DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
7 CCR 1101-3
WORKERS’ COMPENSATION RULES OF PROCEDURE

Rule 18	 Exhibits
Table of Contents

Exhibit #1 - List of MS-DRGs for Inpatient Hospitals
Exhibit #2 - Hospital Base Rates and CCRs
Exhibit #3 - Critical Access Hospitals
Exhibit #4 – Hospital Outpatient APC Codes and Values
Exhibit #5 – Rural Health Clinics
Exhibit #6 - Dental Fees
Exhibit #7 – Evaluation & Management Documentation Guidelines
Exhibit #8 - Clinical Laboratory Fees

Exhibit #1	
List of Medicare Severity Diagnosis-Related Groups (MS-DRG) Relative Weights 	
For Inpatient Hospital Discharges Occurring on or after 1/1/2018 	
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	25.4241	29	37	
2	PRE	SURG	HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC	15.2462	16.8	20.2	
3	PRE	SURG	ECMO OR TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R.	17.6331	24.3	30.9	
4	PRE	SURG	TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.	11.0663	19.4	23.8	
5	PRE	SURG	LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT	10.4265	15.3	20.7	
6	PRE	SURG	LIVER TRANSPLANT W/O MCC	4.4988	7.8	8.5	
7	PRE	SURG	LUNG TRANSPLANT	9.787	16	18.7	
8	PRE	SURG	SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT	5.0587	9.2	10.7	
10	PRE	SURG	PANCREAS TRANSPLANT	4.3618	8.1	9	
11	PRE	SURG	TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES W MCC	4.9187	10.9	13.5	
12	PRE	SURG	TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES W CC	3.5218	8.5	9.7	
13	PRE	SURG	TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES W/O CC/MCC	2.4058	6	6.8	
14	PRE	SURG	ALLOGENEIC BONE MARROW TRANSPLANT	11.6347	23.9	27.4	
16	PRE	SURG	AUTOLOGOUS BONE MARROW TRANSPLANT W CC/MCC	6.4418	17.4	18.8	
17	PRE	SURG	AUTOLOGOUS BONE MARROW TRANSPLANT W/O CC/MCC	4.5209	9.6	12.5	
20	01	SURG	INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W MCC	9.9987	13.5	16.7	
21	01	SURG	INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W CC	7.5361	11.9	13.4	
22	01	SURG	INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC	5.7149	7	8.6	
23	01	SURG	CRANIOTOMY W MAJOR DEVICE IMPLANT OR ACUTE CNS PDX W MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY W NEUROSTIMULATOR	5.4979	7.6	10.6	
24	01	SURG	CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W/O MCC	3.8316	4.2	5.5	
25	01	SURG	CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W MCC	4.3064	7	9.2	
26	01	SURG	CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC	2.9991	4.2	5.6	
27	01	SURG	CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W/O CC/MCC	2.3645	2.2	2.9	
28	01	SURG	SPINAL PROCEDURES W MCC	5.5585	9.1	11.8	
29	01	SURG	SPINAL PROCEDURES W CC OR SPINAL NEUROSTIMULATORS	3.2738	4.2	5.7	
30	01	SURG	SPINAL PROCEDURES W/O CC/MCC	2.1332	2.2	2.8	
31	01	SURG	VENTRICULAR SHUNT PROCEDURES W MCC	4.0723	7	10.1	
32	01	SURG	VENTRICULAR SHUNT PROCEDURES W CC	2.1276	3.2	4.5	
33	01	SURG	VENTRICULAR SHUNT PROCEDURES W/O CC/MCC	1.699	1.9	2.4	
34	01	SURG	CAROTID ARTERY STENT PROCEDURE W MCC	3.9913	5.2	7.6	
35	01	SURG	CAROTID ARTERY STENT PROCEDURE W CC	2.2276	2.1	3.1	
36	01	SURG	CAROTID ARTERY STENT PROCEDURE W/O CC/MCC	1.7638	1.3	1.5	
37	01	SURG	EXTRACRANIAL PROCEDURES W MCC	3.1691	5.1	7.4	
38	01	SURG	EXTRACRANIAL PROCEDURES W CC	1.5678	2.2	3.1	
39	01	SURG	EXTRACRANIAL PROCEDURES W/O CC/MCC	1.1138	1.3	1.5	
40	01	SURG	PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W MCC	3.8089	7.8	10.6	
41	01	SURG	PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM	2.331	4.4	5.5	
42	01	SURG	PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC	1.9096	2.6	3.2	
52	01	MED	SPINAL DISORDERS & INJURIES W CC/MCC	1.5089	4	5.4	
53	01	MED	SPINAL DISORDERS & INJURIES W/O CC/MCC	0.933	2.7	3.2	
54	01	MED	NERVOUS SYSTEM NEOPLASMS W MCC	1.3149	3.9	5.2	
55	01	MED	NERVOUS SYSTEM NEOPLASMS W/O MCC	0.9995	2.9	3.9	
56	01	MED	DEGENERATIVE NERVOUS SYSTEM DISORDERS W MCC	1.9134	5.4	7.7	
57	01	MED	DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC	1.1351	3.8	5.4	
58	01	MED	MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W MCC	1.638	5	6.6	
59	01	MED	MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W CC	1.0725	3.7	4.6	
60	01	MED	MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA W/O CC/MCC	0.8449	3	3.6	
61	01	MED	ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W MCC	2.7982	5	6.4	
62	01	MED	ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W CC	1.9323	3.5	4.1	
63	01	MED	ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA W THROMBOLYTIC AGENT W/O CC/MCC	1.6171	2.6	2.9	
64	01	MED	INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC	1.7691	4.4	6.1	
65	01	MED	INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS	1.0313	3.1	3.8	
66	01	MED	INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC	0.7467	2.2	2.6	
67	01	MED	NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W MCC	1.4131	3.5	4.8	
68	01	MED	NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT W/O MCC	0.896	2.2	2.8	
69	01	MED	TRANSIENT ISCHEMIA W/O THROMBOLYTIC	0.7522	2.1	2.5	
70	01	MED	NONSPECIFIC CEREBROVASCULAR DISORDERS W MCC	1.6486	4.6	6.4	
71	01	MED	NONSPECIFIC CEREBROVASCULAR DISORDERS W CC	0.9897	3.4	4.4	
72	01	MED	NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC/MCC	0.7602	2.4	3	
73	01	MED	CRANIAL & PERIPHERAL NERVE DISORDERS W MCC	1.4038	3.9	5.2	
74	01	MED	CRANIAL & PERIPHERAL NERVE DISORDERS W/O MCC	0.9536	2.9	3.7	
75	01	MED	VIRAL MENINGITIS W CC/MCC	1.6502	5	6.4	
76	01	MED	VIRAL MENINGITIS W/O CC/MCC	0.9617	3.1	3.7	
77	01	MED	HYPERTENSIVE ENCEPHALOPATHY W MCC	1.572	4.3	5.5	
78	01	MED	HYPERTENSIVE ENCEPHALOPATHY W CC	0.9933	3.2	3.9	
79	01	MED	HYPERTENSIVE ENCEPHALOPATHY W/O CC/MCC	0.7684	2.3	2.7	
80	01	MED	NONTRAUMATIC STUPOR & COMA W MCC	1.7369	4.5	6.6	
81	01	MED	NONTRAUMATIC STUPOR & COMA W/O MCC	0.7557	2.5	3.3	
82	01	MED	TRAUMATIC STUPOR & COMA, COMA >1 HR W MCC	2.1586	3.8	6.3	
83	01	MED	TRAUMATIC STUPOR & COMA, COMA >1 HR W CC	1.2567	3.3	4.2	
84	01	MED	TRAUMATIC STUPOR & COMA, COMA >1 HR W/O CC/MCC	0.9002	2.2	2.7	
85	01	MED	TRAUMATIC STUPOR & COMA, COMA <1 HR W MCC	2.0486	4.8	6.6	
86	01	MED	TRAUMATIC STUPOR & COMA, COMA <1 HR W CC	1.1826	3.2	4.1	
87	01	MED	TRAUMATIC STUPOR & COMA, COMA <1 HR W/O CC/MCC	0.8321	2.2	2.7	
88	01	MED	CONCUSSION W MCC	1.4045	3.5	4.5	
89	01	MED	CONCUSSION W CC	1.0068	2.7	3.3	
90	01	MED	CONCUSSION W/O CC/MCC	0.7907	2	2.3	
91	01	MED	OTHER DISORDERS OF NERVOUS SYSTEM W MCC	1.5403	4.1	5.6	
92	01	MED	OTHER DISORDERS OF NERVOUS SYSTEM W CC	0.9368	3	3.9	
93	01	MED	OTHER DISORDERS OF NERVOUS SYSTEM W/O CC/MCC	0.7294	2.2	2.7	
94	01	MED	BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W MCC	3.4149	7.7	10.2	
95	01	MED	BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W CC	2.3516	5.8	7	
96	01	MED	BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W/O CC/MCC	2.2186	4.7	5.5	
97	01	MED	NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W MCC	3.4035	8.5	11.3	
98	01	MED	NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W CC	1.8737	5.5	7.3	
99	01	MED	NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W/O CC/MCC	1.2061	3.6	4.6	
100	01	MED	SEIZURES W MCC	1.6487	4.2	5.7	
101	01	MED	SEIZURES W/O MCC	0.8313	2.6	3.3	
102	01	MED	HEADACHES W MCC	1.0606	3	4.1	
103	01	MED	HEADACHES W/O MCC	0.7499	2.3	2.9	
113	02	SURG	ORBITAL PROCEDURES W CC/MCC	2.1864	4.2	5.8	
114	02	SURG	ORBITAL PROCEDURES W/O CC/MCC	1.2798	2.3	3	
115	02	SURG	EXTRAOCULAR PROCEDURES EXCEPT ORBIT	1.4939	3.9	4.9	
116	02	SURG	INTRAOCULAR PROCEDURES W CC/MCC	1.499	3.2	4.7	
117	02	SURG	INTRAOCULAR PROCEDURES W/O CC/MCC	0.998	2.1	2.8	
121	02	MED	ACUTE MAJOR EYE INFECTIONS W CC/MCC	0.9862	3.7	4.7	
122	02	MED	ACUTE MAJOR EYE INFECTIONS W/O CC/MCC	0.7638	3.3	4.1	
123	02	MED	NEUROLOGICAL EYE DISORDERS	0.749	2.1	2.6	
124	02	MED	OTHER DISORDERS OF THE EYE W MCC	1.2491	3.6	4.9	
125	02	MED	OTHER DISORDERS OF THE EYE W/O MCC	0.7721	2.6	3.3	
129	03	SURG	MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE	2.2915	3.7	5.3	
130	03	SURG	MAJOR HEAD & NECK PROCEDURES W/O CC/MCC	1.4371	2.3	2.9	
131	03	SURG	CRANIAL/FACIAL PROCEDURES W CC/MCC	2.5713	4.4	6.1	
132	03	SURG	CRANIAL/FACIAL PROCEDURES W/O CC/MCC	1.5548	2.2	2.8	
133	03	SURG	OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W CC/MCC	1.9854	3.8	5.4	
134	03	SURG	OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC	1.1606	2	2.5	
135	03	SURG	SINUS & MASTOID PROCEDURES W CC/MCC	2.2711	4.5	6.3	
136	03	SURG	SINUS & MASTOID PROCEDURES W/O CC/MCC	1.299	2	2.7	
137	03	SURG	MOUTH PROCEDURES W CC/MCC	1.3635	3.6	4.7	
138	03	SURG	MOUTH PROCEDURES W/O CC/MCC	0.8654	2	2.5	
139	03	SURG	SALIVARY GLAND PROCEDURES	1.1152	1.9	2.7	
146	03	MED	EAR, NOSE, MOUTH & THROAT MALIGNANCY W MCC	1.9226	5.4	7.8	
147	03	MED	EAR, NOSE, MOUTH & THROAT MALIGNANCY W CC	1.2505	3.7	5	
148	03	MED	EAR, NOSE, MOUTH & THROAT MALIGNANCY W/O CC/MCC	0.8138	2.2	2.9	
149	03	MED	DYSEQUILIBRIUM	0.7043	2.1	2.5	
150	03	MED	EPISTAXIS W MCC	1.3229	3.5	4.7	
151	03	MED	EPISTAXIS W/O MCC	0.732	2.3	2.8	
152	03	MED	OTITIS MEDIA & URI W MCC	1.0512	3.2	4.1	
153	03	MED	OTITIS MEDIA & URI W/O MCC	0.7151	2.4	2.9	
154	03	MED	OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W MCC	1.4529	4.1	5.5	
155	03	MED	OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W CC	0.8975	3	3.7	
156	03	MED	OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES W/O CC/MCC	0.6656	2.2	2.7	
157	03	MED	DENTAL & ORAL DISEASES W MCC	1.5468	4.4	5.8	
158	03	MED	DENTAL & ORAL DISEASES W CC	0.8886	3	3.7	
159	03	MED	DENTAL & ORAL DISEASES W/O CC/MCC	0.6733	2.2	2.6	
163	04	SURG	MAJOR CHEST PROCEDURES W MCC	4.9507	10	12.5	
164	04	SURG	MAJOR CHEST PROCEDURES W CC	2.5786	5.1	6.1	
165	04	SURG	MAJOR CHEST PROCEDURES W/O CC/MCC	1.8506	3.1	3.7	
166	04	SURG	OTHER RESP SYSTEM O.R. PROCEDURES W MCC	3.5476	8.1	10.4	
167	04	SURG	OTHER RESP SYSTEM O.R. PROCEDURES W CC	1.8496	4.5	5.7	
168	04	SURG	OTHER RESP SYSTEM O.R. PROCEDURES W/O CC/MCC	1.2901	2.5	3.1	
175	04	MED	PULMONARY EMBOLISM W MCC	1.468	4.4	5.5	
176	04	MED	PULMONARY EMBOLISM W/O MCC	0.8953	2.9	3.6	
177	04	MED	RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC	1.8509	5.7	7.1	
178	04	MED	RESPIRATORY INFECTIONS & INFLAMMATIONS W CC	1.2955	4.5	5.4	
179	04	MED	RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC	0.9301	3.4	4.1	
180	04	MED	RESPIRATORY NEOPLASMS W MCC	1.6894	5	6.5	
181	04	MED	RESPIRATORY NEOPLASMS W CC	1.1561	3.5	4.6	
182	04	MED	RESPIRATORY NEOPLASMS W/O CC/MCC	0.8449	2.4	3.1	
183	04	MED	MAJOR CHEST TRAUMA W MCC	1.4768	4.5	5.6	
184	04	MED	MAJOR CHEST TRAUMA W CC	1.0149	3.3	3.9	
185	04	MED	MAJOR CHEST TRAUMA W/O CC/MCC	0.7589	2.5	2.9	
186	04	MED	PLEURAL EFFUSION W MCC	1.5247	4.5	5.8	
187	04	MED	PLEURAL EFFUSION W CC	1.0569	3.3	4.2	
188	04	MED	PLEURAL EFFUSION W/O CC/MCC	0.7993	2.5	3.2	
189	04	MED	PULMONARY EDEMA & RESPIRATORY FAILURE	1.2198	3.7	4.8	
190	04	MED	CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC	1.1528	3.8	4.6	
191	04	MED	CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC	0.9178	3.1	3.8	
192	04	MED	CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC	0.7266	2.6	3	
193	04	MED	SIMPLE PNEUMONIA & PLEURISY W MCC	1.3733	4.5	5.4	
194	04	MED	SIMPLE PNEUMONIA & PLEURISY W CC	0.9333	3.4	4.1	
195	04	MED	SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC	0.71	2.7	3.2	
196	04	MED	INTERSTITIAL LUNG DISEASE W MCC	1.5964	5	6.3	
197	04	MED	INTERSTITIAL LUNG DISEASE W CC	1.0449	3.4	4.2	
198	04	MED	INTERSTITIAL LUNG DISEASE W/O CC/MCC	0.7825	2.6	3.1	
199	04	MED	PNEUMOTHORAX W MCC	1.8067	5.4	6.9	
200	04	MED	PNEUMOTHORAX W CC	1.0612	3.4	4.2	
201	04	MED	PNEUMOTHORAX W/O CC/MCC	0.7601	2.5	3.1	
202	04	MED	BRONCHITIS & ASTHMA W CC/MCC	0.9262	3.1	3.8	
203	04	MED	BRONCHITIS & ASTHMA W/O CC/MCC	0.7056	2.4	2.9	
204	04	MED	RESPIRATORY SIGNS & SYMPTOMS	0.7662	2.2	2.8	
205	04	MED	OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC	1.4928	4	5.4	
206	04	MED	OTHER RESPIRATORY SYSTEM DIAGNOSES W/O MCC	0.8518	2.5	3.1	
207	04	MED	RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS	5.4864	12.2	14.1	
208	04	MED	RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS	2.3682	4.9	6.7	
215	05	SURG	OTHER HEART ASSIST SYSTEM IMPLANT	12.8861	7.2	11.9	
216	05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W MCC	9.497	11.2	14.4	
217	05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W CC	6.2785	7.4	8.9	
218	05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W/O CC/MCC	5.685	4.7	5.9	
219	05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W MCC	7.6046	9.2	11.2	
220	05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC	5.1391	6.2	6.8	
221	05	SURG	CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W/O CC/MCC	4.5842	4.5	5	
222	05	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W MCC	8.4862	10.1	12.1	
223	05	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK W/O MCC	6.4424	5.6	6.8	
224	05	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W MCC	7.3416	7.4	9.1	
225	05	SURG	CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK W/O MCC	5.6618	4.1	4.8	
226	05	SURG	CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W MCC	6.7968	6.5	8.5	
227	05	SURG	CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC	5.4047	3.3	4.4	
228	05	SURG	OTHER CARDIOTHORACIC PROCEDURES W MCC	6.5943	6.8	9.8	
229	05	SURG	OTHER CARDIOTHORACIC PROCEDURES W/O MCC	4.5819	3.6	4.8	
231	05	SURG	CORONARY BYPASS W PTCA W MCC	8.113	10.2	12	
232	05	SURG	CORONARY BYPASS W PTCA W/O MCC	5.8397	7.7	8.5	
233	05	SURG	CORONARY BYPASS W CARDIAC CATH W MCC	7.3437	11.5	12.9	
234	05	SURG	CORONARY BYPASS W CARDIAC CATH W/O MCC	5.0569	8.1	8.7	
235	05	SURG	CORONARY BYPASS W/O CARDIAC CATH W MCC	5.7784	8.8	10.1	
236	05	SURG	CORONARY BYPASS W/O CARDIAC CATH W/O MCC	3.8836	6	6.5	
239	05	SURG	AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W MCC	4.6459	10.2	13	
240	05	SURG	AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W CC	2.6671	6.9	8.4	
241	05	SURG	AMPUTATION FOR CIRC SYS DISORDERS EXC UPPER LIMB & TOE W/O CC/MCC	1.4776	4.3	5.1	
242	05	SURG	PERMANENT CARDIAC PACEMAKER IMPLANT W MCC	3.7054	5.5	7	
243	05	SURG	PERMANENT CARDIAC PACEMAKER IMPLANT W CC	2.6089	3.4	4.2	
244	05	SURG	PERMANENT CARDIAC PACEMAKER IMPLANT W/O CC/MCC	2.1396	2.4	2.8	
245	05	SURG	AICD GENERATOR PROCEDURES	5.4528	4.5	6.4	
246	05	SURG	PERCUTANEOUS CARDIOVASCULAR PROCEDURES W DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS	3.2103	4.2	5.5	
247	05	SURG	PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC	2.1158	2.2	2.6	
248	05	SURG	PERCUTANEOUS CARDIOVASCULAR PROCEDURES W NON-DRUG-ELUTING STENT W MCC OR 4+ ARTERIES OR STENTS	3.0479	4.8	6.3	
249	05	SURG	PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC	1.957	2.5	3	
250	05	SURG	PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC	2.506	4	5.3	
251	05	SURG	PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC	1.6629	2.3	2.7	
252	05	SURG	OTHER VASCULAR PROCEDURES W MCC	3.2335	5.4	7.6	
253	05	SURG	OTHER VASCULAR PROCEDURES W CC	2.5349	4.2	5.5	
254	05	SURG	OTHER VASCULAR PROCEDURES W/O CC/MCC	1.8129	2.3	2.9	
255	05	SURG	UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W MCC	2.5155	6.6	8.3	
256	05	SURG	UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W CC	1.7434	5.3	6.3	
257	05	SURG	UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS W/O CC/MCC	1.1261	3.4	4.1	
258	05	SURG	CARDIAC PACEMAKER DEVICE REPLACEMENT W MCC	3.0819	4.9	6.4	
259	05	SURG	CARDIAC PACEMAKER DEVICE REPLACEMENT W/O MCC	2.087	2.8	3.5	
260	05	SURG	CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W MCC	3.5869	6.9	9.3	
261	05	SURG	CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W CC	1.9374	3.3	4.2	
262	05	SURG	CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT W/O CC/MCC	1.6511	2.4	2.8	
263	05	SURG	VEIN LIGATION & STRIPPING	2.3373	4.4	6.1	
264	05	SURG	OTHER CIRCULATORY SYSTEM O.R. PROCEDURES	3.2176	6.7	9.3	
265	05	SURG	AICD LEAD PROCEDURES	3.3368	3.7	5	
266	05	SURG	ENDOVASCULAR CARDIAC VALVE REPLACEMENT W MCC	7.7516	5	7.2	
267	05	SURG	ENDOVASCULAR CARDIAC VALVE REPLACEMENT W/O MCC	6.1053	2.9	3.5	
268	05	SURG	AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W MCC	6.5239	6.6	9.6	
269	05	SURG	AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC	4.1553	1.8	2.5	
270	05	SURG	OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC	4.9406	6.5	9.5	
271	05	SURG	OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC	3.3833	4.4	5.8	
272	05	SURG	OTHER MAJOR CARDIOVASCULAR PROCEDURES W/O CC/MCC	2.4538	2.2	2.8	
273	05	SURG	PERCUTANEOUS INTRACARDIAC PROCEDURES W MCC	3.5792	5.7	7.7	
274	05	SURG	PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC	2.7685	2.3	3	
280	05	MED	ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC	1.6579	4.3	5.5	
281	05	MED	ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC	0.9848	2.7	3.4	
282	05	MED	ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC	0.7587	1.9	2.3	
283	05	MED	ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC	1.7573	3	4.8	
284	05	MED	ACUTE MYOCARDIAL INFARCTION, EXPIRED W CC	0.7872	1.7	2.4	
285	05	MED	ACUTE MYOCARDIAL INFARCTION, EXPIRED W/O CC/MCC	0.5533	1.3	1.4	
286	05	MED	CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W MCC	2.2281	5.3	7.1	
287	05	MED	CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O MCC	1.1751	2.5	3.3	
288	05	MED	ACUTE & SUBACUTE ENDOCARDITIS W MCC	2.7084	7.3	9.6	
289	05	MED	ACUTE & SUBACUTE ENDOCARDITIS W CC	1.6947	5.4	6.7	
290	05	MED	ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC	1.0907	3.9	4.6	
291	05	MED	HEART FAILURE & SHOCK W MCC	1.4761	4.5	5.7	
292	05	MED	HEART FAILURE & SHOCK W CC	0.9589	3.5	4.2	
293	05	MED	HEART FAILURE & SHOCK W/O CC/MCC	0.6737	2.5	3	
294	05	MED	DEEP VEIN THROMBOPHLEBITIS W CC/MCC	1.0214	3.6	4.5	
295	05	MED	DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC	0.7856	3	3.6	
296	05	MED	CARDIAC ARREST, UNEXPLAINED W MCC	1.4903	2	3.1	
297	05	MED	CARDIAC ARREST, UNEXPLAINED W CC	0.657	1.3	1.6	
298	05	MED	CARDIAC ARREST, UNEXPLAINED W/O CC/MCC	0.4849	1.1	1.2	
299	05	MED	PERIPHERAL VASCULAR DISORDERS W MCC	1.4112	4	5.3	
300	05	MED	PERIPHERAL VASCULAR DISORDERS W CC	1.0184	3.3	4.2	
301	05	MED	PERIPHERAL VASCULAR DISORDERS W/O CC/MCC	0.7251	2.4	3	
302	05	MED	ATHEROSCLEROSIS W MCC	1.0729	2.8	3.9	
303	05	MED	ATHEROSCLEROSIS W/O MCC	0.663	1.9	2.3	
304	05	MED	HYPERTENSION W MCC	1.0485	3.1	4.1	
305	05	MED	HYPERTENSION W/O MCC	0.6917	2.1	2.6	
306	05	MED	CARDIAC CONGENITAL & VALVULAR DISORDERS W MCC	1.362	3.8	5.1	
307	05	MED	CARDIAC CONGENITAL & VALVULAR DISORDERS W/O MCC	0.8274	2.5	3.1	
308	05	MED	CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC	1.1885	3.6	4.6	
309	05	MED	CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC	0.7721	2.5	3.1	
310	05	MED	CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC	0.5626	1.9	2.3	
311	05	MED	ANGINA PECTORIS	0.6793	1.9	2.4	
312	05	MED	SYNCOPE & COLLAPSE	0.7965	2.4	2.9	
313	05	MED	CHEST PAIN	0.7025	1.8	2.2	
314	05	MED	OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC	1.958	4.8	6.5	
315	05	MED	OTHER CIRCULATORY SYSTEM DIAGNOSES W CC	0.9658	2.9	3.7	
316	05	MED	OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC/MCC	0.7402	2	2.5	
326	06	SURG	STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC	4.5472	8.8	12	
327	06	SURG	STOMACH, ESOPHAGEAL & DUODENAL PROC W CC	2.1159	4.6	6	
328	06	SURG	STOMACH, ESOPHAGEAL & DUODENAL PROC W/O CC/MCC	1.5042	2.4	3	
329	06	SURG	MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC	4.9129	10.8	13.5	
330	06	SURG	MAJOR SMALL & LARGE BOWEL PROCEDURES W CC	2.4685	6.3	7.5	
331	06	SURG	MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC	1.6757	3.8	4.3	
332	06	SURG	RECTAL RESECTION W MCC	3.8214	7.7	9.6	
333	06	SURG	RECTAL RESECTION W CC	1.9925	4.4	5.5	
334	06	SURG	RECTAL RESECTION W/O CC/MCC	1.2967	2.5	3.1	
335	06	SURG	PERITONEAL ADHESIOLYSIS W MCC	4.0939	10.3	12.5	
336	06	SURG	PERITONEAL ADHESIOLYSIS W CC	2.3395	6.5	7.9	
337	06	SURG	PERITONEAL ADHESIOLYSIS W/O CC/MCC	1.6182	4	5	
338	06	SURG	APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W MCC	2.7642	6.5	8.2	
339	06	SURG	APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC	1.7051	4.3	5.3	
340	06	SURG	APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC	1.1999	2.5	3	
341	06	SURG	APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W MCC	2.4882	4.6	6.4	
342	06	SURG	APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC	1.4884	2.8	3.7	
343	06	SURG	APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC	1.0559	1.7	2.1	
344	06	SURG	MINOR SMALL & LARGE BOWEL PROCEDURES W MCC	2.7516	7.2	9.6	
345	06	SURG	MINOR SMALL & LARGE BOWEL PROCEDURES W CC	1.5607	4.5	5.7	
346	06	SURG	MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC	1.1006	3.2	3.7	
347	06	SURG	ANAL & STOMAL PROCEDURES W MCC	2.6289	6.3	8.4	
348	06	SURG	ANAL & STOMAL PROCEDURES W CC	1.4118	3.7	4.8	
349	06	SURG	ANAL & STOMAL PROCEDURES W/O CC/MCC	1.0147	2.5	3	
350	06	SURG	INGUINAL & FEMORAL HERNIA PROCEDURES W MCC	2.4605	5.2	7.1	
351	06	SURG	INGUINAL & FEMORAL HERNIA PROCEDURES W CC	1.4893	3.4	4.3	
352	06	SURG	INGUINAL & FEMORAL HERNIA PROCEDURES W/O CC/MCC	1.0375	2.1	2.5	
353	06	SURG	HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W MCC	3.0098	6.2	8.1	
354	06	SURG	HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC	1.7237	3.9	4.8	
355	06	SURG	HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC	1.3206	2.6	3.1	
356	06	SURG	OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W MCC	3.8054	7.8	10.5	
357	06	SURG	OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC	2.0998	4.8	6.1	
358	06	SURG	OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC/MCC	1.4082	2.9	3.7	
368	06	MED	MAJOR ESOPHAGEAL DISORDERS W MCC	1.8374	4.6	6.1	
369	06	MED	MAJOR ESOPHAGEAL DISORDERS W CC	1.0879	3.2	3.9	
370	06	MED	MAJOR ESOPHAGEAL DISORDERS W/O CC/MCC	0.7471	2.3	2.8	
371	06	MED	MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC	1.7246	5.5	7.1	
372	06	MED	MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC	1.059	4.1	5	
373	06	MED	MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W/O CC/MCC	0.7623	3.2	3.8	
374	06	MED	DIGESTIVE MALIGNANCY W MCC	2.0015	5.6	7.6	
375	06	MED	DIGESTIVE MALIGNANCY W CC	1.2347	3.8	5	
376	06	MED	DIGESTIVE MALIGNANCY W/O CC/MCC	0.9402	2.6	3.2	
377	06	MED	G.I. HEMORRHAGE W MCC	1.7142	4.5	5.7	
378	06	MED	G.I. HEMORRHAGE W CC	0.9704	3.1	3.6	
379	06	MED	G.I. HEMORRHAGE W/O CC/MCC	0.6447	2.2	2.5	
380	06	MED	COMPLICATED PEPTIC ULCER W MCC	1.8969	5.1	6.7	
381	06	MED	COMPLICATED PEPTIC ULCER W CC	1.0782	3.4	4.1	
382	06	MED	COMPLICATED PEPTIC ULCER W/O CC/MCC	0.8033	2.5	3	
383	06	MED	UNCOMPLICATED PEPTIC ULCER W MCC	1.345	3.9	5	
384	06	MED	UNCOMPLICATED PEPTIC ULCER W/O MCC	0.8767	2.7	3.3	
385	06	MED	INFLAMMATORY BOWEL DISEASE W MCC	1.6535	5.4	7.2	
386	06	MED	INFLAMMATORY BOWEL DISEASE W CC	0.9619	3.6	4.4	
387	06	MED	INFLAMMATORY BOWEL DISEASE W/O CC/MCC	0.7349	2.8	3.4	
388	06	MED	G.I. OBSTRUCTION W MCC	1.524	4.9	6.4	
389	06	MED	G.I. OBSTRUCTION W CC	0.8537	3.4	4.1	
390	06	MED	G.I. OBSTRUCTION W/O CC/MCC	0.5966	2.6	3	
391	06	MED	ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC	1.2351	3.8	5	
392	06	MED	ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC	0.7594	2.7	3.3	
393	06	MED	OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC	1.6407	4.6	6.3	
394	06	MED	OTHER DIGESTIVE SYSTEM DIAGNOSES W CC	0.943	3.2	4.1	
395	06	MED	OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC	0.6747	2.4	2.9	
405	07	SURG	PANCREAS, LIVER & SHUNT PROCEDURES W MCC	5.2847	9.9	13.1	
406	07	SURG	PANCREAS, LIVER & SHUNT PROCEDURES W CC	2.7939	5.7	7.1	
407	07	SURG	PANCREAS, LIVER & SHUNT PROCEDURES W/O CC/MCC	2.0171	4.1	4.8	
408	07	SURG	BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W MCC	3.9456	9.2	11.8	
409	07	SURG	BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC	2.3301	6	7.2	
410	07	SURG	BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC	1.7282	4.2	4.8	
411	07	SURG	CHOLECYSTECTOMY W C.D.E. W MCC	3.2989	7.8	9.5	
412	07	SURG	CHOLECYSTECTOMY W C.D.E. W CC	2.3747	5.5	6.7	
413	07	SURG	CHOLECYSTECTOMY W C.D.E. W/O CC/MCC	1.6868	3.6	4.3	
414	07	SURG	CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W MCC	3.5466	8.1	10	
415	07	SURG	CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC	2.0206	5.3	6.2	
416	07	SURG	CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC/MCC	1.4023	3.4	3.9	
417	07	SURG	LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC	2.3913	5.4	6.7	
418	07	SURG	LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC	1.6664	3.8	4.5	
419	07	SURG	LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC	1.3053	2.5	3	
420	07	SURG	HEPATOBILIARY DIAGNOSTIC PROCEDURES W MCC	4.0582	8.1	11.5	
421	07	SURG	HEPATOBILIARY DIAGNOSTIC PROCEDURES W CC	1.8832	4.2	5.6	
422	07	SURG	HEPATOBILIARY DIAGNOSTIC PROCEDURES W/O CC/MCC	1.5568	3.1	3.8	
423	07	SURG	OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W MCC	3.7853	8.5	11.6	
424	07	SURG	OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W CC	2.2354	5.9	7.7	
425	07	SURG	OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC	1.6022	3.6	4.3	
432	07	MED	CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC	1.8004	4.8	6.5	
433	07	MED	CIRRHOSIS & ALCOHOLIC HEPATITIS W CC	1.0214	3.4	4.3	
434	07	MED	CIRRHOSIS & ALCOHOLIC HEPATITIS W/O CC/MCC	0.6283	2.3	2.7	
435	07	MED	MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W MCC	1.6702	4.9	6.4	
436	07	MED	MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W CC	1.1355	3.6	4.7	
437	07	MED	MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS W/O CC/MCC	0.9093	2.6	3.3	
438	07	MED	DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC	1.6594	4.8	6.5	
439	07	MED	DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC	0.8741	3.3	4.1	
440	07	MED	DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC	0.6381	2.5	3	
441	07	MED	DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W MCC	1.8158	4.7	6.5	
442	07	MED	DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC	0.9394	3.3	4.1	
443	07	MED	DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC/MCC	0.6788	2.5	3	
444	07	MED	DISORDERS OF THE BILIARY TRACT W MCC	1.5997	4.4	5.8	
445	07	MED	DISORDERS OF THE BILIARY TRACT W CC	1.0581	3.2	3.9	
446	07	MED	DISORDERS OF THE BILIARY TRACT W/O CC/MCC	0.7916	2.3	2.8	
453	08	SURG	COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC	9.7406	7.6	9.8	
454	08	SURG	COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC	6.4968	4.1	4.8	
455	08	SURG	COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC	5.0785	2.7	3.1	
456	08	SURG	SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W MCC	9.2033	9.6	11.7	
457	08	SURG	SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W CC	6.8061	5.4	6.4	
458	08	SURG	SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W/O CC/MCC	5.3662	3.2	3.7	
459	08	SURG	SPINAL FUSION EXCEPT CERVICAL W MCC	6.0377	5.8	7.4	
460	08	SURG	SPINAL FUSION EXCEPT CERVICAL W/O MCC	4.0153	2.9	3.4	
461	08	SURG	BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W MCC	4.8928	6.1	7.8	
462	08	SURG	BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC	3.2641	3	3.2	
463	08	SURG	WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W MCC	5.0158	9.8	13.1	
464	08	SURG	WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC	2.8433	5.5	7	
465	08	SURG	WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W/O CC/MCC	1.8808	2.9	3.7	
466	08	SURG	REVISION OF HIP OR KNEE REPLACEMENT W MCC	5.0422	6.7	8.3	
467	08	SURG	REVISION OF HIP OR KNEE REPLACEMENT W CC	3.4775	3.5	4.2	
468	08	SURG	REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC	2.8161	2.4	2.7	
469	08	SURG	MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC OR TOTAL ANKLE REPLACEMENT	3.2011	5.1	6.3	
470	08	SURG	MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC	2.0544	2.4	2.7	
471	08	SURG	CERVICAL SPINAL FUSION W MCC	4.9193	6.2	8.6	
472	08	SURG	CERVICAL SPINAL FUSION W CC	2.8536	2.2	3.1	
473	08	SURG	CERVICAL SPINAL FUSION W/O CC/MCC	2.2919	1.4	1.7	
474	08	SURG	AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W MCC	3.8622	9	11.5	
475	08	SURG	AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W CC	2.1519	5.8	7.2	
476	08	SURG	AMPUTATION FOR MUSCULOSKELETAL SYS & CONN TISSUE DIS W/O CC/MCC	1.1678	3.1	3.9	
477	08	SURG	BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC	3.2332	8.2	10.6	
478	08	SURG	BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC	2.2387	5.4	6.6	
479	08	SURG	BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC	1.767	3.4	4.3	
480	08	SURG	HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC	3.0201	6.5	7.6	
481	08	SURG	HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC	2.0502	4.5	4.9	
482	08	SURG	HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC	1.6693	3.6	3.8	
483	08	SURG	MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES	2.4264	1.7	2	
485	08	SURG	KNEE PROCEDURES W PDX OF INFECTION W MCC	3.2532	8.2	9.9	
486	08	SURG	KNEE PROCEDURES W PDX OF INFECTION W CC	2.2226	5.3	6.2	
487	08	SURG	KNEE PROCEDURES W PDX OF INFECTION W/O CC/MCC	1.6595	3.9	4.3	
488	08	SURG	KNEE PROCEDURES W/O PDX OF INFECTION W CC/MCC	1.9965	3.8	5	
489	08	SURG	KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC	1.2876	2.2	2.6	
492	08	SURG	LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W MCC	3.301	6.2	7.7	
493	08	SURG	LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W CC	2.2037	4	4.8	
494	08	SURG	LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR W/O CC/MCC	1.7563	2.7	3.2	
495	08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W MCC	3.0104	6.5	8.7	
496	08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W CC	1.9733	3.5	4.5	
497	08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR W/O CC/MCC	1.3868	1.8	2.2	
498	08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W CC/MCC	2.4273	5.3	7.1	
499	08	SURG	LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W/O CC/MCC	1.242	2.2	2.8	
500	08	SURG	SOFT TISSUE PROCEDURES W MCC	2.9578	7	9.4	
501	08	SURG	SOFT TISSUE PROCEDURES W CC	1.6888	4.3	5.4	
502	08	SURG	SOFT TISSUE PROCEDURES W/O CC/MCC	1.2634	2.5	3	
503	08	SURG	FOOT PROCEDURES W MCC	2.4875	6.7	8.4	
504	08	SURG	FOOT PROCEDURES W CC	1.7243	4.9	5.8	
505	08	SURG	FOOT PROCEDURES W/O CC/MCC	1.5251	3	3.6	
506	08	SURG	MAJOR THUMB OR JOINT PROCEDURES	1.3796	3.7	4.6	
507	08	SURG	MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC	1.8765	4.3	5.5	
508	08	SURG	MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC	1.5319	2.1	2.6	
509	08	SURG	ARTHROSCOPY	1.8314	3.9	4.9	
510	08	SURG	SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W MCC	2.4881	4.9	6	
511	08	SURG	SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W CC	1.7859	3.4	3.9	
512	08	SURG	SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC W/O CC/MCC	1.4959	2.3	2.6	
513	08	SURG	HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W CC/MCC	1.5867	4.2	5.5	
514	08	SURG	HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC	1.0189	2.4	2.9	
515	08	SURG	OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC	2.9196	6.3	8.1	
516	08	SURG	OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC	1.882	3.9	4.8	
517	08	SURG	OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC	1.4361	2.2	2.7	
518	08	SURG	BACK & NECK PROC EXC SPINAL FUSION W MCC OR DISC DEVICE/NEUROSTIM	2.8927	3.2	5.1	
519	08	SURG	BACK & NECK PROC EXC SPINAL FUSION W CC	1.8034	3.2	4.1	
520	08	SURG	BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC	1.2963	1.9	2.4	
533	08	MED	FRACTURES OF FEMUR W MCC	1.4381	4.3	5.7	
534	08	MED	FRACTURES OF FEMUR W/O MCC	0.761	2.9	3.5	
535	08	MED	FRACTURES OF HIP & PELVIS W MCC	1.2575	3.9	5	
536	08	MED	FRACTURES OF HIP & PELVIS W/O MCC	0.7545	3	3.4	
537	08	MED	SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH W CC/MCC	0.9678	3.3	4.1	
538	08	MED	SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH W/O CC/MCC	0.6765	2.5	2.9	
539	08	MED	OSTEOMYELITIS W MCC	1.885	5.9	7.8	
540	08	MED	OSTEOMYELITIS W CC	1.2916	4.5	5.7	
541	08	MED	OSTEOMYELITIS W/O CC/MCC	0.9452	3.3	4.3	
542	08	MED	PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W MCC	1.8104	5.3	7	
543	08	MED	PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W CC	1.0797	3.7	4.6	
544	08	MED	PATHOLOGICAL FRACTURES & MUSCULOSKELET & CONN TISS MALIG W/O CC/MCC	0.7758	3	3.4	
545	08	MED	CONNECTIVE TISSUE DISORDERS W MCC	2.3625	5.8	8.1	
546	08	MED	CONNECTIVE TISSUE DISORDERS W CC	1.1267	3.6	4.6	
547	08	MED	CONNECTIVE TISSUE DISORDERS W/O CC/MCC	0.8153	2.6	3.2	
548	08	MED	SEPTIC ARTHRITIS W MCC	2.0385	6	7.9	
549	08	MED	SEPTIC ARTHRITIS W CC	1.1943	4.1	5	
550	08	MED	SEPTIC ARTHRITIS W/O CC/MCC	0.9006	3	3.6	
551	08	MED	MEDICAL BACK PROBLEMS W MCC	1.5533	4.5	5.8	
552	08	MED	MEDICAL BACK PROBLEMS W/O MCC	0.8938	3	3.7	
553	08	MED	BONE DISEASES & ARTHROPATHIES W MCC	1.289	4	5.2	
554	08	MED	BONE DISEASES & ARTHROPATHIES W/O MCC	0.7517	2.8	3.4	
555	08	MED	SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W MCC	1.2714	3.8	5.1	
556	08	MED	SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE W/O MCC	0.7789	2.7	3.4	
557	08	MED	TENDONITIS, MYOSITIS & BURSITIS W MCC	1.4434	4.6	5.7	
558	08	MED	TENDONITIS, MYOSITIS & BURSITIS W/O MCC	0.8567	3.2	3.8	
559	08	MED	AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W MCC	1.6813	4.7	6.3	
560	08	MED	AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC	1.0771	3.8	4.8	
561	08	MED	AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W/O CC/MCC	0.7612	2.6	3.4	
562	08	MED	FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W MCC	1.3822	4.1	5.2	
563	08	MED	FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC	0.8235	3	3.4	
564	08	MED	OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W MCC	1.463	4.7	5.9	
565	08	MED	OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC	0.9526	3.5	4.1	
566	08	MED	OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W/O CC/MCC	0.7769	2.6	3.1	
570	09	SURG	SKIN DEBRIDEMENT W MCC	2.5947	7	9.1	
571	09	SURG	SKIN DEBRIDEMENT W CC	1.6287	5	6.1	
572	09	SURG	SKIN DEBRIDEMENT W/O CC/MCC	1.1754	3.5	4.3	
573	09	SURG	SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W MCC	4.0634	8.8	12.8	
574	09	SURG	SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W CC	2.9594	7.3	9.4	
575	09	SURG	SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC	1.7422	4.5	5.6	
576	09	SURG	SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W MCC	4.5329	9	12.9	
577	09	SURG	SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W CC	2.4419	4.7	6.9	
578	09	SURG	SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W/O CC/MCC	1.4891	2.7	3.7	
579	09	SURG	OTHER SKIN, SUBCUT TISS & BREAST PROC W MCC	2.6605	6.6	8.9	
580	09	SURG	OTHER SKIN, SUBCUT TISS & BREAST PROC W CC	1.5559	3.9	5	
581	09	SURG	OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC	1.224	2.4	3	
582	09	SURG	MASTECTOMY FOR MALIGNANCY W CC/MCC	1.4821	2.3	3.1	
583	09	SURG	MASTECTOMY FOR MALIGNANCY W/O CC/MCC	1.3553	1.8	2	
584	09	SURG	BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W CC/MCC	1.856	3.7	4.9	
585	09	SURG	BREAST BIOPSY, LOCAL EXCISION & OTHER BREAST PROCEDURES W/O CC/MCC	1.5925	2.2	2.7	
592	09	MED	SKIN ULCERS W MCC	1.482	5	6.6	
593	09	MED	SKIN ULCERS W CC	1.046	4	4.9	
594	09	MED	SKIN ULCERS W/O CC/MCC	0.7585	3	3.7	
595	09	MED	MAJOR SKIN DISORDERS W MCC	2.1185	5.5	7.5	
596	09	MED	MAJOR SKIN DISORDERS W/O MCC	0.9791	3.5	4.4	
597	09	MED	MALIGNANT BREAST DISORDERS W MCC	1.8034	5.2	7	
598	09	MED	MALIGNANT BREAST DISORDERS W CC	1.0876	3.5	4.5	
599	09	MED	MALIGNANT BREAST DISORDERS W/O CC/MCC	0.8735	2.4	3.1	
600	09	MED	NON-MALIGNANT BREAST DISORDERS W CC/MCC	0.9569	3.7	4.5	
601	09	MED	NON-MALIGNANT BREAST DISORDERS W/O CC/MCC	0.6294	2.6	3.1	
602	09	MED	CELLULITIS W MCC	1.4465	4.7	5.9	
603	09	MED	CELLULITIS W/O MCC	0.8503	3.3	4	
604	09	MED	TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W MCC	1.3914	3.8	5	
605	09	MED	TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC	0.8459	2.7	3.3	
606	09	MED	MINOR SKIN DISORDERS W MCC	1.3822	4.2	5.8	
607	09	MED	MINOR SKIN DISORDERS W/O MCC	0.7897	2.9	3.7	
614	10	SURG	ADRENAL & PITUITARY PROCEDURES W CC/MCC	2.3481	3.7	5	
615	10	SURG	ADRENAL & PITUITARY PROCEDURES W/O CC/MCC	1.4743	2	2.4	
616	10	SURG	AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W MCC	4.0437	10.3	12.6	
617	10	SURG	AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W CC	2.0982	6.1	7.3	
618	10	SURG	AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DIS W/O CC/MCC	1.1787	4	4.7	
619	10	SURG	O.R. PROCEDURES FOR OBESITY W MCC	3.1171	3.5	5.6	
620	10	SURG	O.R. PROCEDURES FOR OBESITY W CC	1.8351	2.2	2.6	
621	10	SURG	O.R. PROCEDURES FOR OBESITY W/O CC/MCC	1.5828	1.6	1.8	
622	10	SURG	SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W MCC	3.612	8.4	11.2	
623	10	SURG	SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC	1.8973	5.5	6.7	
624	10	SURG	SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W/O CC/MCC	1.1889	3.3	4.1	
625	10	SURG	THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W MCC	2.6882	4.8	7.2	
626	10	SURG	THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W CC	1.5179	2.3	3.2	
627	10	SURG	THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES W/O CC/MCC	1.0606	1.5	1.8	
628	10	SURG	OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W MCC	3.5764	7	10.1	
629	10	SURG	OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC	2.316	6.1	7.2	
630	10	SURG	OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC/MCC	1.597	2.7	3.6	
637	10	MED	DIABETES W MCC	1.3349	3.8	5	
638	10	MED	DIABETES W CC	0.8513	2.9	3.6	
639	10	MED	DIABETES W/O CC/MCC	0.6258	2.2	2.6	
640	10	MED	MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC	1.1725	3.3	4.5	
641	10	MED	MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC	0.7461	2.6	3.3	
642	10	MED	INBORN AND OTHER DISORDERS OF METABOLISM	1.251	3.2	4.3	
643	10	MED	ENDOCRINE DISORDERS W MCC	1.5915	5.1	6.5	
644	10	MED	ENDOCRINE DISORDERS W CC	1.0023	3.6	4.4	
645	10	MED	ENDOCRINE DISORDERS W/O CC/MCC	0.7389	2.7	3.3	
652	11	SURG	KIDNEY TRANSPLANT	3.3187	5.5	6.4	
653	11	SURG	MAJOR BLADDER PROCEDURES W MCC	5.5264	10.9	14.1	
654	11	SURG	MAJOR BLADDER PROCEDURES W CC	2.7712	6.2	7.4	
655	11	SURG	MAJOR BLADDER PROCEDURES W/O CC/MCC	2.0491	4	4.7	
656	11	SURG	KIDNEY & URETER PROCEDURES FOR NEOPLASM W MCC	3.254	6	7.8	
657	11	SURG	KIDNEY & URETER PROCEDURES FOR NEOPLASM W CC	1.9774	3.8	4.5	
658	11	SURG	KIDNEY & URETER PROCEDURES FOR NEOPLASM W/O CC/MCC	1.5627	2.4	2.7	
659	11	SURG	KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W MCC	3.4129	6.7	9.4	
660	11	SURG	KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC	1.7926	3.4	4.5	
661	11	SURG	KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W/O CC/MCC	1.454	2.1	2.5	
662	11	SURG	MINOR BLADDER PROCEDURES W MCC	3.0462	7.7	10.4	
663	11	SURG	MINOR BLADDER PROCEDURES W CC	1.7807	3.9	5.2	
664	11	SURG	MINOR BLADDER PROCEDURES W/O CC/MCC	1.2866	1.9	2.4	
665	11	SURG	PROSTATECTOMY W MCC	3.1239	8.2	10.6	
666	11	SURG	PROSTATECTOMY W CC	1.7397	4.4	5.8	
667	11	SURG	PROSTATECTOMY W/O CC/MCC	0.9912	2.2	2.7	
668	11	SURG	TRANSURETHRAL PROCEDURES W MCC	2.6354	6.6	8.8	
669	11	SURG	TRANSURETHRAL PROCEDURES W CC	1.383	3.1	4.2	
670	11	SURG	TRANSURETHRAL PROCEDURES W/O CC/MCC	0.9838	2.2	2.7	
671	11	SURG	URETHRAL PROCEDURES W CC/MCC	1.5341	3.8	5	
672	11	SURG	URETHRAL PROCEDURES W/O CC/MCC	1.0226	1.9	2.4	
673	11	SURG	OTHER KIDNEY & URINARY TRACT PROCEDURES W MCC	3.5245	7.7	10.7	
674	11	SURG	OTHER KIDNEY & URINARY TRACT PROCEDURES W CC	2.3166	5.3	7	
675	11	SURG	OTHER KIDNEY & URINARY TRACT PROCEDURES W/O CC/MCC	1.6404	2.6	3.3	
682	11	MED	RENAL FAILURE W MCC	1.4845	4.3	5.8	
683	11	MED	RENAL FAILURE W CC	0.9293	3.3	4.1	
684	11	MED	RENAL FAILURE W/O CC/MCC	0.6285	2.3	2.8	
685	11	MED	ADMIT FOR RENAL DIALYSIS	1.0551	2.7	3.4	
686	11	MED	KIDNEY & URINARY TRACT NEOPLASMS W MCC	1.7274	5.1	6.7	
687	11	MED	KIDNEY & URINARY TRACT NEOPLASMS W CC	1.0987	3.5	4.5	
688	11	MED	KIDNEY & URINARY TRACT NEOPLASMS W/O CC/MCC	0.8512	2	2.4	
689	11	MED	KIDNEY & URINARY TRACT INFECTIONS W MCC	1.0795	3.9	4.8	
690	11	MED	KIDNEY & URINARY TRACT INFECTIONS W/O MCC	0.7946	3	3.6	
691	11	MED	URINARY STONES W ESW LITHOTRIPSY W CC/MCC	1.5984	2.6	3.4	
692	11	MED	URINARY STONES W ESW LITHOTRIPSY W/O CC/MCC	1.1902	1.9	2.3	
693	11	MED	URINARY STONES W/O ESW LITHOTRIPSY W MCC	1.4272	4.1	5.3	
694	11	MED	URINARY STONES W/O ESW LITHOTRIPSY W/O MCC	0.8143	2.1	2.7	
695	11	MED	KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W MCC	1.1703	3.8	4.9	
696	11	MED	KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC	0.6962	2.5	3.1	
697	11	MED	URETHRAL STRICTURE	1.0297	2.9	3.7	
698	11	MED	OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC	1.5881	4.9	6.3	
699	11	MED	OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC	1.0466	3.5	4.3	
700	11	MED	OTHER KIDNEY & URINARY TRACT DIAGNOSES W/O CC/MCC	0.7766	2.6	3.2	
707	12	SURG	MAJOR MALE PELVIC PROCEDURES W CC/MCC	1.8009	2.4	3.3	
708	12	SURG	MAJOR MALE PELVIC PROCEDURES W/O CC/MCC	1.3836	1.3	1.5	
709	12	SURG	PENIS PROCEDURES W CC/MCC	2.285	4.2	6.6	
710	12	SURG	PENIS PROCEDURES W/O CC/MCC	1.5075	1.8	2.3	
711	12	SURG	TESTES PROCEDURES W CC/MCC	2.0197	5.5	7.3	
712	12	SURG	TESTES PROCEDURES W/O CC/MCC	0.9288	2.3	2.9	
713	12	SURG	TRANSURETHRAL PROSTATECTOMY W CC/MCC	1.4243	2.9	4.2	
714	12	SURG	TRANSURETHRAL PROSTATECTOMY W/O CC/MCC	0.8816	1.7	2	
715	12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC FOR MALIGNANCY W CC/MCC	2.1757	4.9	7.1	
716	12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC FOR MALIGNANCY W/O CC/MCC	1.4267	1.5	1.8	
717	12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W CC/MCC	1.9292	4	5.4	
718	12	SURG	OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXC MALIGNANCY W/O CC/MCC	1.2465	2.4	2.8	
722	12	MED	MALIGNANCY, MALE REPRODUCTIVE SYSTEM W MCC	1.7368	5.1	6.9	
723	12	MED	MALIGNANCY, MALE REPRODUCTIVE SYSTEM W CC	1.1222	3.6	4.6	
724	12	MED	MALIGNANCY, MALE REPRODUCTIVE SYSTEM W/O CC/MCC	0.7579	1.8	2.3	
725	12	MED	BENIGN PROSTATIC HYPERTROPHY W MCC	1.2739	4.2	5.6	
726	12	MED	BENIGN PROSTATIC HYPERTROPHY W/O MCC	0.7375	2.6	3.2	
727	12	MED	INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W MCC	1.4501	4.7	6	
728	12	MED	INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM W/O MCC	0.8116	3.1	3.7	
729	12	MED	OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W CC/MCC	1.0554	3.3	4.3	
730	12	MED	OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES W/O CC/MCC	0.6383	1.9	2.4	
734	13	SURG	PELVIC EVISCERATION, RAD HYSTERECTOMY & RAD VULVECTOMY W CC/MCC	2.1754	3.8	5.3	
735	13	SURG	PELVIC EVISCERATION, RAD HYSTERECTOMY & RAD VULVECTOMY W/O CC/MCC	1.3075	1.8	2.2	
736	13	SURG	UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W MCC	3.9258	9.2	11.4	
737	13	SURG	UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W CC	1.959	4.8	5.6	
738	13	SURG	UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC	1.3935	2.8	3.2	
739	13	SURG	UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC	3.5414	6.8	9.4	
740	13	SURG	UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC	1.7213	3.1	4	
741	13	SURG	UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC/MCC	1.2644	1.8	2.1	
742	13	SURG	UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC	1.6385	3.1	4	
743	13	SURG	UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC	1.0745	1.8	2	
744	13	SURG	D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W CC/MCC	1.6994	4.3	5.7	
745	13	SURG	D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W/O CC/MCC	1.0603	2.2	2.6	
746	13	SURG	VAGINA, CERVIX & VULVA PROCEDURES W CC/MCC	1.634	3.6	5.1	
747	13	SURG	VAGINA, CERVIX & VULVA PROCEDURES W/O CC/MCC	0.9221	1.6	2	
748	13	SURG	FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES	1.267	1.7	2.1	
749	13	SURG	OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES W CC/MCC	2.577	5.9	7.7	
750	13	SURG	OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES W/O CC/MCC	1.2998	2.4	3.1	
754	13	MED	MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W MCC	1.7905	5.1	7	
755	13	MED	MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC	1.0976	3.5	4.6	
756	13	MED	MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC	0.6352	2	2.4	
757	13	MED	INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W MCC	1.4657	5.1	6.5	
758	13	MED	INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W CC	1.0032	3.9	4.8	
759	13	MED	INFECTIONS, FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC	0.7157	2.8	3.3	
760	13	MED	MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W CC/MCC	0.8586	2.7	3.4	
761	13	MED	MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS W/O CC/MCC	0.6427	1.9	2.4	
765	14	SURG	CESAREAN SECTION W CC/MCC	1.1771	3.7	4.7	
766	14	SURG	CESAREAN SECTION W/O CC/MCC	0.8372	2.8	3.1	
767	14	SURG	VAGINAL DELIVERY W STERILIZATION &/OR D&C	0.9309	2.4	2.9	
768	14	SURG	VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C	1.1339	3.4	3.8	
769	14	SURG	POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE	1.7241	3.2	5.1	
770	14	SURG	ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY	0.7879	1.8	2.2	
774	14	MED	VAGINAL DELIVERY W COMPLICATING DIAGNOSES	0.8305	2.6	3.4	
775	14	MED	VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES	0.6455	2.1	2.3	
776	14	MED	POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE	0.8074	2.5	3.3	
777	14	MED	ECTOPIC PREGNANCY	0.8783	1.6	1.9	
778	14	MED	THREATENED ABORTION	0.6088	2.1	3.1	
779	14	MED	ABORTION W/O D&C	0.6736	1.7	2.3	
780	14	MED	FALSE LABOR	0.4879	1.6	2	
781	14	MED	OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS	0.8616	2.7	4.1	
782	14	MED	OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS	0.6116	1.9	2.6	
789	15	MED	NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY	1.6412	 	 	
790	15	MED	EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE	5.4121	323	323	
791	15	MED	PREMATURITY W MAJOR PROBLEMS	3.6963	131	131	
792	15	MED	PREMATURITY W/O MAJOR PROBLEMS	2.2302	 	 	
793	15	MED	FULL TERM NEONATE W MAJOR PROBLEMS	3.7969	 	 	
794	15	MED	NEONATE W OTHER SIGNIFICANT PROBLEMS	1.3439	2	2	
795	15	MED	NORMAL NEWBORN	0.1819	 	 	
799	16	SURG	SPLENECTOMY W MCC	4.8759	8	10.7	
800	16	SURG	SPLENECTOMY W CC	2.6857	5.1	6.5	
801	16	SURG	SPLENECTOMY W/O CC/MCC	1.7031	2.6	3.2	
802	16	SURG	OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W MCC	3.2541	7.3	10.1	
803	16	SURG	OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W CC	1.86	4.4	5.7	
804	16	SURG	OTHER O.R. PROC OF THE BLOOD & BLOOD FORMING ORGANS W/O CC/MCC	1.1987	2.3	2.9	
808	16	MED	MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC	2.1284	5.6	7.5	
809	16	MED	MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W CC	1.1963	3.6	4.5	
810	16	MED	MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W/O CC/MCC	0.9405	2.8	3.4	
811	16	MED	RED BLOOD CELL DISORDERS W MCC	1.3377	3.7	4.9	
812	16	MED	RED BLOOD CELL DISORDERS W/O MCC	0.8829	2.8	3.5	
813	16	MED	COAGULATION DISORDERS	1.7309	3.6	4.9	
814	16	MED	RETICULOENDOTHELIAL & IMMUNITY DISORDERS W MCC	1.755	4.8	6.5	
815	16	MED	RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC	1.0018	3.2	4	
816	16	MED	RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC	0.7022	2.4	2.9	
820	17	SURG	LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W MCC	5.4154	11.2	15.3	
821	17	SURG	LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W CC	2.3329	4.3	6.1	
822	17	SURG	LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W/O CC/MCC	1.2383	2	2.5	
823	17	SURG	LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W MCC	4.3103	10.5	13.6	
824	17	SURG	LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W CC	2.1848	5.3	7.1	
825	17	SURG	LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER PROC W/O CC/MCC	1.2859	2.5	3.4	
826	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W MCC	5.2081	10.7	14.2	
827	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W CC	2.3648	5	6.4	
828	17	SURG	MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W/O CC/MCC	1.619	3.1	3.9	
829	17	SURG	MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS W OTHER  PROCEDURE W CC/MCC	3.1289	6.3	9.5	
830	17	SURG	MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS W OTHER  PROCEDURE W/O CC/MCC	1.2781	2.4	3.1	
834	17	MED	ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC	5.4919	10	16.8	
835	17	MED	ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W CC	2.1141	4.4	7	
836	17	MED	ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W/O CC/MCC	1.3769	3	4.8	
837	17	MED	CHEMO W ACUTE LEUKEMIA AS SDX OR W HIGH DOSE CHEMO AGENT W MCC	5.6988	13.9	19.3	
838	17	MED	CHEMO W ACUTE LEUKEMIA AS SDX W CC OR HIGH DOSE CHEMO AGENT	2.3519	6.1	8.2	
839	17	MED	CHEMO W ACUTE LEUKEMIA AS SDX W/O CC/MCC	1.3322	4.7	5.3	
840	17	MED	LYMPHOMA & NON-ACUTE LEUKEMIA W MCC	3.0786	7	9.8	
841	17	MED	LYMPHOMA & NON-ACUTE LEUKEMIA W CC	1.6201	4.3	5.7	
842	17	MED	LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC/MCC	1.1241	2.9	3.7	
843	17	MED	OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W MCC	1.7887	5.3	7.1	
844	17	MED	OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC	1.2069	3.8	5	
845	17	MED	OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC/MCC	0.9022	2.8	3.5	
846	17	MED	CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W MCC	2.3771	5.8	7.8	
847	17	MED	CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W CC	1.2601	3.5	4	
848	17	MED	CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS W/O CC/MCC	0.9321	2.8	3.3	
849	17	MED	RADIOTHERAPY	1.8	4.8	6.3	
853	18	SURG	INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC	5.1284	10.3	13.3	
854	18	SURG	INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC	2.3913	6.3	7.7	
855	18	SURG	INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W/O CC/MCC	1.4402	3.4	4.2	
856	18	SURG	POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC	4.4499	9.3	12.3	
857	18	SURG	POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC	1.9878	5.3	6.6	
858	18	SURG	POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W/O CC/MCC	1.3487	3.7	4.5	
862	18	MED	POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC	1.8326	5.1	6.7	
863	18	MED	POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC	1.0071	3.6	4.4	
864	18	MED	FEVER	0.8701	2.8	3.5	
865	18	MED	VIRAL ILLNESS W MCC	1.501	4.1	5.6	
866	18	MED	VIRAL ILLNESS W/O MCC	0.8005	2.7	3.4	
867	18	MED	OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W MCC	2.1174	5.6	7.6	
868	18	MED	OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W CC	1.0595	3.8	4.7	
869	18	MED	OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W/O CC/MCC	0.7887	2.9	3.5	
870	18	MED	SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS	6.0907	12.5	14.5	
871	18	MED	SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC	1.8231	4.9	6.4	
872	18	MED	SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC	1.0547	3.7	4.5	
876	19	SURG	O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS	3.51	7.6	14.2	
880	19	MED	ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION	0.8086	2.7	3.7	
881	19	MED	DEPRESSIVE NEUROSES	0.7457	3.8	5.2	
882	19	MED	NEUROSES EXCEPT DEPRESSIVE	0.7792	3.2	4.5	
883	19	MED	DISORDERS OF PERSONALITY & IMPULSE CONTROL	1.177	4.8	7.8	
884	19	MED	ORGANIC DISTURBANCES & INTELLECTUAL DISABILITY	1.2343	4.2	6.5	
885	19	MED	PSYCHOSES	1.1736	5.8	8.2	
886	19	MED	BEHAVIORAL & DEVELOPMENTAL DISORDERS	1.0674	3.8	6.9	
887	19	MED	OTHER MENTAL DISORDER DIAGNOSES	1.0741	3.1	4.6	
894	20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA	0.5244	2.1	2.9	
895	20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY	1.3305	9.1	11.9	
896	20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC	1.6357	4.8	6.7	
897	20	MED	ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC	0.7897	3.4	4.3	
901	21	SURG	WOUND DEBRIDEMENTS FOR INJURIES W MCC	4.1536	9	13.1	
902	21	SURG	WOUND DEBRIDEMENTS FOR INJURIES W CC	1.9973	5.1	6.8	
903	21	SURG	WOUND DEBRIDEMENTS FOR INJURIES W/O CC/MCC	1.2474	3.1	3.9	
904	21	SURG	SKIN GRAFTS FOR INJURIES W CC/MCC	3.2504	6.7	9.7	
905	21	SURG	SKIN GRAFTS FOR INJURIES W/O CC/MCC	1.4614	3.5	4.4	
906	21	SURG	HAND PROCEDURES FOR INJURIES	1.7443	2.9	4.5	
907	21	SURG	OTHER O.R. PROCEDURES FOR INJURIES W MCC	4.1715	7.3	10.3	
908	21	SURG	OTHER O.R. PROCEDURES FOR INJURIES W CC	2.0248	4	5.2	
909	21	SURG	OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC	1.4066	2.5	3.1	
913	21	MED	TRAUMATIC INJURY W MCC	1.3798	3.6	4.8	
914	21	MED	TRAUMATIC INJURY W/O MCC	0.8303	2.5	3.2	
915	21	MED	ALLERGIC REACTIONS W MCC	1.6179	3.7	4.9	
916	21	MED	ALLERGIC REACTIONS W/O MCC	0.6002	1.8	2.1	
917	21	MED	POISONING & TOXIC EFFECTS OF DRUGS W MCC	1.4025	3.5	4.8	
918	21	MED	POISONING & TOXIC EFFECTS OF DRUGS W/O MCC	0.7502	2.3	3	
919	21	MED	COMPLICATIONS OF TREATMENT W MCC	1.7503	4.3	6	
920	21	MED	COMPLICATIONS OF TREATMENT W CC	0.9991	3	3.9	
921	21	MED	COMPLICATIONS OF TREATMENT W/O CC/MCC	0.7094	2.2	2.8	
922	21	MED	OTHER INJURY, POISONING & TOXIC EFFECT DIAG W MCC	1.4818	4	5.4	
923	21	MED	OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O MCC	0.8167	2.6	3.6	
927	22	SURG	EXTENSIVE BURNS OR FULL THICKNESS BURNS W MV >96 HRS W SKIN GRAFT	16.9402	23.7	30	
928	22	SURG	FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC/MCC	5.7042	10.7	14.6	
929	22	SURG	FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W/O CC/MCC	2.6352	5.6	7.5	
933	22	MED	EXTENSIVE BURNS OR FULL THICKNESS BURNS W MV >96 HRS W/O SKIN GRAFT	3.2561	2.8	5.9	
934	22	MED	FULL THICKNESS BURN W/O SKIN GRFT OR INHAL INJ	1.7434	4.3	6.4	
935	22	MED	NON-EXTENSIVE BURNS	1.6881	3.5	5	
939	23	SURG	O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W MCC	3.4809	6.5	9.5	
940	23	SURG	O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W CC	2.3422	4	5.3	
941	23	SURG	O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC	1.8577	2.5	3.2	
945	23	MED	REHABILITATION W CC/MCC	1.2541	8.3	10.9	
946	23	MED	REHABILITATION W/O CC/MCC	1.1301	6.4	7.3	
947	23	MED	SIGNS & SYMPTOMS W MCC	1.1738	3.5	4.8	
948	23	MED	SIGNS & SYMPTOMS W/O MCC	0.7726	2.7	3.3	
949	23	MED	AFTERCARE W CC/MCC	1.1656	4.4	6.1	
950	23	MED	AFTERCARE W/O CC/MCC	0.8045	3.4	4.8	
951	23	MED	OTHER FACTORS INFLUENCING HEALTH STATUS	0.7926	2.4	3.2	
955	24	SURG	CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA	6.0123	7.3	10.9	
956	24	SURG	LIMB REATTACHMENT, HIP & FEMUR PROC FOR MULTIPLE SIGNIFICANT TRAUMA	3.9066	6.3	7.7	
957	24	SURG	OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC	7.3035	9.7	13.8	
958	24	SURG	OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W CC	4.2583	7.1	8.8	
959	24	SURG	OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC	2.6943	3.9	4.8	
963	24	MED	OTHER MULTIPLE SIGNIFICANT TRAUMA W MCC	2.684	5.4	8	
964	24	MED	OTHER MULTIPLE SIGNIFICANT TRAUMA W CC	1.4287	4	4.8	
965	24	MED	OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC	0.9935	2.9	3.3	
969	25	SURG	HIV W EXTENSIVE O.R. PROCEDURE W MCC	5.4431	11.3	15.4	
970	25	SURG	HIV W EXTENSIVE O.R. PROCEDURE W/O MCC	2.5698	4.4	7.1	
974	25	MED	HIV W MAJOR RELATED CONDITION W MCC	2.7736	6.5	9.2	
975	25	MED	HIV W MAJOR RELATED CONDITION W CC	1.3596	4.4	5.8	
976	25	MED	HIV W MAJOR RELATED CONDITION W/O CC/MCC	0.9986	3.3	4.3	
977	25	MED	HIV W OR W/O OTHER RELATED CONDITION	1.2997	3.7	5.2	
981	PRE	SURG	EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC	4.3106	8.5	11.5	
982	PRE	SURG	EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC	2.4836	5	6.6	
983	PRE	SURG	EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC	1.6453	2.5	3.5	
987	PRE	SURG	NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W MCC	3.2362	7.9	10.6	
988	PRE	SURG	NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W CC	1.7103	4.4	5.9	
989	PRE	SURG	NON-EXTENSIVE O.R. PROC UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC	1.1056	2.2	2.9	
998	PRE	**	PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS	
999	PRE	**	UNGROUPABLE	 	 	 	
			 	 	 	 	
**MS-DRGs 998 and 999 contain cases that could not be assigned to valid DRGs.

 

 	

Exhibit #2	
Hospital Base Rates and Cost To Charge Ratios (CCRs)	
For Hospital Discharge Dates of Service on and after 1/1/2018	
Provider Number	Name	Individual Hospital Base Rate	Cost to Charge Ratio (CCR)	
60001	NORTH COLORADO MEDICAL CENTER	$            6,548.71	0.2600	
60003	LONGMONT UNITED HOSPITAL	$            6,133.07	0.3000	
60004	PLATTE VALLEY MEDICAL CENTER	$            6,148.08	0.3910	
60006	MONTROSE MEMORIAL HOSPITAL	$            6,363.53	0.4000	
60008	SAN LUIS VALLEY HEALTH	$            6,363.53	0.3730	
60009	LUTHERAN MEDICAL CENTER	$            6,196.77	0.2450	
60010	POUDRE VALLEY HOSPITAL	$            6,420.87	0.3040	
60011	DENVER HEALTH MEDICAL CENTER	$            7,684.70	0.2890	
60012	CENTURA HEALTH-ST MARY CORWIN MEDICAL CENTER	$            6,463.00	0.2490	
60013	MERCY REGIONAL MEDICAL CENTER	$            7,944.76	0.3400	
60014	PRESBYTERIAN ST LUKES MEDICAL CENTER	$            6,529.83	0.1870	
60015	CENTURA HEALTH-ST ANTHONY HOSPITAL	$            6,224.13	0.2010	
60016	CENTURA HEALTH-ST THOMAS MORE HOSPITAL	$            6,883.81	0.4000	
60020	PARKVIEW MEDICAL CENTER INC	$            6,448.19	0.1810	
60022	UNIVERSITY COLO HEALTH MEMORIAL HOSPITAL CENTRAL	$            6,427.05	0.2560	
60023	ST MARYS  MEDICAL CENTER	$            6,920.54	0.3100	
60024	UNIVERSITY OF COLORADO HOSPITAL AUTHORITY	$            7,737.29	0.1800	
60027	FOOTHILLS HOSPITAL	$            6,107.25	0.2310	
60028	SAINT JOSEPH HOSPITAL	$            6,814.59	0.2030	
60030	MCKEE MEDICAL CENTER	$            6,419.83	0.3590	
60031	CENTURA HEALTH-PENROSE ST FRANCIS HEALTH SERVICES	$            6,170.08	0.2180	
60032	ROSE MEDICAL CENTER	$            6,523.62	0.1400	
60034	SWEDISH MEDICAL CENTER	$            6,346.99	0.1290	
60036	ARKANSAS VALLEY REGIONAL MEDICAL CENTER	$            6,363.53	0.5440	
60043	KEEFE MEMORIAL HOSPITAL	$          15,968.51	1.1360	
60044	COLORADO PLAINS MEDICAL CENTER	$            6,551.50	0.2770	
60049	YAMPA VALLEY MEDICAL CENTER	$            9,596.48	0.5180	
60054	COMMUNITY HOSPITAL	$            6,321.96	0.3370	
60064	CENTURA HEALTH-PORTER ADVENTIST HOSPITAL	$            6,152.56	0.2100	
60065	NORTH SUBURBAN MEDICAL CENTER	$            6,255.33	0.1300	
60071	DELTA COUNTY MEMORIAL HOSPITAL	$            6,363.53	0.4250	
60075	VALLEY VIEW HOSPITAL ASSOCIATION	$            8,212.05	0.4120	
60076	STERLING REGIONAL MEDCENTER	$            7,790.92	0.4990	
60096	VAIL VALLEY MEDICAL CENTER	$          12,024.60	0.5000	
60100	MEDICAL CENTER OF AURORA, THE	$            6,218.96	0.1430	
60103	CENTURA HEALTH-AVISTA ADVENTIST HOSPITAL	$            6,160.05	0.2810	
60104	ST ANTHONY NORTH HEALTH CAMPUS	$            7,007.82	0.2670	
60112	SKY RIDGE MEDICAL CENTER	$            6,121.69	0.1380	
60113	CENTURA HEALTH-LITTLETON ADVENTIST HOSPITAL	$            6,117.59	0.1860	
60114	PARKER ADVENTIST HOSPITAL	$            6,147.55	0.2090	
60116	GOOD SAMARITAN MEDICAL CENTER	$            6,074.86	0.2130	
60117	ANIMAS SURGICAL HOSPITAL, LLC	$            6,321.96	0.3990	
60118	ST ANTHONY SUMMIT MEDICAL CENTER	$            6,106.23	0.3560	
60119	MEDICAL CENTER OF THE ROCKIES	$            6,371.97	0.2930	
60124	ORTHOCOLORADO HOSPITAL AT ST ANTHONY MED CAMPUS	$            6,105.72	0.2160	
60125	CASTLE ROCK ADVENTIST HOSPITAL	$            6,105.72	0.2970	
60126	BANNER FORT COLLINS MEDICAL CENTER	$            6,377.89	0.5700	
69999	ANY OTHER HOSPITAL	$            6,105.72	0.2970	

Exhibit #3	
Critical Access Hospitals	
 Effective for Dates of Service on and after 1/1/2018	
Hospital Name	Location in Colorado	
Arkansas Valley Regional Medical Center	La Junta	
Aspen Valley Hospital	Aspen	
Colorado Canyon Hospital and Medical Center	Fruita	
East Morgan County Hospital	Brush	
Estes Park Medical Center	Estes Park	
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	
Rangely District Hospital	Rangely	
Rio Grande Hospital	Del Norte	
San Luis Valley Hospital	La Jara	
Sedgwick County Health Center	Julesburg	
Southeast Colorado Hospital	Springfield	
Southwest Memorial Hospital 	Cortez 	
Spanish Peaks Regional Health Center	Walsenburg	
St Vincent General Hospital District 	Leadville	
The Memorial Hospital	Craig	
Weisbrod Memorial County Hospital	Eads 	
Wray Community District Hospital 	Wray	
Yuma District Hospital	Yuma	

Exhibit #4	
Hospital Outpatient APC Codes and Values	
Effective for Dates of Service on and after 1/1/2018	
APC	Group Title	Hospitals	ASC 	Notes 	
701	Sr89 strontium	$2,295.20	$1,950.92	 	
726	Dexrazoxane HCl injection	$371.39	$315.68	 	
731	Sargramostim injection	$66.76	$56.75	 	
736	Amphotericin b liposome inj	$35.15	$29.88	 	
738	Rasburicase	$466.47	$396.50	 	
747	Chlorothiazide sodium inj	$140.22	$119.19	 	
751	Mechlorethamine hcl inj	$478.60	$406.81	 	
752	Dactinomycin injection	$2,297.48	$1,952.86	 	
759	Naltrexone, depot form	$5.85	$4.97	 	
800	Leuprolide acetate	$1,844.19	$1,567.56	 	
802	Etoposide oral	$133.65	$113.60	 	
807	Aldesleukin injection	$5,521.75	$4,693.49	 	
809	Bcg live intravesical vac	$231.08	$196.42	 	
810	Goserelin acetate implant	$629.86	$535.38	 	
812	Carmustine injection	$6,924.53	$5,885.85	 	
820	Daunorubicin injection	$70.63	$60.04	 	
821	Daunorubicin citrate inj	$438.84	$373.01	 	
823	Docetaxel injection	$3.40	$2.89	 	
825	Nelarabine injection	$273.65	$232.60	 	
827	Floxuridine injection	$109.06	$92.70	 	
831	Ifosfamide injection	$50.53	$42.95	 	
832	Idarubicin hcl injection	$74.77	$63.55	 	
836	Interferon alfa-2b inj	$51.34	$43.64	 	
838	Interferon gamma 1-b inj	$11,354.63	$9,651.44	 	
840	Inj melphalan hydrochl	$3,247.43	$2,760.32	 	
843	Pegaspargase injection	$25,041.96	$21,285.67	 	
844	Pentostatin injection	$3,389.62	$2,881.18	 	
849	Rituximab injection	$1,472.96	$1,252.02	 	
850	Streptozocin injection	$576.38	$489.92	 	
851	Thiotepa injection	$1,569.85	$1,334.37	 	
856	Porfimer sodium injection	$38,195.23	$32,465.95	 	
858	Inj cladribine	$36.05	$30.64	 	
864	Mitoxantrone hydrochl	$59.13	$50.26	 	
868	Oral aprepitant	$21.20	$18.02	 	
873	Hyalgan/supartz inj per dose	$156.89	$133.36	 	
874	Synvisc or synvisc-one	$22.57	$19.18	 	
875	Euflexxa inj per dose	$276.91	$235.37	 	
877	Orthovisc inj per dose	$276.39	$234.93	 	
887	Azathioprine parenteral	$450.81	$383.19	 	
890	Lymphocyte immune globulin	$2,661.84	$2,262.56	 	
901	Alpha 1 proteinase inhibitor	$8.68	$7.38	 	
902	Injection,onabotulinumtoxinA	$10.69	$9.09	 	
903	Cytomegalovirus imm IV /vial	$2,029.93	$1,725.44	 	
910	Interferon beta-1b / .25 MG	$677.34	$575.74	 	
913	Ganciclovir long act implant	$21.08	$17.92	 	
925	Factor viii	$1.82	$1.55	 	
927	Factor viii recombinant	$2.16	$1.84	 	
928	Factor ix complex	$2.41	$2.05	 	
929	Anti-inhibitor	$3.47	$2.95	 	
931	Factor IX non-recombinant	$2.09	$1.78	 	
932	Factor ix recombinant nos	$2.72	$2.31	 	
943	Octagam injection	$64.96	$55.22	 	
944	Gammagard liquid injection	$72.77	$61.85	 	
946	Hepagam b im injection	$105.57	$89.73	 	
947	Flebogamma injection	$54.32	$46.17	 	
948	Gamunex-C/Gammaked	$61.07	$51.91	 	
961	Albumin (human),5%, 50ml	$21.24	$18.05	 	
963	Albumin (human), 5%, 250 ml	$98.50	$83.73	 	
964	Albumin (human), 25%, 20 ml	$40.48	$34.41	 	
965	Albumin (human), 25%, 50ml	$96.19	$81.76	 	
1015	Injection glatiramer acetate	$356.22	$302.79	 	
1052	Injection, voriconazole	$6.55	$5.57	 	
1064	I131 iodide cap, rx	$73.26	$62.27	 	
1083	Adalimumab injection	$2,118.47	$1,800.70	 	
1086	Temozolomide	$3.35	$2.85	 	
1138	Hepagam b intravenous, inj	$105.57	$89.73	 	
1139	Protein c concentrate	$27.36	$23.26	 	
1142	Supprelin LA implant	$49,926.47	$42,437.50	 	
1150	I131 iodide sol, rx	$22.61	$19.22	 	
1166	Cytarabine liposome inj	$1,069.18	$908.80	 	
1168	Inj, temsirolimus	$121.14	$102.97	 	
1178	Busulfan injection	$65.70	$55.85	 	
1203	Verteporfin injection	$19.37	$16.46	 	
1207	Octreotide injection, depot	$315.99	$268.59	 	
1213	Antihemophilic viii/vwf comp	$1.78	$1.51	 	
1214	Inj IVIG privigen 500 mg	$69.97	$59.47	 	
1232	Mitomycin injection	$208.22	$176.99	 	
1235	Valrubicin injection	$2,084.60	$1,771.91	 	
1236	Levoleucovorin injection	$1.28	$1.09	 	
1237	Inj iron dextran	$22.43	$19.07	 	
1238	Topotecan oral	$186.82	$158.80	 	
1253	Triamcinolone A inj PRS-free	$6.73	$5.72	 	
1263	Antithrombin iii injection	$5.80	$4.93	 	
1268	Xyntha inj	$2.20	$1.87	 	
1274	Edetate calcium disodium inj	$10,069.96	$8,559.47	 	
1280	Corticotropin injection	$6,366.76	$5,411.75	 	
1281	Bevacizumab injection	$3.31	$2.81	 	
1289	AbobotulinumtoxinA	$14.35	$12.20	 	
1291	Rilonacept injection	$43.36	$36.86	 	
1295	Sm 153 lexidronam	$21,700.64	$18,445.54	 	
1296	Degarelix injection	$6.53	$5.55	 	
1297	Ferumoxytol, non-esrd	$1.60	$1.36	 	
1311	Canakinumab injection	$166.52	$141.54	 	
1312	Hizentra injection	$17.69	$15.04	 	
1327	Imiglucerase injection	$75.24	$63.95	 	
1331	Olanzapine long-acting inj	$5.26	$4.47	 	
1332	Antithrombin recombinant	$186.03	$158.13	 	
1338	Methyl aminolevulinate, top	$150.64	$128.04	 	
1340	Collagenase, clost hist inj	$73.24	$62.25	 	
1341	Amobarbital 125 MG inj	$349.67	$297.22	 	
1352	Wilate injection	$1.82	$1.55	 	
1353	Belimumab injection	$76.64	$65.14	 	
1354	Hydroxyprogesterone caproate	$4.93	$4.19	 	
1361	Enfuvirtide injection	$33.53	$28.50	 	
1408	Cyclophosphamide 100 MG inj	$76.16	$64.74	 	
1413	Lumizyme injection	$287.53	$244.40	 	
1415	Glassia injection	$7.85	$6.67	 	
1416	Factor xiii anti-hem factor	$14.74	$12.53	 	
1417	Gel-one	$978.50	$831.73	 	
1420	Aflibercept injection	$1,764.25	$1,499.61	 	
1421	Imported lipodox inj	$915.17	$777.89	 	
1424	Nabilone oral	$68.76	$58.45	 	
1426	Eribulin mesylate injection	$194.96	$165.72	 	
1431	Centruroides immune f(ab)	$7,644.04	$6,497.43	 	
1433	Calcitonin salmon injection	$4,082.20	$3,469.87	 	
1440	Inj desmopressin acetate	$23.67	$20.12	 	
1442	Non-HEU TC-99M add-on/dose	$18.00	$15.30	 	
1443	Icatibant injection	$586.10	$498.19	 	
1446	Visualization adjunct	$5.35	$4.55	 	
1457	Totazoline hcl injection	$2,880.72	$2,448.61	 	
1458	Phentolaine mesylate inj	$602.86	$512.43	 	
1460	Interferon alfa-2a inj	$58.01	$49.31	 	
1464	Factor VIII (porcine)	$0.36	$0.31	 	
1466	Inj, vincristine sul lip 1mg	$4,680.65	$3,978.55	 	
1467	Factor ix recombinan rixubis	$2.25	$1.91	 	
1468	Inj Aripiprazole Ext Rel 1mg	$8.24	$7.00	 	
1469	Inj filgrastim excl biosimil	$1.82	$1.55	 	
1471	Injection, Pertuzumab, 1 mg	$19.58	$16.64	 	
1472	Inj beta interferon im 1 mcg	$83.18	$70.70	 	
1474	Certolizumab pegol inj 1mg	$13.21	$11.23	 	
1475	Golimumab for iv use 1mg	$44.98	$38.23	 	
1476	Obinutuzumab inj	$103.25	$87.76	 	
1478	Human fibrinogen conc inj	$2.07	$1.76	 	
1480	Elosulfase alfa, injection	$403.87	$343.29	 	
1482	Darbepoetin alfa, esrd use	$6.93	$5.89	 	
1484	Pentazocine injection	$246.08	$209.17	 	
1485	Ferumoxytol, esrd use	$1.60	$1.36	 	
1486	Factor ix fc fusion recomb	$5.27	$4.48	 	
1488	Injection, ramucirumab	$101.29	$86.10	 	
1489	Injection, vedolizumab	$32.63	$27.74	 	
1490	Inj pembrolizumab	$85.14	$72.37	 	
1491	New Technology  - Level 1A ($0-$10)	$9.00	$7.65	 	
1492	New Technology  - Level 1B ($11-$20)	$27.90	$23.72	 	
1493	New Technology  - Level 1C ($21-$30)	$45.90	$39.02	 	
1494	New Technology  - Level 1D ($31-$40)	$63.90	$54.32	 	
1495	New Technology  - Level 1E ($41-$50)	$81.90	$69.62	 	
1496	New Technology  - Level 1A ($0-$10)	$9.00	$7.65	 	
1497	New Technology  - Level 1B ($11-$20)	$27.90	$23.72	 	
1498	New Technology  - Level 1C ($21-$30)	$45.90	$39.02	 	
1499	New Technology  - Level 1D ($31-$40)	$63.90	$54.32	 	
1500	New Technology  - Level 1E ($41-$50)	$81.90	$69.62	 	
1502	New Technology - Level 2 ($51 - $100)	$135.90	$115.52	 	
1503	New Technology - Level 3 ($101 - $200)	$270.90	$230.27	 	
1504	New Technology - Level 4 ($201 - $300)	$450.90	$383.27	 	
1505	New Technology - Level 5 ($301 - $400)	$630.90	$536.27	 	
1506	New Technology - Level 6 ($401 - $500)	$810.90	$689.27	 	
1507	New Technology - Level 7 ($501 - $600)	$990.90	$842.27	 	
1508	New Technology - Level 8 ($601 - $700)	$1,170.90	$995.27	 	
1509	New Technology - Level 9 ($701 - $800)	$1,350.90	$1,148.27	 	
1510	New Technology - Level 10 ($801 - $900)	$1,530.90	$1,301.27	 	
1511	New Technology - Level 11 ($901 - $1000)	$1,710.90	$1,454.27	 	
1512	New Technology - Level 12 ($1001 - $1100)	$1,890.90	$1,607.27	 	
1513	New Technology - Level 13 ($1101 - $1200)	$2,070.90	$1,760.27	 	
1514	New Technology - Level 14 ($1201- $1300)	$2,250.90	$1,913.27	 	
1515	New Technology - Level 15 ($1301 - $1400)	$2,430.90	$2,066.27	 	
1516	New Technology - Level 16  ($1401 - $1500)	$2,610.90	$2,219.27	 	
1517	New Technology - Level 17 ($1501-$1600)	$2,790.90	$2,372.27	 	
1518	New Technology - Level 18 ($1601-$1700)	$2,970.90	$2,525.27	 	
1519	New Technology - Level 19 ($1701-$1800)	$3,150.90	$2,678.27	 	
1520	New Technology - Level 20 ($1801-$1900)	$3,330.90	$2,831.27	 	
1521	New Technology - Level 21 ($1901-$2000)	$3,510.90	$2,984.27	 	
1522	New Technology - Level 22 ($2001-$2500)	$4,050.90	$3,443.27	 	
1523	New Technology - Level 23 ($2501-$3000)	$4,950.90	$4,208.27	 	
1524	New Technology - Level 24 ($3001-$3500)	$5,850.90	$4,973.27	 	
1525	New Technology - Level 25 ($3501-$4000)	$6,750.90	$5,738.27	 	
1526	New Technology - Level 26 ($4001-$4500)	$7,650.90	$6,503.27	 	
1527	New Technology - Level 27 ($4501-$5000)	$8,550.90	$7,268.27	 	
1528	New Technology - Level 28 ($5001-$5500)	$9,450.90	$8,033.27	 	
1529	New Technology - Level 29 ($5501-$6000)	$10,350.90	$8,798.27	 	
1530	New Technology - Level 30 ($6001-$6500)	$11,250.90	$9,563.27	 	
1531	New Technology - Level 31 ($6501-$7000)	$12,150.90	$10,328.27	 	
1532	New Technology - Level 32 ($7001-$7500)	$13,050.90	$11,093.27	 	
1533	New Technology - Level 33 ($7501-$8000)	$13,950.90	$11,858.27	 	
1534	New Technology - Level 34 ($8001-$8500)	$14,850.90	$12,623.27	 	
1535	New Technology - Level 35 ($8501-$9000)	$15,750.90	$13,388.27	 	
1536	New Technology - Level 36 ($9001-$9500)	$16,650.90	$14,153.27	 	
1537	New Technology - Level 37 ($9501-$10000)	$17,550.90	$14,918.27	 	
1539	New Technology - Level 2 ($51 - $100)	$135.90	$115.52	 	
1540	New Technology - Level 3 ($101 - $200)	$270.90	$230.27	 	
1541	New Technology - Level 4 ($201 - $300)	$450.90	$383.27	 	
1542	New Technology - Level 5 ($301 - $400)	$630.90	$536.27	 	
1543	New Technology - Level 6 ($401 - $500)	$810.90	$689.27	 	
1544	New Technology - Level 7 ($501 - $600)	$990.90	$842.27	 	
1545	New Technology - Level 8 ($601 - $700)	$1,170.90	$995.27	 	
1546	New Technology - Level 9 ($701 - $800)	$1,350.90	$1,148.27	 	
1547	New Technology - Level 10 ($801 - $900)	$1,530.90	$1,301.27	 	
1548	New Technology - Level 11 ($901 - $1000)	$1,710.90	$1,454.27	 	
1549	New Technology - Level 12 ($1001 - $1100)	$1,890.90	$1,607.27	 	
1550	New Technology - Level 13 ($1101 - $1200)	$2,070.90	$1,760.27	 	
1551	New Technology - Level 14 ($1201- $1300)	$2,250.90	$1,913.27	 	
1552	New Technology - Level 15 ($1301 - $1400)	$2,430.90	$2,066.27	 	
1553	New Technology - Level 16 ($1401 - $1500)	$2,610.90	$2,219.27	 	
1554	New Technology - Level 17 ($1501-$1600)	$2,790.90	$2,372.27	 	
1555	New Technology - Level 18 ($1601-$1700)	$2,970.90	$2,525.27	 	
1556	New Technology - Level 19 ($1701-$1800)	$3,150.90	$2,678.27	 	
1557	New Technology - Level 20 ($1801-$1900)	$3,330.90	$2,831.27	 	
1558	New Technology - Level 21 ($1901-$2000)	$3,510.90	$2,984.27	 	
1559	New Technology - Level 22 ($2001-$2500)	$4,050.90	$3,443.27	 	
1560	New Technology - Level 23 ($2501-$3000)	$4,950.90	$4,208.27	 	
1561	New Technology - Level 24 ($3001-$3500)	$5,850.90	$4,973.27	 	
1562	New Technology - Level 25 ($3501-$4000)	$6,750.90	$5,738.27	 	
1563	New Technology - Level 26 ($4001-$4500)	$7,650.90	$6,503.27	 	
1564	New Technology - Level 27 ($4501-$5000)	$8,550.90	$7,268.27	 	
1565	New Technology - Level 28 ($5001-$5500)	$9,450.90	$8,033.27	 	
1566	New Technology - Level 29 ($5501-$6000)	$10,350.90	$8,798.27	 	
1567	New Technology - Level 30 ($6001-$6500)	$11,250.90	$9,563.27	 	
1568	New Technology - Level 31 ($6501-$7000)	$12,150.90	$10,328.27	 	
1569	New Technology - Level 32 ($7001-$7500)	$13,050.90	$11,093.27	 	
1570	New Technology - Level 33 ($7501-$8000)	$13,950.90	$11,858.27	 	
1571	New Technology - Level 34 ($8001-$8500)	$14,850.90	$12,623.27	 	
1572	New Technology - Level 35 ($8501-$9000)	$15,750.90	$13,388.27	 	
1573	New Technology - Level 36 ($9001-$9500)	$16,650.90	$14,153.27	 	
1574	New Technology - Level 37 ($9501-$10000)	$17,550.90	$14,918.27	 	
1575	New Technology - Level 38 ($10,001-$15,000)	$22,500.90	$19,125.77	 	
1576	New Technology - Level 39 ($15,001-$20,000)	$31,500.90	$26,775.77	 	
1577	New Technology - Level 40 ($20,001-$25,000)	$40,500.90	$34,425.77	 	
1578	New Technology - Level 41 ($25,001-$30,000)	$49,500.90	$42,075.77	 	
1579	New Technology - Level 42 ($30,001-$40,000)	$63,000.90	$53,550.77	 	
1580	New Technology - Level 43 ($40,001-$50,000)	$81,000.90	$68,850.77	 	
1581	New Technology - Level 44 ($50,001-$60,000)	$99,000.90	$84,150.77	 	
1582	New Technology - Level 45 ($60,001-$70,000)	$117,000.90	$99,450.77	 	
1583	New Technology - Level 46 ($70,001-$80,000)	$135,000.90	$114,750.77	 	
1584	New Technology - Level 47 ($80,001-$90,000)	$153,000.90	$130,050.77	 	
1585	New Technology - Level 48 ($90,001-$100,000)	$171,000.90	$145,350.77	 	
1589	New Technology - Level 38 ($10,001-$15,000)	$22,500.90	$19,125.77	 	
1590	New Technology - Level 39 ($15,001-$20,000)	$31,500.90	$26,775.77	 	
1591	New Technology - Level 40 ($20,001-$25,000)	$40,500.90	$34,425.77	 	
1592	New Technology - Level 41 ($25,001-$30,000)	$49,500.90	$42,075.77	 	
1593	New Technology - Level 42 ($30,001-$40,000)	$63,000.90	$53,550.77	 	
1594	New Technology - Level 43 ($40,001-$50,000)	$81,000.90	$68,850.77	 	
1595	New Technology - Level 44 ($50,001-$60,000)	$99,000.90	$84,150.77	 	
1596	New Technology - Level 45 ($60,001-$70,000)	$117,000.90	$99,450.77	 	
1597	New Technology - Level 46 ($70,001-$80,000)	$135,000.90	$114,750.77	 	
1598	New Technology - Level 47 ($80,001-$90,000)	$153,000.90	$130,050.77	 	
1599	New Technology - Level 48 ($90,001-$100,000)	$171,000.90	$145,350.77	 	
1605	Abciximab injection	$2,073.94	$1,762.85	 	
1607	Eptifibatide injection	$42.50	$36.13	 	
1608	Etanercept injection	$787.64	$669.49	 	
1609	Rho(D) immune globulin h, sd	$40.86	$34.73	 	
1612	Daclizumab, parenteral	$18.00	$15.30	 	
1613	Trastuzumab injection	$170.08	$144.57	 	
1630	Hep b ig, im	$201.53	$171.30	 	
1631	Baclofen intrathecal trial	$138.31	$117.56	 	
1633	Alefacept	$74.95	$63.71	 	
1643	Y90 ibritumomab, rx	$84,801.42	$72,081.21	 	
1656	Factor viii fc fusion recomb	$3.56	$3.03	 	
1657	Puraply or puraply am	$187.42	$159.31	 	
1658	Injection, belinostat, 10mg	$61.90	$52.62	 	
1660	Injection, oritavancin	$44.21	$37.58	 	
1661	Gen, neuro, HF, rechg bat	$0.00	$0.00	 	
1662	Inj tedizolid phosphate	$2.29	$1.95	 	
1663	Inj, phenylephrine ketorolac	$878.15	$746.43	 	
1664	Florbetapir f18	$4,960.80	$4,216.68	 	
1666	Tetracyclin injection	$13.12	$11.15	 	
1669	Erythro lactobionate /500 mg	$106.99	$90.94	 	
1670	Tetanus immune globulin inj	$657.27	$558.68	 	
1675	P32 Na phosphate	$101.95	$86.66	 	
1676	P32 chromic phosphate	$128.05	$108.84	 	
1683	Basiliximab	$6,043.21	$5,136.73	 	
1684	Corticorelin ovine triflutal	$14.62	$12.43	 	
1685	Darbepoetin alfa, non-esrd	$6.93	$5.89	 	
1686	Epoetin alfa, non-esrd	$24.52	$20.84	 	
1687	Digoxin immune fab (ovine)	$5,881.57	$4,999.33	 	
1688	Ethanolamine oleate	$760.27	$646.23	 	
1689	Fomepizole	$14.00	$11.90	 	
1690	Hemin	$41.15	$34.98	 	
1693	Lepirudin	$22.88	$19.45	 	
1694	Ziconotide injection	$13.19	$11.21	 	
1695	Nesiritide injection	$131.72	$111.96	 	
1696	Palifermin injection	$31.82	$27.05	 	
1697	Pegaptanib sodium injection	$1,898.46	$1,613.69	 	
1700	Inj secretin synthetic human	$62.60	$53.21	 	
1701	Treprostinil injection	$110.23	$93.70	 	
1704	Humate-P, inj	$1.96	$1.67	 	
1705	Factor viia	$3.47	$2.95	 	
1709	Azacitidine injection	$3.80	$3.23	 	
1710	Clofarabine injection	$274.27	$233.13	 	
1711	Vantas implant	$5,631.86	$4,787.08	 	
1712	Paclitaxel protein bound	$18.81	$15.99	 	
1738	Oxaliplatin	$0.49	$0.42	 	
1739	Pegademase bovine, 25 iu	$621.41	$528.20	 	
1741	Urofollitropin, 75 iu	$238.79	$202.97	 	
1743	Nandrolone decanoate 50 mg	$240.05	$204.04	 	
1745	Radium ra223 dichloride ther	$231.75	$196.99	 	
1746	Factor xiii recomb a-subunit	$26.53	$22.55	 	
1747	Monovisc inj per dose	$1,611.27	$1,369.58	 	
1748	Inj tbo filgrastim 1 microg	$1.21	$1.03	 	
1761	rolapitant, oral, 1mg	$3.87	$3.29	 	
1809	Injection, alemtuzumab	$3,155.44	$2,682.12	 	
1822	Inj filgrastim gcsf biosimil	$1.37	$1.16	 	
1823	Injection, dalbavancin	$26.51	$22.53	 	
1824	Ceftaroline fosamil inj	$4.45	$3.78	 	
1825	Ceftazidime and avibactam	$138.83	$118.01	 	
1826	Hyqvia 100mg immuneglobulin	$23.33	$19.83	 	
1827	Factor viii recomb obizur	$7.13	$6.06	 	
1828	Carbidopa levodopa ent 100ml	$4.03	$3.43	 	
1829	Penicillin g benzathine inj	$19.35	$16.45	 	
1832	Dimethyl sulfoxide 50% 50 ml	$960.70	$816.60	 	
1836	Penicillin g procaine inj	$48.19	$40.96	 	
1838	Urokinase 250,000 iu inj	$473.02	$402.07	 	
1839	Oral busulfan	$42.61	$36.22	 	
1842	Leuprolide acetate implant	$303.26	$257.77	 	
1844	Factor viii pegylated recomb	$3.08	$2.62	 	
1845	Tacrol envarsus ex rel oral	$2.21	$1.88	 	
1846	Factor viii nuwiq recomb 1iu	$2.93	$2.49	 	
1847	Inj., infliximab biosimilar	$180.56	$153.48	 	
1848	Artiss fibrin sealant	$201.02	$170.87	 	
1849	Foscarnet sodium injection	$135.31	$115.01	 	
1850	Gamma globulin 1 cc inj	$64.33	$54.68	 	
1851	Gamma globulin > 10 cc inj	$643.28	$546.79	 	
1852	Interferon beta-1a inj	$867.98	$737.78	 	
1853	Minocycline hydrochloride	$2.72	$2.31	 	
1854	Pentobarbital sodium inj	$85.21	$72.43	 	
1855	Pralidoxime chloride inj	$156.67	$133.17	 	
1856	Factor viii recomb novoeight	$2.32	$1.97	 	
1857	Inj, factor x, (human), 1iu	$11.74	$9.98	 	
1858	Leuprolide acetate injeciton	$46.73	$39.72	 	
1859	Argatroban nonesrd use 1mg	$2.92	$2.48	 	
1860	Monoclonal antibodies	$416.20	$353.77	 	
1861	Inj., bendeka 1 mg	$42.23	$35.90	 	
1862	Gel-syn injection 0.1 mg	$3.92	$3.33	 	
1863	Inj diclofenac sodium 0.5mg	$0.29	$0.25	 	
1901	New Technology - Level 49 ($100,001-$120,000)	$198,000.90	$168,300.77	 	
1902	New Technology - Level 49 ($100,001-$120,000)	$198,000.90	$168,300.77	 	
1903	New Technology - Level 50 ($120,001-$140,000)	$234,000.90	$198,900.77	 	
1904	New Technology - Level 50 ($120,001-$140,000)	$234,000.90	$198,900.77	 	
1905	New Technology - Level 51 ($140,001-$160,000)	$270,000.90	$229,500.77	 	
1906	New Technology - Level 51 ($140,001-$160,000)	$270,000.90	$229,500.77	 	
2613	Lung bx plug w/del sys	$0.00	$0.00	 	
2616	Brachytx, non-str,Yttrium-90	$29,713.91	$25,256.82	 	
2623	Cath, translumin, drug-coat	$0.00	$0.00	 	
2632	Iodine I-125 sodium iodide	$53.87	$45.79	 	
2634	Brachytx, non-str, HA, I-125	$216.94	$184.40	 	
2635	Brachytx, non-str, HA, P-103	$46.26	$39.32	 	
2636	Brachy linear, non-str,P-103	$33.57	$28.53	 	
2638	Brachytx, stranded, I-125	$68.35	$58.10	 	
2639	Brachytx, non-stranded,I-125	$64.26	$54.62	 	
2640	Brachytx, stranded, P-103	$131.80	$112.03	 	
2641	Brachytx, non-stranded,P-103	$117.81	$100.14	 	
2642	Brachytx, stranded, C-131	$157.70	$134.05	 	
2643	Brachytx, non-stranded,C-131	$106.54	$90.56	 	
2645	Brachytx, non-str, Gold-198	$243.54	$207.01	 	
2646	Brachytx, non-str, HDR Ir-192	$506.84	$430.81	 	
2647	Brachytx, NS, Non-HDRIr-192	$60.89	$51.76	 	
2648	Brachytx planar, p-103	$8.44	$7.17	 	
2698	Brachytx, stranded, NOS	$68.35	$58.10	 	
2699	Brachytx, non-stranded, NOS	$33.57	$28.53	 	
2731	Immune globulin, powder	$58.75	$49.94	 	
2770	Quinupristin/dalfopristin	$786.19	$668.26	 	
3041	Bivalirudin	$2.66	$2.26	 	
4001	Echo guidance radiotherapy	$39.40	$33.49	 	
4002	Stereoscopic x-ray guidance 	$100.78	$85.66	 	
4003	Radiation treatment delivery, MeV <= 5; simple 	$347.54	$295.41	 	
4004	Radiation treatment delivery, 6-10 MeV; simple 	$263.57	$224.03	 	
4005	Radiation treatment delivery, 11-19 MeV; simple 	$262.93	$223.49	 	
4006	Radiation treatment delivery, MeV>=20; simple 	$262.93	$223.49	 	
4007	Radiation treatment delivery, MeV<=5; intermediate	$543.28	$461.79	 	
4008	Radiation treatment delivery, 6-10 MeV; intermediate 	$363.04	$308.58	 	
4009	Radiation treatment delivery, 11-19 MeV; intermediate	$361.76	$307.50	 	
4010	Radiation treatment delivery, MeV >=20; intermediate	$360.47	$306.40	 	
4011	Radiation treatment delivery, MeV<=5; complex	$526.48	$447.51	 	
4012	Radiation treatment delivery, 6-10 MeV; complex	$480.62	$408.53	 	
4013	Radiation treatment delivery, 11-19 MeV; complex	$481.27	$409.08	 	
4014	Radiation treatment delivery, MeV >=20; complex	$481.91	$409.62	 	
5012	Clinic Visits and Related Services	$191.90	$163.12	 	
5021	Level 1 Type A ED Visits	$110.47	N/A	 	
5022	Level 2 Type A ED Visits	$200.65	N/A	 	
5023	Level 3 Type A ED Visits	$362.25	N/A	 	
5024	Level 4 Type A ED Visits	$598.34	N/A	 	
5025	Level 5 Type A ED Visits	$879.73	N/A	 	
5031	Level 1 Type B ED Visits	$153.23	N/A	 	
5032	Level 2 Type B ED Visits	$136.03	N/A	 	
5033	Level 3 Type B ED Visits	$225.00	N/A	 	
5034	Level 4 Type B ED Visits	$321.39	N/A	 	
5035	Level 5 Type B ED Visits	$662.20	N/A	 	
5041	Critical Care	$1,236.91	N/A	 	
5045	Trauma Response with Critical Care	$0.00	N/A	See Rule 18-6(J) for Trauma Activation Fees	
5051	Level 1 Skin Procedures	$275.62	$234.28	 	
5052	Level 2 Skin Procedures	$526.72	$447.71	 	
5053	Level 3 Skin Procedures	$815.58	$693.24	 	
5054	Level 4 Skin Procedures	$2,569.99	$2,184.49	 	
5055	Level 5 Skin Procedures	$4,508.44	$3,832.17	 	
5061	Hyperbaric Oxygen	$198.43	$168.67	 	
5071	Level 1 Excision/ Biopsy/ Incision and Drainage	$970.40	$824.84	 	
5072	Level 2 Excision/ Biopsy/ Incision and Drainage	$2,225.92	$1,892.03	 	
5073	Level 3 Excision/ Biopsy/ Incision and Drainage	$3,868.04	$3,287.83	 	
5091	Level 1 Breast/Lymphatic Surgery and Related Procedures	$4,499.06	$3,824.20	 	
5092	Level 2 Breast/Lymphatic Surgery and Related Procedures	$7,955.03	$6,761.78	 	
5093	Level 3 Breast/Lymphatic Surgery and Related Procedures	$11,675.43	$9,924.12	 	
5094	Level 4 Breast/Lymphatic Surgery and Related Procedures	$18,066.69	$15,356.69	 	
5101	Level 1 Strapping and Cast Application	$225.27	$191.48	 	
5102	Level 2 Strapping and Cast Application	$397.35	$337.75	 	
5111	Level 1 Musculoskeletal Procedures	$359.69	$305.74	 	
5112	Level 2 Musculoskeletal Procedures	$2,191.36	$1,862.66	 	
5113	Level 3 Musculoskeletal Procedures	$4,389.01	$3,730.66	 	
5114	Level 4 Musculoskeletal Procedures	$9,398.83	$7,989.01	 	
5115	Level 5 Musculoskeletal Procedures	$17,210.21	$14,628.68	 	
5116	Level 6 Musculoskeletal Procedures	$26,467.43	$22,497.32	 	
5151	Level 1 Airway Endoscopy	$263.16	$223.69	 	
5152	Level 2 Airway Endoscopy	$651.46	$553.74	 	
5153	Level 3 Airway Endoscopy	$2,285.62	$1,942.78	 	
5154	Level 4 Airway Endoscopy	$4,376.21	$3,719.78	 	
5155	Level 5 Airway Endoscopy	$7,853.31	$6,675.31	 	
5161	Level 1 ENT Procedures	$318.76	$270.95	 	
5162	Level 2 ENT Procedures	$796.72	$677.21	 	
5163	Level 3 ENT Procedures	$1,869.39	$1,588.98	 	
5164	Level 4 ENT Procedures	$3,912.64	$3,325.74	 	
5165	Level 5 ENT Procedures	$7,435.69	$6,320.34	 	
5166	Cochlear Implant Procedure	$57,306.58	$48,710.59	 	
5181	Level 1 Vascular Procedures	$1,231.43	$1,046.72	 	
5182	Level 2 Vascular Procedures	$4,249.08	$3,611.72	 	
5183	Level 3 Vascular Procedures	$7,063.70	$6,004.15	 	
5191	Level 1 Endovascular Procedures	$5,100.39	$4,335.33	 	
5192	Level 2 Endovascular Procedures	$8,685.36	$7,382.56	 	
5193	Level 3 Endovascular Procedures	$17,554.37	$14,921.21	 	
5194	Level 4 Endovascular Procedures	$26,607.85	$22,616.67	 	
5200	Implantation Wireless PA Pressure Monitor	$53,131.63	$45,161.89	 	
5211	Level 1 Electrophysiologic Procedures	$1,560.33	$1,326.28	 	
5212	Level 2 Electrophysiologic Procedures	$9,011.52	$7,659.79	 	
5213	Level 3 Electrophysiologic Procedures	$30,213.41	$25,681.40	 	
5221	Level1 Pacemaker and Similar Procedures	$4,607.26	$3,916.17	 	
5222	Level 2 Pacemaker and Similar Procedures	$12,557.83	$10,674.16	 	
5223	Level 3 Pacemaker and Similar Procedures	$16,944.57	$14,402.88	 	
5224	Level 4 Pacemaker and Similar Procedures	$30,180.35	$25,653.30	 	
5231	Level 1 ICD and Similar Procedures	$39,599.96	$33,659.97	 	
5232	Level 2 ICD and Similar Procedures	$54,948.98	$46,706.63	 	
5241	Level 1 Blood Product Exchange and Related Services	$638.17	$542.44	 	
5242	Level 2 Blood Product Exchange and Related Services	$1,977.62	$1,680.98	 	
5243	Level 3 Blood Product Exchange and Related Services	$5,738.09	$4,877.38	 	
5244	Level 4 Blood Product Exchange and Related Services	$49,976.05	$42,479.64	 	
5301	Level 1 Upper GI Procedures	$1,259.62	$1,070.68	 	
5302	Level 2 Upper GI Procedures 	$2,402.69	$2,042.29	 	
5303	Level 3 Upper GI Procedures	$4,519.26	$3,841.37	 	
5311	Level 1 Lower GI Procedures 	$1,201.81	$1,021.54	 	
5312	Level 2 Lower GI Procedures 	$1,579.68	$1,342.73	 	
5313	Level 3 Lower GI Procedures 	$3,901.52	$3,316.29	 	
5331	Complex GI Procedures	$7,093.10	$6,029.14	 	
5341	Abdominal/Peritoneal/Biliary and Related Procedures	$5,152.93	$4,379.99	 	
5361	Level 1 Laparoscopy and Related Services	$7,558.43	$6,424.67	 	
5362	Level 2 Laparoscopy and Related Services	$12,545.71	$10,663.85	 	
5371	Level 1 Urology and Related Services	$388.87	$330.54	 	
5372	Level 2 Urology and Related Services	$988.99	$840.64	 	
5373	Level 3 Urology and Related Services	$2,960.39	$2,516.33	 	
5374	Level 4 Urology and Related Services	$4,576.61	$3,890.12	 	
5375	Level 5 Urology and Related Services	$6,271.22	$5,330.54	 	
5376	Level 6 Urology and Related Services	$13,414.79	$11,402.57	 	
5377	Level 7 Urology and Related Services	$25,854.50	$21,976.33	 	
5401	Dialysis	$994.64	$845.44	 	
5411	Level 1 Gynecologic Procedures	$273.98	$232.88	 	
5412	Level 2 Gynecologic Procedures	$496.37	$421.91	 	
5413	Level 3 Gynecologic Procedures	$1,198.57	$1,018.78	 	
5414	Level 4 Gynecologic Procedures	$3,753.85	$3,190.77	 	
5415	Level 5 Gynecologic Procedures	$6,859.53	$5,830.60	 	
5416	Level 6 Gynecologic Procedures	$10,558.93	$8,975.09	 	
5431	Level 1 Nerve Procedures	$2,814.16	$2,392.04	 	
5432	Level 2 Nerve Procedures	$7,473.35	$6,352.35	 	
5441	Level 1 Nerve Injections	$415.80	$353.43	 	
5442	Level 2 Nerve Injections	$912.94	$776.00	 	
5443	Level 3 Nerve Injections	$1,150.07	$977.56	 	
5461	Level 1 Neurostimulator and Related Procedures	$4,842.83	$4,116.41	 	
5462	Level 2 Neurostimulator and Related Procedures	$10,341.20	$8,790.02	 	
5463	Level 3 Neurostimulator and Related Procedures	$32,046.08	$27,239.17	 	
5464	Level 4 Neurostimulator and Related Procedures	$48,684.80	$41,382.08	 	
5471	Implantation of Drug Infusion Device	$28,120.63	$23,902.54	 	
5481	Laser Eye Procedures	$845.77	$718.90	 	
5491	Level 1 Intraocular Procedures	$3,283.83	$2,791.26	 	
5492	Level 2 Intraocular Procedures	$6,153.77	$5,230.70	 	
5493	Level 3 Intraocular Procedures	$14,762.93	$12,548.49	 	
5494	Level 4 Intraocular Procedures	$21,685.10	$18,432.34	 	
5495	Level 5 Intraocular Procedures	$34,185.15	$29,057.38	 	
5501	Level 1 Extraocular, Repair, and Plastic Eye Procedures	$483.28	$410.79	 	
5502	Level 2 Extraocular, Repair, and Plastic Eye Procedures	$1,394.23	$1,185.10	 	
5503	Level 3 Extraocular, Repair, and Plastic Eye Procedures	$3,062.66	$2,603.26	 	
5504	Level 4 Extraocular, Repair, and Plastic Eye Procedures	$4,994.69	$4,245.49	 	
5521	Level 1 Imaging without Contrast	$107.75	$91.59	 	
5522	Level 2 Imaging without Contrast	$202.91	$172.47	 	
5523	Level 3 Imaging without Contrast	$406.64	$345.64	 	
5524	Level 4 Imaging without Contrast	$809.42	$688.01	 	
5571	Level 1 Imaging with Contrast	$477.04	$405.48	 	
5572	Level 2 Imaging with Contrast	$767.74	$652.58	 	
5573	Level 3 Imaging with Contrast	$1,182.44	$1,005.07	 	
5591	Level 1 Nuclear Medicine and Related Services 	$599.54	$509.61	 	
5592	Level 2 Nuclear Medicine and Related Services	$772.43	$656.57	 	
5593	Level 3 Nuclear Medicine and Related Services 	$2,050.09	$1,742.58	 	
5594	Level 4 Nuclear Medicine and Related Services	$2,378.75	$2,021.94	 	
5611	Level 1 Therapeutic Radiation Treatment Preparation	$211.66	$179.91	 	
5612	Level 2 Therapeutic Radiation Treatment Preparation	$560.83	$476.71	 	
5613	Level 3 Therapeutic Radiation Treatment Preparation	$1,919.23	$1,631.35	 	
5621	Level 1 Radiation Therapy	$205.83	$174.96	 	
5622	Level 2 Radiation Therapy	$368.12	$312.90	 	
5623	Level 3 Radiation Therapy	$890.33	$756.78	 	
5624	Level 4 Radiation Therapy	$1,329.53	$1,130.10	 	
5625	Level 5 Radiation Therapy	$1,789.42	$1,521.01	 	
5626	Level 6 Radiation Therapy	$2,972.32	$2,526.47	 	
5627	Level 7 Radiation Therapy	$13,420.78	$11,407.66	 	
5661	Therapeutic Nuclear Medicine	$390.02	$331.52	 	
5671	Level 1 Pathology	$71.46	$60.74	 	
5672	Level 2 Pathology	$186.98	$158.93	 	
5673	Level 3 Pathology	$331.22	$281.54	 	
5674	Level 4 Pathology	$817.49	$694.87	 	
5691	Level 1 Drug Administration	$62.60	$53.21	 	
5692	Level 2 Drug Administration	$95.71	$81.35	 	
5693	Level 3 Drug Administration	$323.59	$275.05	 	
5694	Level 4 Drug Administration	$503.01	$427.56	 	
5721	Level1 Diagnostic Tests and Related Services	$228.78	$194.46	 	
5722	Level 2 Diagnostic Tests and Related Services	$418.16	$355.44	 	
5723	Level 3 Diagnostic Tests and Related Services	$748.57	$636.28	 	
5724	Level 4 Diagnostic Tests and Related Services	$1,556.17	$1,322.74	 	
5731	Level 1 Minor Procedures	$22.72	$19.31	 	
5732	Level 2 Minor Procedures	$51.08	$43.42	 	
5733	Level 3 Minor Procedures	$98.19	$83.46	 	
5734	Level 4 Minor Procedures	$180.04	$153.03	 	
5735	Level 5 Minor Procedures	$474.50	$403.33	 	
5741	Level 1 Electronic Analysis of Devices	$63.27	$53.78	 	
5742	Level 2 Electronic Analysis of Devices	$196.60	$167.11	 	
5743	Level 3 Electronic Analysis of Devices	$454.73	$386.52	 	
5771	Cardiac Rehabilitation	$198.40	$168.64	 	
5781	Resuscitation and Cardioversion	$866.41	$736.45	 	
5791	Pulmonary Treatment	$291.74	$247.98	 	
5801	Ventilation Initiation and Management	$763.11	$648.64	 	
5811	Manipulation Therapy	$44.32	N/A	 	
5821	Level 1 Health and Behavior Services	$45.41	N/A	 	
5822	Level 2 Health and Behavior Services	$126.47	N/A	 	
5823	Level 3 Health and Behavior Services	$226.82	N/A	 	
5853	Partial Hospitalization (3 or more services) for CMHCs	$218.75	N/A	 	
5863	Partial Hospitalization (3 or more services) for Hospital-based PHPs	$373.25	N/A	 	
5871	Dental Procedures	$923.53	$785.00	 	
5881	Ancillary Outpatient Services When Patient Dies	$12,157.83	$10,334.16	 	
7000	Amifostine	$934.22	$794.09	 	
7011	Oprelvekin injection	$841.00	$714.85	 	
7034	Somatropin injection	$146.86	$124.83	 	
7035	Teniposide	$4,667.02	$3,966.97	 	
7041	Tirofiban HCl	$17.66	$15.01	 	
7043	Infliximab not biosimil 10mg	$154.06	$130.95	 	
7046	Doxorubicin inj 10mg	$734.67	$624.47	 	
7048	Alteplase recombinant	$146.43	$124.47	 	
7308	Aminolevulinic acid hcl top	$662.06	$562.75	 	
8001	LDR Prostate Brachytherapy Composite	$6,300.45	$5,355.38	 	
8004	Ultrasound Composite	$519.05	$441.19	 	
8005	CT and CTA without Contrast Composite	$491.56	$417.83	 	
8006	CT and CTA with Contrast Composite	$880.87	$748.74	 	
8007	MRI and MRA without Contrast Composite	$993.15	$844.18	 	
8008	MRI and MRA with Contrast Composite	$1,533.04	$1,303.08	 	
8010	Mental Health Services Composite	$373.25	$317.26	 	
8011	Comprehensive Observation Services	$4,000.75	$3,400.64	 	
9002	Tenecteplase injection	$184.36	$156.71	 	
9003	Palivizumab	$317.43	$269.82	 	
9005	Reteplase injection	$4,143.44	$3,521.92	 	
9006	Tacrolimus injection	$307.53	$261.40	 	
9012	Arsenic trioxide injection	$116.87	$99.34	 	
9018	Inj, rimabotulinumtoxinB	$21.15	$17.98	 	
9019	Caspofungin acetate	$19.01	$16.16	 	
9024	Amphotericin b lipid complex	$23.72	$20.16	 	
9032	Baclofen 10 MG injection	$303.64	$258.09	 	
9033	Cidofovir injection	$939.82	$798.85	 	
9038	Inj estrogen conjugate	$501.10	$425.94	 	
9042	Glucagon hydrochloride	$361.48	$307.26	 	
9043	Afstyla Factor VIII recomb	$2.56	$2.18	 	
9044	Ibutilide fumarate injection	$346.50	$294.53	 	
9052	Fluciciovine F-18	$701.19	$596.01	 	
9056	Gallium Ga-68	$120.13	$102.11	 	
9058	Buprenorphine implant 74.2mg	$2,269.06	$1,928.70	 	
9059	Vonvendi inj 1 iu vwf:rco	$4.09	$3.48	 	
9060	Diazoxide injection	$1,242.05	$1,055.74	 	
9061	Inj milrinone lactate / 5 mg	$4.46	$3.79	 	
9062	Topotecan injection	$2.27	$1.93	 	
9104	Antithymocyte globuln rabbit	$1,237.99	$1,052.29	 	
9108	Thyrotropin injection	$2,820.47	$2,397.40	 	
9119	Injection, pegfilgrastim 6mg	$7,544.41	$6,412.75	 	
9120	Injection, Fulvestrant	$173.23	$147.25	 	
9122	Triptorelin pamoate	$657.79	$559.12	 	
9124	Daptomycin injection	$1.22	$1.04	 	
9125	Risperidone, long acting	$14.71	$12.50	 	
9126	Natalizumab injection	$33.84	$28.76	 	
9130	Inj, Imm Glob Bivigam, 500mg	$68.96	$58.62	 	
9131	Inj, Ado-trastuzumab Emt 1mg	$53.14	$45.17	 	
9132	Kcentra, per i.u.	$3.33	$2.83	 	
9133	Rabies ig, im/sc	$534.08	$453.97	 	
9134	Rabies ig, heat treated	$533.41	$453.40	 	
9135	Varicella-zoster ig, im	$2,215.76	$1,883.40	 	
9139	Rabies vaccine, im	$485.84	$412.96	 	
9140	Rabies vaccine, id	$253.84	$215.76	 	
9171	Factor ix idelvion inj	$7.47	$6.35	 	
9207	Bortezomib injection	$83.25	$70.76	 	
9208	Agalsidase beta injection	$298.91	$254.07	 	
9209	Laronidase injection	$55.10	$46.84	 	
9210	Palonosetron hcl	$40.73	$34.62	 	
9213	Pemetrexed injection	$115.27	$97.98	 	
9214	Bevacizumab injection	$132.48	$112.61	 	
9215	Cetuximab injection	$101.50	$86.28	 	
9217	Leuprolide acetate suspnsion	$388.82	$330.50	 	
9224	Galsulfase injection	$664.96	$565.22	 	
9225	Fluocinolone acetonide implt	$36,198.70	$30,768.90	 	
9228	Tigecycline injection	$5.72	$4.86	 	
9229	Ibandronate sodium injection	$140.92	$119.78	 	
9230	Abatacept injection	$84.35	$71.70	 	
9231	Decitabine injection	$32.33	$27.48	 	
9232	Idursulfase injection	$939.62	$798.68	 	
9233	Ranibizumab injection	$675.38	$574.07	 	
9234	Alglucosidase alfa injection	$372.06	$316.25	 	
9235	Panitumumab injection	$193.88	$164.80	 	
9236	Eculizumab injection	$407.93	$346.74	 	
9237	Inj, lanreotide acetate	$97.22	$82.64	 	
9240	Injection, ixabepilone	$135.65	$115.30	 	
9242	Injection, fosaprepitant	$3.49	$2.97	 	
9243	Inj., treanda 1 mg	$50.35	$42.80	 	
9245	Romiplostim injection	$117.05	$99.49	 	
9248	Inj, clevidipine butyrate	$3.96	$3.37	 	
9251	C1 esterase inhibitor inj	$99.95	$84.96	 	
9252	Plerixafor injection	$561.78	$477.51	 	
9253	Temozolomide injection	$16.11	$13.69	 	
9255	Paliperidone palmitate inj	$17.10	$14.54	 	
9256	Dexamethasone intra implant	$361.40	$307.19	 	
9258	Telavancin injection	$9.00	$7.65	 	
9259	Pralatrexate injection	$429.62	$365.18	 	
9260	Ofatumumab injection	$96.10	$81.69	 	
9261	Ustekinumab sub cu inj, 1 mg	$313.56	$266.53	 	
9263	Ecallantide injection	$758.92	$645.08	 	
9264	Tocilizumab injection	$7.60	$6.46	 	
9265	Romidepsin injection	$571.64	$485.89	 	
9269	C-1 esterase, berinert	$87.66	$74.51	 	
9270	Gammaplex IVIG	$74.92	$63.68	 	
9271	Velaglucerase alfa	$616.86	$524.33	 	
9272	Inj, denosumab	$29.93	$25.44	 	
9273	Sipuleucel-T auto CD54+	$71,854.22	$61,076.09	 	
9274	Crotalidae Poly Immune Fab	$5,165.86	$4,390.98	 	
9276	Cabazitaxel injection	$281.99	$239.69	 	
9278	Incobotulinumtoxin A	$8.87	$7.54	 	
9281	Injection, pegloticase	$3,278.75	$2,786.94	 	
9284	Ipilimumab injection	$260.39	$221.33	 	
9286	Belatacept injection	$6.89	$5.86	 	
9287	Brentuximab vedotin inj	$241.47	$205.25	 	
9289	Erwinaze injection	$724.93	$616.19	 	
9293	Injection, glucarpidase 	$511.60	$434.86	 	
9294	Inj, Taliglucerace Alfa 10 u	$72.72	$61.81	 	
9295	Injection, Carfilzomib, 1 mg	$57.96	$49.27	 	
9296	Inj, ziv-aflibercept, 1mg	$14.62	$12.43	 	
9297	Inj, Omacetaxine Mep, 0.01mg	$4.90	$4.17	 	
9298	Inj, Ocriplasmin, 0.125 mg	$1,884.15	$1,601.53	 	
9300	Omalizumab injection	$60.50	$51.43	 	
9441	Inj ferric carboxymaltos 1mg	$1.91	$1.62	 	
9445	Injection, ruconest	$50.29	$42.75	 	
9448	Netupitant palonosetron oral	$800.84	$680.71	 	
9449	Injection, blinatumomab	$177.89	$151.21	 	
9450	Fluocinol acet intravit imp	$883.71	$751.15	 	
9451	Injection, peramivir	$2.92	$2.48	 	
9452	Inj ceftolozane tazobactam	$8.53	$7.25	 	
9453	Injection, nivolumab	$47.57	$40.43	 	
9454	Inj, pasireotide long acting	$469.37	$398.96	 	
9455	Injection, siltuximab	$162.04	$137.73	 	
9456	Injection, isavuconazonium	$1.13	$0.96	 	
9457	Inj sulf hexa lipid microsph	$38.90	$33.07	 	
9458	florbetaben f18 diagnostic	$5,342.40	$4,541.04	 	
9459	flutemetamol f18 diagnostic	$6,296.40	$5,351.94	 	
9460	Injection, cangrelor	$27.67	$23.52	 	
9461	Choline c-11, diagnostic, per study dose up to 20 millicuries	$10,260.00	$8,721.00	 	
9470	Aripiprazole lauroxil 1mg	$4.30	$3.66	 	
9471	Hymovis injection 1 mg	$30.17	$25.64	 	
9472	Inj talimogene laherparepvec	$82.87	$70.44	 	
9473	Injection, mepolizumab, 1mg	$47.97	$40.77	 	
9474	Inj irinotecan liposome 1 mg	$71.06	$60.40	 	
9475	Injection, necitumumab, 1 mg	$9.45	$8.03	 	
9476	Injection, daratumumab 10 mg	$86.60	$73.61	 	
9477	Injection, elotuzumab, 1mg	$11.18	$9.50	 	
9478	Inj sebelipase alfa 1 mg	$954.00	$810.90	 	
9479	Instill, ciprofloxacin otic	$53.91	$45.82	 	
9480	Injection trabectedin 0.1mg	$510.19	$433.66	 	
9481	Injection, reslizumab	$15.93	$13.54	 	
9482	Sotalol hydrochloride IV	$17.98	$15.28	 	
9483	Injection, atezolizumab	$136.12	$115.70	 	
9484	Injection, eteplirsen	$305.28	$259.49	 	
9485	Injection, olaratumab	$90.05	$76.54	 	
9486	Inj, granisetron ext	$9.34	$7.94	 	
9487	Ustekinumab IV inj, 1 mg	$23.00	$19.55	 	
9488	Conivaptan HCL	$53.87	$45.79	 	
9497	Loxapine, inhalation powder	$270.07	$229.56	 	
9500	Platelets, irradiated	$301.36	$256.16	 	
9501	Platelet pheres leukoreduced	$899.91	$764.92	 	
9502	Platelet pheresis irradiated	$1,001.84	$851.56	 	
9503	Fr frz plasma donor retested	$120.94	$102.80	 	
9504	RBC deglycerolized	$690.44	$586.87	 	
9505	RBC irradiated	$394.11	$334.99	 	
9507	Platelets, pheresis	$741.78	$630.51	 	
9508	Plasma 1 donor frz w/in 8 hr	$132.71	$112.80	 	
9509	Frozen plasma, pooled, sd	$120.28	$102.24	 	
9510	Whole blood for transfusion	$279.92	$237.93	 	
9511	Cryoprecipitate each unit	$95.45	$81.13	 	
9512	RBC leukocytes reduced	$334.48	$284.31	 	
9513	Plasma, frz between 8-24hour	$133.20	$113.22	 	
9514	Plasma protein fract,5%,50ml	$35.57	$30.23	 	
9515	Platelets, each unit	$173.68	$147.63	 	
9516	Plaelet rich plasma unit	$237.02	$201.47	 	
9517	Red blood cells unit	$256.25	$217.81	 	
9518	Washed red blood cells unit	$619.87	$526.89	 	
9519	Plasmaprotein fract,5%,250ml	$166.81	$141.79	 	
9520	Blood split unit	$237.56	$201.93	 	
9521	Platelets leukoreduced irrad	$291.76	$248.00	 	
9522	RBC leukoreduced irradiated	$479.30	$407.41	 	
9523	Cryoprecipitatereducedplasma	$113.92	$96.83	 	
9524	Blood, l/r, cmv-neg	$371.66	$315.91	 	
9525	Platelets, hla-m, l/r, unit	$1,328.65	$1,129.35	 	
9526	Platelets leukocytes reduced	$226.31	$192.36	 	
9527	Blood, l/r, froz/degly/wash	$496.04	$421.63	 	
9528	Plt, aph/pher, l/r, cmv-neg	$759.60	$645.66	 	
9529	Blood, l/r, irradiated	$223.87	$190.29	 	
9530	Plate pheres leukoredu irrad	$1,165.32	$990.52	 	
9531	Plt, pher, l/r cmv-neg, irr	$1,114.00	$946.90	 	
9532	RBC, frz/deg/wsh, l/r, irrad	$373.41	$317.40	 	
9533	RBC, l/r, cmv-neg, irrad	$450.18	$382.65	 	
9534	Pathogen reduced plasma pool	$133.20	$113.22	 	
9535	Pathogen reduced plasma sing	$132.71	$112.80	 	
9536	Pathogen reduced platelets	$1,165.32	$990.52	 	

Exhibit #5	
Rural Health Clinics	
Find the most updated list at: https://www.colorado.gov/pacific/cdphe/find-and-compare-facilities 
(effective 1/1/2018)	
Facility		Address	City	State	Zip	County	Contact	
AKRON CLINIC	82 MAIN	Akron	CO	80720	Washington	Phone: 
(970)345-6336, 
Fax: (970)345-6576	
ARKANSAS VALLEY FAMILY PRACTICE, LLC	2317 SAN JUAN AVE	La Junta	CO	81050	Otero	Phone: 
(719)383-2325, 
Fax: (719)383-2327	
BANNER HEALTH CENTER STERLING	102 HAYS AVE	Sterling	CO	80751	Logan	Phone: 
(970)521-3223, 
Fax: (970)521-3266	
BASIN CLINIC	421 WEST ADAMS ROAD	Naturita	CO	80723	Montrose	Phone: 
(970)865-2665, 
Fax: (970)825-2674	
BRUSH FAMILY CLINIC	2400 W EDISON	Brush	CO	81211	Morgan	Phone: 
(970)842-6740, 
Fax: (970)842-6241	
BUENA VISTA HEALTH CENTER	28374 COUNTY ROAD 317	Buena Vista	CO	81211	Chaffee	Phone: 
(719)395-9048, 
Fax: (719)395-9064	
BUTTON FAMILY PRACTICE	715 SOUTH 9TH STREET	Canon City	CO	81212	Fremont	Phone: 
(719)269-8820, 
Fax: (719)204-0230	
CENTENNIAL FAMILY HEALTH CENTER	319 MAIN STREET	Ordway	CO	81063	Crowley	Phone: 
(719)267-3503, 
Fax: (719)267-4153	
CORTEZ PRIMARY CARE CLINIC	118 NORTH CHESTNUT	Cortez	CO	81321	Montezuma	Phone: 
(970)564-9777, 
Fax: (970)564-8833	
CREEDE FAMILY PRACTICE OF RIO GRANDE HOSPITAL	802 RIO GRANDE AVENUE	Creede	CO	81130	Mineral	Phone: 
(719)658-0929, 
Fax: (719)657-2851	
CUSTER COUNTY MEDICAL CENTER	704 EDWARDS	Westcliffe	CO	81252	Custer	Phone: 
(719)783-2380, 
Fax: (719)783-2377	
EADS MEDICAL CLINIC	1211 LUTHER STREET	Eads	CO	81036	Kiowa	Phone: 
(719)438-2251, 
Fax: (719)438-2254	
EASTERN PLAINS MEDICAL CLINIC OF CALHAN	560 CRYSTOLA STREET	Calhan	CO	80808	El Paso	Phone: 
(719)347-0100, 
Fax: (719)347-0551	
FAMILY CARE CLINIC	615 FAIRHURST	Sterling	CO	80751	Logan	Phone: 
(970)521-3223, 
Fax: (970)521-3266	
FAMILY PRACTICE OF HOLYOKE	1001 EAST JOHNSON STREET	Holyoke	CO	80734	Phillips	Phone: 
(970)854-2500, 
Fax: (970)854-3440	
FLORENCE MEDICAL CENTER	501 W 5TH ST	Florence	CO	81226	Fremont	Phone: 
(719)784-4816, 
Fax: (719)784-6014	
GRAND RIVER HEALTH CLINIC WEST	201 SIPPERELLE DRIVE	Parachute	CO	81635	Garfield	Phone: 
(970)285-7046, 
Fax: (970)285-6064	
GRAND RIVER PRIMARY CARE	501 AIRPORT ROAD	Rifle	CO	81650	Garfield	Phone: 
(970)625-1100, 
Fax: (970)625-0725	
KIT CARSON CLINIC	102 EAST 2ND AVENUE	Kit Carson	CO	80825	Cheyenne	Phone: 
(719)962-3501, 
Fax: (719)962-3403	
LAKE CITY AREA MEDICAL CENTER	700 N HENSON STREET	Lake City	CO	81235	Hinsdale	Phone: 
(970)944-2331, 
Fax: (970)944-2320	
LAMAR MEDICAL CLINIC	403 KENDALL DRIVE	Lamar	CO	81052	Prowers	Phone: 
(719)336-6767, 
Fax: (719)336-7217	
MANCOS VALLEY HEALTH CENTER	111 RAILROAD AVE	Mancos	CO	81328	Montezuma	Phone: 
(970)564-2104, 
Fax: (970)564-2134	
MEEKER FAMILY HEALTH CENTER	345 CLEVELAND STREET	Meeker	CO	81641	Rio Blanco	Phone: 
(970)878-4014, 
Fax: (970)878-3285	
MONTE VISTA RHC OF RIO GRANDE HOSPITAL	1033 2ND AVENUE	Monte Vista	CO	81144	Rio Grande	Phone: 
(719)852-8827, 
Fax: (719)852-2739	
MT SAN RAFAEL HOSPITAL HEALTH CLINIC	400 BENEDICTA STE A	Trinidad	CO	81082	Las Animas	Phone: 
(719)846-2206, 
Fax: (719)846-7823	
NORTH PARK MEDICAL CENTER - WALDEN	350 MCKINLEY STREET	Walden	CO	80480	Jackson	Phone: 
(970)723-4255, 
Fax: (970)723-4268	
PAGOSA MOUNTAIN CLINIC	95 SOUTH PAGOSA BLVD	Pagosa Springs	CO	81147	Archuleta	Phone: 
(970)731-3700, 
Fax: (970)731-3707	
PARKE HEALTH CLINIC	182 16TH ST	Burlington	CO	80807	Kit Carson	Phone: 
(719)346-9481, 
Fax: (719)346-9485	
PEDIATRIC ASSOCIATION OF CANON CITY	1335 PHAY AVENUE, SUITE A	Canon City	CO	81212	Fremont	Phone: 
(719)269-1727, 
Fax: (719)269-1730	
PRAIRIE VIEW RURAL HEALTH CLINIC	615 WEST 5TH NORTH	Cheyenne Wells	CO	80810	Cheyenne	Phone: 
(719)767-5669, 
Fax: (719)767-5098	
RIO GRANDE HOSPITAL CLINIC	0310C COUNTY RD 14	Del Norte	CO	81132	Rio Grande	Phone:
(719)657-2418, 
Fax: (719)658-3001	
ROCKY FORD FAMILY HEALTH CENTER	1014 ELM AVENUE	Rocky Ford	CO	81067	Otero	Phone: 
(719)254-7421, 
Fax: (719)254-6966	
SABATINI PEDIATRICS PC	612 YALE PLACE	Canon City	CO	81212	Fremont	Phone: 
(719)275-3442, 
Fax: (719)275-2306	
SAN LUIS VALLEY HEALTH ANTONITO CLINIC	115 MAIN STREET	Antonito	CO	81120	Conejos	Phone: 
(719)376-2308, 
Fax: (719)376-2395	
SAN LUIS VALLEY LA JARA MEDICAL CLINIC	509 MAIN STREET	La Jara	CO	81140	Conejos	Phone: 
(719)274-5000, 
Fax: (719)274-4111	
SOUTHEAST COLORADO PHYSICIANS CLINIC	900 CHURCH STREET	Springfield	CO	81073	Baca	Phone: 
(719)523-6628, 
Fax: (719)523-4513	
SOUTHWEST MEMORIAL PRIMARY CARE	33 NORTH ELM STREET	Cortez	CO	81321	Montezuma	Phone: 
(970)565-8556, 
Fax: (970)564-1134	
SOUTHWEST SCHOOL-BASED HEALTH CENTER	418 S SLIGO STREET	Cortez	CO	81321	Montezuma	Phone: 
(970)564-2104, 
Fax: (970)564-2134	
SOUTHWEST WALK-IN CARE	2095 NORTH DOLORES ROAD, STE C	Cortez	CO	81321	Montezuma	Phone: 
(970)564-1037, 
Fax: (970)564-1041	
SPANISH PEAKS FAMILY CLINIC	23400 US HIGHWAY 160	Walsenburg	CO	81089	Huerfano	Phone: 
(719)738-4591, 
Fax: (719)738-4553	
STRATTON MEDICAL CLINIC	500 NEBRASKA AVENUE	Stratton	CO	80836	Kit Carson	Phone: 
(719)348-4650, 
Fax: (719)348-4653	
SURFACE CREEK FAMILY PRACTICE	255 SW 8TH AVE	Cedaredge	CO	81413	Delta	Phone: 
(970)856-3146, 
Fax: (970)856-4385	
VALLEY MEDICAL CLINIC	116 E NINTH STREET	Julesburg	CO	80737	Sedgwick	Phone: 
(970)474-3376, 
Fax: (970)474-2461	
WALSH MEDICAL CLINIC	137 KANSAS STREET	Walsh	CO	81090	Baca	Phone: 
(719)324-5253, 
Fax: (719)324-5621	
WASHINGTON COUNTY CLINIC	482 ADAMS AVENUE	Akron	CO	80720	Washington	Phone: 
(970)345-2262, 
Fax: (970)345-2265	
YUMA CLINIC	1000 W 8TH AVENUE	Yuma	CO	80759	Yuma	Phone: 
(970)848-4676, 
Fax: (970)848-4952	

Exhibit #6 Dental Fees	
Effective for Dates of Service on and after 1/1/2018	
CDT 2017	2018 fees	
D0120	$67.15 	
D0140	$112.29 	
D0145	$104.19 	
D0150	$118.08 	
D0160	$237.31 	
D0170	$78.72 	
D0171	$71.25 	
D0180	$128.50 	
D0190	$62.00 	
D0191	$44.00 	
D0210	$187.18 	
D0220	$37.68 	
D0230	$34.03 	
D0240	$58.35 	
D0250	$71.72 	
D0251	BR	
D0270	$38.89 	
D0272	$63.21 	
D0273	$76.58 	
D0274	$88.74 	
D0277	$133.71 	
D0310	$556.70 	
D0320	$948.10 	
D0321	BR	
D0322	$765.77 	
D0330	$165.54 	
D0340	$186.38 	
D0350	$89.13 	
D0351	$73.75 	
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	
D0393	BR	
D0394	BR	
D0395	BR	
D0414	BR	
D0415	$72.00 	
D0416	$106.00 	
D0417	$97.00 	
D0418	$100.00 	
D0422	BR	
D0423	BR	
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	
D0600	BR	
D0601	$93.00 	
D0602	$93.00 	
D0603	$93.00 	
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 	
D1353	$80.75 	
D1354	BR	
D1510	$503.57 	
D1515	$704.99 	
D1520	$554.51 	
D1525	$856.64 	
D1550	$108.82 	
D1555	$104.19 	
D1575	BR	
D1999	BR	
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 	
D2921	$179.50 	
D2929	$543.00 	
D2930	$395.04 	
D2931	$447.31 	
D2932	$476.48 	
D2933	$545.76 	
D2934	$545.76 	
D2940	$150.73 	
D2941	$130.00 	
D2949	$130.00 	
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 	
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 	
D3355	$577.25 	
D3356	$259.00 	
D3357	BR	
D3410	$1,920.50 	
D3421	$2,138.07 	
D3425	$2,421.29 	
D3426	$818.03 	
D3427	$1,035.75 	
D3428	$1,509.25 	
D3429	$1,439.50 	
D3430	$601.67 	
D3431	$1,772.25 	
D3432	$1,523.50 	
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 	
D4283	BR	
D4285	BR	
D4320	$625.99 	
D4321	$633.28 	
D4341	$361.00 	
D4342	$217.57 	
D4346	BR	
D4355	$246.75 	
D4381	BR	
D4910	$222.44 	
D4920	$161.66 	
D4921	BR	
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 	
D5221	BR	
D5222	BR	
D5223	BR	
D5224	BR	
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 	
D5862	BR	
D5863	$2,295.25 	
D5864	BR	
D5865	$2,295.25 	
D5866	$3,146.00 	
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	$1,411.50 	
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	$241.00 	
D5987	$3,627.07 	
D5988	$641.00 	
D5991	$246.00 	
D5992	BR	
D5993	BR	
D5994	$227.50 	
D5999	BR	
D6010	$3,914.00 	
D6011	BR	
D6012	$3,698.00 	
D6013	$3,623.00 	
D6040	$14,418.34 	
D6050	$10,047.00 	
D6051	BR	
D6052	$1,535.25 	
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 	
D6080	$184.00 	
D6081	BR	
D6085	BR	
D6090	BR	
D6091	$887.00 	
D6092	$173.00 	
D6093	$271.00 	
D6094	$1,887.68 	
D6095	BR	
D6100	BR	
D6101	$587.50 	
D6102	$769.75 	
D6103	$672.50 	
D6104	$672.50 	
D6110	$2,705.00 	
D6111	$2,705.00 	
D6112	$2,705.00 	
D6113	$2,705.00 	
D6114	BR	
D6115	BR	
D6116	BR	
D6117	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 	
D6549	$377.21 	
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 	
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	$446.76 	
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 	
D7881	BR	
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	$5,137.00 	
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 	
D8681	BR	
D8690	$545.76 	
D8691	$512.95 	
D8692	$571.28 	
D8693	$528.75 	
D8694	BR	
D8999	BR	
D9110	$215.15 	
D9120	$243.11 	
D9210	$181.65 	
D9211	$200.55 	
D9212	$312.90 	
D9215	$150.15 	
D9219	BR	
D9223	BR	
D9230	BR	
D9243	BR	
D9248	$437.85 	
D9310	$487.42 	
D9311	BR	
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	
D9932	BR	
D9933	BR	
D9934	BR	
D9935	BR	
D9940	$940.80 	
D9941	$307.52 	
D9942	$354.24 	
D9943	BR	
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 	
D9985	BR	
D9986	BR	
D9987	BR	
D9991	BR	
D9992	BR	
D9993	BR	
D9994	BR	
D9999	BR	

Exhibit #7
Evaluation and Management (E&M) Documentation Guidelines 
for Colorado Workers’ Compensation Claims
Effective for Dates of Service on and after 1/1/2018

This E&M Guidelines for Colorado Workers’ Compensation Claims is intended for the providers who manage injured workers’ medical and non-medical care. Providers may also use the “1997 Documentation Guidelines for Evaluation and Management Services” as developed by Medicare. The Level of Service is determined by:
1. History (Hx), 
2. Examination (Exam), and 
3. Medical Decision Making (MDM) 

Documentation requirements for any billed office visit:
•	Chief complaint and medical necessity. 
•	Patient specific and pertain directly to the current visit.
•	Information copied directly from prior records without change is not considered current or counted.
•	CPT© criteria for a consultation is required to bill a consultation code.

Table I – History (Hx) Component:   All three elements in the table must be met and documented.
HISTORY ELEMENTS	Requirements for a Problem Focused (PF) Level	Requirements for an Extended Problem Focused (EPF) Level	Requirements for a Detailed (D) Level	Requirements for a Comprehensive (C) Level	
A. History of Present Illness/Injury (HPI)	Brief 1-3 elements	Brief 1-3 elements	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)	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)	
B. Review of Systems (ROS) 
(not required for established patient visits)	None	Problem pertinent-limited to injured body part	2-9 body parts or body systems	Complete 10+	
C. 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, regularity of occurrence, only at night, etc.?) 
	6. Context (what ADLs or functions aggravates/relieves, accident described?)
	7. Modifying factors (doing what, what makes it worse or better?) 
	8. Associated signs (nausea, numbness or tingling when?) 
For the provider to achieve an “extended” HPI in an initial patient/injured workers 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. 
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. 

B. Review of Systems (ROS): each system/body part is counted once whether positive or negative. Identify, perform and documentation of all pertinent ROS systems with either a “positive or negative” response is necessary to be counted.
	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

C.  PMFSH consists of a review of four areas (NOTE: Employers should not have access to any patient’s or the family’s genetic/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/Military – 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.

TABLE II: Examination Component: Each bullet is counted only when it is pertinent and related to the workers’ compensation injury and the medical decision making process.
Physician's Examination Component	
Level of Examination Performed and Documented	# of Bullets Required for each level	
Problem Focused	1-5 elements identified by a bullet as indicated in the 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	

Examination Components:
Constitutional Measurement:
•	Vital signs (may be measured and recorded by ancillary staff) – any of three (3) 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: 
•	Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions 
•	Assessment of range of motion with notation of any pain (e.g., straight leg raise), crepitation or contracture 
•	Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
•	Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements (fasciculation, tardive dyskinesia)
•	Examination of gait and station 
•	Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechia, ischemia, infections, nodes)
 Neck: One bullet for both examinations.
•	Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus) and
•	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)
		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, café au lait spots, 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 	

Genitourinary 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

Verify all of the completed examination components listed in the report documents the relevance/relatedness to the injury and or “reasonable and necessity” for that specified patient’s condition.  Any examination bullet that is not clearly related to the injury or a patient’s specific condition will not be counted/considered in the total number of bullets for the level of service. 

TABLE III: Medical Decision Making Component (MDM):  TABLES A, B, AND C
Overall MDM is determined by the highest 2 out of 3 categories below:

Table III. 
Medical Decision Making (MDM) Component 			
Level of Risk	A. # of Points for the # of Diagnosis and Management Options 	
B.  # of Points for Amount and Complexity of Data	
C. Level of Risk	
Straightforward	0-1	0-1	Minimal	
Low	2	2	Low	
Moderate	3	3	Moderate	
High	4+	4+	High	

TABLE III A:
A.  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	(max 1)	X	3	 	 	
New problem, additional workup planned or established patient with worsening of condition and no additional workup planned	 	X	4	 	 	

TABLE III B:
B. 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 records 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	 	

TABLE III C: 
C. Table of Risk (the highest one in any category determines the overall risk for this portion.)	
Level of Risk	Presenting Problem(s)	Diagnostic Procedure(s) Ordered	Management Option(s) Section	

Minimal	One self-limiting or minor problem, e.g., cold, insect bite, tinea corporis, 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, DM2, cataract, BPH; Acute, uncomplicated illness or injury, e.g., allergic rhinitis, sprain. 	Physiologic tests not under stress, e.g., PFTs;
Non-cardiovascular imaging studies with contrast, e.g., barium enema;
Superficial needle biopsy;
ABG; Skin biopsies	Over the counter drugs; 
Minor surgery with no identified risk factors;
PT/OT;
IV fluids w/o additives; 
Simple or layered closure;
Vaccine injection	

Moderate	One or more chronic illness with mild exacerbation, 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; 
Diagnostic injections;
Deep needle, or incisional biopsies; 
Cardiovascular imaging studies, with contrast, and no identified risk factors, e.g., arteriogram, cardiac catheterization;
Obtain fluid from body cavity, e.g., LP/thoracentesis.
	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 treatment of fracture or dislocation, without manipulation;
Inability to return the injured worker to work and requires detailed functional improvement plan.	

High

High cont.	One or more chronic illness, with severe exacerbation, progression or side effects of treatment; 
Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolism, 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 EP studies;
Diagnostic endoscopies, with identified risk factors.
	Elective major surgery (open, percutaneous, endoscopic), 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.	

Time Component: 
•	If greater than 50% 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.
•	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.
•	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.

	A. 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.
1. 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:
•	Injury/disease education that includes discussion of diagnostic tests results and a disease specific treatment plan.
•	Return to work
•	Temporary and/or permanent restrictions
•	Self-management of symptoms while at home and/or work
•	Correct posture/mechanics to perform work functions
•	Job task exercises for muscle strengthening and stretching
•	Appropriate tool and equipment use to prevent re-injury and/or worsening of the existing injury/condition
•	Patient/injured worker expectations and specific goals
•	Family and other interpersonal relationships and how they relate to psychological/social issues
•	Discussion of pharmaceutical management (includes drug dosage, specific drug side effects and potential of addiction /problems
•	Assessment of vocational plans (i.e., restrictions as they relate to current and future employment job requirements)

B. 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.

Table V:  New Patient/Office Consultations Level of Service: CPT consultation criteria must be met before a consultation can be billed for any level of service.

New Patient/ Level of Service (requires all three key components at the same level or higher)	

History	

Examination	

Medical Decision Making (MDM)	
Average Time (minutes) as listed for the specific CPT© code	
99201/99241	Problem Focused (PF)	PF	Straight Forward (SF)	10	
99202/99242	Extended PF	EPF	SF	20	
99203/99243	Detailed (D)	D	Low	30	
99204/99244	Comprehensive (C)	C	Moderate	45	
99205/99245	C	C	High	60	

Table VI: Established Patient Office Visit Level of Service

Established Patient/ Level of Service (Requires at least two of the three key components at the same level or higher and one of the two must be MDM)	

History	

Examination	

Medical Decision Making (MDM)	

Average Time (minutes) as listed for the specific CPT© code	
99211	N/A	N/A	N/A	5	
99212	Problem Focused (PF)	PF	SF	10	
99213	Extended PF	EPF	Low	15	
99214	Detailed (D)	D	Moderate	25	
99215	Comprehensive (C)	C	High	40	

Exhibit #8 Clinical Laboratory Fees	
Effective for Dates of Service on and after 1/1/2018	
HCPCS	Modifier	Maximum Fees 	SHORTDESC	
36415		5.10	Routine venipuncture	
36416		5.10		
78267		18.33	Breath tst attain/anal c-14	
78268		157.08	Breath test analysis c-14	
80047		19.72	Metabolic panel ionized ca	
80047	QW	19.72	Metabolic panel ionized ca	
80048		19.72	Metabolic panel total ca	
80048	QW	19.72	Metabolic panel total ca	
80050		52.75	General Health panel(85025,85004,80053)	
80051		16.35	Electrolyte panel	
80051	QW	16.35	Electrolyte panel	
80053		24.63	Comprehen metabolic panel	
80053	QW	24.63	Comprehen metabolic panel	
80055		111.49	Obstetric panel	
80061		31.23	Lipid panel	
80061	QW	31.23	Lipid panel	
80069		20.25	Renal function panel	
80069	QW	20.25	Renal function panel	
80074		111.08	Acute hepatitis panel	
80076		19.06	Hepatic function panel	
80081		174.57	Obstetric panel	
80150		35.16	Assay of amikacin	
80155		32.98	Drug screen quant caffeine	
80156		33.97	Assay carbamazepine total	
80157		30.91	Assay carbamazepine free	
80158		42.09	Assay of cyclosporine	
80159		43.13	Drug screen quant clozapine	
80162		30.96	Assay of digoxin	
80163		30.96	Assay of digoxin free	
80164		31.59	Assay dipropylacetic acid	
80165		31.59	Dipropylacetic acid free	
80168		38.10	Assay of ethosuximide	
80169		32.03	Drug screen quant everolimus	
80170		38.20	Assay of gentamicin	
80171		30.91	Drug screen quant gabapentin	
80173		33.97	Assay of haloperidol	
80175		30.91	Drug screen quan lamotrigine	
80176		34.26	Assay of lidocaine	
80177		30.91	Drug scrn quan levetiracetam	
80178		15.42	Assay of lithium	
80178	QW	15.42	Assay of lithium	
80180		42.09	Drug scrn quan mycophenolate	
80183		30.91	Drug scrn quant oxcarbazepin	
80184		26.71	Assay of phenobarbital	
80185		30.91	Assay of phenytoin total	
80186		32.10	Assay of phenytoin free	
80188		38.69	Assay of primidone	
80190		39.07	Assay of procainamide	
80192		39.07	Assay of procainamide	
80194		34.05	Assay of quinidine	
80195		32.03	Assay of sirolimus	
80197		32.03	Assay of tacrolimus	
80198		32.98	Assay of theophylline	
80199		42.11	Drug screen quant tiagabine	
80200		37.60	Assay of tobramycin	
80201		27.80	Assay of topiramate	
80202		31.59	Assay of vancomycin	
80203		30.91	Drug screen quant zonisamide	
80299	 	31.94	Quantitative assay drug	
80305	 	25.43	Drug test prsmv dir opt obs	
80306	 	33.92	Drug test prsmv instrmnt	
80307	 	135.68	Drug test prsmv chem anlyzr	
80400		76.06	Acth stimulation panel	
80402		202.78	Acth stimulation panel	
80406		145.67	Acth stimulation panel	
80408		292.66	Aldosterone suppression eval	
80410		187.36	Calcitonin stimul panel	
80412		768.67	CRH stimulation panel	
80414		120.41	Testosterone response	
80415		130.32	Estradiol response panel	
80416		307.73	Renin stimulation panel	
80417		102.58	Renin stimulation panel	
80418		1351.60	Pituitary evaluation panel	
80420		168.01	Dexamethasone panel	
80422		107.44	Glucagon tolerance panel	
80424		117.76	Glucagon tolerance panel	
80426		346.09	Gonadotropin hormone panel	
80428		155.55	Growth hormone panel	
80430		183.02	Growth hormone panel	
80432		275.09	Insulin suppression panel	
80434		235.93	Insulin tolerance panel	
80435		240.23	Insulin tolerance panel	
80436		212.59	Metyrapone panel	
80438		117.56	TRH stimulation panel	
80439		156.74	TRH stimulation panel	
81000		7.40	Urinalysis nonauto w/scope	
81001		7.40	Urinalysis auto w/scope	
81002		5.95	Urinalysis nonauto w/o scope	
81003		5.24	Urinalysis auto w/o scope	
81003	QW	5.24	Urinalysis auto w/o scope	
81005		5.05	Urinalysis	
81007		5.98	Urine screen for bacteria	
81007	QW	5.98	Urine screen for bacteria	
81015		7.11	Microscopic exam of urine	
81020		8.60	Urinalysis glass test	
81025		14.74	Urine pregnancy test	
81050		7.00	Urinalysis volume measure	
81161		239.90	Dmd dup/delet analysis	
81162		4255.54	Brca1&2 seq & full dup/del	
81170		564.09	Abl1 gene	
81206		382.35	Bcr/abl1 gene major bp	
81207		337.76	Bcr/abl1 gene minor bp	
81208		375.07	Bcr/abl1 gene other bp	
81210		306.39	Braf gene	
81211		3732.32	Brca1&2 seq & com dup/del	
81212		302.06	Brca1&2 185&5385&6174 var	
81213		996.05	Brca1&2 uncom dup/del var	
81214		2458.23	Brca1 full seq & com dup/del	
81215		159.38	Brca1 gene known fam variant	
81217		159.38	Brca2 gene known fam variant	
81218		564.09	Cebpa gene full sequence	
81219		283.63	Calr gene com variants	
81225		498.78	Cyp2c19 gene com variants	
81226		771.92	Cyp2d6 gene com variants	
81227		299.25	Cyp2c9 gene com variants	
81235		564.09	Egfr gene com variants	
81240		114.75	F2 gene	
81241		142.49	F5 gene	
81245		283.63	Flt3 gene	
81246		142.15	Flt3 gene analysis	
81256		152.42	Hfe gene	
81261		461.70	Igh gene rearrange amp meth	
81262		101.80	Igh gene rearrang dir probe	
81263		686.80	Igh vari regional mutation	
81264		348.21	Igk rearrangeabn clonal pop	
81265		501.48	Str markers specimen anal	
81267		483.79	Chimerism anal no cell selec	
81268		608.14	Chimerism anal w/cell select	
81270		213.76	Jak2 gene	
81272		564.09	Kit gene targeted seq analys	
81273		213.76	Kit gene analys d816 variant	
81275		337.57	Kras gene	
81276		337.57	Kras gene addl variants	
81287		142.24	Mgmt gene methylation anal	
81288		273.29	Mlh1 gene	
81291		101.80	Mthfr gene	
81292		1104.63	Mlh1 gene full seq	
81293		442.82	Mlh1 gene known variants	
81294		325.92	Mlh1 gene dup/delete variant	
81295		259.32	Msh2 gene full seq	
81296		221.43	Msh2 gene known variants	
81297		259.32	Msh2 gene dup/delete variant	
81298		492.00	Msh6 gene full seq	
81299		275.62	Msh6 gene known variants	
81300		276.37	Msh6 gene dup/delete variant	
81301		675.24	Microsatellite instability	
81310		422.45	Npm1 gene	
81311		506.36	Nras gene variants exon 2&3	
81313		445.54	Pca3/klk3 antigen	
81314		564.09	Pdgfra gene	
81315		483.45	Pml/raralpha com breakpoints	
81316		737.39	Pml/raralpha 1 breakpoint	
81317		1335.49	Pms2 gene full seq analysis	
81318		315.55	Pms2 known familial variants	
81319		378.90	Pms2 gene dup/delet variants	
81321		1026.80	Pten gene full sequence	
81322		99.82	Pten gene known fam variant	
81323		149.74	Pten gene dup/delet variant	
81327		142.24	Sept9 methylation analysis	
81332		101.80	Serpina1 gene	
81340		487.19	Trb@ gene rearrange amplify	
81341		115.63	Trb@ gene rearrange dirprobe	
81342		469.88	Trg gene rearrangement anal	
81370		937.74	Hla i & ii typing lr	
81371		561.29	Hla i & ii type verify lr	
81372		515.13	Hla i typing complete lr	
81373		259.69	Hla i typing 1 locus lr	
81374		169.64	Hla i typing 1 antigen lr	
81375		514.76	Hla ii typing ag equiv lr	
81376		285.02	Hla ii typing 1 locus lr	
81377		214.10	Hla ii type 1 ag equiv lr	
81378		805.85	Hla i & ii typing hr	
81379		782.10	Hla i typing complete hr	
81380		413.34	Hla i typing 1 locus hr	
81381		220.56	Hla i typing 1 allele hr	
81382		288.42	Hla ii typing 1 loc hr	
81383		254.49	Hla ii typing 1 allele hr	
81410		0.00	Aortic dysfunction/dilation	
81411		0.00	Aortic dysfunction/dilation	
81412		1023.57	Ashkenazi jewish assoc dis	
81413		1363.96	Car ion chnnlpath inc 10 gns	
81414		1363.96	Car ion chnnlpath inc 2 gns	
81415		0.00	Exome sequence analysis	
81416		0.00	Exome sequence analysis	
81417		0.00	Exome re-evaluation	
81420		1363.96	Fetal chrmoml aneuploidy	
81422		1363.96	Fetal chrmoml microdeltj	
81425		0.00	Genome sequence analysis	
81426		0.00	Genome sequence analysis	
81427		0.00	Genome re-evaluation	
81430		0.00	Hearing loss sequence analys	
81431		0.00	Hearing loss dup/del analys	
81432		1583.52	Hrdtry brst ca-rlatd dsordrs	
81433		1023.57	Hrdtry brst ca-rlatd dsordrs	
81434		1023.57	Hereditary retinal disorders	
81435		1363.96	Hereditary colon cancer	
81436		1363.96	Hereditary colon ca synd	
81437		1023.57	Heredtry nurondcrn tum dsrdr	
81438		1023.57	Heredtry nurondcrn tum dsrdr	
81439		1363.96	Inherited cardmypthy 5 gns	
81440		0.00	Mitochondrial gene	
81442		1023.57	Noonan spectrum disorders	
81445		1023.57	Targeted genomic seq analys	
81450		1110.00	Targeted genomic seq analys	
81455		0.00	Targeted genomic seq analys	
81460		0.00	Whole mitochondrial genome	
81465		0.00	Whole mitochondrial genome	
81470		0.00	X-linked intellectual dblt	
81471		0.00	X-linked intellectual dblt	
81490		1004.04	Autoimmune rheumatoid arthr	
81493		1772.00	Cor artery disease mrna	
81519		5853.71	Oncology breast mrna	
81525		5313.74	Oncology colon mrna	
81528		871.13	Oncology colorectal scr	
81535		991.98	Oncology gynecologic	
81536		303.96	Oncology gynecologic	
81538		3615.53	Oncology lung	
81539		1023.57	Oncology prostate prob score	
81540		4964.51	Oncology tum unknown origin	
81545		5478.08	Oncology thyroid	
81595		4829.28	Cardiology hrt trnspl mrna	
82009		10.54	Test for acetone/ketones	
82010		19.06	Acetone assay	
82010	QW	19.06	Acetone assay	
82013		26.04	Acetylcholinesterase assay	
82016		32.35	Acylcarnitines qual	
82017		6.15	Acylcarnitines quant	
82024		90.07	Assay of acth	
82030		33.05	Assay of adp & amp	
82040		11.54	Assay of serum albumin	
82040	QW	11.54	Assay of serum albumin	
82042		6.77	Assay of urine albumin	
82042	QW	6.77	Assay of urine albumin	
82043		13.48	Microalbumin quantitative	
82043	QW	13.48	Microalbumin quantitative	
82044		10.68	Microalbumin semiquant	
82044	QW	10.68	Microalbumin semiquant	
82045		76.04	Albumin ischemia modified	
82075		28.10	Assay of breath ethanol	
82085		22.64	Assay of aldolase	
82088		95.03	Assay of aldosterone	
82103		31.33	Alpha-1-antitrypsin total	
82104		33.73	Alpha-1-antitrypsin pheno	
82105		39.12	Alpha-fetoprotein serum	
82106		39.12	Alpha-fetoprotein amniotic	
82107		150.21	Alpha-fetoprotein l3	
82108		59.42	Assay of aluminum	
82120		4.03	Amines vaginal fluid qual	
82120	QW	4.03	Amines vaginal fluid qual	
82127		32.35	Amino acid single qual	
82128		32.35	Amino acids mult qual	
82131		39.34	Amino acids single quant	
82135		38.37	Assay aminolevulinic acid	
82136		6.15	Amino acids quant 2-5	
82139		6.15	Amino acids quan 6 or more	
82140		33.98	Assay of ammonia	
82143		16.01	Amniotic fluid scan	
82150		15.11	Assay of amylase	
82150	QW	15.11	Assay of amylase	
82154		34.80	Androstanediol glucuronide	
82157		68.27	Assay of androstenedione	
82160		58.31	Assay of androsterone	
82163		47.86	Assay of angiotensin II	
82164		34.05	Angiotensin I enzyme test	
82172		36.14	Assay of apolipoprotein	
82175		44.23	Assay of arsenic	
82180		23.05	Assay of ascorbic acid	
82190		34.77	Atomic absorption	
82232		37.72	Assay of beta-2 protein	
82239		19.67	Bile acids total	
82240		29.84	Bile acids cholylglycine	
82247		11.70	Bilirubin total	
82247	QW	11.70	Bilirubin total	
82248		11.70	Bilirubin direct	
82252		3.26	Fecal bilirubin test	
82261		6.15	Assay of biotinidase	
82270		7.58	Occult blood feces	
82271		7.58	Occult blood other sources	
82271	QW	7.58	Occult blood other sources	
82272		7.58	Occult bld feces 1-3 tests	
82274		37.09	Assay test for blood fecal	
82274	QW	37.09	Assay test for blood fecal	
82286		16.07	Assay of bradykinin	
82300		53.98	Assay of cadmium	
82306		69.04	Vitamin d 25 hydroxy	
82308		62.48	Assay of calcitonin	
82310		12.04	Assay of calcium	
82310	QW	12.04	Assay of calcium	
82330		31.89	Assay of calcium	
82330	QW	31.89	Assay of calcium	
82331		12.07	Calcium infusion test	
82340		14.06	Assay of calcium in urine	
82355		27.00	Calculus analysis qual	
82360		30.02	Calculus assay quant	
82365		30.07	Calculus spectroscopy	
82370		29.21	X-ray assay calculus	
82373		42.11	Assay c-d transfer measure	
82374		6.63	Assay blood carbon dioxide	
82374	QW	6.63	Assay blood carbon dioxide	
82375		28.73	Assay carboxyhb quant	
82376		11.63	Assay carboxyhb qual	
82378		44.22	Carcinoembryonic antigen	
82379		6.15	Assay of carnitine	
82380		21.51	Assay of carotene	
82382		40.09	Assay urine catecholamines	
82383		58.43	Assay blood catecholamines	
82384		58.89	Assay three catecholamines	
82387		18.85	Assay of cathepsin-d	
82390		25.04	Assay of ceruloplasmin	
82397		18.85	Chemiluminescent assay	
82415		29.55	Assay of chloramphenicol	
82435		6.49	Assay of blood chloride	
82435	QW	6.49	Assay of blood chloride	
82436		11.73	Assay of urine chloride	
82438		11.39	Assay other fluid chlorides	
82441		14.01	Test for chlorohydrocarbons	
82465		10.15	Assay bld/serum cholesterol	
82465	QW	10.15	Assay bld/serum cholesterol	
82480		18.36	Assay serum cholinesterase	
82482		17.90	Assay rbc cholinesterase	
82485		41.41	Assay chondroitin sulfate	
82495		47.29	Assay of chromium	
82507		64.84	Assay of citrate	
82523		43.57	Collagen crosslinks	
82523	QW	43.57	Collagen crosslinks	
82525		28.93	Assay of copper	
82528		52.51	Assay of corticosterone	
82530		38.96	Cortisol free	
82533		38.01	Total cortisol	
82540		10.81	Assay of creatine	
82542		42.11	Column chromotography quant	
82550		15.18	Assay of ck (cpk)	
82550	QW	15.18	Assay of ck (cpk)	
82552		31.23	Assay of cpk in blood	
82553		26.93	Creatine mb fraction	
82554		27.68	Creatine isoforms	
82565		11.95	Assay of creatinine	
82565	QW	11.95	Assay of creatinine	
82570		12.07	Assay of urine creatinine	
82570	QW	12.07	Assay of urine creatinine	
82575		22.05	Creatinine clearance test	
82585		16.52	Assay of cryofibrinogen	
82595		15.08	Assay of cryoglobulin	
82600		45.24	Assay of cyanide	
82607		35.16	Vitamin B-12	
82608		33.39	B-12 binding capacity	
82610		13.21	Cystatin c	
82615		19.04	Test for urine cystines	
82626		58.94	Dehydroepiandrosterone	
82627		51.85	Dehydroepiandrosterone	
82633		72.25	Desoxycorticosterone	
82634		68.27	Deoxycortisol	
82638		28.56	Assay of dibucaine number	
82652		89.78	Vit d 1 25-dihydroxy	
82656		26.89	Pancreatic elastase fecal	
82657		42.11	Enzyme cell activity	
82658		42.11	Enzyme cell activity ra	
82664		80.10	Electrophoretic test	
82668		43.83	Assay of erythropoietin	
82670		65.14	Assay of estradiol	
82671		75.33	Assay of estrogens	
82672		50.59	Assay of estrogen	
82677		56.39	Assay of estriol	
82679		58.19	Assay of estrone	
82679	QW	58.19	Assay of estrone	
82693		34.75	Assay of ethylene glycol	
82696		55.00	Assay of etiocholanolone	
82705		11.88	Fats/lipids feces qual	
82710		39.19	Fats/lipids feces quant	
82715		23.17	Assay of fecal fat	
82725		31.04	Assay of blood fatty acids	
82726		42.11	Long chain fatty acids	
82728		31.79	Assay of ferritin	
82731		150.21	Assay of fetal fibronectin	
82735		43.23	Assay of fluoride	
82746		34.29	Assay of folic acid serum	
82747		40.12	Assay of folic acid rbc	
82757		18.17	Assay of semen fructose	
82759		36.33	Assay of rbc galactokinase	
82760		26.11	Assay of galactose	
82775		49.13	Assay galactose transferase	
82776		13.29	Galactose transferase test	
82777		51.29	Galectin-3	
82784		13.29	Assay iga/igd/igg/igm each	
82785		38.39	Assay of ige	
82787		10.71	Igg 1 2 3 or 4 each	
82800		19.74	Blood pH	
82803		45.12	Blood gases any combination	
82805		66.16	Blood gases w/o2 saturation	
82810		20.35	Blood gases o2 sat only	
82820		22.59	Hemoglobin-oxygen affinity	
82930		12.70	Gastric analy w/ph ea spec	
82938		41.26	Gastrin test	
82941		41.12	Assay of gastrin	
82943		33.32	Assay of glucagon	
82945		9.16	Glucose other fluid	
82946		31.09	Glucagon tolerance test	
82947		9.16	Assay glucose blood quant	
82947	QW	9.16	Assay glucose blood quant	
82948		7.40	Reagent strip/blood glucose	
82950		11.07	Glucose test	
82950	QW	11.07	Glucose test	
82951		14.96	Glucose tolerance test (GTT)	
82951	QW	14.96	Glucose tolerance test (GTT)	
82952		9.15	GTT-added samples	
82952	QW	9.15	GTT-added samples	
82955		22.61	Assay of g6pd enzyme	
82960		14.11	Test for G6PD enzyme	
82962		4.20	Glucose blood test	
82963		50.10	Assay of glucosidase	
82965		18.02	Assay of gdh enzyme	
82977		16.80	Assay of GGT	
82977	QW	16.80	Assay of GGT	
82978		24.82	Assay of glutathione	
82979		16.07	Assay rbc glutathione	
82985		35.16	Assay of glycated protein	
82985	QW	35.16	Assay of glycated protein	
83001		43.33	Assay of gonadotropin (fsh)	
83001	QW	43.33	Assay of gonadotropin (fsh)	
83002		43.18	Assay of gonadotropin (lh)	
83002	QW	43.18	Assay of gonadotropin (lh)	
83003		38.88	Assay growth hormone (hgh)	
83006		51.29	Growth stimulation gene 2	
83009		157.08	H pylori (c-13) blood	
83010		15.45	Assay of haptoglobin quant	
83012		40.09	Assay of haptoglobins	
83013		157.08	H pylori (c-13) breath	
83014		18.33	H pylori drug admin	
83015		43.91	Heavy metal screen	
83018		51.22	Quantitative screen metals	
83020		27.10	Hemoglobin electrophoresis	
83021		42.11	Hemoglobin chromotography	
83026		5.51	Hemoglobin copper sulfate	
83030		19.28	Fetal hemoglobin chemical	
83033		13.91	Fetal hemoglobin assay qual	
83036		22.64	Glycosylated hemoglobin test	
83036	QW	22.64	Glycosylated hemoglobin test	
83037		22.64	Glycosylated hb home device	
83037	QW	22.64	Glycosylated hb home device	
83045		11.54	Blood methemoglobin test	
83050		17.09	Blood methemoglobin assay	
83051		8.16	Assay of plasma hemoglobin	
83060		19.28	Blood sulfhemoglobin assay	
83065		16.07	Assay of hemoglobin heat	
83068		19.74	Hemoglobin stability screen	
83069		9.21	Assay of urine hemoglobin	
83070		11.07	Assay of hemosiderin qual	
83080		6.15	Assay of b hexosaminidase	
83088		68.87	Assay of histamine	
83090		39.34	Assay of homocystine	
83150		45.12	Assay of homovanillic acid	
83491		40.87	Assay of corticosteroids 17	
83497		30.07	Assay of 5-hiaa	
83498		63.36	Assay of progesterone 17-d	
83499		58.79	Assay of progesterone 20-	
83500		52.82	Assay free hydroxyproline	
83505		56.68	Assay total hydroxyproline	
83516		26.89	Immunoassay nonantibody	
83516	QW	26.89	Immunoassay nonantibody	
83518		19.77	Immunoassay dipstick	
83518	QW	19.77	Immunoassay dipstick	
83519		31.50	Ria nonantibody	
83520		30.19	Immunoassay quant nos nonab	
83520	QW	30.19	Immunoassay quant nos nonab	
83525		26.66	Assay of insulin	
83527		29.53	Assay of insulin	
83528		37.09	Assay of intrinsic factor	
83540		15.10	Assay of iron	
83550		20.38	Iron binding test	
83570		20.64	Assay of idh enzyme	
83582		33.05	Assay of ketogenic steroids	
83586		29.85	Assay 17- ketosteroids	
83593		61.34	Fractionation ketosteroids	
83605		3.26	Assay of lactic acid	
83605	QW	3.26	Assay of lactic acid	
83615		14.08	Lactate (LD) (LDH) enzyme	
83625		13.86	Assay of ldh enzymes	
83630		45.78	Lactoferrin fecal (qual)	
83631		45.78	Lactoferrin fecal (quant)	
83632		47.16	Placental lactogen	
83633		12.82	Test urine for lactose	
83655		28.24	Assay of lead	
83655	QW	28.24	Assay of lead	
83661		23.17	L/s ratio fetal lung	
83662		44.10	Foam stability fetal lung	
83663		44.10	Fluoro polarize fetal lung	
83664		44.10	Lamellar bdy fetal lung	
83670		21.37	Assay of lap enzyme	
83690		16.07	Assay of lipase	
83695		30.19	Assay of lipoprotein(a)	
83698		76.04	Assay lipoprotein pla2	
83700		23.04	Lipopro bld electrophoretic	
83701		57.89	Lipoprotein bld hr fraction	
83704		73.58	Lipoprotein bld by nmr	
83718		19.11	Assay of lipoprotein	
83718	QW	19.11	Assay of lipoprotein	
83719		27.13	Assay of blood lipoprotein	
83721		22.25	Assay of blood lipoprotein	
83721	QW	22.25	Assay of blood lipoprotein	
83727		40.09	Assay of lrh hormone	
83735		15.62	Assay of magnesium	
83775		17.19	Assay malate dehydrogenase	
83785		57.36	Assay of manganese	
83789		42.11	Mass spectrometry quant	
83825		37.91	Assay of mercury	
83835		39.51	Assay of metanephrines	
83857		25.04	Assay of methemalbumin	
83861		38.52	Microfluid analy tears	
83861	QW	38.52	Microfluid analy tears	
83864		46.44	Mucopolysaccharides	
83872		13.67	Assay synovial fluid mucin	
83873		40.12	Assay of csf protein	
83874		30.12	Assay of myoglobin	
83876		76.04	Assay myeloperoxidase	
83880		76.04	Assay of natriuretic peptide	
83880	QW	76.04	Assay of natriuretic peptide	
83883		13.21	Assay nephelometry not spec	
83885		57.15	Assay of nickel	
83915		26.01	Assay of nucleotidase	
83916		46.90	Oligoclonal bands	
83918		38.37	Organic acids total quant	
83919		38.37	Organic acids qual each	
83921		38.37	Organic acid single quant	
83930		15.42	Assay of blood osmolality	
83935		15.90	Assay of urine osmolality	
83937		34.80	Assay of osteocalcin	
83945		30.02	Assay of oxalate	
83950		150.21	Oncoprotein her-2/neu	
83951		150.21	Oncoprotein dcp	
83970		96.25	Assay of parathormone	
83986		8.35	Assay ph body fluid nos	
83986	QW	8.35	Assay ph body fluid nos	
83987		37.04	Exhaled breath condensate	
83992		34.29	Assay for phencyclidine	
83993		45.78	Assay for calprotectin fecal	
84030		12.82	Assay of blood pku	
84035		7.14	Assay of phenylketones	
84060		17.22	Assay acid phosphatase	
84061		18.45	Phosphatase forensic exam	
84066		22.53	Assay prostate phosphatase	
84075		12.07	Assay alkaline phosphatase	
84075	QW	12.07	Assay alkaline phosphatase	
84078		17.02	Assay alkaline phosphatase	
84080		34.48	Assay alkaline phosphatases	
84081		38.52	Assay phosphatidylglycerol	
84085		15.73	Assay of rbc pg6d enzyme	
84087		24.07	Assay phosphohexose enzymes	
84100		11.05	Assay of phosphorus	
84105		12.07	Assay of urine phosphorus	
84106		9.91	Test for porphobilinogen	
84110		19.69	Assay of porphobilinogen	
84112		150.21	Placenta alpha micro ig c/v	
84119		20.09	Test urine for porphyrins	
84120		34.31	Assay of urine porphyrins	
84126		59.40	Assay of feces porphyrins	
84132		10.73	Assay of serum potassium	
84132	QW	10.73	Assay of serum potassium	
84133		10.05	Assay of urine potassium	
84134		13.21	Assay of prealbumin	
84135		44.63	Assay of pregnanediol	
84138		44.15	Assay of pregnanetriol	
84140		34.80	Assay of pregnenolone	
84143		34.80	Assay of 17-hydroxypregneno	
84144		36.33	Assay of progesterone	
84145		62.48	Procalcitonin (pct)	
84146		45.19	Assay of prolactin	
84150		58.19	Assay of prostaglandin	
84152		42.89	Assay of psa complexed	
84153		42.89	Assay of psa total	
84154		42.89	Assay of psa free	
84155		8.55	Assay of protein serum	
84155	QW	8.55	Assay of protein serum	
84156		8.55	Assay of protein urine	
84157		8.55	Assay of protein other	
84157	QW	8.55	Assay of protein other	
84160		12.07	Assay of protein any source	
84163		35.11	Pappa serum	
84165		25.04	Protein e-phoresis serum	
84166		41.58	Protein e-phoresis/urine/csf	
84181		39.71	Western blot test	
84182		41.97	Protein western blot test	
84202		33.46	Assay RBC protoporphyrin	
84203		20.08	Test RBC protoporphyrin	
84206		41.41	Assay of proinsulin	
84207		65.52	Assay of vitamin b-6	
84210		25.31	Assay of pyruvate	
84220		22.02	Assay of pyruvate kinase	
84228		27.13	Assay of quinine	
84233		150.21	Assay of estrogen	
84234		151.30	Assay of progesterone	
84235		122.04	Assay of endocrine hormone	
84238		85.27	Assay nonendocrine receptor	
84244		51.29	Assay of renin	
84252		47.19	Assay of vitamin b-2	
84255		59.53	Assay of selenium	
84260		43.37	Assay of serotonin	
84270		50.68	Assay of sex hormone globul	
84275		31.33	Assay of sialic acid	
84285		54.89	Assay of silica	
84295		11.22	Assay of serum sodium	
84295	QW	11.22	Assay of serum sodium	
84300		11.34	Assay of urine sodium	
84302		11.34	Assay of sweat sodium	
84305		45.80	Assay of somatomedin	
84307		42.62	Assay of somatostatin	
84311		16.30	Spectrophotometry	
84315		5.85	Body fluid specific gravity	
84375		5.58	Chromatogram assay sugars	
84376		12.82	Sugars single qual	
84377		12.82	Sugars multiple qual	
84378		26.88	Sugars single quant	
84379		26.88	Sugars multiple quant	
84392		11.07	Assay of urine sulfate	
84402		59.40	Assay of free testosterone	
84403		60.20	Assay of total testosterone	
84410		123.34	Testosterone bioavailable	
84425		49.50	Assay of vitamin b-1	
84430		27.13	Assay of thiocyanate	
84431		39.19	Thromboxane urine	
84432		35.65	Assay of thyroglobulin	
84436		16.01	Assay of total thyroxine	
84437		15.08	Assay of neonatal thyroxine	
84439		19.01	Assay of free thyroxine	
84442		27.10	Assay of thyroid activity	
84443		39.19	Assay thyroid stim hormone	
84443	QW	39.19	Assay thyroid stim hormone	
84445		118.59	Assay of tsi globulin	
84446		33.07	Assay of vitamin e	
84449		34.80	Assay of transcortin	
84450		12.07	Transferase (AST) (SGOT)	
84450	QW	12.07	Transferase (AST) (SGOT)	
84460		12.36	Alanine amino (ALT) (SGPT)	
84460	QW	12.36	Alanine amino (ALT) (SGPT)	
84466		29.77	Assay of transferrin	
84478		13.40	Assay of triglycerides	
84478	QW	13.40	Assay of triglycerides	
84479		15.08	Assay of thyroid (t3 or t4)	
84480		33.07	Assay triiodothyronine (t3)	
84481		39.51	Free assay (FT-3)	
84482		36.75	T3 reverse	
84484		15.59	Assay of troponin quant	
84485		9.91	Assay duodenal fluid trypsin	
84488		9.91	Test feces for trypsin	
84490		13.29	Assay of feces for trypsin	
84510		24.26	Assay of tyrosine	
84512		17.95	Assay of troponin qual	
84520		9.21	Assay of urea nitrogen	
84520	QW	9.21	Assay of urea nitrogen	
84525		4.03	Urea nitrogen semi-quant	
84540		11.07	Assay of urine/urea-n	
84545		15.42	Urea-N clearance test	
84550		10.54	Assay of blood/uric acid	
84550	QW	10.54	Assay of blood/uric acid	
84560		11.07	Assay of urine/uric acid	
84577		29.10	Assay of feces/urobilinogen	
84578		3.26	Test urine urobilinogen	
84580		16.54	Assay of urine urobilinogen	
84583		11.73	Assay of urine urobilinogen	
84585		36.14	Assay of urine vma	
84586		34.80	Assay of vip	
84588		76.04	Assay of vasopressin	
84590		27.06	Assay of vitamin a	
84591		27.06	Assay of nos vitamin	
84597		31.99	Assay of vitamin k	
84600		37.50	Assay of volatiles	
84620		27.63	Xylose tolerance test	
84630		26.55	Assay of zinc	
84681		40.53	Assay of c-peptide	
84702		35.11	Chorionic gonadotropin test	
84703		16.30	Chorionic gonadotropin assay	
84703	QW	16.30	Chorionic gonadotropin assay	
84704		35.11	Hcg free betachain test	
84830		23.39	Ovulation tests	
85002		10.52	Bleeding time test	
85004		11.63	Automated diff wbc count	
85007		8.01	Bl smear w/diff wbc count	
85008		8.01	Bl smear w/o diff wbc count	
85009		8.69	Manual diff wbc count b-coat	
85013		5.53	Spun microhematocrit	
85014		5.53	Hematocrit	
85014	QW	5.53	Hematocrit	
85018		5.53	Hemoglobin	
85018	QW	5.53	Hemoglobin	
85025		16.49	Complete cbc w/auto diff wbc	
85027		11.63	Complete cbc automated	
85032		10.05	Manual cell count each	
85041		7.04	Automated rbc count	
85044		10.05	Manual reticulocyte count	
85045		9.32	Automated reticulocyte count	
85046		12.99	Reticyte/hgb concentrate	
85048		5.92	Automated leukocyte count	
85049		10.44	Automated platelet count	
85055		42.19	Reticulated platelet assay	
85130		16.49	Chromogenic substrate assay	
85170		8.45	Blood clot retraction	
85175		10.63	Blood clot lysis time	
85210		30.28	Clot factor ii prothrom spec	
85220		41.16	Blooc clot factor v test	
85230		41.75	Clot factor vii proconvertin	
85240		41.75	Clot factor viii ahg 1 stage	
85244		47.62	Clot factor viii reltd antgn	
85245		53.50	Clot factor viii vw ristoctn	
85246		53.50	Clot factor viii vw antigen	
85247		53.50	Clot factor viii multimetric	
85250		44.40	Clot factor ix ptc/chrstmas	
85260		41.75	Clot factor x stuart-power	
85270		41.75	Clot factor xi pta	
85280		45.12	Clot factor xii hageman	
85290		38.10	Clot factor xiii fibrin stab	
85291		20.74	Clot factor xiii fibrin scrn	
85292		44.15	Clot factor fletcher fact	
85293		44.15	Clot factor wght kininogen	
85300		27.64	Antithrombin iii activity	
85301		25.21	Antithrombin iii antigen	
85302		28.02	Clot inhibit prot c antigen	
85303		32.27	Clot inhibit prot c activity	
85305		27.06	Clot inhibit prot s total	
85306		35.73	Clot inhibit prot s free	
85307		35.73	Assay activated protein c	
85335		21.49	Factor inhibitor test	
85337		24.31	Thrombomodulin	
85345		10.05	Coagulation time lee & white	
85347		9.93	Coagulation time activated	
85348		8.69	Coagulation time otr method	
85360		10.80	Euglobulin lysis	
85362		16.07	Fibrin degradation products	
85366		20.09	Fibrinogen test	
85370		26.49	Fibrinogen test	
85378		16.64	Fibrin degrade semiquant	
85379		18.89	Fibrin degradation quant	
85380		18.89	Fibrin degradj d-dimer	
85384		19.81	Fibrinogen activity	
85385		19.81	Fibrinogen antigen	
85390		9.91	Fibrinolysins screen i&r	
85397		53.50	Clotting funct activity	
85400		20.64	Fibrinolytic plasmin	
85410		16.52	Fibrinolytic antiplasmin	
85415		40.09	Fibrinolytic plasminogen	
85420		15.23	Fibrinolytic plasminogen	
85421		23.75	Fibrinolytic plasminogen	
85441		9.79	Heinz bodies direct	
85445		15.90	Heinz bodies induced	
85460		18.04	Hemoglobin fetal	
85461		15.47	Hemoglobin fetal	
85475		20.69	Hemolysin acid	
85520		24.82	Heparin assay	
85525		27.61	Heparin neutralization	
85530		33.07	Heparin-protamine tolerance	
85536		15.08	Iron stain peripheral blood	
85540		20.06	Wbc alkaline phosphatase	
85547		20.06	RBC mechanical fragility	
85549		43.72	Muramidase	
85555		15.59	RBC osmotic fragility	
85557		31.14	RBC osmotic fragility	
85576		50.10	Blood platelet aggregation	
85576	QW	50.10	Blood platelet aggregation	
85597		35.84	Phospholipid pltlt neutraliz	
85598		35.84	Hexagnal phosph pltlt neutrl	
85610		9.16	Prothrombin time	
85610	QW	9.16	Prothrombin time	
85611		9.20	Prothrombin test	
85612		22.34	Viper venom prothrombin time	
85613		22.34	Russell viper venom diluted	
85635		22.97	Reptilase test	
85651		8.28	Rbc sed rate nonautomated	
85652		6.29	Rbc sed rate automated	
85660		12.85	RBC sickle cell test	
85670		13.45	Thrombin time plasma	
85675		15.96	Thrombin time titer	
85705		16.30	Thromboplastin inhibition	
85730		14.01	Thromboplastin time partial	
85732		15.08	Thromboplastin time partial	
85810		27.22	Blood viscosity examination	
86000		16.29	Agglutinins febrile antigen	
86001		11.17	Allergen specific igg	
86003		11.17	Allergen specific IgE	
86005		16.34	Allergen specific IgE	
86021		35.11	WBC antibody identification	
86022		42.84	Platelet antibodies	
86023		29.05	Immunoglobulin assay	
86038		28.19	Antinuclear antibodies	
86039		26.03	Antinuclear antibodies (ANA)	
86060		13.12	Antistreptolysin o titer	
86063		8.30	Antistreptolysin o screen	
86140		12.07	C-reactive protein	
86141		30.19	C-reactive protein hs	
86146		35.65	Beta-2 glycoprotein antibody	
86147		35.65	Cardiolipin antibody ea ig	
86148		37.47	Anti-phospholipid antibody	
86152		572.97	Cell enumeration & id	
86155		36.33	Chemotaxis assay	
86156		15.62	Cold agglutinin screen	
86157		18.80	Cold agglutinin titer	
86160		27.98	Complement antigen	
86161		27.98	Complement/function activity	
86162		47.40	Complement total (ch50)	
86171		23.34	Complement fixation each	
86185		20.88	Counterimmunoelectrophoresis	
86200		30.19	Ccp antibody	
86215		30.89	Deoxyribonuclease antibody	
86225		32.05	Dna antibody native	
86226		28.24	Dna antibody single strand	
86235		34.83	Nuclear antigen antibody	
86243		47.84	Fc receptor	
86255		28.10	Fluorescent antibody screen	
86256		28.10	Fluorescent antibody titer	
86277		36.70	Growth hormone antibody	
86280		19.11	Hemagglutination inhibition	
86294		45.76	Immunoassay tumor qual	
86294	QW	45.76	Immunoassay tumor qual	
86300		48.54	Immunoassay tumor ca 15-3	
86301		48.54	Immunoassay tumor ca 19-9	
86304		48.54	Immunoassay tumor ca 125	
86305		48.54	Human epididymis protein 4	
86308		12.07	Heterophile antibody screen	
86308	QW	12.07	Heterophile antibody screen	
86309		15.08	Heterophile antibody titer	
86310		17.19	Heterophile antibody absrbj	
86316		48.54	Immunoassay tumor other	
86317		34.95	Immunoassay infectious agent	
86318		30.19	Immunoassay infectious agent	
86318	QW	30.19	Immunoassay infectious agent	
86320		52.28	Serum immunoelectrophoresis	
86325		52.16	Other immunoelectrophoresis	
86327		52.90	Immunoelectrophoresis assay	
86329		32.76	Immunodiffusion nes	
86331		27.93	Immunodiffusion ouchterlony	
86332		40.15	Immune complex assay	
86334		52.11	Immunofix e-phoresis serum	
86335		68.44	Immunfix e-phorsis/urine/csf	
86336		30.21	Inhibin A	
86337		49.93	Insulin antibodies	
86340		35.16	Intrinsic factor antibody	
86341		31.31	Islet cell antibody	
86343		29.05	Leukocyte histamine release	
86344		18.62	Leukocyte phagocytosis	
86352		316.83	Cell function assay w/stim	
86353		114.33	Lymphocyte transformation	
86355		41.41	B cells total count	
86356		42.19	Mononuclear cell antigen	
86357		41.41	Nk cells total count	
86359		41.41	T cells total count	
86360		82.81	T cell absolute count/ratio	
86361		42.19	T cell absolute count	
86367		41.41	Stem cells total count	
86376		33.93	Microsomal antibody each	
86378		45.92	Migration inhibitory factor	
86382		39.44	Neutralization test viral	
86384		26.55	Nitroblue tetrazolium dye	
86386		37.25	Nuclear matrix protein 22	
86386	QW	37.25	Nuclear matrix protein 22	
86403		16.30	Particle agglut antbdy scrn	
86406		24.80	Particle agglut antbdy titr	
86430		13.23	Rheumatoid factor test qual	
86431		13.23	Rheumatoid factor quant	
86480		144.53	Tb test cell immun measure	
86481		174.74	Tb ag response t-cell susp	
86590		24.82	Streptokinase antibody	
86592		9.96	Syphilis test non-trep qual	
86593		10.27	Syphilis test non-trep quant	
86602		23.73	Antinomyces antibody	
86603		26.16	Adenovirus antibody	
86606		32.79	Aspergillus antibody	
86609		30.04	Bacterium antibody	
86611		23.73	Bartonella antibody	
86612		26.16	Blastomyces antibody	
86615		30.75	Bordetella antibody	
86617		36.13	Lyme disease antibody	
86618		39.71	Lyme disease antibody	
86618	QW	39.71	Lyme disease antibody	
86619		31.20	Borrelia antibody	
86622		19.07	Brucella antibody	
86625		30.60	Campylobacter antibody	
86628		28.00	Candida antibody	
86631		27.57	Chlamydia antibody	
86632		29.58	Chlamydia igm antibody	
86635		26.16	Coccidioides antibody	
86638		26.16	Q fever antibody	
86641		16.30	Cryptococcus antibody	
86644		33.56	CMV antibody	
86645		33.30	Cmv antibody igm	
86648		35.46	Diphtheria antibody	
86651		30.75	Encephalitis californ antbdy	
86652		30.75	Encephaltis east eqne anbdy	
86653		30.75	Encephaltis st louis antbody	
86654		30.75	Encephaltis west eqne antbdy	
86658		26.16	Enterovirus antibody	
86663		30.60	Epstein-barr antibody	
86664		33.30	Epstein-barr nuclear antigen	
86665		33.30	Epstein-barr capsid vca	
86666		23.73	Ehrlichia antibody	
86668		18.17	Francisella tularensis	
86671		26.16	Fungus nes antibody	
86674		33.30	Giardia lamblia antibody	
86677		33.83	Helicobacter pylori antibody	
86682		24.12	Helminth antibody	
86684		16.30	Hemophilus influenza antibdy	
86687		19.57	Htlv-i antibody	
86688		23.27	Htlv-ii antibody	
86689		45.14	Htlv/hiv confirmj antibody	
86692		40.02	Hepatitis delta agent antbdy	
86694		33.56	Herpes simplex nes antbdy	
86695		30.75	Herpes simplex type 1 test	
86696		45.14	Herpes simplex type 2 test	
86698		26.16	Histoplasma antibody	
86701		20.72	Hiv-1antibody	
86701	QW	20.72	Hiv-1antibody	
86702		23.27	Hiv-2 antibody	
86703		23.27	Hiv-1/hiv-2 1 result antbdy	
86704		28.10	Hep b core antibody total	
86705		27.46	Hep b core antibody igm	
86706		25.04	Hep b surface antibody	
86707		26.98	Hepatitis be antibody	
86708		28.88	Hepatitis a total antibody	
86709		26.25	Hepatitis a igm antibody	
86710		31.60	Influenza virus antibody	
86711		33.56	John cunningham antibody	
86713		33.30	Legionella antibody	
86717		28.56	Leishmania antibody	
86720		30.75	Leptospira antibody	
86723		30.75	Listeria monocytogenes	
86727		26.16	Lymph choriomeningitis ab	
86729		27.85	Lympho venereum antibody	
86732		30.75	Mucormycosis antibody	
86735		30.43	Mumps antibody	
86738		30.87	Mycoplasma antibody	
86741		30.75	Neisseria meningitidis	
86744		30.75	Nocardia antibody	
86747		35.05	Parvovirus antibody	
86750		30.75	Malaria antibody	
86753		24.12	Protozoa antibody nos	
86756		30.06	Respiratory virus antibody	
86757		45.14	Rickettsia antibody	
86759		30.75	Rotavirus antibody	
86762		33.56	Rubella antibody	
86765		30.04	Rubeola antibody	
86768		30.75	Salmonella antibody	
86771		30.75	Shigella antibody	
86774		34.51	Tetanus antibody	
86777		33.56	Toxoplasma antibody	
86778		33.30	Toxoplasma antibody igm	
86780		30.87	Treponema pallidum	
86780	QW	30.87	Treponema pallidum	
86784		14.82	Trichinella antibody	
86787		30.04	Varicella-zoster antibody	
86788		33.30	West nile virus ab igm	
86789		33.56	West nile virus antibody	
86790		30.04	Virus antibody nos	
86793		30.75	Yersinia antibody	
86800		37.09	Thyroglobulin antibody	
86803		33.27	Hepatitis c ab test	
86803	QW	33.27	Hepatitis c ab test	
86804		36.13	Hep c ab test confirm	
86805		121.94	Lymphocytotoxicity assay	
86806		110.98	Lymphocytotoxicity assay	
86807		92.29	Cytotoxic antibody screening	
86808		69.21	Cytotoxic antibody screening	
86812		60.18	Hla typing a b or c	
86813		74.46	Hla typing a b or c	
86816		64.96	Hla typing dr/dq	
86817		150.14	Hla typing dr/dq	
86821		131.67	Lymphocyte culture mixed	
86822		85.26	Lymphocyte culture primed	
86825		126.60	Hla x-math non-cytotoxic	
86826		42.19	Hla x-match noncytotoxc addl	
86828		92.29	Hla class i&ii antibody qual	
86829		69.21	Hla class i/ii antibody qual	
86830		188.28	Hla class i phenotype qual	
86831		161.38	Hla class ii phenotype qual	
86832		295.87	Hla class i high defin qual	
86833		268.97	Hla class ii high defin qual	
86834		833.82	Hla class i semiquant panel	
86835		753.13	Hla class ii semiquant panel	
86850		8.93	Rbc antibody screen	
86880		12.56	Coombs test direct	
86885		13.35	Coombs test indirect qual	
86886		12.07	Coombs test indirect titer	
86900		6.97	Blood typing abo	
86901		6.97	Blood typing rh (d)	
86902		8.93	Blood type antigen donor ea	
86904		22.19	Blood typing patient serum	
86905		8.93	Blood typing rbc antigens	
86906		14.96	Blood typing rh phenotype	
86940		19.13	Hemolysins/agglutinins auto	
86941		28.24	Hemolysins/agglutinins	
87003		39.27	Small animal inoculation	
87015		15.57	Specimen infect agnt concntj	
87040		24.07	Blood culture for bacteria	
87045		22.02	Feces culture aerobic bact	
87046		22.02	Stool cultr aerobic bact ea	
87070		20.09	Culture othr specimn aerobic	
87071		22.02	Culture aerobic quant other	
87073		22.02	Culture bacteria anaerobic	
87075		22.08	Cultr bacteria except blood	
87076		16.52	Culture anaerobe ident each	
87077		16.52	Culture aerobic identify	
87077	QW	16.52	Culture aerobic identify	
87081		15.45	Culture screen only	
87084		20.09	Culture of specimen by kit	
87086		18.82	Urine culture/colony count	
87088		18.87	Urine bacteria culture	
87101		17.97	Skin fungi culture	
87102		19.60	Fungus isolation culture	
87103		21.03	Blood fungus culture	
87106		24.07	Fungi identification yeast	
87107		24.07	Fungi identification mold	
87109		35.89	Mycoplasma	
87110		45.70	Chlamydia culture	
87116		25.19	Mycobacteria culture	
87118		25.52	Mycobacteric identification	
87140		12.99	Culture type immunofluoresc	
87143		29.21	Culture typing glc/hplc	
87147		12.07	Culture type immunologic	
87149		46.77	Dna/rna direct probe	
87150		81.84	Dna/rna amplified probe	
87152		12.21	Culture type pulse field gel	
87153		269.01	Dna/rna sequencing	
87158		12.21	Culture typing added method	
87164		25.04	Dark field examination	
87166		26.35	Dark field examination	
87168		9.96	Macroscopic exam arthropod	
87169		9.96	Macroscopic exam parasite	
87172		9.96	Pinworm exam	
87176		13.72	Tissue homogenization cultr	
87177		20.76	Ova and parasites smears	
87181		11.07	Microbe susceptible diffuse	
87184		16.08	Microbe susceptible disk	
87185		11.07	Microbe susceptible enzyme	
87186		20.16	Microbe susceptible mic	
87187		24.17	Microbe susceptible mlc	
87188		15.49	Microbe suscept macrobroth	
87190		9.91	Microbe suscept mycobacteri	
87197		35.04	Bactericidal level serum	
87205		9.96	Smear gram stain	
87206		12.56	Smear fluorescent/acid stai	
87207		13.29	Smear special stain	
87209		39.90	Smear complex stain	
87210		9.96	Smear wet mount saline/ink	
87210	QW	9.96	Smear wet mount saline/ink	
87220		9.96	Tissue exam for fungi	
87230		46.04	Assay toxin or antitoxin	
87250		45.61	Virus inoculate eggs/animal	
87252		60.79	Virus inoculation tissue	
87253		47.11	Virus inoculate tissue addl	
87254		45.61	Virus inoculation shell via	
87255		78.97	Genet virus isolate hsv	
87260		27.95	Adenovirus ag if	
87265		27.95	Pertussis ag if	
87267		27.95	Enterovirus antibody dfa	
87269		27.95	Giardia ag if	
87270		27.95	Chlamydia trachomatis ag if	
87271		27.95	Cytomegalovirus dfa	
87272		27.95	Cryptosporidium ag if	
87273		27.95	Herpes simplex 2 ag if	
87274		27.95	Herpes simplex 1 ag if	
87275		27.95	Influenza b ag if	
87276		27.95	Influenza a ag if	
87277		27.95	Legionella micdadei ag if	
87278		27.95	Legion pneumophilia ag if	
87279		27.95	Parainfluenza ag if	
87280		27.95	Respiratory syncytial ag if	
87281		27.95	Pneumocystis carinii ag if	
87283		27.95	Rubeola ag if	
87285		27.95	Treponema pallidum ag if	
87290		27.95	Varicella zoster ag if	
87299		27.95	Antibody detection nos if	
87300		27.95	Ag detection polyval if	
87301		27.95	Adenovirus ag eia	
87305		27.95	Aspergillus ag eia	
87320		27.95	Chylmd trach ag eia	
87324		27.95	Clostridium ag eia	
87327		27.95	Cryptococcus neoform ag eia	
87328		27.95	Cryptosporidium ag eia	
87329		27.95	Giardia ag eia	
87332		27.95	Cytomegalovirus ag eia	
87335		27.95	E coli 0157 ag eia	
87336		27.95	Entamoeb hist dispr ag eia	
87337		27.95	Entamoeb hist group ag eia	
87338		27.98	Hpylori stool eia	
87338	QW	27.98	Hpylori stool ia	
87339		27.95	H pylori ag eia	
87340		24.09	Hepatitis b surface ag eia	
87341		24.09	Hepatitis b surface ag eia	
87350		26.88	Hepatitis be ag eia	
87380		38.27	Hepatitis delta ag eia	
87385		27.95	Histoplasma capsul ag eia	
87389		56.15	Hiv-1 ag w/hiv-1 & hiv-2 ab	
87389	QW	56.15	Hiv-1 ag w/hiv-1 & hiv-2 ab	
87390		41.14	Hiv-1 ag eia	
87391		41.14	Hiv-2 ag eia	
87400		27.95	Influenza a/b ag eia	
87420		27.95	Resp syncytial ag eia	
87425		27.95	Rotavirus ag eia	
87427		27.95	Shiga-like toxin ag eia	
87430		27.95	Strep a ag eia	
87449		27.95	Ag detect nos eia mult	
87449	QW	27.95	Ag detect nos eia mult	
87450		22.37	Ag detect nos eia single	
87451		22.37	Ag detect polyval eia mult	
87470		46.77	Bartonella dna dir probe	
87471		81.84	Bartonella dna amp probe	
87472		99.89	Bartonella dna quant	
87475		46.77	Lyme dis dna dir probe	
87476		81.84	Lyme dis dna amp probe	
87477		99.89	Lyme dis dna quant	
87480		46.77	Candida dna dir probe	
87481		81.84	Candida dna amp probe	
87482		97.38	Candida dna quant	
87483		971.92	Cns dna amp probe type 12-25	
87485		46.77	Chylmd pneum dna dir probe	
87486		81.84	Chylmd pneum dna amp probe	
87487		99.89	Chylmd pneum dna quant	
87490		46.77	Chylmd trach dna dir probe	
87491		81.84	Chylmd trach dna amp probe	
87492		81.52	Chylmd trach dna quant	
87493		81.84	C diff amplified probe	
87495		46.77	Cytomeg dna dir probe	
87496		81.84	Cytomeg dna amp probe	
87497		99.89	Cytomeg dna quant	
87498		81.84	Enterovirus probe&revrs trns	
87500		81.84	Vanomycin dna amp probe	
87501		119.66	Influenza dna amp prob 1+	
87502		198.44	Influenza dna amp probe	
87502	QW	198.44	Influenza dna amp probe	
87503		48.43	Influenza dna amp prob addl	
87505		299.17	Nfct agent detection gi	
87506		497.71	Iadna-dna/rna probe tq 6-11	
87507		971.92	Iadna-dna/rna probe tq 12-25	
87510		46.77	Gardner vag dna dir probe	
87511		81.84	Gardner vag dna amp probe	
87512		97.38	Gardner vag dna quant	
87515		46.77	Hepatitis b dna dir probe	
87516		81.84	Hepatitis b dna amp probe	
87517		99.89	Hepatitis b dna quant	
87520		46.77	Hepatitis c rna dir probe	
87521		81.84	Hepatitis c probe&rvrs trnsc	
87522		99.89	Hepatitis c revrs trnscrpj	
87525		46.77	Hepatitis g dna dir probe	
87526		81.84	Hepatitis g dna amp probe	
87527		97.38	Hepatitis g dna quant	
87528		46.77	Hsv dna dir probe	
87529		81.84	Hsv dna amp probe	
87530		99.89	Hsv dna quant	
87531		46.77	Hhv-6 dna dir probe	
87532		81.84	Hhv-6 dna amp probe	
87533		97.38	Hhv-6 dna quant	
87534		46.77	Hiv-1 dna dir probe	
87535		81.84	Hiv-1 probe&reverse trnscrpj	
87536		198.44	Hiv-1 quant&revrse trnscrpj	
87537		46.77	Hiv-2 dna dir probe	
87538		81.84	Hiv-2 probe&revrse trnscripj	
87539		99.89	Hiv-2 quant&revrse trnscripj	
87540		46.77	Legion pneumo dna dir prob	
87541		81.84	Legion pneumo dna amp prob	
87542		97.38	Legion pneumo dna quant	
87550		46.77	Mycobacteria dna dir probe	
87551		81.84	Mycobacteria dna amp probe	
87552		99.89	Mycobacteria dna quant	
87555		46.77	M.tuberculo dna dir probe	
87556		81.84	M.tuberculo dna amp probe	
87557		99.89	M.tuberculo dna quant	
87560		46.77	M.avium-intra dna dir prob	
87561		81.84	M.avium-intra dna amp prob	
87562		99.89	M.avium-intra dna quant	
87580		46.77	M.pneumon dna dir probe	
87581		81.84	M.pneumon dna amp probe	
87582		97.38	M.pneumon dna quant	
87590		46.77	N.gonorrhoeae dna dir prob	
87591		81.84	N.gonorrhoeae dna amp prob	
87592		99.89	N.gonorrhoeae dna quant	
87623		81.84	Hpv low-risk types	
87624		81.84	Hpv high-risk types	
87625		81.84	Hpv types 16 & 18 only	
87631		299.17	Resp virus 3-11 targets	
87631	QW	299.17	Resp virus 3-5 targets	
87632		497.71	Resp virus 6-11 targets	
87633		971.92	Resp virus 12-25 targets	
87640		81.84	Staph a dna amp probe	
87641		81.84	Mr-staph dna amp probe	
87650		46.77	Strep a dna dir probe	
87650	QW	46.77	Strep a dna dir probe	
87651		81.84	Strep a dna amp probe	
87651	QW	81.84	Strep a dna amp probe	
87652		97.38	Strep a dna quant	
87653		81.84	Strep b dna amp probe	
87660		46.77	Trichomonas vagin dir probe	
87661		81.84	Trichomonas vaginalis amplif	
87797		46.77	Detect agent nos dna dir	
87798		81.84	Detect agent nos dna amp	
87799		99.89	Detect agent nos dna quant	
87800		93.55	Detect agnt mult dna direc	
87801		163.69	Detect agnt mult dna ampli	
87802		27.95	Strep b assay w/optic	
87803		27.95	Clostridium toxin a w/optic	
87804		27.95	Influenza assay w/optic	
87804	QW	27.95	Influenza assay w/optic	
87806		56.15	Hiv antigen w/hiv antibodies	
87806	QW	56.15	Hiv antigen w/hiv antibodies	
87807		27.95	Rsv assay w/optic	
87807	QW	27.95	Rsv assay w/optic	
87808		27.95	Trichomonas assay w/optic	
87808	QW	27.95	Trichomonas assay w/optic	
87809		27.95	Adenovirus assay w/optic	
87809	QW	27.95	Adenovirus assay w/optic	
87810		27.95	Chylmd trach assay w/optic	
87850		27.95	N. gonorrhoeae assay w/optic	
87880		27.95	Strep a assay w/optic	
87880	QW	27.95	Strep a assay w/optic	
87899		27.95	Agent nos assay w/optic	
87899	QW	27.95	Agent nos assay w/optic	
87900		303.96	Phenotype infect agent drug	
87901		600.36	Genotype dna hiv reverse t	
87902		600.36	Genotype dna/rna hep c	
87903		1139.53	Phenotype dna hiv w/culture	
87904		60.79	Phenotype dna hiv w/clt add	
87905		12.22	Sialidase enzyme assay	
87905	QW	12.22	Sialidase enzyme assay	
87906		300.19	Genotype dna/rna hiv	
87910		600.36	Genotype cytomegalovirus	
87912		600.36	Genotype dna hepatitis b	
88130		35.11	Sex chromatin identification	
88140		6.77	Sex chromatin identification	
88142		47.24	Cytopath c/v thin layer	
88143		47.24	Cytopath c/v thin layer redo	
88147		26.54	Cytopath c/v automated	
88148		35.43	Cytopath c/v auto rescreen	
88150		24.63	Cytopath c/v manual	
88152		24.63	Cytopath c/v auto redo	
88153		24.63	Cytopath c/v redo	
88154		24.63	Cytopath c/v select	
88155		13.97	Cytopath c/v index add-on	
88164		24.63	Cytopath tbs c/v manual	
88165		24.63	Cytopath tbs c/v redo	
88166		24.63	Cytopath tbs c/v auto redo	
88167		24.63	Cytopath tbs c/v select	
88174		49.83	Cytopath c/v auto in fluid	
88175		61.78	Cytopath c/v auto fluid redo	
88230		85.99	Tissue culture lymphocyte	
88233		171.94	Tissue culture skin/biopsy	
88235		171.94	Tissue culture placenta	
88237		294.54	Tissue culture bone marrow	
88239		344.01	Tissue culture tumor	
88240		23.55	Cell cryopreserve/storage	
88241		23.55	Frozen cell preparation	
88245		347.14	Chromosome analysis 20-25	
88248		403.84	Chromosome analysis 50-100	
88249		403.84	Chromosome analysis 100	
88261		412.17	Chromosome analysis 5	
88262		290.67	Chromosome analysis 15-20	
88263		350.47	Chromosome analysis 45	
88264		290.67	Chromosome analysis 20-25	
88267		419.24	Chromosome analys placenta	
88269		387.87	Chromosome analys amniotic	
88271		49.95	Cytogenetics dna probe	
88272		62.44	Cytogenetics 3-5	
88273		74.92	Cytogenetics 10-30	
88274		81.18	Cytogenetics 25-99	
88275		93.65	Cytogenetics 100-300	
88280		58.51	Chromosome karyotype study	
88283		159.97	Chromosome banding study	
88285		44.30	Chromosome count additional	
88289		80.29	Chromosome study additional	
88371		51.78	Protein western blot tissue	
88372		46.07	Protein analysis w/probe	
88720		11.70	Bilirubin total transcut	
88738		11.70	Hgb quant transcutaneous	
88740		11.70	Transcutaneous carboxyhb	
88741		11.70	Transcutaneous methb	
89050		9.91	Body fluid cell count	
89051		12.84	Body fluid cell count	
89055		9.96	Leukocyte assessment fecal	
89060		16.68	Exam synovial fluid crystals	
89125		10.08	Specimen fat stain	
89160		8.30	Exam feces for meat fibers	
89190		8.30	Nasal smear for eosinophils	
89300		20.83	Semen analysis w/huhner	
89300	QW	20.83	Semen analysis w/huhner	
89310		14.82	Semen analysis w/count	
89320		28.10	Semen anal vol/count/mot	
89321		28.10	Semen anal sperm detection	
89321	QW	28.10	Semen anal sperm detection	
89322		36.14	Semen anal strict criteria	
89325		18.17	Sperm antibody test	
89329		48.89	Sperm evaluation test	
89330		23.07	Evaluation cervical mucus	
89331		45.68	Retrograde ejaculation anal	
0006M		0.00	Onc hep gene risk classifier	
0007M		0.00	Onc gastro 51 gene nomogram	
0008M		5853.71	Onc breast risk score	
0009M		1023.57	Fetal aneuploidy trisom risk	
ATP02		12.16	Auto.Test Panel Pricing Code, 1-2 Tests	
ATP03		15.50	Auto.Test Panel Pricing Code, 3 Tests	
ATP04		16.35	Auto.Test Panel Pricing Code, 4 Tests	
ATP05		18.24	Auto.Test Panel Pricing Code, 5 Tests	
ATP06		18.29	Auto.Test Panel Pricing Code, 6 Tests	
ATP07		19.06	Auto.Test Panel Pricing Code, 7 Tests	
ATP08		19.72	Auto.Test Panel Pricing Code, 8 Tests	
ATP09		20.25	Auto.Test Panel Pricing Code, 9 Tests	
ATP10		20.25	Auto.Test Panel Pricing Code, 10 Tests	
ATP11		20.60	Auto.Test Panel Pricing Code, 11 Tests	
ATP12		21.06	Auto.Test Panel Pricing Code, 12 Tests	
ATP16		24.63	Auto Test Panel Pricing Code  13-16 Test	
ATP18		24.82	Auto Test Panel Pricing Code, 17-18 Test	
ATP19		25.81	Auto Test Panel Pricing Code, 19 Tests	
ATP20		26.62	Auto Test Panel Pricing Code, 20 Tests	
ATP21		27.47	Auto Test Panel Pricing Code, 21 Tests	
ATP22		28.29	Auto.Test Panel Pricing Code, 22+ Tests	
ATP23		28.29	Auto.Test Panel Pricing Code, 23+ Tests	
G0027		15.16	Semen analysis	
G0103		42.89	PSA screening	
G0123		47.24	Screen cerv/vag thin layer	
G0143		47.24	Scr c/v cyto,thinlayer,rescr	
G0144		49.83	Scr c/v cyto,thinlayer,rescr	
G0145		61.78	Scr c/v cyto,thinlayer,rescr	
G0147		26.54	Scr c/v cyto, automated sys	
G0148		35.43	Scr c/v cyto, autosys, rescr	
G0306		16.49	CBC/diffwbc w/o platelet	
G0307		11.63	CBC without platelet	
G0328		37.09	Fecal blood scrn immunoassay	
G0328	QW	37.09	Fecal blood scrn immunoassay	
G0432		23.27	EIA HIV-1/HIV-2 screen	
G0433		23.27	ELISA HIV-1/HIV-2 screen	
G0433	QW	23.27	ELISA HIV-1/HIV-2 screen	
G0435		27.95	Oral HIV-1/HIV-2 screen	
G0471		8.50	Ven blood coll SNF/HHA	
G0472		33.27	Hep c screen high risk/other	
G0472	QW	33.27	Hep c screen high risk/other	
G0475		56.15	Hiv combination assay	
G0476		81.84	Hpv combo assay ca screen	
G0480	 	200.01	Drug test def 1-7 classes	
G0481	 	273.68	Drug test def 8-14 classes	
G0482	 	347.38	Drug test def 15-21 classes	
G0483	 	431.58	Drug test def 22+ classes	
G0659		135.68	Drug test def simple all cl	
G9143		281.50	Warfarin respon genetic test	
P2038		11.73	Blood mucoprotein	
P3000		24.63	Screen pap by tech w md supv	
P9612		5.10	Catheterize for urine spec	
P9615		5.10	Urine specimen collect mult	
Q0111		9.96	Wet mounts/ w preparations	
Q0112		9.96	Potassium hydroxide preps	
Q0113		12.61	Pinworm examinations	
Q0114		16.68	Fern test	
Q0115		23.07	Post-coital mucous exam