mt San Rafael Hospital Health Clinic	
400 Benedicta, Suite A	
Trinidad, CO 81082 – Las Animas County	
Telephone:  (719) 846-2206, Fax:  (719) 846-7823	
 	
North Park Medical Center - Walden	
350 McKinley Street	
Walden, CO 80480 - Jackson County	
Telephone: (970) 723-4255, Fax: (970) 723-4268	

	
Pagosa Mountain Clinic	
95 South Pagosa Blvd.	
Pagosa Springs, CO  81147 – Archuleta County	
Telephone:  (970) 731-3700, Fax:  (970) 731-3707	
 	
Parke Health Clinic	
182 16th St	
Burlington, CO 80807 - Kit Carson County	
Telephone: (719) 346-9481, Fax: (719) 346-9485	
	
Pediatric Associates, The	
947 South 5th Street	
Montrose, CO 81401 – Montrose County	
Telephone:  (970) 249-2421, Fax:  (970) 249-8897	
 	
Pediatric Association Of Canon City	
1335 Phay Avenue, Suite A	
Canon City, CO 81212 - Fremont County	
Telephone: (719) 269-1727, Fax: (719) 269-1730	
 	
Prairie View Rural Health Clinic	
615 West 5th North 	
Cheyenne Wells, CO 80810 - Cheyenne County	
Telephone: (719) 767-5669, Fax: (719) 767-8042	
 	
R and D Medical Management Corp.	
109 Latigo Lane, Suite C	
Canon City, CO 81212 – Fremont County	
Telephone: (719) 276-3211; Fax:  (719) 276-3011	
 	
Rio Grande Hospital Clinic	
0310C County Road 14	
Del Norte CO 81132 – Rio Grande County	
Telephone:  (719) 657-2418, Fax:  (719) 658-3001	

	
Rocky Ford Family Health Center	
1014 Elm Avenue	
Rocky Ford, CO 81067 - Otero County	
Telephone: (719) 254-7421, Fax: (719) 254-6966	
 	
Sabatini Pediatrics, PC	
612 Yale Place	
Canon City, CO  81212 – Fremont County	
Telephone:  (719) 275-3442, Fax:  (719) 275-2306	
 	
San Luis Valley Health Antonio Clinic	
115 Main Street 	
Antonio, CO 81120 – Conejos County	
Telephone: (719) 376-2308, Fax: (719) 376-2395	
	
San Luis Valley La Jara Medical Clinic	
509 Main Street	
La Jara, CO 81140 – Conejos County	
Telephone: (719) 274-5000, Fax: (719) 274-4111	
 	
Southeast Colorado Physician's Clinic	
900 Church Street	
Springfield, CO 81073 - Baca County	
Telephone: (719) 523-6628, Fax: (719) 523-4513	
 	
Southwest Memorial Primary Care	
33 North Elm Street	
Cortez, CO 81321 – Montezuma County	
Telephone:  (970) 565-8556, Fax:  (970) 564-1134	
 	
Southwest Walk-In Care	
2095 North Dolores Road, Suite C	
Cortez, CO 81321 – Montezuma County	
Telephone: (970) 564-1037, Fax: (970) 564-1041	

	
Spanish Peaks Family Clinic	
23400 US Highway 160	
Walsenburg, CO  81089 – Huerfano County	
Telephone: (719) 738-4591, Fax: (719) 738-4553	
 	
Stratton Medical Clinic	
500 Nebraska Avenue	
Stratton, CO 80836 - Kit Carson County	
Telephone: (719) 348-4650, Fax: (719) 348-4653	
 	
Surface Creek Family Practice	
255 SW 8th Ave	
Cedaredge, CO 81413 - Delta County	
Telephone: (970) 856-3146, Fax: (970) 856-4385	
 	
Trinidad Family Medical Center	
1502 E Main St	
Trinidad, CO 81082 - Las Animas County	
Telephone: (719) 846-3305, Fax: (719) 846-4922	
 	
Valley Medical Clinic	
116 E Ninth Street	
Julesburg, CO 80737 - Sedgwick County	
Telephone: (970) 474-3376, Fax: (970) 474-2461	
 	
Walsh Medical Clinic	
137 Kansas Street	
Walsh, CO 81090 – Baca County	
Telephone:  (719) 324-5253, Fax:  (719) 324-5621	
 	
Washington County Clinic	
482 Adams Avenue	
Akron, CO 80720 - Washington County	
Telephone:  (970) 345-2262, Fax:  (970) 345-2265	

	
Yuma Clinic	
1000 W 8th Avenue	
Yuma, CO  80759	
Telephone:  (970) 8848-4792, Fax:  (970) 848-5405	

Exhibit # 6
Dental Free Schedule
Effective January 1, 2015 

CDT 2014	2015 Fees	
D0120	$67.15	
D0140	$112.29	
D0145	$104.19	
D0150	$118.08	
D0160	$237.31	
D0170	$78.72	
D0180	$128.50	
D0190	$62.00	
D0191	$44.00	
D0210	$187.18	
D0220	$37.68	
D0230	$34.03	
D0240	$58.35	
D0250	$71.72	
D0260	$65.64	
D0270	$38.89	
D0272	$63.21	
D0273	$76.58	
D0274	$88.74	
D0277	$133.71	
D0290	$218.79	
D0310	$556.70	
D0320	$948.10	
D0321	BR	
D0322	$765.77	
D0330	$165.54	
D0340	$186.38	
D0350	$89.13	
D0360	$1,067.34	
D0362	$853.17	
D0363	$889.06	
D0364	$1,251.00	
D0365	$1,251.00	
D0366	$1,251.00	
D0367	$1,251.00	
D0368	$1,831.00	
D0369	$3,274.00	
D0370	$1,102.00	
D0371	BR	
D0380	$998.00	
D0381	$998.00	
D0382	$998.00	
D0383	$998.00	
D0384	$1,459.00	
D0385	$2,382.00	
D0386	$596.00	
D0391	BR	
D0415	$72.00	
D0416	$106.00	
D0417	$97.00	
D0418	$100.00	
D0421	$72.00	
D0425	$62.00	
D0431	$100.00	
D0460	$100.00	
D0470	$219.00	
D0472	$137.00	
D0473	$290.00	
D0474	$325.00	
D0475	$175.00	
D0476	$170.00	
D0477	$232.00	
D0478	$212.00	
D0479	$325.00	
D0480	$200.00	
D0481	$858.14	
D0482	$250.00	
D0483	$250.00	
D0484	$375.00	
D0485	$517.00	
D0486	$240.00	
D0502	BR	
D0999	BR	
D1110	$120.33	
D1120	$83.87	
D1206	$72.93	
D1208	$45.15	
D1310	$70.61	
D1320	$77.56	
D1330	$97.24	
D1351	$78.72	
D1352	$94.50	
D1510	$503.57	
D1515	$704.99	
D1520	$554.51	
D1525	$856.64	
D1550	$108.82	
D1555	$104.19	
D2140	$262.55	
D2150	$339.13	
D2160	$410.84	
D2161	$500.79	
D2330	$239.45	
D2331	$306.31	
D2332	$374.38	
D2335	$443.66	
D2390	$491.06	
D2391	$280.78	
D2392	$368.30	
D2393	$457.03	
D2394	$560.35	
D2410	$457.26	
D2420	$762.88	
D2430	$1,322.01	
D2510	$1,209.72	
D2520	$1,372.95	
D2530	$1,582.48	
D2542	$1,551.22	
D2543	$1,623.00	
D2544	$1,687.82	
D2610	$1,423.88	
D2620	$1,502.60	
D2630	$1,601.00	
D2642	$1,555.85	
D2643	$1,677.40	
D2644	$1,779.27	
D2650	$935.36	
D2651	$1,114.80	
D2652	$1,171.52	
D2662	$1,016.40	
D2663	$1,195.82	
D2664	$1,281.49	
D2710	$628.41	
D2712	$628.41	
D2720	$1,548.55	
D2721	$1,451.31	
D2722	$1,482.92	
D2740	$1,588.67	
D2750	$1,568.01	
D2751	$1,459.83	
D2752	$1,495.07	
D2780	$1,503.58	
D2781	$1,414.85	
D2782	$1,461.04	
D2783	$1,546.13	
D2790	$1,512.09	
D2791	$1,433.08	
D2792	$1,459.83	
D2794	$1,548.55	
D2799	$628.41	
D2910	$143.43	
D2915	$143.43	
D2920	$144.65	
D2929	$543.00	
D2930	$395.04	
D2931	$447.31	
D2932	$476.48	
D2933	$545.76	
D2934	$545.76	
D2940	$150.73	
D2950	$376.80	
D2951	$85.08	
D2952	$595.60	
D2953	$297.80	
D2954	$476.48	
D2955	$367.08	
D2957	$238.23	
D2960	$1,152.30	
D2961	$1,306.67	
D2962	$1,419.72	
D2970	$357.36	
D2971	$228.51	
D2975	$695.27	
D2980	BR	
D2981	BR	
D2982	BR	
D2983	BR	
D2990	$94.00	
D2999	BR	
D3110	$131.25	
D3120	$105.35	
D3220	$268.80	
D3221	$295.20	
D3222	$273.20	
D3230	$307.52	
D3240	$379.24	
D3310	$1,207.00	
D3320	$1,479.27	
D3330	$1,834.20	
D3331	$472.84	
D3332	$899.47	
D3333	$414.49	
D3346	$1,609.34	
D3347	$1,893.76	
D3348	$2,343.50	
D3351	$968.76	
D3352	$433.93	
D3353	$1,335.84	
D3354	BR	
D3410	$1,920.50	
D3421	$2,138.07	
D3425	$2,421.29	
D3426	$818.03	
D3430	$601.67	
D3450	$1,251.97	
D3460	$4,676.05	
D3470	$2,388.47	
D3910	$334.27	
D3920	$951.74	
D3950	$433.93	
D3999	BR	
D4210	$1,603.00	
D4211	$712.00	
D4212	$570.00	
D4230	$2,244.00	
D4231	$1,096.39	
D4240	$2,030.00	
D4241	$1,175.00	
D4245	$1,496.00	
D4249	$2,226.00	
D4260	$3,383.00	
D4261	$1,816.00	
D4263	$1,211.00	
D4264	$1,033.00	
D4265	BR	
D4266	$1,247.00	
D4267	$1,603.00	
D4268	BR	
D4270	$2,404.00	
D4273	$2,938.00	
D4274	$1,667.00	
D4275	$2,208.00	
D4276	$3,294.00	
D4277	$2,493.00	
D4278	$819.00	
D4320	$625.99	
D4321	$633.28	
D4341	$361.00	
D4342	$217.57	
D4355	$246.75	
D4381	BR	
D4910	$222.44	
D4920	$161.66	
D4999	BR	
D5110	$2,343.00	
D5120	$2,343.00	
D5130	$2,555.00	
D5140	$2,555.00	
D5211	$1,977.00	
D5212	$2,298.00	
D5213	$2,771.36	
D5214	$2,589.00	
D5225	$1,977.00	
D5226	$2,298.00	
D5281	$1,509.00	
D5410	$128.00	
D5411	$128.00	
D5421	$128.00	
D5422	$128.00	
D5510	$274.70	
D5520	$214.00	
D5610	$278.00	
D5620	$316.03	
D5630	$363.00	
D5640	$235.00	
D5650	$321.00	
D5660	$385.00	
D5670	$1,006.44	
D5671	$1,006.44	
D5710	$951.00	
D5711	$909.00	
D5720	$898.00	
D5721	$898.00	
D5730	$537.00	
D5731	$537.00	
D5740	$492.00	
D5741	$492.00	
D5750	$716.00	
D5751	$716.00	
D5760	$705.00	
D5761	$705.00	
D5810	$1,133.00	
D5811	$1,218.00	
D5820	$876.00	
D5821	$930.00	
D5850	$224.00	
D5851	$224.00	
D5860	BR	
D5861	BR	
D5862	BR	
D5867	BR	
D5875	BR	
D5899	BR	
D5911	$594.00	
D5912	$594.00	
D5913	$12,514.00	
D5914	$12,514.00	
D5915	$16,935.00	
D5916	$4,517.00	
D5919	BR	
D5922	BR	
D5923	BR	
D5924	BR	
D5925	BR	
D5926	BR	
D5927	BR	
D5928	BR	
D5929	BR	
D5931	$6,738.00	
D5932	$12,602.00	
D5933	BR	
D5934	$11,486.00	
D5935	$9,994.00	
D5936	$11,225.00	
D5937	$1,411.00	
D5951	$1,834.00	
D5952	$5,956.00	
D5953	$11,310.00	
D5954	$10,481.00	
D5955	$9,694.00	
D5958	BR	
D5959	BR	
D5960	BR	
D5982	$997.93	
D5983	$2,416.43	
D5984	$2,416.43	
D5985	$2,416.43	
D5986	$214.00	
D5987	$3,627.07	
D5988	$641.00	
D5991	$246.00	
D5992	BR	
D5993	BR	
D5999	BR	
D6101	BR	
D6102	BR	
D6103	BR	
D6104	BR	
D6010	$3,914.00	
D6012	$3,698.00	
D6040	$14,418.34	
D6050	$10,047.00	
D6051	BR	
D6053	$2,922.00	
D6054	$2,922.00	
D6055	$1,176.00	
D6056	$812.00	
D6057	$1,005.00	
D6058	$2,253.00	
D6059	$2,379.96	
D6060	$2,249.90	
D6061	$2,294.88	
D6062	$2,286.36	
D6063	$1,963.04	
D6064	$2,079.74	
D6065	$2,217.00	
D6066	$2,311.89	
D6067	$2,242.61	
D6068	$2,234.00	
D6069	$2,379.96	
D6070	$2,249.90	
D6071	$2,144.00	
D6072	$2,343.50	
D6073	$2,121.06	
D6074	$2,106.00	
D6075	$2,217.00	
D6076	$2,311.89	
D6077	$2,242.61	
D6078	BR	
D6079	BR	
D6080	$184.00	
D6090	BR	
D6091	$887.00	
D6092	$173.00	
D6093	$271.00	
D6094	$1,887.68	
D6095	BR	
D6100	BR	
D6190	$395.00	
D6194	$1,817.00	
D6199	BR	
D6205	$1,016.16	
D6210	$1,553.41	
D6211	$1,454.96	
D6212	$1,514.52	
D6214	$1,563.15	
D6240	$1,533.97	
D6241	$1,416.06	
D6242	$1,493.86	
D6245	$1,582.59	
D6250	$1,514.52	
D6251	$1,396.62	
D6252	$1,441.59	
D6253	$652.72	
D6545	$610.19	
D6548	$651.00	
D6600	$1,186.33	
D6601	$1,266.56	
D6602	$1,294.51	
D6603	$1,424.58	
D6604	$1,268.99	
D6605	$1,344.35	
D6606	$1,248.32	
D6607	$1,385.67	
D6608	$1,277.00	
D6609	$1,355.29	
D6610	$1,396.62	
D6611	$1,527.89	
D6612	$1,389.33	
D6613	$1,452.53	
D6614	$1,358.93	
D6615	$1,413.64	
D6624	$1,294.51	
D6634	$1,358.93	
D6710	$1,345.00	
D6720	$1,619.06	
D6721	$1,535.18	
D6722	$1,563.15	
D6740	$1,650.00	
D6750	$1,656.73	
D6751	$1,546.13	
D6752	$1,583.81	
D6780	$1,563.15	
D6781	$1,516.00	
D6782	$1,563.15	
D6783	$1,561.00	
D6790	$1,599.60	
D6791	$1,516.96	
D6792	$1,571.65	
D6793	$637.00	
D6794	$1,571.65	
D6920	$420.57	
D6930	$245.53	
D6940	$556.70	
D6950	$1,074.51	
D6975	$1,191.19	
D6980	BR	
D6985	$934.72	
D6999	BR	
D7111	$229.73	
D7140	$305.09	
D7210	$405.98	
D7220	$509.29	
D7230	$678.25	
D7240	$796.15	
D7241	$1,000.37	
D7250	$429.07	
D7251	$770.70	
D7260	$3,182.19	
D7261	$1,104.60	
D7270	$828.45	
D7272	$1,104.60	
D7280	$772.80	
D7282	$386.40	
D7283	$331.80	
D7285	$1,546.65	
D7286	$662.55	
D7287	$265.65	
D7288	$265.65	
D7290	$662.55	
D7291	$466.76	
D7292	$1,060.50	
D7293	$662.55	
D7294	$552.30	
D7295	BR	
D7310	$1,009.00	
D7311	$883.00	
D7320	$1,640.00	
D7321	$1,388.00	
D7340	$6,938.00	
D7350	$20,182.00	
D7410	$3,027.00	
D7411	$4,793.00	
D7412	$5,298.00	
D7413	$3,532.00	
D7414	$5,298.00	
D7415	$5,928.00	
D7440	$4,793.00	
D7441	$7,064.00	
D7450	$3,027.00	
D7451	$4,137.00	
D7460	$3,027.00	
D7461	$4,137.00	
D7465	$1,640.00	
D7471	$3,749.00	
D7472	$4,455.00	
D7473	$4,203.00	
D7485	$3,749.00	
D7490	$30,273.00	
D7510	$1,085.00	
D7511	$1,640.00	
D7520	$5,167.00	
D7521	$5,676.00	
D7530	$1,862.00	
D7540	$2,064.00	
D7550	$1,287.00	
D7560	$10,217.00	
D7610	$16,524.00	
D7620	$12,392.00	
D7630	$21,484.00	
D7640	$13,633.00	
D7650	$10,328.00	
D7660	$6,090.00	
D7670	$4,753.00	
D7671	$8,956.00	
D7680	$30,984.00	
D7710	$19,420.00	
D7720	$13,633.00	
D7730	$28,093.00	
D7740	$13,900.00	
D7750	$17,679.00	
D7760	$7,094.00	
D7770	$9,612.00	
D7771	$7,417.00	
D7780	$41,313.00	
D7810	$18,174.00	
D7820	$2,977.00	
D7830	$1,705.00	
D7840	$24,773.00	
D7850	$21,393.00	
D7852	$24,496.00	
D7854	$25,278.00	
D7856	$17,937.00	
D7858	$51,126.00	
D7860	$21,792.00	
D7865	$35,117.00	
D7870	$1,160.00	
D7871	$2,321.00	
D7872	$12,387.00	
D7873	$14,914.00	
D7874	$21,393.00	
D7875	$23,436.00	
D7876	$25,268.00	
D7877	$22,301.00	
D7880	$2,785.00	
D7899	BR	
D7910	$1,655.00	
D7911	$4,132.00	
D7912	$7,437.00	
D7920	$12,185.00	
D7921	$1,125.00	
D7940	BR	
D7941	$31,030.00	
D7943	$28,507.00	
D7944	$25,404.00	
D7945	$33,805.00	
D7946	$41,878.00	
D7947	$35,218.00	
D7948	$45,712.00	
D7949	$59,537.00	
D7950	BR	
D7951	BR	
D7952	BR	
D7953	$858.00	
D7955	BR	
D7960	$1,388.00	
D7963	$2,270.00	
D7970	$2,018.00	
D7971	$757.00	
D7972	$2,825.00	
D7980	$3,179.00	
D7981	BR	
D7982	$7,518.00	
D7983	$7,215.00	
D7990	$6,206.00	
D7991	$15,137.00	
D7995	BR	
D7996	BR	
D7997	$1,160.00	
D7998	$5,046.00	
D7999	BR	
D8010	BR	
D8020	BR	
D8030	BR	
D8040	BR	
D8050	BR	
D8060	BR	
D8070	BR	
D8080	BR	
D8090	BR	
D8210	BR	
D8220	BR	
D8660	$700.13	
D8670	$525.09	
D8680	$1,154.73	
D8690	$545.76	
D8691	$512.95	
D8692	$571.28	
D8693	$528.75	
D8999	BR	
D9110	$215.15	
D9120	$243.11	
D9210	$181.65	
D9211	$200.55	
D9212	$312.90	
D9215	$150.15	
D9220	$1,815.45	
D9221	$813.75	
D9230	$300.30	
D9241	$1,408.05	
D9242	$688.80	
D9248	$437.85	
D9310	$487.42	
D9410	$557.92	
D9420	$903.13	
D9430	$151.94	
D9440	$305.09	
D9450	$151.94	
D9610	BR	
D9612	BR	
D9630	BR	
D9910	$103.03	
D9911	$144.70	
D9920	BR	
D9930	BR	
D9940	$940.80	
D9941	$307.52	
D9942	$354.24	
D9950	$560.29	
D9951	$251.20	
D9952	$1,179.62	
D9970	$133.13	
D9971	$171.33	
D9972	$590.39	
D9973	$97.24	
D9974	$516.31	
D9975	$576.00	
D9999	BR	

Exhibit # 7
(Effective January 1, 2015)
Evaluation and Management (E&M) Guidelines for Colorado
Workers’ Compensation Claims
This E&M Guidelines for Colorado Workers’ Compensation Claims is intended for the physicians who manage injured workers’ medical and non-medical care.  Providers may use the “1997 Documentation Guidelines for Evaluation and Management Services” as developed by Medicare and available on Medicare’s web site when indicated in this Exhibit.
1.	History (Hx),  2.  Examination (Exam), and 3.  Medical Decision Making (MDM) Determines the Level of Service:
New Patient/Office Consultations

Level of Service (Requires all three key components at the same level or higher)	1. Hx	2. Exam	3. MDM	Avg. time (minutes) as listed for the specific  CPT®  code	
99201/99241	Problem Focused (PF)	PF	Straight Forward (SF)	10	
99202/99242	Extended Problem Focused (EPF)	EPF	SF	20	
99203/99243	Detailed (D)	D	Low	30	
99204/99244	Comprehensive(C)	C	Moderate	45	
99205/99245	C	C	High	60	
Established Patient Office Visit

Level of Service (Requires at least two of the three key components at the same level or higher)	1. Hx	2. Exam	3. MDM	Avg. time (minutes) as listed for the specific  CPT® code	
99211	N/A	N/A	N/A	5	
99212	PF	PF	SF	10	
99213	EPF	EPF	Low	15	
99214	D	D	Moderate	25	
99215	C	C	High	40	
NOTES:  Documentation of a chief complaint is required for any billed office visit.
CPT® criteria for a consultation is still required to bill a consultation code.
1.  History Component – To qualify for a given level of history all three elements in the table below must be met and documented in the record.  Documentation must be patient specific and pertain directly to the current visit.  Information copied directly from prior records without change is not considered current nor counted.

History Elements	Requirements for a Problem Focused (PF) History Level	Requirements for an Expanded Problem Focused  (EPF) History Level	Requirements for a Detailed (D) History Level	Requirements for a Comprehensive (C) History Level	
History of Present Illness/Injury (HPI)	Brief 1-3 elements	Brief 1-3 elements	Extended 4+ elements (required a detailed patient specific description of the patient’s progress with the current TX plan, which should include objective functional gains/losses, ADLs)	Extended 4+ elements (requires a detailed patient specific description of the patient’s progress with the current TX plan, which should include objective functional gains/losses, ADLs)	
Review of Systems (ROS) is not required for established patient visits.	None	Problem pertinent – limited to injured body part	2 to 9 body parts or body systems	Complete 10+	
Past Medical, Family and Social/Work History (PMFSH)	None	None	Pertinent 1 of 4 types of histories	2 or more of the 4 types of histories	
A.	HPI Elements represents the injured worker relaying their condition to the physician and should include the following:
1.	Location (where?)
2.	Quality (sharp, dull)
3.	Severity (pain level 1-10 or pain diagram)
4.	Duration (how long?)
5.	Timing (how often?)
6.	Context (what ADLs or functions aggravates/relieves?)**
7.	Modifying factors (doing what?)
8.	Associated signs (nausea, when?)
For the provider to achieve an “extended” HPI in an established patient/injured worker visit it is necessary to document a detailed description of the patient’s progress since the last visit with current treatment plan that includes patient pertinent objective functional gains, such as ADLs, physical therapy goals and return to work. 
For the provider to achieve an “extended” HPI in an initial patient/injured worker’s visit it is necessary for the provider to discuss the causality of the patient/injured worker’s work related injury(s) to the patient/injured worker’s job duties.
B.	Review of Systems (ROS) each system/body part is counted once whether positive or negative:
1.	Constitutional symptoms (e.g., fever, weight loss)
2.	Eyes
3.	Ears, Nose, Mouth, Throat
4.	Cardiovascular
5.	Respiratory
6.	Gastrointestinal 
7.	Genitourinary
8.	Musculoskeletal
9.	Integumentary (skin and/or breast)
10.	Neurological
11.	Psychiatric
12.	Endocrine
13.	Hematologic/Lymphatic
14.	Allergic/Immunologic
Identify, perform and documentation of all pertinent ROS systems with either a “positive or negative” response is necessary to be counted.
C.	The PMFSH consists of a review of four areas (NOTE:  Employers should not have access to any patient’s or the family’s generic/hereditary diagnoses or testing information, etc.)
1.	Past history – the patient’s past experiences with illnesses, operations, injuries and treatments;
2.	Family history – a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk and any family situations that can interfere with or support the injured worker’s treatment plan and returning to work;
3.	Occupational/Social History – an age appropriate review of past and current work activities, occupational history, current work status, any work situations that support or interfere with return to work.  For established visits specific updates of progress must be discussed.
4.	Non-Occupational/Social History – Hobbies, current recreational physical activities and the patient’s support relationships, etc.  For established visits specific updates of progress must be discussed.
2.	Pertinent Physician’s Examination Component – Each bullet is counted only when it is pertinent and related to the workers’ compensation injury and the medical decision making process.
The 1997 Evaluation and Management (E&M) guidelines may be used for specialist examination.
Content and Documentation Requirements
Level of Examination
Performed and Documented	# of Bullets Required for each Level	
Problem Focused	1 to 5 elements identified by a bullet as indicated in this guideline	
Expanded Problem Focused	6 elements identified by a bullet as indicated in this guideline	
Detailed	7-12 elements identified by a bullet as indicated in this guideline	
Comprehensive	> 13 elements identified by a bullet as indicated in this guideline	
Constitutional Measurement
Vital signs (may be measured and recorded by ancillary staff) – any of three vital signs is counted as one bullet:
1.	sitting or standing blood pressure
2.	supine blood pressure
3.	pulse rate and regularity
4.	respiration
5.	temperature
6.	height
7.	weight or BMI
One bullet for commenting on the general appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)
Musculoskeletal
Each of the six body areas with three (3) assessments is counted as one bullet.
1.	head and or neck
2.	spine or ribs and pelvis or all three
3.	right upper extremity (shoulder, elbow, wrist, entire hand)
4.	left upper extremity (shoulder, elbow, wrist, entire hand)
5.	right lower extremity (hip, knee, ankle, entire foot)
6.	left lower extremity (hip, knee, ankle, entire foot)
Assessment of a given body area includes:
1.	Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
2.	Assessment of range of motion with notation of any pain (e.g., straight leg raising), crepitation or contracture
3.	Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
4.	Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements (fasciculation, tardive dyskinesia)
7.	Examination of gait and station
Neck – one bullet for both examinations
1.	Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
2.	Examination of thyroid (e.g., enlargement, tenderness, mass)
Neurological
One bullet for each neurological examination/assessment(s) per extremity:
1.	Test coordination (e.g., finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities
2.	Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes (e.g., Babinski)
3.	Examination of sensation (e.g., by touch, pin, vibration, proprioception)
4.	One bullet for all of the 12 cranial nerves assessments with notations of any deficits
Cardiovascular
1.	One bullet per extremity examination/assessment of peripheral vascular system by:
a.	Observation (e.g., swelling, varicosities); and
b.	Palpation (e.g., pulses, temperature, edema, tenderness)
2.	One bullet for palpation of heart (e.g., location, size, thrills)
3.	One bullet for auscultation of heart with notation of abnormal sounds and murmurs
4.	One bullet for examination of each one of the following:
a.	carotid arteries (e.g., pulse amplitude, bruits)
b.	abdominal aorta (e.g., size, bruits)
c.	femoral arteries (e.g., pulse amplitude, bruits)
Skin
One bullet for pertinent body part(s) inspection and/or palpation of skin and subcutaneous tissue (e.g., scars, rashes, lesions, cafeau-lait pots, ulcers)
Respiratory (one bullet for each examination/assessment)
1.	Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
2.	Percussion of chest (e.g., dullness, flatness, hyperresonance)
3.	Palpation of chest (e.g., tactile fremitus)
4.	Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)
Gastrointestinal (one bullet for each examination /assessment)
1.	Examination of abdomen with notation of presence of masses or tenderness and liver and spleen
2.	Examination of presence or absence of hernia
3.	Examination (when indicated) of anus, perineum and rectum, including sphincter tone, present of hemorrhoids, rectal masses and/or obtain stool sample of occult blood test when indicated
Psychiatric
1.	One bullet for assessment of mood and affect (e.g., depression, anxiety, agitation) if not counted under the Neurological system
2.	One bullet for a mental status examination which includes:
a.	Attention span and concentration; and
b.	Language (e.g., naming objects, repeating phrases, spontaneous speech) orientation to time, place and person; and
c.	Recent and remote memory; and
d.	Fund of knowledge (e.g., awareness of current events, past history, vocabulary)
Eyes (one bullet for both eyes and all three examinations/assessments)
1.	Inspection of conjunctivae and lids; and
2.	Examination of pupils and irises (e.g., reaction of light and accommodation, size and symmetry); and
3.	Opthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages)
Ears and Nose, Mouth and Throat
One bullet for all of the following examination/assessment:
1.	External inspection of ears and nose (e.g., overall appearance, scars, lesions, asses)
2.	Otoscopic examination of external auditory canals and tympanic membranes
3.	Assessment of hearing with tuning fork and clinical speech reception thresholds (e.g., whispered voice, finger rub, tuning fork)
One bullet for all of the following examinations/assessments:
1.	Inspection of nasal mucosa, septum and turbinates
2.	Inspection of lips, teeth and gums
3.	Examination of oropharynx:  oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx (e.g., asymmetry, lesions, hydration of mucosal surfaces)
Genitourinary
	MALE – 
	One bullet for each of the following examination of the male genitalia:
1.	The scrotal contents (e.g., hydrocele, spermatocele, tenderness of cord, testicular mass)
2.	Epididymides (e.g., size, symmetry, masses)
3.	Testes (e.g., size symmetry, masses)
4.	Urethral meatus (e.g., size location, lesions, discharge)
5.	Examination of the penis (e.g., lesions, presence of absence of foreskin, foreskin retract ability, plaque, masses, scarring, deformities)
6.	Digital rectal examination of prostate gland (e.g., size, symmetry, nodularity, tenderness)
7.	Inspection of anus and perineum
	FEMALE –
	One bullet for each of the following female pelvic examination(s) (with or without specimen collection for smears and cultures):
1.	Examination of external genitalia (e.g., general appearance, hair distribution, lesions) and vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele rectocele)
2.	Examination of urethra (e.g., masses, tenderness, scarring)
3.	Examination of bladder (e.g., fullness, masses, tenderness)
4.	Cervix (e.g., general appearance, lesions, discharge)
5.	Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)
6.	Adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)
Chest (one bullet for both examinations/assessments of both breasts)
1.	Inspection of breasts (e.g., symmetry, nipple discharge); and
2.	Palpation of breasts and axillae (e.g., masses or lumps, tenderness)
Lymphatic palpation of lymph nodes -- two or more areas is counted as one bullet:
1.	Neck
2.	Axillae
3.	Groin
4.	Other
3.	Medical Decision Making (MDM) Component
Documentation must be patient specific and pertain directly to the current visit.  Information copied directly from prior records without change is not considered current nor counted.

Level of Risk	1.  # of Points for the # of Dxs and Management Options)	2.  # of Points for Amount and Complexity of Data)	3.  Level of Risk	
Straightforward	0-1	0-1	Minimal	
Low	2	2	Low	
Moderate	3	3	Moderate	
High	4+	4+	High	
Overall MDM is determined by the highest 2 out of the 3 above categories.

1.  Number of Diagnosis & Management Options	
Category of Problem(s)	Occurrence of Problem(s)		Value		TOTAL	
Self-limited or minor problem	(max 2)	X	1	=		
Established problem, stable or improved		X	1	=		
Established problem, minor worsening		X	2	=		
New problem with no additional workup planned or established patient with worsening of condition and no additional workup planned	(max1)	X	3	=		
New problem, additional workup planned or established patient with worsening of condition and additional workup planned.		X	4	=		

2.  Amount and/or Complexity of Data Reviewed		
Date Type:	Points	
Lab(s) ordered and/or reports reviewed	1	
X-ray(s) ordered and/or reports reviewed	1	
Discussion of test results with performing physician	1	
Decision to obtain old records and/or obtain history from someone other than the patient	1	
Medicine section (90701-99199) ordered and/or physical therapy reports reviewed and commented on progress (state whether the patient is progressing and how they are functionally progressing or not and document any planned changes to the plan of care)	2	
Review and summary of old records and/or discussion with other health provider	2	
Independent visualization of images, tracing or specimen	2	
TOTAL		

3.  Table of Risk (the highest one in any one category determines the overall risk for this portion)	
Level of Risk	Presenting Problem(s)	Diagnostic Procedure(s) Ordered	Management Option(s) Selected	
Minimal	One self-limited or minor problem, e.g., cold, insect bite, tinea corpori, minor non-sutured laceration	Lab tests requiring venipuncture
Chest x-rays
EKG/EEG
Urinalysis
Ultrasound
KOH prep	Rest
Gargles
Elastic bandages
Superficial dressings	
Low	Two or more self-limited or minor problems
One stable chronic illness, e.g., well-controlled HTN, NIDDM, cataract, BPH
Acute, uncomplicated illness or injury, e.g., allergic rhinitis or simple sprain cyctitis 
Acute laceration repair	Physiologic tests nor under stress, e.g., PFTs
Non-cardiovascular imaging studies w/contrast, e.g., barium enema
Superficial needle biopsies
Lab tests requiring arterial puncture
Skin biopsies	Over-the-counter drugs
Minor surgery w/no identified risk factors
PT/OT
IV fluids w/o additives
Simple or layered closure
Vaccine injection	
Moderate	One of more chronic illnesses with mild exacerabation, progression or side effects of treatment
Two or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis, e.g., new extremity neurologic complaints
Acute illness with systemic symptoms, e.g., pyelonephritis, colitis
Acute complicated injury, e.g., head injury with brief loss of consciousness	Physiologic tests under stress, e.g. cardiac stress test, 
Discography, stress tests
Diagnostic injections  
Deep needle or incisional biopsies
Cardiovascular imaging studies with contrast and no identified risk factors e.g. arteriogram, cardiac cath
Obtain fluid from body cavity, e.g. lumbar puncture, thoracentesis, culdocentesis
	Minor surgery with identified risk factors
Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors
Prescription drug management 
Therapeutic nuclear medicine IV fluids with additives
Closed Tx of Fx or dislocation w/o manipulation
Inability to return the injured worker to work and requires detailed functional improvement plan.	
High	One or more chronic illness with severe exacerbation, progression or side effects of treatment
Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g., multiple trauma, acute MI, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others;
An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss	Cardiovascular imaging studies with contrast with identified risk factors
Cardiac electrophysiological tests
Diagnostic endoscopies with identified risk factors	Elective major surgery with identified risk factors
Emergency major surgery
Parenteral controlled substances
Drug therapy requiring intensive monitoring for toxicity
Decision not to resuscitate or to de-escalate care because of poor prognosis,
Potential for significant permanent work restrictions or total disability
Management of addiction behavior or other significant psychiatric condition
Treatment plan for patients with symptoms causing severe functional deficits without supporting physiological \findings or verified related medical diagnosis.	
If greater than fifty percent of a physician’s time at an E&M visit is spent either face-to-face with the patient counseling and/or coordination of care and there is detailed patient specific documentation of the counseling and/or coordination of care, then time can determine the level of service.
The total time spent face-to-face with the patient and/or coordination of care must be documented in the record and the total visit time.
If time is used to establish the level of visit and total amount of time falls in between two levels, then the provider’s time shall be more than half way to reaching the higher level.
Documentation must be patient specific and pertain directly to the current visit.  Information copied directly from prior records without change is not considered current nor counted.
Counseling:
Primary care physicians should have shared decision making conferences with their patients to establish viable functional goals prior to making referrals for diagnostic testing and/or to specialists.  Shared decision making occurs when the physician shares with the patient all the treatment alternatives reflected in the Colorado Medical Treatment Guidelines as well as any possible side effects or limitations, and the patient shares with the primary physician their desired outcome from the treatment.  Patients should be encouraged to express their goals, outcome expectations and desires from treatment as well as any personal habits or traits that may be impacted by procedures or their possible side effects.  
The physician’s time spent face-to-face with the patient and/or their family counseling him/her or them in one or more of the following:
1.	Injury/disease education that includes discussion of diagnostic tests results and a disease specific treatment plan.
2.	Return to work
3.	Temporary and/or permanent restrictions
4.	Self-management of symptoms while at home and/or work
5.	Correct posture/mechanics to perform work functions
6.	Job task exercises for muscle strengthening and stretching
7.	Appropriate tool and equipment use to prevent re-injury and/or worsening of the existing injury/condition
8.	Patient/injured worker expectations and specific goals
9.	Family and other interpersonal relationships and how they relate to psychological/social issues
10.	Discussion of pharmaceutical management (includes drug dosage, specific drug side effects and potential of addiction /problems
11.	Assessment of vocational plans (i.e., restrictions as they relate to current and future employment job requirements)
Coordination of Care:

Coordination of care requires the physician to either call another health care provider (outside of 
their own clinic) regarding the patient’s diagnosis and/or treatment or the physician telephones or 
visits the employer in person to safely return the patient to work.
The counseling or coordination of care activities must be done 24 hours prior to the actual patient 
encounter or within seven (7) business days after the actual patient encounter.  If these activities 
are done outside of the 24 hours prior to or 7 business days after the patient encounter, then Rule 
18-5(I)(4) “Treating Physician Telephone or On-line Services” or Rule 18-6(A) “Face-to-Face or 
Telephonic meeting by a Treating Physician with the Employer … With or Without the Injured 
Workers” is applicable.
Exhibit #8, Pathology Laboratory Maximum Fees	
For Dates of Service on and After 1/1/2015	
HCPCS	Modifier	SHORTDESC	216%	
36415		Routine venipuncture	 $            6.48 	
78267		Breath tst attain/anal c-14	 $          23.18 	
78268		Breath test analysis c-14	 $       198.48 	
80047	QW	Metabolic panel ionized ca	 $          24.93 	
80047		Metabolic panel ionized ca	 $          24.93 	
80048	QW	Metabolic panel total ca	 $          24.93 	
80048		Metabolic panel total ca	 $          24.93 	
80050	QW	Health Panel	 $       116.16 	
80050		Health Panel	 $       116.16 	
80051	QW	Electrolyte panel	 $          20.67 	
80051		Electrolyte panel	 $          20.67 	
80053	QW	Comprehen metabolic panel	 $          31.13 	
80053		Comprehen metabolic panel	 $          31.13 	
80061	QW	Lipid panel	 $          39.46 	
80061		Lipid panel	 $          39.46 	
80069	QW	Renal function panel	 $          25.60 	
80069		Renal function panel	 $          25.60 	
80074		Acute hepatitis panel	 $       140.38 	
80076		Hepatic function panel	 $          24.06 	
80102		Drug confirmation	 $          39.03 	
80150		Assay of amikacin	 $          44.41 	
80152		Assay of amitriptyline	 $          52.75 	
80154		Assay of benzodiazepines	 $          54.50 	
80155		Drug screen quant caffeine	 $          41.69 	
80156		Assay carbamazepine total	 $          42.92 	
80157		Assay carbamazepine free	 $          39.07 	
80158		Assay of cyclosporine	 $          53.20 	
80159		Drug screen quant clozapine	 $          54.50 	
80160		Assay of desipramine	 $          50.72 	
80162		Assay of digoxin	 $          39.14 	
80164		Assay dipropylacetic acid	 $          39.94 	
80166		Assay of doxepin	 $          45.66 	
80168		Assay of ethosuximide	 $          48.17 	
80169		Drug screen quant everolimus	 $          40.46 	
80170		Assay of gentamicin	 $          48.30 	
80171		Drug screen quant gabapentin	 $          39.07 	
80172		Assay of gold	 $          48.00 	
80173		Assay of haloperidol	 $          42.92 	
80174		Assay of imipramine	 $          50.72 	
80175		Drug screen quan lamotrigine	 $          39.07 	
80176		Assay of lidocaine	 $          43.29 	
80177		Drug scrn quan levetiracetam	 $          39.07 	
80178	QW	Assay of lithium	 $          19.48 	
80178		Assay of lithium	 $          19.48 	
80180		Drug scrn quan mycophenolate	 $          53.20 	
80182		Assay of nortriptyline	 $          39.94 	
80183		Drug scrn quant oxcarbazepin	 $          39.07 	
80184		Assay of phenobarbital	 $          33.74 	
80185		Assay of phenytoin total	 $          39.07 	
80186		Assay of phenytoin free	 $          40.56 	
80188		Assay of primidone	 $          48.90 	
80190		Assay of procainamide	 $          49.36 	
80192		Assay of procainamide	 $          49.36 	
80194		Assay of quinidine	 $          43.03 	
80195		Assay of sirolimus	 $          40.46 	
80196		Assay of salicylate	 $          20.91 	
80197		Assay of tacrolimus	 $          40.46 	
80198		Assay of theophylline	 $          41.69 	
80199		Drug screen quant tiagabine	 $          53.20 	
80200		Assay of tobramycin	 $          47.50 	
80201		Assay of topiramate	 $          35.14 	
80202		Assay of vancomycin	 $          39.94 	
80203		Drug screen quant zonisamide	 $          39.07 	
80299		Quantitative assay drug	 $          40.35 	
80400		Acth stimulation panel	 $          96.12 	
80402		Acth stimulation panel	 $       256.24 	
80406		Acth stimulation panel	 $       184.05 	
80408		Aldosterone suppression eval	 $       369.81 	
80410		Calcitonin stimul panel	 $       236.74 	
80412		CRH stimulation panel	 $       971.33 	
80414		Testosterone response	 $       152.17 	
80415		Estradiol response panel	 $       164.68 	
80416		Renin stimulation panel	 $       388.86 	
80417		Renin stimulation panel	 $       129.62 	
80418		Pituitary evaluation panel	 $    1,707.96 	
80420		Dexamethasone panel	 $       212.31 	
80422		Glucagon tolerance panel	 $       135.78 	
80424		Glucagon tolerance panel	 $       148.80 	
80426		Gonadotropin hormone panel	 $       437.34 	
80428		Growth hormone panel	 $       196.56 	
80430		Growth hormone panel	 $       231.27 	
80432		Insulin suppression panel	 $       347.63 	
80434		Insulin tolerance panel	 $       298.14 	
80435		Insulin tolerance panel	 $       303.57 	
80436		Metyrapone panel	 $       268.64 	
80438		TRH stimulation panel	 $       148.54 	
80439		TRH stimulation panel	 $       198.07 	
80440		TRH stimulation panel	 $       171.33 	
81000		Urinalysis nonauto w/scope	 $            9.33 	
81001		Urinalysis auto w/scope	 $            9.33 	
81002		Urinalysis nonauto w/o scope	 $            7.54 	
81003	QW	Urinalysis auto w/o scope	 $            6.61 	
81003		Urinalysis auto w/o scope	 $            6.61 	
81005		Urinalysis	 $            6.39 	
81007	QW	Urine screen for bacteria	 $            7.56 	
81007		Urine screen for bacteria	 $            7.56 	
81015		Microscopic exam of urine	 $            8.96 	
81020		Urinalysis glass test	 $          10.86 	
81025		Urine pregnancy test	 $          18.64 	
81050		Urinalysis volume measure	 $            8.83 	
81161		Dmd dup/delet analysis	 $                -   	
81201	0		 $    1,619.83 	
81202	0		 $       202.91 	
81203	0		 $    1,231.31 	
81206		Bcr/abl1 gene major bp	 $       483.17 	
81207		Bcr/abl1 gene minor bp	 $       426.79 	
81208		Bcr/abl1 gene other bp	 $       473.97 	
81210		Braf gene	 $       387.18 	
81211		Brca1&2 seq & com dup/del	 $    4,716.36 	
81212		Brca1&2 185&5385&6174 var	 $       381.67 	
81213		Brca1&2 uncom dup/del var	 $    1,258.68 	
81214		Brca1 full seq & com dup/del	 $    3,106.38 	
81215		Brca1 gene known fam variant	 $       201.40 	
81217		Brca2 gene known fam variant	 $       201.40 	
81225		Cyp2c19 gene com variants	 $       630.29 	
81226		Cyp2d6 gene com variants	 $       975.43 	
81227		Cyp2c9 gene com variants	 $       378.17 	
81235		Egfr gene com variants	 $       712.82 	
81240		F2 gene	 $       145.00 	
81241		F5 gene	 $       180.08 	
81245		Flt3 gene	 $       358.39 	
81256		Hfe gene	 $       192.61 	
81261		Igh gene rearrange amp meth	 $       583.44 	
81262		Igh gene rearrang dir probe	 $       128.63 	
81263		Igh vari regional mutation	 $       867.87 	
81264		Igk rearrangeabn clonal pop	 $       440.04 	
81265		Str markers specimen anal	 $       633.70 	
81266	0		 $       344.74 	
81267		Chimerism anal no cell selec	 $       611.34 	
81268		Chimerism anal w/cell select	 $       768.48 	
81270		Jak2 gene	 $       270.13 	
81275		Kras gene	 $       426.56 	
81287		Mgmt gene methylation anal	 $                -   	
81291		Mthfr gene	 $       128.63 	
81292		Mlh1 gene full seq	 $    1,395.88 	
81293		Mlh1 gene known variants	 $       559.57 	
81294		Mlh1 gene dup/delete variant	 $       411.87 	
81295		Msh2 gene full seq	 $       327.69 	
81296		Msh2 gene known variants	 $       279.78 	
81297		Msh2 gene dup/delete variant	 $       327.69 	
81298		Msh6 gene full seq	 $       621.71 	
81299		Msh6 gene known variants	 $       348.28 	
81300		Msh6 gene dup/delete variant	 $       349.23 	
81301		Microsatellite instability	 $       853.29 	
81310		Npm1 gene	 $       533.82 	
81315		Pml/raralpha com breakpoints	 $       610.91 	
81316		Pml/raralpha 1 breakpoint	 $       931.80 	
81317		Pms2 gene full seq analysis	 $    1,687.59 	
81318		Pms2 known familial variants	 $       398.76 	
81319		Pms2 gene dup/delet variants	 $       478.79 	
81321		Pten gene full sequence	 $    1,297.51 	
81322		Pten gene known fam variant	 $       126.14 	
81323		Pten gene dup/delet variant	 $       189.22 	
81332		Serpina1 gene	 $       128.63 	
81340		Trb@ gene rearrange amplify	 $       615.64 	
81341		Trb@ gene rearrange dirprobe	 $       146.12 	
81342		Trg gene rearrangement anal	 $       593.78 	
81370		Hla i & ii typing lr	 $    1,184.98 	
81371		Hla i & ii type verify lr	 $       709.26 	
81372		Hla i typing complete lr	 $       650.94 	
81373		Hla i typing 1 locus lr	 $       328.17 	
81374		Hla i typing 1 antigen lr	 $       214.38 	
81375		Hla ii typing ag equiv lr	 $       650.48 	
81376		Hla ii typing 1 locus lr	 $       360.16 	
81377		Hla ii type 1 ag equiv lr	 $       270.54 	
81378		Hla i & ii typing hr	 $    1,018.31 	
81379		Hla i typing complete hr	 $       988.29 	
81380		Hla i typing 1 locus hr	 $       522.31 	
81381		Hla i typing 1 allele hr	 $       278.70 	
81382		Hla ii typing 1 loc hr	 $       364.46 	
81383		Hla ii typing 1 allele hr	 $       321.58 	
82000		Assay of blood acetaldehyde	 $          36.50 	
82003		Assay of acetaminophen	 $          56.42 	
82009		Test for acetone/ketones	 $          13.31 	
82010	QW	Acetone assay	 $          24.08 	
82010		Acetone assay	 $          24.08 	
82013		Acetylcholinesterase assay	 $          32.92 	
82016		Acylcarnitines qual	 $          40.85 	
82017		Acylcarnitines quant	 $            7.78 	
82024		Assay of acth	 $       113.83 	
82030		Assay of adp & amp	 $          41.75 	
82040	QW	Assay of serum albumin	 $          14.58 	
82040		Assay of serum albumin	 $          14.58 	
82042	QW	Assay of urine albumin	 $            8.55 	
82042		Assay of urine albumin	 $            8.55 	
82043	QW	Microalbumin quantitative	 $          17.04 	
82043		Microalbumin quantitative	 $          17.04 	
82044	QW	Microalbumin semiquant	 $          13.48 	
82044		Microalbumin semiquant	 $          13.48 	
82045		Albumin ischemia modified	 $          96.10 	
82055	QW	Assay of ethanol	 $          31.84 	
82055		Assay of ethanol	 $          31.84 	
82075		Assay of breath ethanol	 $          35.51 	
82085		Assay of aldolase	 $          28.60 	
82088		Assay of aldosterone	 $       120.10 	
82101		Assay of urine alkaloids	 $          88.45 	
82103		Alpha-1-antitrypsin total	 $          39.59 	
82104		Alpha-1-antitrypsin pheno	 $          42.62 	
82105		Alpha-fetoprotein serum	 $          49.44 	
82106		Alpha-fetoprotein amniotic	 $          49.44 	
82107		Alpha-fetoprotein l3	 $       189.82 	
82108		Assay of aluminum	 $          75.08 	
82120	QW	Amines vaginal fluid qual	 $            5.10 	
82120		Amines vaginal fluid qual	 $            5.10 	
82127		Amino acid single qual	 $          40.85 	
82128		Amino acids mult qual	 $          40.85 	
82131		Amino acids single quant	 $          49.70 	
82135		Assay aminolevulinic acid	 $          48.49 	
82136		Amino acids quant 2-5	 $            7.78 	
82139		Amino acids quan 6 or more	 $            7.78 	
82140		Assay of ammonia	 $          42.94 	
82143		Amniotic fluid scan	 $          20.24 	
82145		Assay of amphetamines	 $          45.79 	
82150	QW	Assay of amylase	 $          19.09 	
82150		Assay of amylase	 $          19.09 	
82154		Androstanediol glucuronide	 $          43.98 	
82157		Assay of androstenedione	 $          86.27 	
82160		Assay of androsterone	 $          73.68 	
82163		Assay of angiotensin II	 $          60.46 	
82164		Angiotensin I enzyme test	 $          43.03 	
82172		Assay of apolipoprotein	 $          45.66 	
82175		Assay of arsenic	 $          55.92 	
82180		Assay of ascorbic acid	 $          29.12 	
82190		Atomic absorption	 $          43.93 	
82205		Assay of barbiturates	 $          33.74 	
82232		Assay of beta-2 protein	 $          47.67 	
82239		Bile acids total	 $          24.86 	
82240		Bile acids cholylglycine	 $          37.69 	
82247	QW	Bilirubin total	 $          14.77 	
82247		Bilirubin total	 $          14.77 	
82248		Bilirubin direct	 $          14.77 	
82252		Fecal bilirubin test	 $            4.13 	
82261		Assay of biotinidase	 $            7.78 	
82270		Occult blood feces	 $            9.59 	
82271	QW	Occult blood other sources	 $            9.59 	
82271		Occult blood other sources	 $            9.59 	
82272	QW	Occult bld feces 1-3 tests	 $            9.59 	
82272		Occult bld feces 1-3 tests	 $            9.59 	
82274	QW	Assay test for blood fecal	 $          46.87 	
82274		Assay test for blood fecal	 $          46.87 	
82286		Assay of bradykinin	 $          20.30 	
82300		Assay of cadmium	 $          68.21 	
82306		Vitamin d 25 hydroxy	 $          87.26 	
82308		Assay of calcitonin	 $          78.93 	
82310	QW	Assay of calcium	 $          15.21 	
82310		Assay of calcium	 $          15.21 	
82330	QW	Assay of calcium	 $          40.28 	
82330		Assay of calcium	 $          40.28 	
82331		Calcium infusion test	 $          15.25 	
82340		Assay of calcium in urine	 $          17.78 	
82355		Calculus analysis qual	 $          34.11 	
82360		Calculus assay quant	 $          37.93 	
82365		Calculus spectroscopy	 $          37.99 	
82370		X-ray assay calculus	 $          36.91 	
82373		Assay c-d transfer measure	 $          53.20 	
82374	QW	Assay blood carbon dioxide	 $            8.38 	
82374		Assay blood carbon dioxide	 $            8.38 	
82375		Assay carboxyhb quant	 $          36.31 	
82376		Assay carboxyhb qual	 $          14.69 	
82378		Carcinoembryonic antigen	 $          55.90 	
82379		Assay of carnitine	 $            7.78 	
82380		Assay of carotene	 $          27.17 	
82382		Assay urine catecholamines	 $          50.67 	
82383		Assay blood catecholamines	 $          73.85 	
82384		Assay three catecholamines	 $          74.41 	
82387		Assay of cathepsin-d	 $          23.82 	
82390		Assay of ceruloplasmin	 $          31.64 	
82397		Chemiluminescent assay	 $          23.82 	
82415		Assay of chloramphenicol	 $          37.35 	
82435	QW	Assay of blood chloride	 $            8.21 	
82435		Assay of blood chloride	 $            8.21 	
82436		Assay of urine chloride	 $          14.82 	
82438		Assay other fluid chlorides	 $          14.41 	
82441		Test for chlorohydrocarbons	 $          17.69 	
82465	QW	Assay bld/serum cholesterol	 $          12.81 	
82465		Assay bld/serum cholesterol	 $          12.81 	
82480		Assay serum cholinesterase	 $          23.22 	
82482		Assay rbc cholinesterase	 $          22.64 	
82485		Assay chondroitin sulfate	 $          52.34 	
82486		Gas/liquid chromatography	 $          53.20 	
82487		Paper chromatography	 $          47.07 	
82488		Paper chromatography	 $          62.96 	
82489		Thin layer chromatography	 $          54.50 	
82491		Chromotography quant sing	 $          53.20 	
82492		Chromotography quant mult	 $          53.20 	
82495		Assay of chromium	 $          59.77 	
82507		Assay of citrate	 $          81.93 	
82520		Assay of cocaine	 $          44.67 	
82523	QW	Collagen crosslinks	 $          55.08 	
82523		Collagen crosslinks	 $          55.08 	
82525		Assay of copper	 $          36.57 	
82528		Assay of corticosterone	 $          66.36 	
82530		Cortisol free	 $          49.25 	
82533		Total cortisol	 $          48.04 	
82540		Assay of creatine	 $          13.65 	
82541		Column chromotography qual	 $          53.20 	
82542		Column chromotography quant	 $          53.20 	
82543		Column chromotograph/isotope	 $          53.20 	
82544		Column chromotograph/isotope	 $          53.20 	
82550	QW	Assay of ck (cpk)	 $          19.18 	
82550		Assay of ck (cpk)	 $          19.18 	
82552		Assay of cpk in blood	 $          39.48 	
82553		Creatine mb fraction	 $          34.02 	
82554		Creatine isoforms	 $          34.97 	
82565	QW	Assay of creatinine	 $          15.10 	
82565		Assay of creatinine	 $          15.10 	
82570	QW	Assay of urine creatinine	 $          15.25 	
82570		Assay of urine creatinine	 $          15.25 	
82575		Creatinine clearance test	 $          27.84 	
82585		Assay of cryofibrinogen	 $          20.87 	
82595		Assay of cryoglobulin	 $          19.07 	
82600		Assay of cyanide	 $          57.15 	
82607		Vitamin B-12	 $          44.41 	
82608		B-12 binding capacity	 $          42.21 	
82610		Cystatin c	 $          16.70 	
82615		Test for urine cystines	 $          24.06 	
82626		Dehydroepiandrosterone	 $          74.48 	
82627		Dehydroepiandrosterone	 $          65.51 	
82633		Desoxycorticosterone	 $          91.28 	
82634		Deoxycortisol	 $          86.27 	
82638		Assay of dibucaine number	 $          36.09 	
82646		Assay of dihydrocodeinone	 $          60.85 	
82649		Assay of dihydromorphinone	 $          75.75 	
82651		Assay of dihydrotestosterone	 $          56.42 	
82652		Vit d 1 25-dihydroxy	 $       113.46 	
82654		Assay of dimethadione	 $          40.80 	
82656		Pancreatic elastase fecal	 $          34.00 	
82657		Enzyme cell activity	 $          53.20 	
82658		Enzyme cell activity ra	 $          53.20 	
82664		Electrophoretic test	 $       101.24 	
82666		Assay of epiandrosterone	 $          63.31 	
82668		Assay of erythropoietin	 $          55.40 	
82670		Assay of estradiol	 $          82.34 	
82671		Assay of estrogens	 $          95.19 	
82672		Assay of estrogen	 $          63.94 	
82677		Assay of estriol	 $          71.26 	
82679	QW	Assay of estrone	 $          73.55 	
82679		Assay of estrone	 $          73.55 	
82690		Assay of ethchlorvynol	 $          50.93 	
82693		Assay of ethylene glycol	 $          43.89 	
82696		Assay of etiocholanolone	 $          69.51 	
82705		Fats/lipids feces qual	 $          14.99 	
82710		Fats/lipids feces quant	 $          49.53 	
82715		Assay of fecal fat	 $          29.29 	
82725		Assay of blood fatty acids	 $          39.23 	
82726		Long chain fatty acids	 $          53.20 	
82728		Assay of ferritin	 $          40.15 	
82731		Assay of fetal fibronectin	 $       189.82 	
82735		Assay of fluoride	 $          54.63 	
82742		Assay of flurazepam	 $          58.32 	
82746		Assay of folic acid serum	 $          43.33 	
82747		Assay of folic acid rbc	 $          50.72 	
82757		Assay of semen fructose	 $          22.98 	
82759		Assay of rbc galactokinase	 $          45.90 	
82760		Assay of galactose	 $          32.98 	
82775		Assay galactose transferase	 $          62.08 	
82776		Galactose transferase test	 $          16.80 	
82777		Galectin-3	 $          64.82 	
82784		Assay iga/igd/igg/igm each	 $          16.80 	
82785		Assay of ige	 $          48.54 	
82787		Igg 1 2 3 or 4 each	 $          13.54 	
82800		Blood pH	 $          24.93 	
82803		Blood gases any combination	 $          57.02 	
82805		Blood gases w/o2 saturation	 $          83.61 	
82810		Blood gases o2 sat only	 $          25.73 	
82820		Hemoglobin-oxygen affinity	 $          28.56 	
82930		Gastric analy w/ph ea spec	 $          16.07 	
82938		Gastrin test	 $          52.14 	
82941		Assay of gastrin	 $          51.97 	
82943		Assay of glucagon	 $          42.10 	
82945		Glucose other fluid	 $          11.58 	
82946		Glucagon tolerance test	 $          39.29 	
82947	QW	Assay glucose blood quant	 $          11.58 	
82947		Assay glucose blood quant	 $          11.58 	
82948		Reagent strip/blood glucose	 $            9.33 	
82950	QW	Glucose test	 $          14.00 	
82950		Glucose test	 $          14.00 	
82951	QW	Glucose tolerance test (GTT)	 $          18.90 	
82951		Glucose tolerance test (GTT)	 $          18.90 	
82952	QW	GTT-added samples	 $          11.56 	
82952		GTT-added samples	 $          11.56 	
82953		Glucose-tolbutamide test	 $          44.65 	
82955		Assay of g6pd enzyme	 $          28.56 	
82960		Test for G6PD enzyme	 $          17.84 	
82962		Glucose blood test	 $            5.31 	
82963		Assay of glucosidase	 $          63.31 	
82965		Assay of gdh enzyme	 $          22.79 	
82975		Assay of glutamine	 $          35.58 	
82977	QW	Assay of GGT	 $          21.21 	
82977		Assay of GGT	 $          21.21 	
82978		Assay of glutathione	 $          31.38 	
82979		Assay rbc glutathione	 $          20.30 	
82980		Assay of glutethimide	 $          54.00 	
82985	QW	Assay of glycated protein	 $          44.41 	
82985		Assay of glycated protein	 $          44.41 	
83001	QW	Assay of gonadotropin (fsh)	 $          54.76 	
83001		Assay of gonadotropin (fsh)	 $          54.76 	
83002	QW	Assay of gonadotropin (lh)	 $          54.56 	
83002		Assay of gonadotropin (lh)	 $          54.56 	
83003		Assay growth hormone (hgh)	 $          49.16 	
83008		Assay of guanosine	 $          49.46 	
83009		H pylori (c-13) blood	 $       198.48 	
83010		Assay of haptoglobin quant	 $          19.53 	
83012		Assay of haptoglobins	 $          50.67 	
83013		H pylori (c-13) breath	 $       198.48 	
83014		H pylori drug admin	 $          23.18 	
83015		Heavy metal screen	 $          55.49 	
83018		Quantitative screen metals	 $          64.71 	
83020		Hemoglobin electrophoresis	 $          34.24 	
83021		Hemoglobin chromotography	 $          53.20 	
83026		Hemoglobin copper sulfate	 $            6.98 	
83030		Fetal hemoglobin chemical	 $          24.36 	
83033		Fetal hemoglobin assay qual	 $          17.56 	
83036	QW	Glycosylated hemoglobin test	 $          28.60 	
83036		Glycosylated hemoglobin test	 $          28.60 	
83037	QW	Glycosylated hb home device	 $          28.60 	
83037		Glycosylated hb home device	 $          28.60 	
83045		Blood methemoglobin test	 $          14.60 	
83050		Blood methemoglobin assay	 $          21.60 	
83051		Assay of plasma hemoglobin	 $          10.32 	
83055		Blood sulfhemoglobin test	 $          14.49 	
83060		Blood sulfhemoglobin assay	 $          24.36 	
83065		Assay of hemoglobin heat	 $          20.30 	
83068		Hemoglobin stability screen	 $          24.93 	
83069		Assay of urine hemoglobin	 $          11.64 	
83070		Assay of hemosiderin qual	 $          14.00 	
83071		Assay of hemosiderin quant	 $          20.24 	
83080		Assay of b hexosaminidase	 $            7.78 	
83088		Assay of histamine	 $          87.03 	
83090		Assay of homocystine	 $          49.70 	
83150		Assay of homovanillic acid	 $          57.02 	
83491		Assay of corticosteroids 17	 $          51.62 	
83497		Assay of 5-hiaa	 $          37.99 	
83498		Assay of progesterone 17-d	 $          80.07 	
83499		Assay of progesterone 20-	 $          74.30 	
83500		Assay free hydroxyproline	 $          66.74 	
83505		Assay total hydroxyproline	 $          71.65 	
83516		Immunoassay nonantibody	 $          34.00 	
83518	QW	Immunoassay dipstick	 $          24.97 	
83518		Immunoassay dipstick	 $          24.97 	
83519		Ria nonantibody	 $          39.81 	
83520	QW	Immunoassay quant nos nonab	 $          38.15 	
83520		Immunoassay quant nos nonab	 $          38.15 	
83525		Assay of insulin	 $          33.67 	
83527		Assay of insulin	 $          37.30 	
83528		Assay of intrinsic factor	 $          46.87 	
83540		Assay of iron	 $          19.07 	
83550		Iron binding test	 $          25.77 	
83570		Assay of idh enzyme	 $          26.07 	
83582		Assay of ketogenic steroids	 $          41.77 	
83586		Assay 17- ketosteroids	 $          37.74 	
83593		Fractionation ketosteroids	 $          77.50 	
83605	QW	Assay of lactic acid	 $            4.13 	
83605		Assay of lactic acid	 $            4.13 	
83615		Lactate (LD) (LDH) enzyme	 $          17.78 	
83625		Assay of ldh enzymes	 $          17.50 	
83630		Lactoferrin fecal (qual)	 $          57.84 	
83631		Lactoferrin fecal (quant)	 $          57.84 	
83632		Placental lactogen	 $          59.57 	
83633		Test urine for lactose	 $          16.20 	
83634		Assay of urine for lactose	 $          33.98 	
83655	QW	Assay of lead	 $          35.68 	
83655		Assay of lead	 $          35.68 	
83661		L/s ratio fetal lung	 $          29.29 	
83662		Foam stability fetal lung	 $          55.75 	
83663		Fluoro polarize fetal lung	 $          55.75 	
83664		Lamellar bdy fetal lung	 $          55.75 	
83670		Assay of lap enzyme	 $          26.98 	
83690		Assay of lipase	 $          20.30 	
83695		Assay of lipoprotein(a)	 $          38.15 	
83698		Assay lipoprotein pla2	 $          96.10 	
83700		Lipopro bld electrophoretic	 $          29.12 	
83701		Lipoprotein bld hr fraction	 $          73.14 	
83704		Lipoprotein bld by nmr	 $          92.97 	
83718	QW	Assay of lipoprotein	 $          24.13 	
83718		Assay of lipoprotein	 $          24.13 	
83719		Assay of blood lipoprotein	 $          34.28 	
83721	QW	Assay of blood lipoprotein	 $          28.12 	
83721		Assay of blood lipoprotein	 $          28.12 	
83727		Assay of lrh hormone	 $          50.67 	
83735		Assay of magnesium	 $          19.74 	
83775		Assay malate dehydrogenase	 $          21.73 	
83785		Assay of manganese	 $          72.47 	
83788		Mass spectrometry qual	 $          53.20 	
83789		Mass spectrometry quant	 $          53.20 	
83805		Assay of meprobamate	 $          51.93 	
83825		Assay of mercury	 $          47.91 	
83835		Assay of metanephrines	 $          49.92 	
83840		Assay of methadone	 $          48.12 	
83857		Assay of methemalbumin	 $          31.64 	
83858		Assay of methsuximide	 $          43.65 	
83861	QW	Microfluid analy tears	 $          48.69 	
83861		Microfluid analy tears	 $          48.69 	
83864		Mucopolysaccharides	 $          58.69 	
83866		Mucopolysaccharides screen	 $          29.03 	
83872		Assay synovial fluid mucin	 $          17.28 	
83873		Assay of csf protein	 $          50.70 	
83874		Assay of myoglobin	 $          38.06 	
83876		Assay myeloperoxidase	 $          96.10 	
83880	QW	Assay of natriuretic peptide	 $          96.10 	
83880		Assay of natriuretic peptide	 $          96.10 	
83883		Assay nephelometry not spec	 $          16.70 	
83885		Assay of nickel	 $          72.21 	
83887		Assay of nicotine	 $          69.79 	
83915		Assay of nucleotidase	 $          32.85 	
83916		Oligoclonal bands	 $          59.25 	
83918		Organic acids total quant	 $          48.49 	
83919		Organic acids qual each	 $          48.49 	
83921		Organic acid single quant	 $          48.49 	
83925		Assay of opiates	 $          57.33 	
83930		Assay of blood osmolality	 $          19.48 	
83935		Assay of urine osmolality	 $          20.09 	
83937		Assay of osteocalcin	 $          43.98 	
83945		Assay of oxalate	 $          37.93 	
83950		Oncoprotein her-2/neu	 $       189.82 	
83951		Oncoprotein dcp	 $       189.82 	
83970		Assay of parathormone	 $       121.63 	
83986	QW	Assay ph body fluid nos	 $          10.54 	
83986		Assay ph body fluid nos	 $          10.54 	
83987		Exhaled breath condensate	 $          46.79 	
83992		Assay for phencyclidine	 $          43.31 	
83993		Assay for calprotectin fecal	 $          57.84 	
84022		Assay of phenothiazine	 $          45.90 	
84030		Assay of blood pku	 $          16.20 	
84035		Assay of phenylketones	 $            9.03 	
84060		Assay acid phosphatase	 $          21.77 	
84061		Phosphatase forensic exam	 $          23.31 	
84066		Assay prostate phosphatase	 $          28.47 	
84075	QW	Assay alkaline phosphatase	 $          15.25 	
84075		Assay alkaline phosphatase	 $          15.25 	
84078		Assay alkaline phosphatase	 $          21.51 	
84080		Assay alkaline phosphatases	 $          43.57 	
84081		Assay phosphatidylglycerol	 $          48.69 	
84085		Assay of rbc pg6d enzyme	 $          19.87 	
84087		Assay phosphohexose enzymes	 $          30.43 	
84100		Assay of phosphorus	 $          13.95 	
84105		Assay of urine phosphorus	 $          15.25 	
84106		Test for porphobilinogen	 $          12.51 	
84110		Assay of porphobilinogen	 $          24.86 	
84112		Placenta alpha micro ig c/v	 $       189.82 	
84119		Test urine for porphyrins	 $          25.38 	
84120		Assay of urine porphyrins	 $          43.35 	
84126		Assay of feces porphyrins	 $          75.06 	
84127		Assay of feces porphyrins	 $          29.40 	
84132	QW	Assay of serum potassium	 $          13.54 	
84132		Assay of serum potassium	 $          13.54 	
84133		Assay of urine potassium	 $          12.68 	
84134		Assay of prealbumin	 $          16.70 	
84135		Assay of pregnanediol	 $          56.38 	
84138		Assay of pregnanetriol	 $          55.79 	
84140		Assay of pregnenolone	 $          43.98 	
84143		Assay of 17-hydroxypregneno	 $          43.98 	
84144		Assay of progesterone	 $          45.90 	
84145		Procalcitonin (pct)	 $          78.93 	
84146		Assay of prolactin	 $          57.11 	
84150		Assay of prostaglandin	 $          73.55 	
84152		Assay of psa complexed	 $          54.19 	
84153		Assay of psa total	 $          54.19 	
84154		Assay of psa free	 $          54.19 	
84155	QW	Assay of protein serum	 $          10.80 	
84155		Assay of protein serum	 $          10.80 	
84156		Assay of protein urine	 $          10.80 	
84157	QW	Assay of protein other	 $          10.80 	
84157		Assay of protein other	 $          10.80 	
84160		Assay of protein any source	 $          15.25 	
84163		Pappa serum	 $          44.37 	
84165		Protein e-phoresis serum	 $          31.64 	
84166		Protein e-phoresis/urine/csf	 $          52.55 	
84181		Western blot test	 $          50.20 	
84182		Protein western blot test	 $          53.03 	
84202		Assay RBC protoporphyrin	 $          42.27 	
84203		Test RBC protoporphyrin	 $          25.36 	
84206		Assay of proinsulin	 $          52.34 	
84207		Assay of vitamin b-6	 $          82.79 	
84210		Assay of pyruvate	 $          31.99 	
84220		Assay of pyruvate kinase	 $          27.82 	
84228		Assay of quinine	 $          34.28 	
84233		Assay of estrogen	 $       189.82 	
84234		Assay of progesterone	 $       191.18 	
84235		Assay of endocrine hormone	 $       154.22 	
84238		Assay nonendocrine receptor	 $       107.76 	
84244		Assay of renin	 $          64.82 	
84252		Assay of vitamin b-2	 $          59.64 	
84255		Assay of selenium	 $          75.23 	
84260		Assay of serotonin	 $          54.78 	
84270		Assay of sex hormone globul	 $          64.04 	
84275		Assay of sialic acid	 $          39.59 	
84285		Assay of silica	 $          69.38 	
84295	QW	Assay of serum sodium	 $          14.17 	
84295		Assay of serum sodium	 $          14.17 	
84300		Assay of urine sodium	 $          14.34 	
84302		Assay of sweat sodium	 $          14.34 	
84305		Assay of somatomedin	 $          57.87 	
84307		Assay of somatostatin	 $          53.87 	
84311		Spectrophotometry	 $          20.61 	
84315		Body fluid specific gravity	 $            7.41 	
84375		Chromatogram assay sugars	 $            7.06 	
84376		Sugars single qual	 $          16.20 	
84377		Sugars multiple qual	 $          16.20 	
84378		Sugars single quant	 $          33.98 	
84379		Sugars multiple quant	 $          33.98 	
84392		Assay of urine sulfate	 $          14.00 	
84402		Assay of free testosterone	 $          75.04 	
84403		Assay of total testosterone	 $          76.08 	
84425		Assay of vitamin b-1	 $          62.55 	
84430		Assay of thiocyanate	 $          34.28 	
84431		Thromboxane urine	 $          49.53 	
84432		Assay of thyroglobulin	 $          45.04 	
84436		Assay of total thyroxine	 $          20.24 	
84437		Assay of neonatal thyroxine	 $          19.07 	
84439		Assay of free thyroxine	 $          24.02 	
84442		Assay of thyroid activity	 $          34.24 	
84443	QW	Assay thyroid stim hormone	 $          49.53 	
84443		Assay thyroid stim hormone	 $          49.53 	
84445		Assay of tsi globulin	 $       149.86 	
84446		Assay of vitamin e	 $          41.77 	
84449		Assay of transcortin	 $          43.98 	
84450	QW	Transferase (AST) (SGOT)	 $          15.25 	
84450		Transferase (AST) (SGOT)	 $          15.25 	
84460	QW	Alanine amino (ALT) (SGPT)	 $          15.60 	
84460		Alanine amino (ALT) (SGPT)	 $          15.60 	
84466		Assay of transferrin	 $          37.63 	
84478	QW	Assay of triglycerides	 $          16.93 	
84478		Assay of triglycerides	 $          16.93 	
84479		Assay of thyroid (t3 or t4)	 $          19.07 	
84480		Assay triiodothyronine (t3)	 $          41.77 	
84481		Free assay (FT-3)	 $          49.92 	
84482		T3 reverse	 $          46.44 	
84484		Assay of troponin quant	 $          19.70 	
84485		Assay duodenal fluid trypsin	 $          12.51 	
84488		Test feces for trypsin	 $          12.51 	
84490		Assay of feces for trypsin	 $          16.80 	
84510		Assay of tyrosine	 $          30.65 	
84512		Assay of troponin qual	 $          22.70 	
84520	QW	Assay of urea nitrogen	 $          11.64 	
84520		Assay of urea nitrogen	 $          11.64 	
84525		Urea nitrogen semi-quant	 $            5.10 	
84540		Assay of urine/urea-n	 $          14.00 	
84545		Urea-N clearance test	 $          19.46 	
84550	QW	Assay of blood/uric acid	 $          13.31 	
84550		Assay of blood/uric acid	 $          13.31 	
84560		Assay of urine/uric acid	 $          14.00 	
84577		Assay of feces/urobilinogen	 $          36.78 	
84578		Test urine urobilinogen	 $            4.13 	
84580		Assay of urine urobilinogen	 $          20.91 	
84583		Assay of urine urobilinogen	 $          14.82 	
84585		Assay of urine vma	 $          45.66 	
84586		Assay of vip	 $          43.98 	
84588		Assay of vasopressin	 $          96.10 	
84590		Assay of vitamin a	 $          34.19 	
84591		Assay of nos vitamin	 $          34.19 	
84597		Assay of vitamin k	 $          40.41 	
84600		Assay of volatiles	 $          47.37 	
84620		Xylose tolerance test	 $          34.91 	
84630		Assay of zinc	 $          33.54 	
84681		Assay of c-peptide	 $          51.21 	
84702		Chorionic gonadotropin test	 $          44.37 	
84703	QW	Chorionic gonadotropin assay	 $          20.58 	
84703		Chorionic gonadotropin assay	 $          20.58 	
84704		Hcg free betachain test	 $          44.37 	
84830		Ovulation tests	 $          29.55 	
85002		Bleeding time test	 $          13.28 	
85004		Automated diff wbc count	 $          14.69 	
85007		Bl smear w/diff wbc count	 $          10.13 	
85008		Bl smear w/o diff wbc count	 $          10.13 	
85009		Manual diff wbc count b-coat	 $          10.97 	
85013		Spun microhematocrit	 $            6.98 	
85014	QW	Hematocrit	 $            6.98 	
85014		Hematocrit	 $            6.98 	
85018	QW	Hemoglobin	 $            6.98 	
85018		Hemoglobin	 $            6.98 	
85025		Complete cbc w/auto diff wbc	 $          20.82 	
85027		Complete cbc automated	 $          14.69 	
85032		Manual cell count each	 $          12.68 	
85041		Automated rbc count	 $            8.88 	
85044		Manual reticulocyte count	 $          12.68 	
85045		Automated reticulocyte count	 $          11.77 	
85046		Reticyte/hgb concentrate	 $          16.44 	
85048		Automated leukocyte count	 $            7.47 	
85049		Automated platelet count	 $          13.20 	
85055		Reticulated platelet assay	 $          53.33 	
85130		Chromogenic substrate assay	 $          20.82 	
85170		Blood clot retraction	 $          10.67 	
85175		Blood clot lysis time	 $          13.41 	
85210		Clot factor ii prothrom spec	 $          38.28 	
85220		Blooc clot factor v test	 $          51.99 	
85230		Clot factor vii proconvertin	 $          52.77 	
85240		Clot factor viii ahg 1 stage	 $          52.77 	
85244		Clot factor viii reltd antgn	 $          60.16 	
85245		Clot factor viii vw ristoctn	 $          67.61 	
85246		Clot factor viii vw antigen	 $          67.61 	
85247		Clot factor viii multimetric	 $          67.61 	
85250		Clot factor ix ptc/chrstmas	 $          56.10 	
85260		Clot factor x stuart-power	 $          52.77 	
85270		Clot factor xi pta	 $          52.77 	
85280		Clot factor xii hageman	 $          57.02 	
85290		Clot factor xiii fibrin stab	 $          48.17 	
85291		Clot factor xiii fibrin scrn	 $          26.22 	
85292		Clot factor fletcher fact	 $          55.81 	
85293		Clot factor wght kininogen	 $          55.81 	
85300		Antithrombin iii activity	 $          34.93 	
85301		Antithrombin iii antigen	 $          31.86 	
85302		Clot inhibit prot c antigen	 $          35.42 	
85303		Clot inhibit prot c activity	 $          40.76 	
85305		Clot inhibit prot s total	 $          34.19 	
85306		Clot inhibit prot s free	 $          45.17 	
85307		Assay activated protein c	 $          45.17 	
85335		Factor inhibitor test	 $          27.15 	
85337		Thrombomodulin	 $          30.72 	
85345		Coagulation time lee & white	 $          12.68 	
85347		Coagulation time activated	 $          12.55 	
85348		Coagulation time otr method	 $          10.97 	
85360		Euglobulin lysis	 $          13.65 	
85362		Fibrin degradation products	 $          20.30 	
85366		Fibrinogen test	 $          25.38 	
85370		Fibrinogen test	 $          33.46 	
85378		Fibrin degrade semiquant	 $          21.02 	
85379		Fibrin degradation quant	 $          23.87 	
85380		Fibrin degradj d-dimer	 $          23.87 	
85384		Fibrinogen activity	 $          25.01 	
85385		Fibrinogen antigen	 $          25.01 	
85390		Fibrinolysins screen i&r	 $          12.51 	
85397		Clotting funct activity	 $          67.61 	
85400		Fibrinolytic plasmin	 $          26.07 	
85410		Fibrinolytic antiplasmin	 $          20.87 	
85415		Fibrinolytic plasminogen	 $          50.67 	
85420		Fibrinolytic plasminogen	 $          19.27 	
85421		Fibrinolytic plasminogen	 $          30.02 	
85441		Heinz bodies direct	 $          12.40 	
85445		Heinz bodies induced	 $          20.09 	
85460		Hemoglobin fetal	 $          22.81 	
85461		Hemoglobin fetal	 $          19.55 	
85475		Hemolysin acid	 $          26.16 	
85520		Heparin assay	 $          31.38 	
85525		Heparin neutralization	 $          34.91 	
85530		Heparin-protamine tolerance	 $          41.77 	
85536		Iron stain peripheral blood	 $          19.07 	
85540		Wbc alkaline phosphatase	 $          25.36 	
85547		RBC mechanical fragility	 $          25.36 	
85549		Muramidase	 $          55.27 	
85555		RBC osmotic fragility	 $          19.70 	
85557		RBC osmotic fragility	 $          39.38 	
85576	QW	Blood platelet aggregation	 $          63.31 	
85576		Blood platelet aggregation	 $          63.31 	
85597		Phospholipid pltlt neutraliz	 $          45.27 	
85598		Hexagnal phosph pltlt neutrl	 $          45.27 	
85610	QW	Prothrombin time	 $          11.60 	
85610		Prothrombin time	 $          11.60 	
85611		Prothrombin test	 $          11.62 	
85612		Viper venom prothrombin time	 $          28.21 	
85613		Russell viper venom diluted	 $          28.21 	
85635		Reptilase test	 $          29.01 	
85651		Rbc sed rate nonautomated	 $          10.45 	
85652		Rbc sed rate automated	 $            7.97 	
85660		RBC sickle cell test	 $          16.26 	
85670		Thrombin time plasma	 $          17.00 	
85675		Thrombin time titer	 $          20.17 	
85705		Thromboplastin inhibition	 $          20.58 	
85730		Thromboplastin time partial	 $          17.69 	
85732		Thromboplastin time partial	 $          19.07 	
85810		Blood viscosity examination	 $          34.39 	
86000		Agglutinins febrile antigen	 $          20.56 	
86001		Allergen specific igg	 $          14.10 	
86003		Allergen specific IgE	 $          14.10 	
86005		Allergen specific IgE	 $          20.63 	
86021		WBC antibody identification	 $          44.37 	
86022		Platelet antibodies	 $          54.13 	
86023		Immunoglobulin assay	 $          36.72 	
86038		Antinuclear antibodies	 $          35.62 	
86039		Antinuclear antibodies (ANA)	 $          32.90 	
86060		Antistreptolysin o titer	 $          16.59 	
86063		Antistreptolysin o screen	 $          10.50 	
86140		C-reactive protein	 $          15.25 	
86141		C-reactive protein hs	 $          38.15 	
86146		Beta-2 glycoprotein antibody	 $          45.04 	
86147		Cardiolipin antibody ea ig	 $          45.04 	
86148		Anti-phospholipid antibody	 $          47.35 	
86152		Cell enumeration & id	 $       724.05 	
86155		Chemotaxis assay	 $          45.90 	
86156		Cold agglutinin screen	 $          19.74 	
86157		Cold agglutinin titer	 $          23.76 	
86160		Complement antigen	 $          35.38 	
86161		Complement/function activity	 $          35.38 	
86162		Complement total (ch50)	 $          59.88 	
86171		Complement fixation each	 $          29.51 	
86185		Counterimmunoelectrophoresis	 $          26.35 	
86200		Ccp antibody	 $          38.15 	
86215		Deoxyribonuclease antibody	 $          39.05 	
86225		Dna antibody native	 $          40.48 	
86226		Dna antibody single strand	 $          35.68 	
86235		Nuclear antigen antibody	 $          44.02 	
86243		Fc receptor	 $          60.46 	
86255		Fluorescent antibody screen	 $          35.51 	
86256		Fluorescent antibody titer	 $          35.51 	
86277		Growth hormone antibody	 $          46.38 	
86280		Hemagglutination inhibition	 $          24.13 	
86294	QW	Immunoassay tumor qual	 $          57.82 	
86294		Immunoassay tumor qual	 $          57.82 	
86300		Immunoassay tumor ca 15-3	 $          61.32 	
86301		Immunoassay tumor ca 19-9	 $          61.32 	
86304		Immunoassay tumor ca 125	 $          61.32 	
86305		Human epididymis protein 4	 $          61.32 	
86308	QW	Heterophile antibody screen	 $          15.25 	
86308		Heterophile antibody screen	 $          15.25 	
86309		Heterophile antibody titer	 $          19.07 	
86310		Heterophile antibody absrbj	 $          21.73 	
86316		Immunoassay tumor other	 $          61.32 	
86317		Immunoassay infectious agent	 $          44.17 	
86318	QW	Immunoassay infectious agent	 $          38.15 	
86318		Immunoassay infectious agent	 $          38.15 	
86320		Serum immunoelectrophoresis	 $          66.05 	
86325		Other immunoelectrophoresis	 $          65.90 	
86327		Immunoelectrophoresis assay	 $          66.85 	
86329		Immunodiffusion nes	 $          41.36 	
86331		Immunodiffusion ouchterlony	 $          35.32 	
86332		Immune complex assay	 $          50.76 	
86334		Immunofix e-phoresis serum	 $          65.84 	
86335		Immunfix e-phorsis/urine/csf	 $          86.49 	
86336		Inhibin A	 $          38.17 	
86337		Insulin antibodies	 $          63.09 	
86340		Intrinsic factor antibody	 $          44.41 	
86341		Islet cell antibody	 $          39.57 	
86343		Leukocyte histamine release	 $          36.74 	
86344		Leukocyte phagocytosis	 $          23.54 	
86352		Cell function assay w/stim	 $       400.38 	
86353		Lymphocyte transformation	 $       144.48 	
86355		B cells total count	 $          52.34 	
86356		Mononuclear cell antigen	 $          53.33 	
86357		Nk cells total count	 $          52.34 	
86359		T cells total count	 $          52.34 	
86360		T cell absolute count/ratio	 $       104.63 	
86361		T cell absolute count	 $          53.33 	
86367		Stem cells total count	 $          52.34 	
86376		Microsomal antibody each	 $          42.88 	
86378		Migration inhibitory factor	 $          58.02 	
86382		Neutralization test viral	 $          49.83 	
86384		Nitroblue tetrazolium dye	 $          33.54 	
86386	QW	Nuclear matrix protein 22	 $          47.07 	
86386		Nuclear matrix protein 22	 $          47.07 	
86403		Particle agglut antbdy scrn	 $          20.58 	
86406		Particle agglut antbdy titr	 $          31.34 	
86430		Rheumatoid factor test qual	 $          16.72 	
86431		Rheumatoid factor quant	 $          16.72 	
86480		Tb test cell immun measure	 $       182.65 	
86481		Tb ag response t-cell susp	 $       220.80 	
86590		Streptokinase antibody	 $          31.38 	
86592		Syphilis test non-trep qual	 $          12.57 	
86593		Syphilis test non-trep quant	 $          12.96 	
86602		Antinomyces antibody	 $          30.00 	
86603		Adenovirus antibody	 $          33.05 	
86606		Aspergillus antibody	 $          41.45 	
86609		Bacterium antibody	 $          37.97 	
86611		Bartonella antibody	 $          30.00 	
86612		Blastomyces antibody	 $          33.05 	
86615		Bordetella antibody	 $          38.88 	
86617		Lyme disease antibody	 $          45.64 	
86618	QW	Lyme disease antibody	 $          50.20 	
86618		Lyme disease antibody	 $          50.20 	
86619		Borrelia antibody	 $          39.42 	
86622		Brucella antibody	 $          24.11 	
86625		Campylobacter antibody	 $          38.66 	
86628		Candida antibody	 $          35.38 	
86631		Chlamydia antibody	 $          34.84 	
86632		Chlamydia igm antibody	 $          37.39 	
86635		Coccidioides antibody	 $          33.05 	
86638		Q fever antibody	 $          33.05 	
86641		Cryptococcus antibody	 $          20.58 	
86644		CMV antibody	 $          42.42 	
86645		Cmv antibody igm	 $          42.08 	
86648		Diphtheria antibody	 $          44.82 	
86651		Encephalitis californ antbdy	 $          38.88 	
86652		Encephaltis east eqne anbdy	 $          38.88 	
86653		Encephaltis st louis antbody	 $          38.88 	
86654		Encephaltis west eqne antbdy	 $          38.88 	
86658		Enterovirus antibody	 $          33.05 	
86663		Epstein-barr antibody	 $          38.66 	
86664		Epstein-barr nuclear antigen	 $          42.08 	
86665		Epstein-barr capsid vca	 $          42.08 	
86666		Ehrlichia antibody	 $          30.00 	
86668		Francisella tularensis	 $          22.98 	
86671		Fungus nes antibody	 $          33.05 	
86674		Giardia lamblia antibody	 $          42.08 	
86677		Helicobacter pylori antibody	 $          42.77 	
86682		Helminth antibody	 $          30.50 	
86684		Hemophilus influenza antibdy	 $          20.58 	
86687		Htlv-i antibody	 $          24.73 	
86688		Htlv-ii antibody	 $          29.40 	
86689		Htlv/hiv confirmj antibody	 $          57.02 	
86692		Hepatitis delta agent antbdy	 $          50.57 	
86694		Herpes simplex nes antbdy	 $          42.42 	
86695		Herpes simplex type 1 test	 $          38.88 	
86696		Herpes simplex type 2 test	 $          57.02 	
86698		Histoplasma antibody	 $          33.05 	
86701	QW	Hiv-1antibody	 $          26.18 	
86701		Hiv-1antibody	 $          26.18 	
86702		Hiv-2 antibody	 $          29.40 	
86703		Hiv-1/hiv-2 1 result antbdy	 $          29.40 	
86704		Hep b core antibody total	 $          35.51 	
86705		Hep b core antibody igm	 $          34.71 	
86706		Hep b surface antibody	 $          31.64 	
86707		Hepatitis be antibody	 $          34.08 	
86708		Hepatitis a total antibody	 $          36.50 	
86709		Hepatitis a igm antibody	 $          33.18 	
86710		Influenza virus antibody	 $          39.94 	
86711		John cunningham antibody	 $          42.42 	
86713		Legionella antibody	 $          42.08 	
86717		Leishmania antibody	 $          36.09 	
86720		Leptospira antibody	 $          38.88 	
86723		Listeria monocytogenes	 $          38.88 	
86727		Lymph choriomeningitis ab	 $          33.05 	
86729		Lympho venereum antibody	 $          35.21 	
86732		Mucormycosis antibody	 $          38.88 	
86735		Mumps antibody	 $          38.45 	
86738		Mycoplasma antibody	 $          39.03 	
86741		Neisseria meningitidis	 $          38.88 	
86744		Nocardia antibody	 $          38.88 	
86747		Parvovirus antibody	 $          44.30 	
86750		Malaria antibody	 $          38.88 	
86753		Protozoa antibody nos	 $          30.50 	
86756		Respiratory virus antibody	 $          37.97 	
86757		Rickettsia antibody	 $          57.02 	
86759		Rotavirus antibody	 $          38.88 	
86762		Rubella antibody	 $          42.42 	
86765		Rubeola antibody	 $          37.97 	
86768		Salmonella antibody	 $          38.88 	
86771		Shigella antibody	 $          38.88 	
86774		Tetanus antibody	 $          43.61 	
86777		Toxoplasma antibody	 $          42.42 	
86778		Toxoplasma antibody igm	 $          42.08 	
86780		Treponema pallidum	 $          39.01 	
86784		Trichinella antibody	 $          18.73 	
86787		Varicella-zoster antibody	 $          37.97 	
86788		West nile virus ab igm	 $          42.08 	
86789		West nile virus antibody	 $          42.42 	
86790		Virus antibody nos	 $          37.97 	
86793		Yersinia antibody	 $          38.88 	
86800		Thyroglobulin antibody	 $          46.87 	
86803	QW	Hepatitis c ab test	 $          42.06 	
86803		Hepatitis c ab test	 $          42.06 	
86804		Hep c ab test confirm	 $          45.64 	
86805		Lymphocytotoxicity assay	 $       154.09 	
86806		Lymphocytotoxicity assay	 $       140.25 	
86807		Cytotoxic antibody screening	 $       116.62 	
86808		Cytotoxic antibody screening	 $          87.46 	
86812		Hla typing a b or c	 $          76.05 	
86813		Hla typing a b or c	 $          94.11 	
86816		Hla typing dr/dq	 $          82.10 	
86817		Hla typing dr/dq	 $       189.73 	
86821		Lymphocyte culture mixed	 $       166.38 	
86822		Lymphocyte culture primed	 $       107.74 	
86825		Hla x-math non-cytotoxic	 $       159.99 	
86826		Hla x-match noncytotoxc addl	 $          53.33 	
86828		Hla class i&ii antibody qual	 $       116.62 	
86829		Hla class i/ii antibody qual	 $          87.46 	
86830		Hla class i phenotype qual	 $       237.92 	
86831		Hla class ii phenotype qual	 $       203.93 	
86832		Hla class i high defin qual	 $       373.87 	
86833		Hla class ii high defin qual	 $       339.90 	
86834		Hla class i semiquant panel	 $    1,053.65 	
86835		Hla class ii semiquant panel	 $       951.70 	
86880		Coombs test direct	 $          15.85 	
86885		Coombs test indirect qual	 $          16.87 	
86886		Coombs test indirect titer	 $          15.25 	
86900		Blood typing abo	 $            8.79 	
86901		Blood typing rh (d)	 $            8.79 	
86902		Blood type antigen donor ea	 $          11.28 	
86904		Blood typing patient serum	 $          28.02 	
86905		Blood typing rbc antigens	 $          11.28 	
86906		Blood typing rh phenotype	 $          18.90 	
86940		Hemolysins/agglutinins auto	 $          24.17 	
86941		Hemolysins/agglutinins	 $          35.68 	
87001		Small animal inoculation	 $          38.94 	
87003		Small animal inoculation	 $          49.62 	
87015		Specimen infect agnt concntj	 $          19.68 	
87040		Blood culture for bacteria	 $          30.43 	
87045		Feces culture aerobic bact	 $          27.82 	
87046		Stool cultr aerobic bact ea	 $          27.82 	
87070		Culture othr specimn aerobic	 $          25.38 	
87071		Culture aerobic quant other	 $          27.82 	
87073		Culture bacteria anaerobic	 $          27.82 	
87075		Cultr bacteria except blood	 $          27.89 	
87076		Culture anaerobe ident each	 $          20.87 	
87077	QW	Culture aerobic identify	 $          20.87 	
87077		Culture aerobic identify	 $          20.87 	
87081		Culture screen only	 $          19.55 	
87084		Culture of specimen by kit	 $          25.38 	
87086		Urine culture/colony count	 $          23.78 	
87088		Urine bacteria culture	 $          23.87 	
87101		Skin fungi culture	 $          22.72 	
87102		Fungus isolation culture	 $          24.75 	
87103		Blood fungus culture	 $          26.57 	
87106		Fungi identification yeast	 $          30.43 	
87107		Fungi identification mold	 $          30.43 	
87109		Mycoplasma	 $          45.34 	
87110		Chlamydia culture	 $          57.74 	
87116		Mycobacteria culture	 $          31.84 	
87118		Mycobacteric identification	 $          32.25 	
87140		Culture type immunofluoresc	 $          16.44 	
87143		Culture typing glc/hplc	 $          36.91 	
87147		Culture type immunologic	 $          15.25 	
87149		Dna/rna direct probe	 $          59.10 	
87150		Dna/rna amplified probe	 $       103.40 	
87152		Culture type pulse field gel	 $          15.40 	
87153		Dna/rna sequencing	 $       339.94 	
87158		Culture typing added method	 $          15.40 	
87164		Dark field examination	 $          31.64 	
87166		Dark field examination	 $          33.29 	
87168		Macroscopic exam arthropod	 $          12.57 	
87169		Macroscopic exam parasite	 $          12.57 	
87172		Pinworm exam	 $          12.57 	
87176		Tissue homogenization cultr	 $          17.34 	
87177		Ova and parasites smears	 $          26.22 	
87181		Microbe susceptible diffuse	 $          14.00 	
87184		Microbe susceptible disk	 $          20.33 	
87185		Microbe susceptible enzyme	 $          14.00 	
87186		Microbe susceptible mic	 $          25.49 	
87187		Microbe susceptible mlc	 $          30.54 	
87188		Microbe suscept macrobroth	 $          19.57 	
87190		Microbe suscept mycobacteri	 $          12.51 	
87197		Bactericidal level serum	 $          44.28 	
87205		Smear gram stain	 $          12.57 	
87206		Smear fluorescent/acid stai	 $          15.85 	
87207		Smear special stain	 $          16.80 	
87209		Smear complex stain	 $          50.44 	
87210	QW	Smear wet mount saline/ink	 $          12.57 	
87210		Smear wet mount saline/ink	 $          12.57 	
87220		Tissue exam for fungi	 $          12.57 	
87230		Assay toxin or antitoxin	 $          58.19 	
87250		Virus inoculate eggs/animal	 $          57.63 	
87252		Virus inoculation tissue	 $          76.81 	
87253		Virus inoculate tissue addl	 $          59.53 	
87254		Virus inoculation shell via	 $          57.63 	
87255		Genet virus isolate hsv	 $          99.79 	
87260		Adenovirus ag if	 $          35.34 	
87265		Pertussis ag if	 $          35.34 	
87267		Enterovirus antibody dfa	 $          35.34 	
87269		Giardia ag if	 $          35.34 	
87270		Chlamydia trachomatis ag if	 $          35.34 	
87271		Cytomegalovirus dfa	 $          35.34 	
87272		Cryptosporidium ag if	 $          35.34 	
87273		Herpes simplex 2 ag if	 $          35.34 	
87274		Herpes simplex 1 ag if	 $          35.34 	
87275		Influenza b ag if	 $          35.34 	
87276		Influenza a ag if	 $          35.34 	
87277		Legionella micdadei ag if	 $          35.34 	
87278		Legion pneumophilia ag if	 $          35.34 	
87279		Parainfluenza ag if	 $          35.34 	
87280		Respiratory syncytial ag if	 $          35.34 	
87281		Pneumocystis carinii ag if	 $          35.34 	
87283		Rubeola ag if	 $          35.34 	
87285		Treponema pallidum ag if	 $          35.34 	
87290		Varicella zoster ag if	 $          35.34 	
87299		Antibody detection nos if	 $          35.34 	
87300		Ag detection polyval if	 $          35.34 	
87301		Adenovirus ag eia	 $          35.34 	
87305		Aspergillus ag eia	 $          35.34 	
87320		Chylmd trach ag eia	 $          35.34 	
87324		Clostridium ag eia	 $          35.34 	
87327		Cryptococcus neoform ag eia	 $          35.34 	
87328		Cryptosporidium ag eia	 $          35.34 	
87329		Giardia ag eia	 $          35.34 	
87332		Cytomegalovirus ag eia	 $          35.34 	
87335		E coli 0157 ag eia	 $          35.34 	
87336		Entamoeb hist dispr ag eia	 $          35.34 	
87337		Entamoeb hist group ag eia	 $          35.34 	
87338		Hpylori stool eia	 $          35.36 	
87339		H pylori ag eia	 $          35.34 	
87340		Hepatitis b surface ag eia	 $          30.46 	
87341		Hepatitis b surface ag eia	 $          30.46 	
87350		Hepatitis be ag eia	 $          33.98 	
87380		Hepatitis delta ag eia	 $          48.36 	
87385		Histoplasma capsul ag eia	 $          35.34 	
87389		Hiv-1 ag w/hiv-1 & hiv-2 ab	 $          70.98 	
87390		Hiv-1 ag eia	 $          51.97 	
87391		Hiv-2 ag eia	 $          51.97 	
87400		Influenza a/b ag eia	 $          35.34 	
87420		Resp syncytial ag eia	 $          35.34 	
87425		Rotavirus ag eia	 $          35.34 	
87427		Shiga-like toxin ag eia	 $          35.34 	
87430		Strep a ag eia	 $          35.34 	
87449	QW	Ag detect nos eia mult	 $          35.34 	
87449		Ag detect nos eia mult	 $          35.34 	
87450		Ag detect nos eia single	 $          28.25 	
87451		Ag detect polyval eia mult	 $          28.25 	
87470		Bartonella dna dir probe	 $          59.10 	
87471		Bartonella dna amp probe	 $       103.40 	
87472		Bartonella dna quant	 $       126.23 	
87475		Lyme dis dna dir probe	 $          59.10 	
87476		Lyme dis dna amp probe	 $       103.40 	
87477		Lyme dis dna quant	 $       126.23 	
87480		Candida dna dir probe	 $          59.10 	
87481		Candida dna amp probe	 $       103.40 	
87482		Candida dna quant	 $       123.03 	
87485		Chylmd pneum dna dir probe	 $          59.10 	
87486		Chylmd pneum dna amp probe	 $       103.40 	
87487		Chylmd pneum dna quant	 $       126.23 	
87490		Chylmd trach dna dir probe	 $          59.10 	
87491		Chylmd trach dna amp probe	 $       103.40 	
87492		Chylmd trach dna quant	 $       103.01 	
87493		C diff amplified probe	 $       103.40 	
87495		Cytomeg dna dir probe	 $          59.10 	
87496		Cytomeg dna amp probe	 $       103.40 	
87497		Cytomeg dna quant	 $       126.23 	
87498		Enterovirus probe&revrs trns	 $       103.40 	
87500		Vanomycin dna amp probe	 $       103.40 	
87501		Influenza dna amp prob 1+	 $       151.22 	
87502		Influenza dna amp probe	 $       250.75 	
87503		Influenza dna amp prob addl	 $          61.19 	
87510		Gardner vag dna dir probe	 $          59.10 	
87511		Gardner vag dna amp probe	 $       103.40 	
87512		Gardner vag dna quant	 $       123.03 	
87515		Hepatitis b dna dir probe	 $          59.10 	
87516		Hepatitis b dna amp probe	 $       103.40 	
87517		Hepatitis b dna quant	 $       126.23 	
87520		Hepatitis c rna dir probe	 $          59.10 	
87521		Hepatitis c probe&rvrs trnsc	 $       103.40 	
87522		Hepatitis c revrs trnscrpj	 $       126.23 	
87525		Hepatitis g dna dir probe	 $          59.10 	
87526		Hepatitis g dna amp probe	 $       103.40 	
87527		Hepatitis g dna quant	 $       123.03 	
87528		Hsv dna dir probe	 $          59.10 	
87529		Hsv dna amp probe	 $       103.40 	
87530		Hsv dna quant	 $       126.23 	
87531		Hhv-6 dna dir probe	 $          59.10 	
87532		Hhv-6 dna amp probe	 $       103.40 	
87533		Hhv-6 dna quant	 $       123.03 	
87534		Hiv-1 dna dir probe	 $          59.10 	
87535		Hiv-1 probe&reverse trnscrpj	 $       103.40 	
87536		Hiv-1 quant&revrse trnscrpj	 $       250.75 	
87537		Hiv-2 dna dir probe	 $          59.10 	
87538		Hiv-2 probe&revrse trnscripj	 $       103.40 	
87539		Hiv-2 quant&revrse trnscripj	 $       126.23 	
87540		Legion pneumo dna dir prob	 $          59.10 	
87541		Legion pneumo dna amp prob	 $       103.40 	
87542		Legion pneumo dna quant	 $       123.03 	
87550		Mycobacteria dna dir probe	 $          59.10 	
87551		Mycobacteria dna amp probe	 $       103.40 	
87552		Mycobacteria dna quant	 $       126.23 	
87555		M.tuberculo dna dir probe	 $          59.10 	
87556		M.tuberculo dna amp probe	 $       103.40 	
87557		M.tuberculo dna quant	 $       126.23 	
87560		M.avium-intra dna dir prob	 $          59.10 	
87561		M.avium-intra dna amp prob	 $       103.40 	
87562		M.avium-intra dna quant	 $       126.23 	
87580		M.pneumon dna dir probe	 $          59.10 	
87581		M.pneumon dna amp probe	 $       103.40 	
87582		M.pneumon dna quant	 $       123.03 	
87590		N.gonorrhoeae dna dir prob	 $          59.10 	
87591		N.gonorrhoeae dna amp prob	 $       103.40 	
87592		N.gonorrhoeae dna quant	 $       126.23 	
87620		Hpv dna dir probe	 $          59.10 	
87621		Hpv dna amp probe	 $       103.40 	
87622		Hpv dna quant	 $       123.03 	
87631		Resp virus 3-11 targets	 $       378.04 	
87632		Resp virus 6-11 targets	 $       628.95 	
87633		Resp virus 12-25 targets	 $    1,228.18 	
87640		Staph a dna amp probe	 $       103.40 	
87641		Mr-staph dna amp probe	 $       103.40 	
87650		Strep a dna dir probe	 $          59.10 	
87651		Strep a dna amp probe	 $       103.40 	
87652		Strep a dna quant	 $       123.03 	
87653		Strep b dna amp probe	 $       103.40 	
87660		Trichomonas vagin dir probe	 $          59.10 	
87661		Trichomonas vaginalis amplif	 $       103.40 	
87797		Detect agent nos dna dir	 $          59.10 	
87798		Detect agent nos dna amp	 $       103.40 	
87799		Detect agent nos dna quant	 $       126.23 	
87800		Detect agnt mult dna direc	 $       118.20 	
87801		Detect agnt mult dna ampli	 $       206.84 	
87802		Strep b assay w/optic	 $          35.34 	
87803		Clostridium toxin a w/optic	 $          35.34 	
87804	QW	Influenza assay w/optic	 $          35.34 	
87804		Influenza assay w/optic	 $          35.34 	
87807	QW	Rsv assay w/optic	 $          35.34 	
87807		Rsv assay w/optic	 $          35.34 	
87808	QW	Trichomonas assay w/optic	 $          35.34 	
87808		Trichomonas assay w/optic	 $          35.34 	
87809	QW	Adenovirus assay w/optic	 $          35.34 	
87809		Adenovirus assay w/optic	 $          35.34 	
87810		Chylmd trach assay w/optic	 $          35.34 	
87850		N. gonorrhoeae assay w/optic	 $          35.34 	
87880	QW	Strep a assay w/optic	 $          35.34 	
87880		Strep a assay w/optic	 $          35.34 	
87899	QW	Agent nos assay w/optic	 $          35.34 	
87899		Agent nos assay w/optic	 $          35.34 	
87900		Phenotype infect agent drug	 $       384.09 	
87901		Genotype dna hiv reverse t	 $       758.64 	
87902		Genotype dna/rna hep c	 $       758.64 	
87903		Phenotype dna hiv w/culture	 $    1,439.94 	
87904		Phenotype dna hiv w/clt add	 $          76.81 	
87905	QW	Sialidase enzyme assay	 $          15.44 	
87905		Sialidase enzyme assay	 $          15.44 	
87906		Genotype dna/rna hiv	 $       379.34 	
87910		Genotype cytomegalovirus	 $       758.64 	
87912		Genotype dna hepatitis b	 $       758.64 	
88130		Sex chromatin identification	 $          44.37 	
88140		Sex chromatin identification	 $            8.55 	
88142		Cytopath c/v thin layer	 $          59.70 	
88143		Cytopath c/v thin layer redo	 $          59.70 	
88147		Cytopath c/v automated	 $          33.54 	
88148		Cytopath c/v auto rescreen	 $          44.78 	
88150		Cytopath c/v manual	 $          31.15 	
88152		Cytopath c/v auto redo	 $          31.15 	
88153		Cytopath c/v redo	 $          31.15 	
88154		Cytopath c/v select	 $          31.15 	
88155		Cytopath c/v index add-on	 $          17.67 	
88164		Cytopath tbs c/v manual	 $          31.15 	
88165		Cytopath tbs c/v redo	 $          31.15 	
88166		Cytopath tbs c/v auto redo	 $          31.15 	
88167		Cytopath tbs c/v select	 $          31.15 	
88174		Cytopath c/v auto in fluid	 $          62.96 	
88175		Cytopath c/v auto fluid redo	 $          78.06 	
88230		Tissue culture lymphocyte	 $       108.67 	
88233		Tissue culture skin/biopsy	 $       217.27 	
88235		Tissue culture placenta	 $       217.27 	
88237		Tissue culture bone marrow	 $       372.21 	
88239		Tissue culture tumor	 $       434.72 	
88240		Cell cryopreserve/storage	 $          29.76 	
88241		Frozen cell preparation	 $          29.76 	
88245		Chromosome analysis 20-25	 $       438.67 	
88248		Chromosome analysis 50-100	 $       510.32 	
88249		Chromosome analysis 100	 $       510.32 	
88261		Chromosome analysis 5	 $       520.80 	
88262		Chromosome analysis 15-20	 $       367.29 	
88263		Chromosome analysis 45	 $       442.86 	
88264		Chromosome analysis 20-25	 $       367.29 	
88267		Chromosome analys placenta	 $       529.76 	
88269		Chromosome analys amniotic	 $       490.13 	
88271		Cytogenetics dna probe	 $          63.12 	
88272		Cytogenetics 3-5	 $          78.90 	
88273		Cytogenetics 10-30	 $          94.69 	
88274		Cytogenetics 25-99	 $       102.58 	
88275		Cytogenetics 100-300	 $       118.35 	
88280		Chromosome karyotype study	 $          73.96 	
88283		Chromosome banding study	 $       202.15 	
88285		Chromosome count additional	 $          55.99 	
88289		Chromosome study additional	 $       101.48 	
88371		Protein western blot tissue	 $          65.45 	
88372		Protein analysis w/probe	 $          58.21 	
88720		Bilirubin total transcut	 $          14.77 	
88738		Hgb quant transcutaneous	 $          14.77 	
88740		Transcutaneous carboxyhb	 $          14.77 	
88741		Transcutaneous methb	 $          14.77 	
89050		Body fluid cell count	 $          12.51 	
89051		Body fluid cell count	 $          16.22 	
89055		Leukocyte assessment fecal	 $          12.57 	
89060		Exam synovial fluid crystals	 $          21.08 	
89125		Specimen fat stain	 $          12.72 	
89160		Exam feces for meat fibers	 $          10.50 	
89190		Nasal smear for eosinophils	 $          10.50 	
89300	QW	Semen analysis w/huhner	 $          26.29 	
89300		Semen analysis w/huhner	 $          26.29 	
89310		Semen analysis w/count	 $          18.73 	
89320		Semen anal vol/count/mot	 $          35.51 	
89321	QW	Semen anal sperm detection	 $          35.51 	
89321		Semen anal sperm detection	 $          35.51 	
89322		Semen anal strict criteria	 $          45.66 	
89325		Sperm antibody test	 $          22.98 	
89329		Sperm evaluation test	 $          61.80 	
89330		Evaluation cervical mucus	 $          29.16 	
89331		Retrograde ejaculation anal	 $          57.74 	
ATP02		Auto.Test Pane Pricing Code, 1-2 Tests	 $          15.34 	
ATP03		Auto.Test Pane Pricing Code, 3 Tests	 $          19.59 	
ATP04		Auto.Test Pane Pricing Code, 4 Tests	 $          20.67 	
ATP05		Auto.Test Pane Pricing Code, 5 Tests	 $          23.07 	
ATP06		Auto.Test Pane Pricing Code, 6 Tests	 $          23.11 	
ATP07		Auto.Test Pane Pricing Code, 7 Tests	 $          24.06 	
ATP08		Auto.Test Pane Pricing Code, 8 Tests	 $          24.93 	
ATP09		Auto.Test Pane Pricing Code, 9 Tests	 $          25.60 	
ATP10		Auto.Test Pane Pricing Code, 10 Tests	 $          25.60 	
ATP11		Auto.Test Pane Pricing Code, 11 Tests	 $          26.03 	
ATP12		Auto.Test Pane Pricing Code, 12 Tests	 $          26.59 	
ATP16		Auto Test Panel Pricing Code  13-16 Test	 $          31.13 	
ATP18		Auto Test Panel Pricing Code, 17-18 Test	 $          31.36 	
ATP19		Auto Test Panel Pricing Code, 19 Tests	 $          32.62 	
ATP20		Auto Test Panel Pricing Code, 20 Tests	 $          33.63 	
ATP21		Auto Test Panel Pricing Code, 21 Tests	 $          34.71 	
ATP22		Auto.Test Panel Pricing Code, 22+ Tests	 $          35.75 	
ATP23		Auto.Test Panel Pricing Code, 23+ Tests	 $          35.75 	
G0027		Semen analysis	 $          19.16 	
G0103		PSA screening	 $          54.19 	
G0123		Screen cerv/vag thin layer	 $          59.70 	
G0143		Scr c/v cyto,thinlayer,rescr	 $          59.70 	
G0144		Scr c/v cyto,thinlayer,rescr	 $          62.96 	
G0145		Scr c/v cyto,thinlayer,rescr	 $          78.06 	
G0147		Scr c/v cyto, automated sys	 $          33.54 	
G0148		Scr c/v cyto, autosys, rescr	 $          44.78 	
G0306		CBC/diffwbc w/o platelet	 $          20.82 	
G0307		CBC without platelet	 $          14.69 	
G0328	QW	Fecal blood scrn immunoassay	 $          46.87 	
G0328		Fecal blood scrn immunoassay	 $          46.87 	
G0431		Drug screen multiple class	 $       214.27 	
G0432		EIA HIV-1/HIV-2 screen	 $          29.40 	
G0433	QW	ELISA HIV-1/HIV-2 screen	 $          29.40 	
G0433		ELISA HIV-1/HIV-2 screen	 $          29.40 	
G0434	QW	Drug screen multi drug class	 $          42.85 	
G0434		Drug screen multi drug class	 $          42.85 	
G0435		Oral HIV-1/HIV-2 screen	 $          35.34 	
G9143		Warfarin respon genetic test	 $       355.73 	
P2038		Blood mucoprotein	 $          14.82 	
P3000		Screen pap by tech w md supv	 $          31.15 	
P9612		Catheterize for urine spec	 $            6.48 	
P9615		Urine specimen collect mult	 $            6.48 	
Q0111		Wet mounts/ w preparations	 $          12.57 	
Q0112		Potassium hydroxide preps	 $          12.57 	
Q0113		Pinworm examinations	 $          15.94 	
Q0114		Fern test	 $          21.08 	
Q0115		Post-coital mucous exam	 $          29.16