| # | These amounts apply when service is performed in a facility setting. |
| C | The payment for the technical component is capped at the OPPS amount. |
| Limiting charge applies to unassigned claims by non-participating providers. | |
| All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2006 by the American Medical Association. |
| NOTE | PROCEDURE | MOD | PAR AMOUNT | NON-PAR AMOUNT | LIMITING CHARGE |
|---|---|---|---|---|---|
| 0024T | 705.43 | 670.16 | 770.68 | ||
| 0026T | 16.06 | 15.26 | 17.55 | ||
| 0048T | 1,127.74 | 1,071.35 | 1,232.05 | ||
| 0049T | 577.91 | 549.01 | 631.36 | ||
| 0050T | 1,222.42 | 1,161.30 | 1,335.50 | ||
| 0054T | 327.79 | 311.40 | 358.11 | ||
| 0055T | 408.27 | 387.86 | 446.04 | ||
| 0056T | 247.31 | 234.94 | 270.18 | ||
| 0067T | 761.20 | 723.14 | 831.61 | ||
| C | 0067T | TC | 271.19 | 257.63 | 296.27 |
| 0067T | 26 | 131.20 | 124.64 | 143.34 | |
| 0073T | 588.39 | 558.97 | 642.82 | ||
| 0075T | 2,137.24 | 2,030.38 | 2,334.94 | ||
| 0075T | TC | 1,118.65 | 1,062.72 | 1,222.13 | |
| 0075T | 26 | 1,018.59 | 967.66 | 1,112.81 | |
| 0076T | 598.42 | 568.50 | 653.78 | ||
| 0076T | TC | 313.22 | 297.56 | 342.19 | |
| 0076T | 26 | 285.20 | 270.94 | 311.58 | |
| 0145T | 535.44 | 508.67 | 584.97 | ||
| C | 0145T | TC | 279.11 | 265.15 | 304.92 |
| 0145T | 26 | 81.45 | 77.38 | 88.99 | |
| 0146T | 540.66 | 513.63 | 590.67 | ||
| C | 0146T | TC | 279.11 | 265.15 | 304.92 |
| 0146T | 26 | 82.23 | 78.12 | 89.84 | |
| 0147T | 544.85 | 517.61 | 595.25 | ||
| C | 0147T | TC | 279.11 | 265.15 | 304.92 |
| 0147T | 26 | 82.82 | 78.68 | 90.48 | |
| 0148T | 549.04 | 521.59 | 599.83 | ||
| C | 0148T | TC | 364.11 | 345.90 | 397.79 |
| 0148T | 26 | 83.50 | 79.33 | 91.23 | |
| 0149T | 553.23 | 525.57 | 604.41 | ||
| C | 0149T | TC | 364.11 | 345.90 | 397.79 |
| 0149T | 26 | 84.13 | 79.92 | 91.91 | |
| 0150T | 546.44 | 519.12 | 596.99 | ||
| C | 0150T | TC | 231.08 | 219.53 | 252.46 |
| 0150T | 26 | 83.11 | 78.95 | 90.79 | |
| 0151T | 171.60 | 163.02 | 187.47 | ||
| C | 0151T | TC | 86.05 | 81.75 | 94.01 |
| 0151T | 26 | 26.10 | 24.80 | 28.52 |