179
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. Procedure Code Modifier Facility RVU Non-Facility RVU 10021 1.80951 3.38481 10021 26 1.79385 1.79385 10021 TC .45006 .45006 10022 1.73897 3.34987 10022 26 1.71281 1.71281 10022 TC .59406 .59406 10030 4.26512 19.94692 10040 2.18995 2.47475 10060 2.26470 2.62070 10061 4.02227 4.49397 10080 2.38180 3.88590 10081 4.20928 6.19398 10120 2.24667 3.19897 10121 4.55916 6.23236 10140 2.88338 3.67548 10160 2.34457 2.99427 10180 4.33508 5.58108 11000 0.78784 1.25954 11001 0.39392 0.52742 11004 15.29196 15.29196 11005 20.38874 20.38874 11006 18.63024 18.63024 11008 7.16440 7.16440 11010 7.03133 11.12533 11011 7.65436 12.38026 11012 10.92765 16.74825 11042 1.13308 1.75608 11043 5.88632 6.69622 11044 8.15920 9.21830 11045 0.51351 0.85171 11046 1.08852 1.49792 11047 1.88932 2.46782 11055 0.55601 1.12561 11056 0.77771 1.37401 11057 1.00831 1.65801 11100 1.25851 2.43331 11101 0.63857 0.80767 11200 1.70434 1.98914 11201 0.43075 0.46635 11300 0.76463 1.59233 11301 1.30839 2.20729 11302 1.61391 2.64631 11303 1.89190 3.10230 11305 0.91141 1.63231 BCBSNM RVUs effective 5/1/15

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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association.

Procedure Code Modifier Facility RVU Non-Facility RVU10021 1.80951 3.3848110021 26 1.79385 1.7938510021 TC .45006 .4500610022 1.73897 3.3498710022 26 1.71281 1.7128110022 TC .59406 .5940610030 4.26512 19.9469210040 2.18995 2.4747510060 2.26470 2.6207010061 4.02227 4.4939710080 2.38180 3.8859010081 4.20928 6.1939810120 2.24667 3.1989710121 4.55916 6.2323610140 2.88338 3.6754810160 2.34457 2.9942710180 4.33508 5.5810811000 0.78784 1.2595411001 0.39392 0.5274211004 15.29196 15.2919611005 20.38874 20.3887411006 18.63024 18.6302411008 7.16440 7.1644011010 7.03133 11.1253311011 7.65436 12.3802611012 10.92765 16.7482511042 1.13308 1.7560811043 5.88632 6.6962211044 8.15920 9.2183011045 0.51351 0.8517111046 1.08852 1.4979211047 1.88932 2.4678211055 0.55601 1.1256111056 0.77771 1.3740111057 1.00831 1.6580111100 1.25851 2.4333111101 0.63857 0.8076711200 1.70434 1.9891411201 0.43075 0.4663511300 0.76463 1.5923311301 1.30839 2.2072911302 1.61391 2.6463111303 1.89190 3.1023011305 0.91141 1.63231

BCBSNM RVUs effective 5/1/15

Page 2 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

11306 1.41585 2.2702511307 1.70148 2.6982811308 1.98199 2.9965911310 1.10947 1.9994711311 1.62281 2.5484111312 1.87078 2.9476811313 2.48348 3.6849811400 1.86640 2.7564011401 2.46688 3.3924811402 2.72747 3.7865711403 3.47324 4.3810411404 3.85783 4.9792311406 5.91794 7.2173411420 1.97303 2.7651311421 2.68051 3.6061111422 3.22922 4.0302211423 3.79822 4.7238211424 4.38834 5.4652411426 6.73683 7.9116311440 2.37931 3.0379111441 3.12571 3.8733111442 3.49001 4.3622111443 4.32604 5.2516411444 5.57625 6.6798511446 7.96718 9.2131811450 5.89782 8.4432211451 7.73523 10.9570311462 5.65772 8.3010211463 7.84887 11.2130711470 6.68108 9.2620811471 8.33617 11.5490711600 2.84031 4.2910111601 3.64363 5.2723311602 4.01145 5.7736511603 4.79242 6.6169211604 5.27883 7.3258311606 7.89100 10.4720011620 2.88564 4.3719411621 3.68006 5.3176611622 4.22983 6.0009311623 5.24303 7.0764311624 5.95838 7.9697811626 7.41535 9.6937511640 3.01479 4.5455911641 3.88539 5.5585911642 4.59164 6.4161411643 5.76650 7.6177011644 7.16492 9.3899211646 10.06358 12.4309811719 0.22087 0.4967711720 0.41338 0.72488

Page 3 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

11721 0.70070 1.0300011730 1.41196 2.2841611732 0.73879 1.0591911740 0.75573 1.0583311750 4.26804 5.1313411752 6.44657 7.3899711755 2.05651 3.1067111760 3.19837 4.8448711762 4.78384 6.3680411765 1.62716 3.0244611770 4.46220 6.2511011771 10.43019 13.0467911772 13.52459 15.7762911900 0.80106 1.3350611901 1.24878 1.7204811920 2.86675 4.2284511921 3.38421 4.8616111922 0.77599 1.4345911950 1.29660 1.8039011951 1.86039 2.5011911952 2.51599 3.3080911954 2.92845 3.9074511960 22.43083 22.4308311970 14.91099 14.9109911971 7.51147 10.8667711976 2.49816 3.5928611980 2.10490 2.5944011981 2.18706 3.2817611982 2.61452 3.7181211983 4.71310 5.7366012001 2.64285 3.6129512002 2.92931 3.8549112004 3.43189 4.5265912005 4.26523 5.6447312006 5.39559 7.0153912007 6.10390 7.8750012011 2.73205 3.8356512013 3.11332 4.2347212014 3.72333 4.9782312015 4.67466 6.2588612016 5.69035 7.4792512017 6.69445 6.6944512018 8.07361 8.0736112020 4.62867 6.3730712021 3.35279 3.8066912031 3.95430 5.6809012032 4.80584 7.1910412034 5.07327 7.2181712035 5.90967 8.7576712036 6.79369 9.6238912037 7.87623 10.82213

Page 4 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

12041 4.22588 5.9613812042 4.93027 6.8882712044 5.30719 8.0483912045 6.10304 8.8086412046 7.35937 10.7591712047 8.09023 11.4989312051 4.49434 6.3366412052 5.33057 7.2351712053 5.38357 7.9645712054 5.71496 8.4561612055 6.97035 10.1921512056 7.99532 11.8668212057 9.43120 13.1692013100 5.81077 7.5017713101 7.10322 9.4884213102 1.91588 2.6011813120 6.07697 7.7946713121 8.09098 10.5562813122 2.18580 2.8978013131 6.86375 8.6259513132 11.69552 14.0095213133 3.39277 4.1314713151 7.94755 9.8076513152 10.73469 13.5737913153 3.66392 4.5272213160 20.20170 20.2017014000 12.38193 14.8294314001 16.41942 19.3030214020 14.11340 16.6677014021 18.16380 21.1008014040 16.01758 18.5362814041 19.77923 23.0366314060 16.93869 18.9233914061 21.13126 24.7001614301 22.82781 26.7260114302 5.97369 5.9736914350 18.39879 18.3987915002 5.73293 8.0202315003 1.17486 1.7444615004 7.00478 9.5501815005 2.33192 2.9727215040 3.24762 5.9710215050 10.84283 13.0678315100 17.78458 20.8550815101 2.83756 4.4662615110 18.45609 20.8323915111 2.75663 3.0325315115 18.87466 20.9661615116 3.84850 4.1778015120 19.56920 22.8800015121 4.33843 6.36763

Page 5 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

15130 13.85993 16.2006315131 2.23668 2.4413815135 19.02713 21.0563315136 2.00998 2.1434815150 15.97939 17.2342915151 2.97106 3.1846615152 3.80400 4.0443015155 15.68442 16.7257215156 4.24857 4.4532715157 4.22260 4.4985015200 16.40431 19.5460115201 2.01564 3.4841415220 15.26259 18.3508915221 1.85833 3.2378315240 19.69443 22.2932315241 2.90052 4.3957215260 21.40676 24.2547615261 3.64941 5.1446115271 2.47220 3.9496015272 0.48953 0.7476315273 5.89172 8.1701215274 1.24400 1.9115015275 2.87685 4.2652515276 0.70356 0.9349615277 6.10504 8.2499415278 1.54268 2.2635815570 17.91373 21.4648315572 18.04924 20.7993415574 18.96752 21.8689215576 16.69089 19.4231915600 4.87715 7.5293515610 5.75064 7.7976415620 7.77793 10.3055315630 8.47010 10.9087015650 9.50917 12.1435715731 25.44024 27.8165415732 33.31876 36.8876615734 33.88454 37.6759415736 28.99620 32.9567015738 31.70438 35.3711815740 21.54464 24.7308415750 22.81390 22.8139015756 59.64406 59.6440615757 59.16837 59.1683715758 58.90938 58.9093815760 17.62774 20.5024415770 16.41318 16.4131815775 5.54885 7.3555515776 7.85027 10.1998715777 6.05967 6.0596715780 15.80513 19.80123

Page 6 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

15781 10.46920 12.7743015782 10.02666 13.4175615783 9.07187 11.5015715786 3.50412 5.7202215787 0.46967 1.1371715788 5.73407 9.9793715789 10.30943 13.2553315792 6.11614 9.6494415793 8.70382 11.2581215819 18.64173 18.6417315820 12.25867 13.3800715821 13.05226 14.2893615822 9.22288 10.2997815823 15.49330 16.6770015824 12.27900 12.2790015825 20.06500 20.0650015826 12.24800 12.2480015828 22.42900 22.4290015829 24.43500 24.4350015830 28.96847 28.9684715832 22.31675 22.3167515833 21.21910 21.2191015834 21.24975 21.2497515835 22.52417 22.5241715836 18.28035 18.2803515837 16.70673 19.1008315838 14.29399 14.2939915839 18.12602 20.9384215840 25.45527 25.4552715841 41.50279 41.5027915842 63.65503 63.6550315845 24.09384 24.0938415850 1.05198 2.0843815851 1.19352 2.2259215852 1.23324 1.2332415860 2.95183 2.9518315876 13.63900 13.6390015877 13.87060 13.8706015878 13.63900 13.6390015879 24.35300 24.3530015920 14.74329 14.7432915922 18.23044 18.2304415931 16.80263 16.8026315933 20.63327 20.6332715934 22.97452 22.9745215935 27.26284 27.2628415936 22.17618 22.1761815937 25.84934 25.8493415940 17.18928 17.1892815941 22.22749 22.2274915944 21.91848 21.91848

Page 7 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

15945 24.32489 24.3248915946 40.80120 40.8012015950 14.16917 14.1691715951 20.07180 20.0718015952 21.16289 21.1628915953 23.92585 23.9258515956 28.54553 28.5455315958 29.05429 29.0542916000 1.20491 1.6766116020 1.41104 1.9539416025 2.92227 3.5897716030 3.32546 4.2955616035 5.36042 5.3604216036 2.16614 2.1661417000 1.34791 1.8819117003 0.11467 0.1769717004 3.34123 4.1867317106 6.84389 8.2322917107 8.91519 10.7485917108 12.97947 15.1777717110 1.64576 2.5446617111 2.06595 3.0538517250 0.88840 1.7339017260 1.70228 2.2896817261 2.27088 3.3655817262 2.91835 4.1198517263 3.22470 4.5508017264 3.45487 4.8788717266 4.03921 5.5611117270 2.47435 3.5334517271 2.76642 3.8789217272 3.21414 4.4512417273 3.63516 4.9790617274 4.47554 5.9262417276 5.37719 6.8901917280 2.24418 3.2943817281 3.12989 4.2334917282 3.63433 4.9070317283 4.55089 5.9481917284 5.42936 6.9423617286 7.30592 8.8456217311 9.77578 16.2104817312 5.20334 9.6266417313 8.77580 14.7833017314 4.82124 8.9241417315 1.37235 1.9686517340 1.19289 1.2373917360 2.51948 3.1869817380 1.07440 1.0744019000 1.17200 2.6227019001 0.58600 0.68390

Page 8 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

19020 7.16849 10.4525919030 2.09875 4.0033519081 5.07815 17.3690519082 2.40249 13.8745919083 4.75426 17.2231619084 2.25657 13.6752719085 5.54742 25.9284219086 2.43292 20.4643219100 1.79995 3.3841519101 5.41121 7.7786119105 5.08301 48.4883119110 8.09618 10.9441819112 7.28665 10.2058519120 9.96630 11.4971019125 11.10307 12.7762719126 4.16289 4.1628919260 30.27238 30.2723819271 40.94509 40.9450919272 45.48947 45.4894719281 2.81284 6.3105419282 1.33518 4.3255819283 2.83954 7.1382419284 1.34408 5.1710819285 2.40796 11.9042619286 1.15363 9.9112319287 3.95615 22.0587519288 1.72538 17.4160819296 5.38763 89.3235319297 2.43706 2.4370619298 8.57886 29.9032619300 9.64381 12.0379119301 15.88341 15.8834119302 22.05693 22.0569319303 24.62543 24.6254319304 13.77439 13.7743919305 27.81876 27.8187619306 29.18547 29.1854719307 29.27387 29.2738719316 19.23763 19.2376319318 27.87783 27.8778319324 11.98852 11.9885219325 15.89852 15.8985219328 12.08854 12.0885419330 15.51230 15.5123019340 19.23351 19.2335119342 22.81807 22.8180719350 16.67079 20.2040919355 14.22088 17.2468819357 38.50073 38.5007319361 41.65680 41.6568019364 70.08716 70.08716

Page 9 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

19366 34.88160 34.8816019367 45.28764 45.2876419368 56.11530 56.1153019369 51.68355 51.6835519370 16.85377 16.8537719371 19.34712 19.3471219380 19.03187 19.0318719396 3.38979 5.5702920005 5.90166 7.3434620100 15.24070 15.2407020101 5.13259 9.3244920102 6.33066 11.0565620103 8.79322 13.4034220150 23.99651 23.9965120200 2.35796 4.5384620205 3.82855 6.3383520206 1.58495 5.8836520220 1.96625 4.0488520225 2.96703 14.7951320240 5.62616 5.6261620245 15.61341 15.6134120250 9.36965 9.3696520251 10.31806 10.3180620500 2.26078 2.7235820501 1.04348 2.9747820520 3.52066 4.5797620525 6.15578 10.9350820526 1.45348 1.8272820527 1.67140 2.0986020550 1.05361 1.4007120551 1.08921 1.4096120552 0.93728 1.2754820553 1.05361 1.4541120555 8.68912 8.6891220600 0.99068 1.3110820605 1.03890 1.4127020610 1.25891 1.8463120612 1.07822 1.4164220615 3.91919 5.1651920650 3.81920 4.7092020660 6.25098 6.2509820661 11.71154 11.7115420662 11.20228 11.2022820663 11.01450 11.0145020664 20.19062 20.1906220665 2.39202 2.8103220670 3.61833 8.9138320680 10.44808 14.3551820690 14.21774 14.2177420692 26.55163 26.5516320693 11.20398 11.20398

Page 10 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

20694 8.22044 10.0983420696 25.69340 25.6934020697 31.22326 31.2232620802 59.83264 59.8326420805 79.68396 79.6839620808 104.90823 104.9082320816 53.86693 53.8669320822 47.10736 47.1073620824 55.50829 55.5082920827 49.10268 49.1026820838 62.02104 62.0210420900 5.98290 9.6141020902 8.41518 8.4151820910 10.43209 10.4320920912 11.99686 11.9968620920 9.94983 9.9498320922 12.47505 14.8068520924 12.38854 12.3885420926 10.83109 10.8310920930 3.41770 3.4177020931 2.92043 2.9204320936 3.90880 3.9088020937 4.39091 4.3909120938 4.81536 4.8153620950 2.23794 5.6288420955 64.44164 64.4416420956 66.89288 66.8928820957 65.64245 65.6424520962 65.66327 65.6632720969 71.35679 71.3567920970 72.14020 72.1402020972 61.29731 61.2973120973 65.53683 65.5368320974 1.19346 1.6117620975 4.44972 4.4497220979 0.88262 1.2653220982 10.24589 83.5551920985 3.81290 3.8129021010 18.29932 18.2993221011 6.22369 7.8701921012 8.56657 8.5665721013 10.08344 12.2995421014 13.24535 13.2453521015 15.33997 15.3399721016 26.78482 26.7848221025 18.34421 21.2812121026 11.87778 14.2095821029 15.80929 18.4169921030 9.92813 11.9217321031 6.91280 8.9242021032 6.84492 9.06102

Page 11 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

21034 29.21092 32.5217221040 9.87951 11.9977121044 21.97886 21.9788621045 30.70069 30.7006921046 26.57671 26.5767121047 32.47873 32.4787321048 27.10911 27.1091121049 31.46072 31.4607221050 21.70176 21.7017621060 20.20203 20.2020321070 15.57688 15.5768821073 6.16817 8.8915721076 20.61628 23.3841821077 52.27000 57.8414021079 34.57213 39.4760321080 38.72338 44.6507821081 35.39265 40.8928521082 32.77684 38.0723421083 29.47823 35.2276321084 35.44476 41.7815621085 15.74551 18.4155121086 38.18812 42.0685221087 38.17032 42.0418221100 9.68789 16.6387921110 15.22015 17.7744521116 1.10993 3.4951321120 12.19980 14.9499021121 15.36907 17.9411721122 16.53781 16.5378121123 20.58524 20.5852421125 19.45246 72.5498621127 21.18350 83.8662021137 18.29480 18.2948021138 22.06889 22.0688921139 23.95376 23.9537621141 34.20683 34.2068321142 34.48010 34.4801021143 35.65947 35.6594721145 37.67196 37.6719621146 42.43743 42.4374321147 41.72683 41.7268321150 40.03182 40.0318221151 49.87742 49.8774221154 51.32427 51.3242721155 54.92362 54.9236221159 67.72672 67.7267221160 69.31269 69.3126921172 44.54394 44.5439421175 58.80052 58.8005221179 37.24503 37.2450321180 40.73962 40.73962

Page 12 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

21181 17.20038 17.2003821182 50.75708 50.7570821183 58.49192 58.4919221184 61.73794 61.7379421188 41.09097 41.0909721193 31.25674 31.2567421194 35.26464 35.2646421195 33.33902 33.3390221196 36.19633 36.1963321198 28.50601 28.5060121199 25.90287 25.9028721206 29.34879 29.3487921208 21.04914 41.8128421209 16.18638 20.2358821210 20.55297 48.7214721215 21.98453 83.1809321230 19.55577 19.5557721235 14.06676 17.4665621240 27.20221 27.2022121242 25.02339 25.0233921243 41.38425 41.3842521244 25.92122 25.9212221245 22.64070 27.4289021246 21.07344 21.0734421247 40.99105 40.9910521248 21.75542 25.8939221249 30.83517 35.8191721255 34.52140 34.5214021256 29.43878 29.4387821260 31.11024 31.1102421261 57.48633 57.4863321263 48.49673 48.4967321267 39.44341 39.4434121268 49.46569 49.4656921270 17.84361 22.4805121275 20.62008 20.6200821280 13.64527 13.6452721282 8.90491 8.9049121295 4.32990 4.3299021296 10.40882 10.4088221310 0.75676 2.5278621315 3.65313 6.1896321320 3.39028 5.9000821325 11.26616 11.2661621330 13.67069 13.6706921335 17.98918 17.9891821336 15.53895 15.5389521337 7.05723 9.3623321338 17.75601 17.7560121339 20.05004 20.0500421340 19.62651 19.62651

Page 13 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

21343 28.97490 28.9749021344 40.91535 40.9153521345 16.04200 19.2549021346 22.91619 22.9161921347 26.35867 26.3586721348 28.15446 28.1544621355 8.04345 10.4731521356 9.20809 11.7445921360 13.02157 13.0215721365 27.88569 27.8856921366 31.24470 31.2447021385 17.34953 17.3495321386 16.72545 16.7254521387 18.62699 18.6269921390 19.55103 19.5510321395 23.70370 23.7037021400 3.54358 4.2555821401 7.34154 11.1685421406 13.14268 13.1426821407 16.04024 16.0402421408 22.27122 22.2712221421 15.22008 17.7298821422 16.26447 16.2644721423 19.89271 19.8927121431 18.36874 18.3687421432 16.69600 16.6960021433 42.98331 42.9833121435 33.01482 33.0148221436 50.88764 50.8876421440 10.60638 12.6622821445 14.72364 17.6606421450 11.08063 13.2077321451 14.70515 17.1615521452 7.90132 13.5083221453 17.89424 20.1548421454 13.60734 13.6073421461 22.15661 45.0474121462 24.40017 48.3233721465 23.16892 23.1689221470 29.86450 29.8645021480 0.83935 2.1120521485 13.24503 15.4433321490 23.06169 23.0616921495 16.61817 16.6181721497 13.50890 15.6627021501 7.84432 10.5232221502 13.20579 13.2057921510 11.54712 11.5471221550 3.92285 6.0321521552 11.53073 11.5307321554 18.95747 18.95747

Page 14 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

21555 7.70990 9.8459021556 12.42258 12.4225821557 21.16031 21.1603121558 35.67454 35.6745421600 13.84098 13.8409821610 28.59879 28.5987921615 17.21431 17.2143121616 21.33221 21.3322121620 13.14984 13.1498421627 13.78752 13.7875221630 32.10290 32.1029021632 32.40084 32.4008421685 25.14476 25.1447621700 10.81689 10.8168921705 16.12828 16.1282821720 10.98362 10.9836221725 13.11147 13.1114721740 27.30543 27.3054321750 18.42288 18.4228821805 6.39676 6.3967621820 3.21840 3.1739021825 14.28446 14.2844621920 3.98037 6.0629721925 8.43235 10.2390521930 9.09072 11.1733221931 12.09100 12.0910021932 17.36244 17.3624421933 19.17667 19.1766721935 26.60774 26.6077421936 37.20871 37.2087122010 23.08991 23.0899122015 22.82738 22.8273822100 21.35732 21.3573222101 21.66178 21.6617822102 20.29952 20.2995222103 3.73328 3.7332822110 26.41280 26.4128022112 26.24473 26.2447322114 24.64927 24.6492722116 3.65424 3.6542422206 59.52132 59.5213222207 60.35900 60.3590022208 15.20038 15.2003822210 44.17568 44.1756822212 36.54333 36.5433322214 36.83548 36.8354822216 9.51617 9.5161722220 40.12548 40.1254822222 36.73115 36.7311522224 39.37823 39.3782322226 9.53537 9.53537

Page 15 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

22305 4.14363 4.4729322310 6.78871 7.2337122315 18.83671 21.0083122318 40.70886 40.7088622319 45.21865 45.2186522325 35.47853 35.4785322326 36.95526 36.9552622327 36.52193 36.5219322328 7.37232 7.3723222505 2.95747 2.9574722526 8.32074 45.9321422527 3.77531 36.0912122532 44.76409 44.7640922533 42.26167 42.2616722534 9.48961 9.4896122548 48.32758 48.3275822551 49.19830 49.1983022552 11.52388 11.5238822554 31.94905 31.9490522556 42.03796 42.0379622558 38.93291 38.9329122585 8.81186 8.8118622586 43.98122 43.9812222590 39.23914 39.2391422595 37.27834 37.2783422600 31.75992 31.7599222610 31.13018 31.1301822612 40.22777 40.2277722614 10.24505 10.2450522630 38.70139 38.7013922632 8.35218 8.3521822633 52.55375 52.5537522634 14.28608 14.2860822800 33.95708 33.9570822802 53.48057 53.4805722804 61.71658 61.7165822808 46.42641 46.4264122810 51.93424 51.9342422812 55.70965 55.7096522818 55.22201 55.2220122819 68.58636 68.5863622830 20.13256 20.1325622840 19.97510 19.9751022841 13.67898 13.6789822842 19.99894 19.9989422843 21.21942 21.2194222844 25.68750 25.6875022845 19.23968 19.2396822846 19.96390 19.9639022847 22.79004 22.7900422848 9.40531 9.40531

Page 16 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

22849 32.90289 32.9028922850 17.85902 17.8590222851 10.68856 10.6885622852 17.05413 17.0541322855 28.02530 28.0253022856 41.80905 41.8090522857 43.35521 43.3552122861 46.76740 46.7674022862 49.64697 49.6469722864 41.46692 41.4669222865 52.61081 52.6108122900 12.77938 12.7793822901 17.13047 17.1304722902 8.53326 10.5535622903 11.28073 11.2807322904 26.93119 26.9311922905 34.92306 34.9230623000 8.77450 12.6638023020 16.94964 16.9496423030 6.27869 9.9365923031 5.20485 9.0229523035 16.79954 16.7995423040 17.67695 17.6769523044 14.04703 14.0470323065 4.14472 5.1504223066 8.35700 12.0772023071 10.71579 10.7157923073 17.78455 17.7845523075 6.57349 8.5759923076 13.47007 13.4700723077 29.36822 29.3682223078 36.35167 36.3516723100 11.94136 11.9413623101 10.90604 10.9060423105 15.60522 15.6052223106 11.72879 11.7287923107 16.21749 16.2174923120 14.10229 14.1022923125 17.32072 17.3207223130 14.75823 14.7582323140 12.72296 12.7229623145 17.00570 17.0057023146 14.84082 14.8408223150 16.15645 16.1564523155 19.47730 19.4773023156 16.54619 16.5461923170 13.19323 13.1932323172 13.53495 13.5349523174 18.50425 18.5042523180 16.71423 16.7142323182 16.22533 16.22533

Page 17 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

23184 18.22340 18.2234023190 13.74815 13.7481523195 18.54028 18.5402823200 32.97441 32.9744123210 38.27719 38.2771923220 42.59505 42.5950523330 3.67130 5.3534023333 12.30762 12.3076223334 29.21580 29.2158023335 34.90010 34.9001023350 1.37012 3.5951223395 32.01946 32.0194623397 28.56422 28.5642223400 24.18355 24.1835523405 15.51230 15.5123023406 19.37817 19.3781723410 20.41475 20.4147523412 21.28389 21.2838923415 17.02101 17.0210123420 24.09930 24.0993023430 18.23147 18.2314723440 18.80110 18.8011023450 23.64022 23.6402223455 25.15849 25.1584923460 27.27778 27.2777823462 26.82242 26.8224223465 27.90642 27.9064223466 27.78614 27.7861423470 30.39771 30.3977123472 37.77079 37.7707923473 45.99608 45.9960823474 49.72269 49.7226923480 20.30878 20.3087823485 23.98011 23.9801123490 21.18868 21.1886823491 25.27436 25.2743623500 4.99577 4.9957723505 7.77435 8.1659523515 17.59871 17.5987123520 5.23793 5.2023323525 7.80869 8.3159923530 13.44638 13.4463823532 15.19104 15.1910423540 5.10818 5.1348823545 6.90381 7.4556123550 13.99841 13.9984123552 16.14898 16.1489823570 5.40394 5.3149423575 8.68527 9.1658723585 24.15525 24.1552523600 6.91969 7.40029

Page 18 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

23605 10.12756 10.9018623615 21.79660 21.7966023616 31.51791 31.5179123620 5.80859 6.1111923625 8.36570 8.8730023630 18.90687 18.9068723650 6.53147 7.0565723655 9.30026 9.3002623660 14.21304 14.2130423665 9.37000 9.9129023670 21.33214 21.3321423675 11.98755 12.8953523680 22.79761 22.7976123700 4.75321 4.7532123800 25.52565 25.5256523802 31.44608 31.4460823900 33.72732 33.7273223920 27.28445 27.2844523921 10.17772 10.1777223930 5.35635 8.2844523931 3.79776 6.3787623935 12.11172 12.1117224000 11.51376 11.5137624006 17.45700 17.4570024065 4.10869 5.9509924066 9.83675 13.9218524071 10.38546 10.3854624073 17.86943 17.8694324075 7.91864 11.3362424076 12.77299 12.7729924077 24.39380 24.3938024079 33.49445 33.4944524100 9.86551 9.8655124101 12.09206 12.0920624102 15.03648 15.0364824105 8.13510 8.1351024110 14.22214 14.2221424115 17.74672 17.7467224116 21.35675 21.3567524120 12.74388 12.7438824125 14.97040 14.9704024126 15.81676 15.8167624130 12.26906 12.2690624134 18.49784 18.4978424136 14.87562 14.8756224138 16.24768 16.2476824140 17.49941 17.4994124145 14.68557 14.6855724147 15.22478 15.2247824149 28.68150 28.6815024150 34.62712 34.62712

Page 19 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

24152 28.96047 28.9604724155 21.07401 21.0740124160 14.76636 14.7663624164 12.10219 12.1021924200 3.35711 4.6832124201 8.90096 12.9148624220 1.81827 3.9809724300 9.40952 9.4095224301 18.56864 18.5686424305 14.10012 14.1001224310 11.58144 11.5814424320 19.19250 19.1925024330 17.63989 17.6398924331 19.48683 19.4868324332 14.83833 14.8383324340 14.99006 14.9900624341 17.93465 17.9346524342 19.28010 19.2801024343 17.18562 17.1856224344 27.01965 27.0196524345 17.06992 17.0699224346 27.07305 27.0730524357 10.74790 10.7479024358 12.66896 12.6689624359 16.06914 16.0691424360 22.29357 22.2935724361 25.10815 25.1081524362 26.42086 26.4208624363 37.54409 37.5440924365 15.70106 15.7010624366 16.78738 16.7873824370 43.41423 43.4142324371 50.06906 50.0690624400 20.27009 20.2700924410 26.05699 26.0569924420 24.47041 24.4704124430 26.21373 26.2137324435 26.54197 26.5419724470 15.77269 15.7726924495 16.15879 16.1587924498 21.56766 21.5676624500 7.40673 8.0920324505 10.77045 11.6960524515 21.64198 21.6419824516 21.40477 21.4047724530 7.93661 8.6842124535 13.70179 14.6362924538 18.18797 18.1879724545 22.84895 22.8489524546 25.98147 25.9814724560 6.52208 7.26078

Page 20 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

24565 11.35124 12.1878424566 17.26978 17.2697824575 17.94335 17.9433524576 6.92238 7.6343824577 11.75031 12.6581124579 20.53938 20.5393824582 19.33052 19.3305224586 27.14434 27.1443424587 27.07529 27.0752924600 7.92531 8.5928124605 11.08902 11.0890224615 17.55759 17.5575924620 13.38846 13.3884624635 17.48504 17.4850424640 2.13715 2.8758524650 5.37103 5.8694324655 9.38926 10.1724624665 15.81636 15.8163624666 17.96470 17.9647024670 5.98247 6.5876724675 9.89739 10.6805924685 15.84595 15.8459524800 19.95567 19.9556724802 24.82956 24.8295624900 17.88932 17.8893224920 17.74961 17.7496124925 13.68542 13.6854224930 18.84291 18.8429124931 19.78334 19.7833424935 26.57019 26.5701924940 29.21300 29.2130025000 8.23715 8.2371525001 7.99213 7.9921325020 13.68502 13.6850225023 27.02823 27.0282325024 19.15587 19.1558725025 30.09448 30.0944825028 12.31015 12.3101525031 9.01912 9.0191225035 15.26719 15.2671925040 13.89436 13.8943625065 4.03480 5.8949025066 8.96927 8.9692725071 10.86775 10.8677525073 13.50765 13.5076525075 8.02956 8.8483625076 12.41190 12.4119025077 21.47287 21.4728725078 29.19889 29.1988925085 11.17324 11.1732425100 8.35222 8.35222

Page 21 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

25101 9.79763 9.7976325105 11.88118 11.8811825107 14.98580 14.9858025109 12.86814 12.8681425110 8.57226 8.5722625111 7.58991 7.5899125112 9.29073 9.2907325115 19.43103 19.4310325116 15.48832 15.4883225118 9.24045 9.2404525119 12.27149 12.2714925120 13.06923 13.0692325125 15.47083 15.4708325126 15.52320 15.5232025130 10.88123 10.8812325135 13.77462 13.7746225136 12.01442 12.0144225145 13.52848 13.5284825150 14.02680 14.0268025151 15.32036 15.3203625170 33.21623 33.2162325210 11.92096 11.9209625215 15.30646 15.3064625230 10.50995 10.5099525240 10.59603 10.5960325246 2.01201 4.0590125248 10.61457 10.6145725250 12.83285 12.8328525251 17.69578 17.6957825259 9.46498 9.4649825260 16.24296 16.2429625263 16.25944 16.2594425265 19.41826 19.4182625270 12.90757 12.9075725272 14.55147 14.5514725274 17.43782 17.4378225275 16.54058 16.5405825280 14.76493 14.7649325290 12.15393 12.1539325295 13.69604 13.6960425300 16.84132 16.8413225301 15.89363 15.8936325310 16.01826 16.0182625312 18.68566 18.6856625315 20.13258 20.1325825316 23.02154 23.0215425320 23.90963 23.9096325332 20.80252 20.8025225335 21.75499 21.7549925337 21.76281 21.7628125350 17.58781 17.58781

Page 22 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

25355 19.96471 19.9647125360 17.11994 17.1199425365 23.60333 23.6033325370 25.82862 25.8286225375 22.79383 22.7938325390 20.03214 20.0321425391 25.80524 25.8052425392 26.28338 26.2833825393 29.34244 29.3424425394 19.29641 19.2964125400 21.00596 21.0059625405 26.90367 26.9036725415 25.39498 25.3949825420 30.33326 30.3332625425 25.82238 25.8223825426 27.96955 27.9695525430 17.30569 17.3056925431 19.31959 19.3195925440 19.05354 19.0535425441 22.76845 22.7684525442 19.44104 19.4410425443 19.26762 19.2676225444 18.69618 18.6961825445 17.69590 17.6959025446 29.20724 29.2072425447 20.12140 20.1214025449 25.80736 25.8073625450 14.73920 14.7392025455 16.00811 16.0081125490 17.77633 17.7763325491 19.31767 19.3176725492 23.33404 23.3340425500 5.58612 6.0667225505 10.92467 11.7612725515 16.30134 16.3013425520 12.55300 13.1226025525 19.44399 19.4439925526 24.04567 24.0456725530 5.30086 5.8348625535 10.73714 11.4135425545 15.14408 15.1440825560 5.57845 6.1569525565 11.34197 12.3031725574 16.32120 16.3212025575 22.09219 22.0921925600 6.07210 6.6506025605 13.98041 14.7013125606 16.15041 16.1504125607 17.65154 17.6515425608 19.96297 19.9629725609 25.48828 25.48828

Page 23 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

25622 6.24203 6.8472325624 9.92409 10.7784925628 17.57439 17.5743925630 6.41053 6.9979325635 9.35011 10.3024125645 13.82204 13.8220425650 6.82285 7.3212525651 11.49762 11.4976225652 15.07872 15.0787225660 9.72998 9.7299825670 14.84297 14.8429725671 12.64552 12.6455225675 9.42263 10.1524325676 15.35525 15.3552525680 11.20919 11.2091925685 18.03793 18.0379325690 11.26204 11.2620425695 15.53857 15.5385725800 18.17653 18.1765325805 21.10503 21.1050325810 21.37719 21.3771925820 14.85828 14.8582825825 18.38867 18.3886725830 22.98350 22.9835025900 18.18491 18.1849125905 17.98201 17.9820125907 15.69605 15.6960525909 17.58357 17.5835725915 29.28376 29.2837625920 16.88665 16.8866525922 13.17323 13.1732325924 16.48841 16.4884125927 19.09883 19.0988325929 14.04560 14.0456025931 17.13238 17.1323826010 3.22381 5.8048126011 4.44646 8.7629626020 10.31200 10.3120026025 10.05184 10.0518426030 11.89071 11.8907126034 12.88485 12.8848526035 20.55343 20.5534326037 13.92143 13.9214326040 7.30268 7.3026826045 11.21425 11.2142526055 7.10247 12.7628726060 6.27391 6.2739126070 7.26399 7.2639926075 7.64815 7.6481526080 9.18167 9.1816726100 7.79089 7.79089

Page 24 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

26105 7.92087 7.9208726110 7.56905 7.5690526111 10.48880 10.4888026113 13.79583 13.7958326115 8.38144 13.4099426116 12.54268 12.5426826117 17.46737 17.4673726118 27.19659 27.1965926121 14.49813 14.4981326123 20.10254 20.1025426125 7.09618 7.0961826130 10.96711 10.9671126135 13.34193 13.3419326140 12.16312 12.1631226145 12.35975 12.3597526160 7.74041 12.9380126170 9.71799 9.7179926180 10.59729 10.5972926185 12.97980 12.9798026200 10.87213 10.8721326205 14.72635 14.7263526210 10.55648 10.5564826215 13.60967 13.6096726230 12.09859 12.0985926235 11.93361 11.9336126236 10.59686 10.5968626250 22.65801 22.6580126260 17.79308 17.7930826262 13.95573 13.9557326320 8.23970 8.2397026340 7.47790 7.4779026341 2.05347 2.6853726350 16.66941 16.6694126352 19.21381 19.2138126356 25.51474 25.5147426357 20.61263 20.6126326358 21.81522 21.8152226370 18.09470 18.0947026372 21.13029 21.1302926373 20.12745 20.1274526390 19.97601 19.9760126392 23.22852 23.2285226410 13.22393 13.2239326412 16.13730 16.1373026415 17.06641 17.0664126416 19.54386 19.5438626418 13.30443 13.3044326420 16.92044 16.9204426426 13.33626 13.3362626428 17.82538 17.8253826432 11.58836 11.58836

Page 25 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

26433 12.43970 12.4397026434 15.15240 15.1524026437 14.62055 14.6205526440 14.53312 14.5331226442 22.66977 22.6697726445 13.46091 13.4609126449 17.97277 17.9727726450 9.48461 9.4846126455 9.41092 9.4109226460 9.11868 9.1186826471 14.42412 14.4241226474 13.95127 13.9512726476 13.60829 13.6082926477 13.62632 13.6263226478 14.72297 14.7229726479 14.65915 14.6591526480 17.69340 17.6934026483 20.04080 20.0408026485 19.15721 19.1572126489 21.45696 21.4569626490 18.82330 18.8233026492 21.05274 21.0527426494 19.04394 19.0439426496 20.53692 20.5369226497 20.72364 20.7236426498 27.80877 27.8087726499 19.77503 19.7750326500 14.78009 14.7800926502 16.78345 16.7834526508 14.76026 14.7602626510 14.02608 14.0260826516 16.62812 16.6281226517 19.72990 19.7299026518 19.98119 19.9811926520 15.24555 15.2455526525 15.28158 15.2815826530 12.95900 12.9590026531 15.09887 15.0988726535 9.80877 9.8087726536 16.01316 16.0131626540 15.59274 15.5927426541 19.13435 19.1343526542 16.10379 16.1037926545 16.46623 16.4662326546 23.35917 23.3591726548 18.16456 18.1645626550 37.95448 37.9544826551 80.38250 80.3825026553 68.99493 68.9949326554 84.43103 84.4310326555 33.54948 33.54948

Page 26 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

26556 69.10851 69.1085126560 13.50192 13.5019226561 21.92428 21.9242826562 29.63492 29.6349226565 16.12379 16.1237926567 16.15845 16.1584526568 21.31619 21.3161926580 35.32471 35.3247126587 24.17370 24.1737026590 32.13573 32.1357326591 10.10366 10.1036626593 14.00476 14.0047626596 17.89464 17.8946426600 6.05988 6.4781826605 6.72203 7.3183326607 10.63964 10.6396426608 11.38003 11.3800326615 13.52797 13.5279726641 7.93275 8.5913526645 9.07172 9.7570226650 11.33945 11.3394526665 15.01330 15.0133026670 7.08081 7.7483126675 9.65251 10.3734126676 11.91406 11.9140626685 13.73819 13.7381926686 15.16185 15.1618526700 6.99865 7.4347526705 8.78466 9.4966626706 10.41325 10.4132526715 13.50001 13.5000126720 4.08960 4.4189026725 7.13664 7.8575426727 11.17616 11.1761626735 14.08352 14.0835226740 4.83351 5.1272126742 7.90333 8.6153326746 17.58040 17.5804026750 4.08402 4.1552226755 6.40455 7.2500526756 9.85558 9.8555826765 11.56118 11.5611826770 5.85773 6.3205326775 8.01634 8.8173426776 10.48937 10.4893726785 12.66670 12.6667026820 18.78003 18.7800326841 17.27693 17.2769326842 18.86345 18.8634526843 17.51122 17.5112226844 19.56824 19.56824

Page 27 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

26850 16.42694 16.4269426852 18.93297 18.9329726860 13.10434 13.1043426861 2.67284 2.6728426862 17.19506 17.1950626863 6.02537 6.0253726910 17.06087 17.0608726951 14.91980 14.9198026952 15.31784 15.3178426990 15.11277 15.1127726991 12.79602 16.5963226992 23.79790 23.7979027000 10.76802 10.7680227001 13.21206 13.2120627003 14.40077 14.4007727005 17.95411 17.9541127006 18.14227 18.1422727025 22.41797 22.4179727027 20.59152 20.5915227030 23.48065 23.4806527033 24.33425 24.3342527035 28.28835 28.2883527036 24.98856 24.9885627040 5.02940 8.0109027041 17.01086 17.0108627043 12.07320 12.0732027045 19.19785 19.1978527047 10.09048 12.2976827048 14.28709 14.2870927049 31.87679 31.8767927050 8.92208 8.9220827052 13.81314 13.8131427054 16.76125 16.7612527057 23.31067 23.3106727059 47.26857 47.2685727060 10.58853 10.5885327062 10.97083 10.9708327065 12.31891 12.3189127066 20.00532 20.0053227067 25.69392 25.6939227070 20.98890 20.9889027071 22.45995 22.4599527075 53.94653 53.9465327076 57.24821 57.2482127077 70.59923 70.5992327078 44.46499 44.4649927080 12.37663 12.3766327086 3.59558 5.6870827087 15.65141 15.6514127090 20.60125 20.6012527091 40.27261 40.27261

Page 28 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

27093 1.84826 4.5093627095 2.11612 5.4447227096 1.82574 4.2732427097 16.49239 16.4923927098 15.65310 15.6531027100 20.29573 20.2957327105 21.39710 21.3971027110 23.86169 23.8616927111 21.54906 21.5490627120 32.36055 32.3605527122 27.56241 27.5624127125 28.27218 28.2721827130 36.34587 36.3458727132 42.51447 42.5144727134 49.14364 49.1436427137 37.48058 37.4805827138 39.00752 39.0075227140 22.31572 22.3157227146 31.85116 31.8511627147 36.91135 36.9113527151 38.94588 38.9458827156 43.15427 43.1542727158 34.87462 34.8746227161 30.48671 30.4867127165 34.35839 34.3583927170 29.62959 29.6295927175 16.45224 16.4522427176 22.64296 22.6429627177 27.71577 27.7157727178 22.54506 22.5450627179 24.22061 24.2206127181 27.77870 27.7787027185 15.41161 15.4116127187 24.75773 24.7577327193 11.48311 11.3852127194 17.36984 17.3698427200 4.23366 4.1357627202 14.95005 14.9500527215 17.59273 17.5927327216 25.97363 25.9736327217 24.52905 24.5290527218 33.84067 33.8406727220 12.73103 12.8200327222 24.35889 24.3588927226 26.10959 26.1095927227 42.07359 42.0735927228 48.17471 48.1747127230 11.23391 11.3585127232 19.28036 19.2803627235 22.63180 22.6318027236 29.88769 29.88769

Page 29 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

27238 11.02423 11.0242327240 23.79653 23.7965327244 30.75042 30.7504227245 31.18652 31.1865227246 9.30541 9.2787127248 18.68334 18.6833427250 5.59574 5.5957427252 18.85061 18.8506127253 23.52824 23.5282427254 31.83502 31.8350227256 6.22478 7.2482827257 8.42958 8.4295827258 27.66300 27.6630027259 38.94974 38.9497427265 9.61328 9.6132827266 14.20932 14.2093227267 10.30310 10.3031027268 12.75650 12.7565027269 30.75875 30.7587527275 4.32644 4.3264427280 25.60586 25.6058627282 20.39821 20.3982127284 39.71340 39.7134027286 41.82499 41.8249927290 40.09275 40.0927527295 32.05168 32.0516827301 12.24356 15.7501627303 15.69299 15.6929927305 11.50566 11.5056627306 9.25138 9.2513827307 11.41832 11.4183227310 17.95514 17.9551427323 4.40259 6.3071927324 9.44406 9.4440627325 13.13900 13.1390027326 12.06101 12.0610127327 7.92284 10.2902427328 13.84407 13.8440727329 26.12072 26.1207227330 9.69355 9.6935527331 11.51290 11.5129027332 15.64600 15.6460027333 14.18405 14.1840527334 16.70619 16.7061927335 18.88057 18.8805727337 10.73153 10.7315327339 19.38475 19.3847527340 8.81256 8.8125627345 11.68781 11.6878127347 12.69397 12.6939727350 15.96454 15.96454

Page 30 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

27355 14.75886 14.7588627356 18.15363 18.1536327357 20.04444 20.0444427358 7.31241 7.3124127360 20.93404 20.9340427364 40.62729 40.6272927365 46.09467 46.0946727370 1.37092 3.8985227372 9.87441 14.0040127380 14.40303 14.4030327381 19.68738 19.6873827385 15.43071 15.4307127386 20.43149 20.4314927390 10.70815 10.7081527391 13.99011 13.9901127392 17.31783 17.3178327393 12.37769 12.3776927394 16.01093 16.0109327395 21.72248 21.7224827396 15.05339 15.0533927397 22.47964 22.4796427400 16.94443 16.9444327403 15.75446 15.7544627405 16.60600 16.6060027407 19.15401 19.1540127409 23.94365 23.9436527412 41.43874 41.4387427415 34.13234 34.1323427416 24.15356 24.1535627418 20.62526 20.6252627420 18.42996 18.4299627422 18.36145 18.3614527424 18.41050 18.4105027425 10.70131 10.7013127427 17.70219 17.7021927428 27.48786 27.4878627429 30.86566 30.8656627430 18.25940 18.2594027435 19.76170 19.7617027437 16.22659 16.2265927438 20.86433 20.8643327440 19.24447 19.2444727441 19.88158 19.8815827442 21.58609 21.5860927443 20.18913 20.1891327445 31.55640 31.5564027446 27.85282 27.8528227447 38.86675 38.8667527448 20.33568 20.3356827450 25.38013 25.3801327454 32.26079 32.26079

Page 31 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

27455 23.39700 23.3970027457 24.11401 24.1140127465 31.05096 31.0509627466 29.62066 29.6206627468 33.53355 33.5335527470 29.48716 29.4871627472 31.83728 31.8372827475 16.22659 16.2265927477 18.07974 18.0797427479 21.01294 21.0129427485 16.49651 16.4965127486 35.49536 35.4953627487 44.72737 44.7273727488 30.06280 30.0628027495 28.30838 28.3083827496 12.60228 12.6022827497 13.70491 13.7049127498 15.11014 15.1101427499 16.53171 16.5317127500 11.60462 12.3878227501 12.06619 12.2085927502 19.53388 19.5338827503 19.85777 19.8577727506 33.46109 33.4610927507 24.55532 24.5553227508 11.86604 12.5068427509 15.69130 15.6913027510 17.24294 17.2429427511 25.48739 25.4873927513 31.96689 31.9668927514 25.11024 25.1102427516 11.17593 11.7900327517 16.71612 16.7161227519 22.86755 22.8675527520 6.72492 7.3479227524 18.61025 18.6102527530 8.65857 9.2370727532 14.04849 14.7871927535 22.83155 22.8315527536 29.76329 29.7632927538 10.41691 11.0399127540 20.29158 20.2915827550 11.06590 11.7957027552 15.21402 15.2140227556 22.48256 22.4825627557 26.99278 26.9927827558 30.63575 30.6357527560 8.06971 8.7461127562 11.36512 11.3651227566 22.19215 22.1921527570 3.59097 3.59097

Page 32 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

27580 36.14340 36.1434027590 21.34215 21.3421527591 23.16388 23.1638827592 17.98052 17.9805227594 12.91787 12.9178727596 18.77783 18.7778327598 18.96642 18.9664227600 10.64499 10.6449927601 11.08069 11.0806927602 13.18444 13.1844427603 9.62069 12.5309927604 8.33517 10.9428727605 4.83080 8.2929027606 7.26256 7.2625627607 15.21288 15.2128827610 16.18905 16.1890527612 13.95301 13.9530127613 4.07438 5.8721827614 10.19722 13.4546227615 25.03946 25.0394627616 33.10071 33.1007127618 8.11798 10.5120827619 12.81101 12.8110127620 11.31619 11.3161927625 14.50707 14.5070727626 15.76958 15.7695827630 9.05842 12.6807227632 10.58361 10.5836127634 17.29835 17.2983527635 14.61755 14.6175527637 18.68537 18.6853727638 19.39431 19.3943127640 21.30888 21.3088827641 17.06406 17.0640627645 39.48157 39.4815727646 34.05795 34.0579527647 27.12246 27.1224627648 1.36202 3.7739227650 16.54889 16.5488927652 17.90740 17.9074027654 17.77095 17.7709527656 8.94423 13.1806327658 9.36912 9.3691227659 12.17890 12.1789027664 8.92323 8.9232327665 10.25749 10.2574927675 12.43311 12.4331127676 15.48291 15.4829127680 10.62282 10.6228227681 12.98003 12.9800327685 11.66287 15.10717

Page 33 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

27686 13.80897 13.8089727687 11.37403 11.3740327690 15.76229 15.7622927691 18.62079 18.6207927692 2.81235 2.8123527695 12.10260 12.1026027696 14.26666 14.2666627698 16.25485 16.2548527700 15.27712 15.2771227702 24.72620 24.7262027703 28.74068 28.7406827704 14.07073 14.0707327705 19.02472 19.0247227707 9.68668 9.6866827709 28.90812 28.9081227712 27.45103 27.4510327715 26.68912 26.6891227720 21.84814 21.8481427722 21.88849 21.8884927724 32.18753 32.1875327725 30.16545 30.1654527726 23.74130 23.7413027727 24.77350 24.7735027730 14.25402 14.2540227732 10.18408 10.1840827734 13.91543 13.9154327740 16.73767 16.7376727742 17.88357 17.8835727745 18.74003 18.7400327750 7.33221 7.9374127752 12.01837 12.8193727756 13.99363 13.9936327758 22.10272 22.1027227759 24.99371 24.9937127760 7.00603 7.6468327762 10.61961 11.4206127766 14.88867 14.8886727767 6.28776 6.2610627768 10.05138 10.0513827769 17.56148 17.5614827780 6.30081 6.8882127781 9.32859 9.9515927784 17.38823 17.3882327786 6.59660 7.2552027788 9.24852 9.9694227792 17.43877 17.4387727808 6.87333 7.5764327810 10.36686 11.1945627814 19.14926 19.1492627816 6.56515 7.2237527818 10.61735 11.55185

Page 34 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

27822 20.90571 20.9057127823 23.83562 23.8356227824 7.03625 7.2676527825 12.19497 13.1739727826 20.43650 20.4365027827 26.88615 26.8861527828 32.38619 32.3861927829 16.53274 16.5327427830 8.07612 8.5745227831 9.31079 9.3107927832 18.03567 18.0356727840 8.67669 8.6766927842 11.90748 11.9074827846 18.28988 18.2898827848 20.65654 20.6565427860 4.34115 4.3411527870 26.20847 26.2084727871 17.16862 17.1686227880 24.12551 24.1255127881 22.66545 22.6654527882 16.14889 16.1488927884 14.94530 14.9453027886 17.06482 17.0648227888 17.69899 17.6989927889 17.67414 17.6741427892 13.83858 13.8385827893 13.94824 13.9482427894 21.64189 21.6418928001 4.39330 6.3157028002 9.62251 12.1145128003 13.97168 16.5081828005 15.17184 15.1718428008 7.50731 10.0260128010 5.23405 5.6078528011 7.40288 7.9724828020 8.93477 12.0497728022 8.16983 11.0267328024 7.69936 10.4405628035 9.03041 12.1276128039 8.70930 11.9578028041 11.46107 11.4610728043 6.69918 8.5770828045 8.81241 11.8028128046 18.76176 18.7617628047 24.30345 24.3034528050 7.57081 10.4099128052 7.09982 9.9211228054 6.21835 8.9150528055 9.74955 9.7495528060 8.99244 11.8760428062 10.47629 13.84049

Page 35 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

28070 8.74982 11.7491228072 8.57662 11.7272228080 8.82846 11.6319628086 8.97732 12.4750228088 7.40608 10.5655828090 7.76349 10.6915928092 6.80818 9.6472828100 10.14483 13.7671328102 13.01904 13.0190428103 10.70257 10.7025728104 8.77612 11.8021228106 11.43475 11.4347528107 9.35045 12.7057528108 7.23882 9.9266228110 7.24520 10.4136028111 8.52397 11.8525728112 7.94335 11.2185528113 10.59041 13.6520128114 20.75950 25.1116028116 14.41574 17.6731428118 10.36347 13.6030728119 9.11046 12.0741628120 12.74557 16.2343728122 12.63284 15.5787428124 8.36220 11.0144028126 6.28786 8.9222628130 16.39990 16.3999028140 11.57562 14.7084228150 7.22345 9.9735528153 6.57910 9.3025028160 6.84112 9.5645228171 21.53387 21.5338728173 19.26600 19.2660028175 12.07965 12.0796528190 3.36407 5.6691728192 8.00508 10.8975828193 9.52550 12.5159028200 7.95520 10.8833028202 11.07677 14.3519728208 7.72457 10.5814728210 10.42386 13.4943628220 7.72071 10.3729128222 9.13868 11.9332828225 6.41724 9.0338428226 7.80831 10.5940128230 7.29036 9.9247628232 6.22367 8.8313728234 6.58422 9.2186228238 12.57200 15.9451028240 7.51120 10.2346028250 10.14818 13.20088

Page 36 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

28260 13.12105 16.2004528261 19.72529 23.1428928262 28.51175 33.2287528264 16.55173 19.7379328270 8.40435 11.1722528272 6.47608 9.0214828280 9.06401 12.1345128285 8.07256 10.7870628286 7.67458 10.4602828288 10.70688 13.7684828289 13.85463 17.2455328290 9.99419 13.3672928292 15.01891 18.4365128293 18.02550 24.3178028294 13.63371 17.5586128296 13.36219 16.9844928297 15.19367 19.4478728298 12.91541 16.7869128299 17.49221 21.5150128300 16.63523 16.6352328302 17.04628 17.0462828304 15.03593 18.7739328305 16.91769 16.9176928306 10.23154 14.1030428307 11.99230 17.0297028308 9.31676 12.7165628309 22.57316 22.5731628310 8.98875 12.4063528312 8.01953 11.4015328313 9.23465 12.1182528315 8.19244 10.9870428320 15.63789 15.6378928322 14.55217 18.3613728340 10.94439 14.1483928341 12.99578 16.3688828344 7.57914 10.6585428345 9.88285 12.9355528360 24.99110 24.9911028400 5.26283 5.6989328405 8.64058 9.2368828406 12.76400 12.7640028415 28.17781 28.1778128420 30.41010 30.4101028430 4.82816 5.3710628435 7.23886 7.8262628436 10.41688 10.4168828445 26.77630 26.7763028446 30.06715 30.0671528450 4.46595 4.9465528455 6.44024 6.9208428456 6.87702 6.87702

Page 37 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

28465 15.19824 15.1982428470 4.45227 4.8972728475 5.67421 6.1548128476 8.09132 8.0913228485 13.11764 13.1176428490 2.82743 3.2012328495 3.53932 4.0021228496 5.44604 9.5222428505 12.30568 15.7232828510 2.72541 2.7788128515 3.34040 3.6341028525 9.76316 13.1807628530 2.42261 2.6362128531 5.10031 9.0786128540 4.36691 4.6873128545 5.62790 6.1174028546 7.48806 11.3506628555 16.55533 20.6849328570 3.51992 3.9293228575 7.49075 8.0247528576 8.93098 8.9309828585 18.50201 22.1777128600 4.43636 4.9436628605 6.28321 6.7460128606 9.53301 9.5330128615 19.34198 19.3419828630 2.75031 3.5424128635 3.32638 4.1006828636 4.95325 6.8400528645 11.90444 14.9393428660 2.14648 2.6181828665 3.33817 3.7119728666 4.94486 4.9448628675 10.04524 13.5429428705 33.02169 33.0216928715 24.49186 24.4918628725 19.98382 19.9838228730 21.04026 21.0402628735 20.03379 20.0337928737 17.49675 17.4967528740 15.79417 20.1818728750 15.05183 19.5908328755 8.31326 11.6062628760 14.69510 18.5666028800 14.37795 14.3779528805 19.54869 19.5486928810 11.25080 11.2508028820 8.76352 12.4125228825 10.21663 13.7143328890 5.66005 8.0630529000 3.92483 5.84723

Page 38 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

29010 3.59492 5.2681229015 3.96423 5.6463329035 3.42021 5.4939129040 3.87042 5.4724229044 3.97576 6.0049629046 4.49757 6.5089729049 1.56915 2.0942529055 3.32314 4.8539429058 2.06615 2.6535529065 1.65443 2.1884329075 1.49071 2.0247129085 1.61677 2.1596729086 1.19412 1.6747229105 1.47437 2.0172729125 1.05129 1.5674929126 1.29969 1.8069929130 0.73916 0.9705629131 0.84121 1.1972129200 1.00559 1.2636929240 1.09067 1.3754729260 0.92815 1.2129529280 0.87827 1.1719729305 3.85943 5.4614329325 4.36344 6.0811429345 2.49604 3.1546429355 2.65129 3.2742929358 2.55399 3.5685929365 2.16010 2.8187029405 1.56938 2.0677829425 1.72423 2.2226329435 2.11560 2.7564029440 0.86957 1.2344729445 2.76376 3.4134629450 3.02484 3.5855429505 1.20611 1.7935129515 1.22311 1.6681129520 0.89650 1.1635029530 0.93871 1.2324129540 0.80501 1.0008129550 0.75719 0.9707929580 0.90145 1.2396529581 0.85426 2.1981629582 0.43161 1.8556129583 0.31651 1.1531129584 0.43161 1.8556129700 0.88053 1.4946329705 1.20508 1.5877829710 2.10836 2.8381629720 1.10738 1.8549829730 1.15769 1.5403929740 1.66628 2.18248

Page 39 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

29750 1.97506 2.4734629800 12.83182 12.8318229804 16.02169 16.0216929805 11.48703 11.4870329806 26.44902 26.4490229807 25.75479 25.7547929819 14.40595 14.4059529820 13.29113 13.2911329821 14.54091 14.5409129822 14.11700 14.1170029823 15.45764 15.4576429824 16.58468 16.5846829825 14.39705 14.3970529826 16.51474 16.5147429827 27.00809 27.0080929828 22.80050 22.8005029830 11.08776 11.0877629834 12.05958 12.0595829835 12.38908 12.3890829836 14.32894 14.3289429837 12.98149 12.9814929838 14.52500 14.5250029840 10.93832 10.9383229843 11.75921 11.7592129844 12.13207 12.1320729845 13.99229 13.9922929846 12.73939 12.7393929847 13.34742 13.3474229848 12.24259 12.2425929850 14.50677 14.5067729851 23.18878 23.1887829855 19.43818 19.4381829856 24.89744 24.8974429860 16.20570 16.2057029861 17.93196 17.9319629862 20.09661 20.0966129863 20.05211 20.0521129866 25.96361 25.9636129867 31.70169 31.7016929868 42.02182 42.0218229870 9.98639 13.8934929871 12.53935 12.5393529873 12.54988 12.5498829874 13.21827 13.2182729875 12.13055 12.1305529876 16.10179 16.1017929877 15.23700 15.2370029879 16.29181 16.2918129880 17.00095 17.0009529881 15.87079 15.8707929882 17.17978 17.17978

Page 40 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

29883 20.87695 20.8769529884 15.20864 15.2086429885 18.45045 18.4504529886 15.55265 15.5526529887 18.34634 18.3463429888 24.72794 24.7279429889 30.32153 30.3215329891 17.17933 17.1793329892 18.10833 18.1083329893 10.61806 14.0445629894 12.76867 12.7686729895 12.26017 12.2601729897 12.90174 12.9017429898 14.38659 14.3865929899 26.27901 26.2790129900 10.41788 10.4178829901 12.47353 12.4735329902 14.48418 14.4841829904 15.48995 15.4899529905 16.66770 16.6677029906 17.55979 17.5597929907 21.42174 21.4217429914 28.84637 28.8463729915 29.38930 29.3893029916 29.38930 29.3893030000 2.89288 5.3225830020 2.91068 5.2068830100 1.73416 3.2471630110 3.20524 5.2611430115 10.30528 10.3052830117 8.00418 19.0312830118 18.88614 18.8861430120 10.92167 12.4435730124 6.60874 6.6087430125 14.91956 14.9195630130 8.96023 8.9602330140 10.20563 10.2056330150 19.18135 19.1813530160 19.27053 19.2705330200 1.48536 2.5978630210 2.41059 3.4518930220 3.08001 6.7201130300 2.92347 5.1662730310 4.89421 4.8942130320 10.83124 10.8312430400 24.78410 24.7841030410 29.42096 29.4209630420 33.69500 33.6950030430 21.83854 21.8385430435 28.34059 28.3405930450 38.05030 38.05030

Page 41 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

30460 19.42696 19.4269630462 37.68822 37.6882230465 24.07216 24.0721630520 14.82907 14.8290730540 16.40738 16.4073830545 22.00784 22.0078430560 3.30185 6.1142530580 12.25096 15.0633630600 10.82604 13.7986430620 14.83656 14.8365630630 15.16521 15.1652130801 3.15902 5.1437230802 4.55498 6.7265830901 1.63131 2.5302130903 2.11878 4.5751830905 2.70767 5.6980730906 3.50813 6.5252330915 14.20072 14.2007230920 20.52100 20.5210030930 2.94585 2.9458531000 2.54100 4.1341031002 4.80106 4.8010631020 8.34029 11.1081931030 12.58057 16.2829731032 13.84609 13.8460931040 18.43899 18.4389931050 11.86745 11.8674531051 15.58291 15.5829131070 10.45326 10.4532631075 19.12455 19.1245531080 24.81702 24.8170231081 32.59767 32.5976731084 28.80841 28.8084131085 34.13814 34.1381431086 27.49012 27.4901231087 26.98179 26.9817931090 24.41963 24.4196331200 12.98484 12.9848431201 17.77970 17.7797031205 21.29612 21.2961231225 46.16722 46.1672231230 51.72886 51.7288631231 1.94530 4.4106031233 3.51514 6.2652431235 4.17566 7.1838631237 4.68382 7.7810231238 5.09388 8.0486831239 16.70867 16.7086731240 4.14647 4.1464731254 7.11310 7.1131031255 10.47199 10.47199

Page 42 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

31256 5.13197 5.1319731267 8.28055 8.2805531276 13.22024 13.2202431287 6.04129 6.0412931288 7.01829 7.0182931290 29.73551 29.7355131291 31.45286 31.4528631292 25.57242 25.5724231293 27.87441 27.8744131294 31.99069 31.9906931295 4.89750 53.8030031296 5.85979 100.4044931297 4.79256 99.3906631300 31.07823 31.0782331320 15.49021 15.4902131360 51.02415 51.0241531365 63.82629 63.8262931367 54.40687 54.4068731368 60.55619 60.5561931370 50.90097 50.9009731375 48.20223 48.2022331380 47.42747 47.4274731382 52.15951 52.1595131390 70.93059 70.9305931395 74.68040 74.6804031400 24.45466 24.4546631420 20.77853 20.7785331500 2.93541 2.9354131502 0.92071 0.9207131505 1.21999 1.9675931510 3.10674 5.0558431511 3.34850 5.1018031512 3.34375 5.0169531513 3.41060 3.4106031515 2.83662 4.9815231520 4.00882 4.0088231525 4.12143 6.0616331526 4.08975 4.0897531527 5.04131 5.0413131528 3.73973 3.7397331529 4.20774 4.2077431530 5.16136 5.1613631531 5.55382 5.5538231535 4.94318 4.9431831536 5.51573 5.5157331540 6.33874 6.3387431541 6.93198 6.9319831545 9.50678 9.5067831546 14.40529 14.4052931560 8.23605 8.2360531561 9.01413 9.01413

Page 43 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

31570 5.97212 8.4285231571 6.53932 6.5393231575 1.93640 2.7819031576 3.17113 5.3783331577 3.86579 5.8593931578 4.40792 6.7931231579 3.63064 5.2593431580 29.66816 29.6681631582 46.84412 46.8441231584 37.55963 37.5596331587 25.11205 25.1120531588 28.22433 28.2243331590 21.25685 21.2568531595 18.70948 18.7094831600 10.43907 10.4390731601 6.77198 6.7719831603 5.89342 5.8934231605 4.86571 4.8657131610 17.61518 17.6151831611 13.06240 13.0624031612 1.25997 1.9719731613 10.84669 10.8466931614 18.17107 18.1710731615 3.29201 4.4757131620 1.83670 6.5804031622 3.85798 7.6404831623 3.86282 8.2327231624 3.88062 7.7076231625 4.51816 8.3451631626 5.58820 10.8125031627 2.71626 28.9267631628 5.01542 9.8481231629 5.41057 14.9157731630 5.39219 5.3921931631 6.13756 6.1375631632 1.30825 1.8155531633 1.69244 2.2353431634 5.82008 47.8458831635 5.01905 8.6146531636 5.97510 5.9751031637 2.04538 2.0453831638 6.82086 6.8208631640 6.87635 6.8763531641 6.84888 6.8488831643 4.62067 4.6206731645 4.23728 7.4857831646 3.67154 6.7865431647 6.38332 6.3833231648 6.63166 6.6316631649 2.08032 2.0803231651 2.20970 2.20970

Page 44 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

31660 6.38455 6.3845531661 6.75380 6.7538031717 2.85082 6.9270231720 1.36414 1.3641431725 2.49662 2.4966231730 3.94463 22.0650331750 33.11709 33.1170931755 41.45750 41.4575031760 36.83240 36.8324031766 48.47645 48.4764531770 35.85566 35.8556631775 37.23479 37.2347931780 30.92776 30.9277631781 39.16921 39.1692131785 28.02977 28.0297731786 39.43976 39.4397631800 17.15604 17.1560431805 21.97410 21.9741031820 8.23384 10.4677431825 12.16545 14.7019531830 8.50536 10.5345632035 18.70943 18.7094332036 20.33106 20.3310632096 23.38707 23.3870732097 23.38707 23.3870732098 21.97469 21.9746932100 25.54478 25.5447832110 38.78314 38.7831432120 23.18433 23.1843332124 24.63755 24.6375532140 26.39280 26.3928032141 40.94432 40.9443232150 26.57040 26.5704032151 26.94938 26.9493832160 20.57208 20.5720832200 29.85362 29.8536232215 21.21491 21.2149132220 42.46393 42.4639332225 26.52009 26.5200932310 24.43242 24.4324232320 42.66231 42.6623132400 2.36910 3.7486032405 2.64337 2.6522732440 42.36838 42.3683832442 74.47721 74.4772132445 93.92464 93.9246432480 40.03918 40.0391832482 42.77466 42.7746632484 38.89832 38.8983232486 63.64536 63.6453632488 64.31375 64.31375

Page 45 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

32491 39.82392 39.8239232501 6.75036 6.7503632503 48.81296 48.8129632504 55.91420 55.9142032505 26.95311 26.9531132506 4.59606 4.5960632507 4.59606 4.5960632540 46.12327 46.1232732550 6.07391 18.9522132551 4.62129 4.6212932552 4.24811 4.7554132553 5.54694 14.7851432554 2.53568 23.6019832555 3.18169 15.2856932556 3.48970 16.1099032557 4.74430 29.4952032560 2.35710 6.4600032561 1.93245 2.4753532562 1.72898 2.2006832601 8.34721 8.3472132604 13.17923 13.1792332606 12.59721 12.5972132607 8.98828 8.9882832608 11.05222 11.0522232609 7.63090 7.6309032650 17.76411 17.7641132651 28.97332 28.9733232652 44.18433 44.1843332653 27.95045 27.9504532654 31.28332 31.2833232655 25.39019 25.3901932656 21.29736 21.2973632658 19.14899 19.1489932659 19.58572 19.5857232661 21.43947 21.4394732662 24.06257 24.0625732663 37.78868 37.7886832664 22.69048 22.6904832665 32.96091 32.9609132666 25.19314 25.1931432667 4.59606 4.5960632668 4.62688 4.6268832669 38.94887 38.9488732670 46.52274 46.5227432671 51.72860 51.7286032672 44.19746 44.1974632673 34.71395 34.7139532674 6.29802 6.2980232701 6.39274 6.3927432800 24.59205 24.5920532810 23.97709 23.97709

Page 46 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

32815 74.50057 74.5005732820 35.88233 35.8823332850 10.49800 10.4980032851 68.85713 68.8571332852 76.12618 76.1261832853 82.24970 82.2497032854 89.78020 89.7802032900 36.74409 36.7440932905 35.92935 35.9293532906 44.62844 44.6284432940 32.99598 32.9959832960 2.78868 3.7053832997 9.57149 9.5714932998 8.00042 66.4912233010 3.38876 3.3887633011 3.35522 3.3552233015 14.12636 14.1263633020 23.50745 23.5074533025 21.57772 21.5777233030 34.72155 34.7215533031 38.87170 38.8717033050 26.78483 26.7848333120 42.27989 42.2798933130 39.15941 39.1594133140 43.30424 43.3042433141 3.84366 3.8436633202 20.98780 20.9878033203 22.18069 22.1806933206 12.67837 12.6783733207 13.54791 13.5479133208 14.65383 14.6538333210 5.08706 5.0870633211 5.15411 5.1541133212 9.41278 9.4127833213 10.75611 10.7561133214 13.39080 13.3908033215 8.48592 8.4859233216 10.47357 10.4735733217 10.39098 10.3909833218 10.87905 10.8790533220 10.99455 10.9945533221 10.10994 10.1099433222 9.50590 9.5059033223 11.54263 11.5426333224 14.32370 14.3237033225 12.93653 12.9365333226 13.78306 13.7830633227 9.64548 9.6454833228 10.06295 10.0629533229 10.48042 10.4804233230 10.88982 10.88982

Page 47 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

33231 11.30729 11.3072933233 6.59179 6.5917933234 13.57873 13.5787333235 17.63293 17.6329333236 21.12885 21.1288533237 22.92022 22.9202233238 25.12496 25.1249633240 12.98326 12.9832633241 6.24323 6.2432333243 37.45537 37.4553733244 23.87327 23.8732733249 25.43295 25.4329533250 40.13432 40.1343233251 44.50592 44.5059233254 37.18441 37.1844133255 45.37860 45.3786033256 54.01118 54.0111833257 15.80161 15.8016133258 17.80294 17.8029433259 22.97602 22.9760233261 44.41222 44.4122233262 10.49098 10.4909833263 10.90845 10.9084533264 11.32592 11.3259233265 36.88511 36.8851133266 50.59496 50.5949633282 8.95038 8.9503833284 6.39164 6.3916433300 65.87909 65.8790933305 111.14973 111.1497333310 31.53258 31.5325833315 40.48801 40.4880133320 28.82674 28.8267433321 32.22351 32.2235133322 37.95600 37.9560033330 39.18883 39.1888333335 51.65927 51.6592733361 38.60115 38.6011533362 42.22840 42.2284033363 43.72566 43.7256633364 46.48340 46.4834033365 51.11644 51.1164433366 54.23340 54.2334033367 17.98268 17.9826833368 21.79657 21.7965733369 28.77820 28.7782033400 62.74886 62.7488633401 39.41705 39.4170533403 40.90573 40.9057333404 48.27421 48.2742133405 63.13170 63.13170

Page 48 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

33406 79.20446 79.2044633410 69.95655 69.9565533411 92.19559 92.1955933412 67.83796 67.8379633413 89.07353 89.0735333414 59.77129 59.7712933415 55.35385 55.3538533416 55.51206 55.5120633417 45.70107 45.7010733420 36.92675 36.9267533422 46.15479 46.1547933425 74.18400 74.1840033426 65.74962 65.7496233427 67.86519 67.8651933430 76.89355 76.8935533460 69.21354 69.2135433463 84.17004 84.1700433464 66.81808 66.8180833465 75.19130 75.1913033468 51.31794 51.3179433470 33.51510 33.5151033471 32.97218 32.9721833474 57.89424 57.8942433475 64.11232 64.1123233476 41.08479 41.0847933478 42.96252 42.9625233496 45.76186 45.7618633500 43.18336 43.1833633501 30.52251 30.5225133502 34.62613 34.6261333503 36.57637 36.5763733504 39.74312 39.7431233505 56.73862 56.7386233506 56.29009 56.2900933507 47.33536 47.3353633508 0.44543 0.4454333510 53.73014 53.7301433511 58.89847 58.8984733512 66.77996 66.7799633513 68.39959 68.3995933514 72.58460 72.5846033516 75.49712 75.4971233517 5.20665 5.2066533518 11.38901 11.3890133519 15.09877 15.0987733521 18.17949 18.1794933522 20.50182 20.5018233523 23.29196 23.2919633530 14.52459 14.5245933533 52.00949 52.0094933534 61.04924 61.04924

Page 49 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

33535 68.04339 68.0433933536 73.15935 73.1593533542 71.65545 71.6554533545 84.32512 84.3251233548 81.95608 81.9560833572 6.45248 6.4524833600 46.37599 46.3759933602 44.67668 44.6766833606 48.21053 48.2105333608 49.12306 49.1230633610 48.14320 48.1432033611 53.90461 53.9046133612 54.28297 54.2829733615 54.82711 54.8271133617 58.60375 58.6037533619 72.66494 72.6649433620 49.35858 49.3585833621 26.45694 26.4569433622 103.85104 103.8510433641 44.70178 44.7017833645 43.36302 43.3630233647 48.34811 48.3481133660 48.30513 48.3051333665 55.10173 55.1017333670 54.71225 54.7122533675 54.27097 54.2709733676 51.29641 51.2964133677 53.30433 53.3043333681 50.11848 50.1184833684 54.28891 54.2889133688 51.74497 51.7449733690 31.96976 31.9697633692 44.10580 44.1058033694 54.09151 54.0915133697 57.66111 57.6611133702 42.11742 42.1174233710 49.03171 49.0317133720 42.05934 42.0593433722 44.35759 44.3575933724 42.44267 42.4426733726 56.39810 56.3981033730 54.22172 54.2217233732 45.09194 45.0919433735 34.99000 34.9900033736 38.28598 38.2859833737 35.08691 35.0869133750 39.36194 39.3619433755 34.68336 34.6833633762 32.23508 32.2350833764 34.86268 34.8626833766 36.84177 36.84177

Page 50 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

33767 38.65566 38.6556633768 10.70550 10.7055033770 58.72191 58.7219133771 55.12979 55.1297933774 49.32989 49.3298933775 46.83047 46.8304733776 49.43369 49.4336933777 48.08887 48.0888733778 59.49155 59.4915533779 59.13707 59.1370733780 63.11486 63.1148633781 58.59251 58.5925133782 87.86210 87.8621033783 94.99164 94.9916433786 57.63711 57.6371133788 38.70988 38.7098833800 26.72378 26.7237833802 28.98733 28.9873333803 31.11615 31.1161533813 34.47504 34.4750433814 41.60099 41.6009933820 26.57205 26.5720533822 25.70997 25.7099733824 31.97265 31.9726533840 33.02556 33.0255633845 37.02647 37.0264733851 34.35830 34.3583033852 39.79277 39.7927733853 53.28607 53.2860733860 87.94216 87.9421633863 86.95403 86.9540333864 89.20954 89.2095433870 69.49132 69.4913233875 54.10400 54.1040033877 99.53651 99.5365133880 50.78566 50.7856633881 43.60206 43.6020633883 31.47715 31.4771533884 11.57912 11.5791233886 27.15863 27.1586333889 22.49202 22.4920233891 28.18136 28.1813633910 45.83067 45.8306733915 37.20427 37.2042733916 45.05528 45.0552833917 40.26912 40.2691233920 49.84240 49.8424033922 37.82172 37.8217233924 7.88089 7.8808933925 47.53860 47.5386033926 65.94289 65.94289

Page 51 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

33930 77.91000 77.9100033935 95.03473 95.0347333940 46.75200 46.7520033945 131.53468 131.5346833967 7.47358 7.4735833968 0.96372 0.9637233970 10.06600 10.0660033971 19.47417 19.4741733973 14.59293 14.5929333974 24.77937 24.7793733975 30.48423 30.4842333976 33.92303 33.9230333977 32.72580 32.7258033978 36.27990 36.2799033979 66.66541 66.6654133980 99.09922 99.0992233981 24.76235 24.7623533982 57.88570 57.8857033983 67.97234 67.9723433990 12.55017 12.5501733991 18.29064 18.2906433992 5.98884 5.9888433993 5.25801 5.2580134001 26.93914 26.9391434051 26.80305 26.8030534101 16.88035 16.8803534111 16.87829 16.8782934151 39.15042 39.1504234201 28.61798 28.6179834203 27.03950 27.0395034401 40.04850 40.0485034421 20.48151 20.4815134451 42.05934 42.0593434471 31.16039 31.1603934490 16.94577 16.9457734501 26.03139 26.0313934502 42.15715 42.1571534510 30.23161 30.2316134520 28.79918 28.7991834530 27.65381 27.6538134800 31.92044 31.9204434802 35.20051 35.2005134803 36.37806 36.3780634804 35.25325 35.2532534805 33.40831 33.4083134806 2.93566 2.9356634808 5.80902 5.8090234812 9.53678 9.5367834813 6.73485 6.7348534820 13.74998 13.7499834825 19.63996 19.63996

Page 52 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

34826 5.84050 5.8405034830 51.41291 51.4129134831 54.75302 54.7530234832 55.27812 55.2781234833 17.26614 17.2661434834 7.79996 7.7999634900 25.30621 25.3062135001 31.73261 31.7326135002 33.63591 33.6359135005 29.42859 29.4285935011 27.86746 27.8674635013 34.68035 34.6803535021 33.96797 33.9679735022 38.67024 38.6702435045 27.10873 27.1087335081 49.28753 49.2875335082 61.49695 61.4969535091 51.27767 51.2776735092 73.72073 73.7207335102 53.38025 53.3802535103 63.41300 63.4130035111 39.13034 39.1303435112 48.10731 48.1073135121 46.29850 46.2985035122 55.75769 55.7576935131 39.29250 39.2925035132 47.76317 47.7631735141 31.21103 31.2110335142 37.43752 37.4375235151 35.24826 35.2482635152 40.87332 40.8733235180 23.88826 23.8882635182 48.02695 48.0269535184 28.44866 28.4486635188 23.67742 23.6774235189 44.97338 44.9733835190 20.73148 20.7314835201 25.91607 25.9160735206 21.18464 21.1846435207 18.72530 18.7253035211 37.95082 37.9508235216 54.68159 54.6815935221 39.10664 39.1066435226 23.40506 23.4050635231 32.22966 32.2296635236 27.12324 27.1232435241 39.59766 39.5976635246 42.40083 42.4008335251 46.45399 46.4539935256 28.56664 28.5666435261 29.15134 29.15134

Page 53 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

35266 23.99747 23.9974735271 38.05292 38.0529235276 39.48615 39.4861535281 44.34302 44.3430235286 26.21157 26.2115735301 29.48869 29.4886935302 31.44681 31.4468135303 34.62692 34.6269235304 35.99778 35.9977835305 34.59132 34.5913235306 12.91927 12.9192735311 42.51164 42.5116435321 25.03551 25.0355135331 41.32256 41.3225635341 38.77215 38.7721535351 36.25877 36.2587735355 29.44714 29.4471435361 44.41770 44.4177035363 48.43095 48.4309535371 23.11219 23.1121935372 27.73124 27.7312435390 4.53915 4.5391535400 4.27690 4.2769035450 14.51581 14.5158135452 10.07038 10.0703835458 13.74002 13.7400235460 8.75069 8.7506935471 15.23729 72.8024935472 10.27228 51.5682835475 13.58708 54.7495835476 8.60739 41.0122935500 9.12094 9.1209435501 43.86951 43.8695135506 37.80293 37.8029335508 39.57983 39.5798335509 42.13589 42.1358935510 36.05641 36.0564135511 33.77812 33.7781235512 35.18647 35.1864735515 38.37339 38.3733935516 34.97413 34.9741335518 33.65873 33.6587335521 35.70413 35.7041335522 34.57111 34.5711135523 36.35235 36.3523535525 32.12811 32.1281135526 47.55069 47.5506935531 57.11969 57.1196935533 44.98398 44.9839835535 51.65591 51.6559135536 49.10091 49.10091

Page 54 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

35537 60.84160 60.8416035538 68.28825 68.2882535539 63.53261 63.5326135540 71.37379 71.3737935556 39.45233 39.4523335558 34.60703 34.6070335560 50.29311 50.2931135563 39.23918 39.2391835565 37.30013 37.3001335566 47.30609 47.3060935570 40.00231 40.0023135571 37.82686 37.8268635572 9.82673 9.8267335583 40.77869 40.7786935585 47.47379 47.4737935587 38.95493 38.9549335600 7.23342 7.2334235601 40.89095 40.8909535606 33.33072 33.3307235612 25.70850 25.7085035616 32.31682 32.3168235621 31.21827 31.2182735623 38.24424 38.2442435626 43.92376 43.9237635631 52.49325 52.4932535632 49.01769 49.0176935633 52.92919 52.9291935634 47.98185 47.9818535636 46.54157 46.5415735637 48.43705 48.4370535638 49.42824 49.4282435642 29.00448 29.0044835645 27.98867 27.9886735646 48.64756 48.6475635647 44.00281 44.0028135650 30.05466 30.0546635654 38.87586 38.8758635656 30.55761 30.5576135661 30.65923 30.6592335663 35.56623 35.5662335665 33.27635 33.2763535666 35.85326 35.8532635671 31.57865 31.5786535681 2.27992 2.2799235682 10.13351 10.1335135683 11.96817 11.9681735685 5.69764 5.6976435686 4.75152 4.7515235691 27.61585 27.6158535693 24.37055 24.3705535694 28.66236 28.66236

Page 55 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

35695 29.83762 29.8376235697 4.25020 4.2502035700 4.36570 4.3657035701 14.73723 14.7372335721 12.53740 12.5374035741 13.85715 13.8571535761 10.19581 10.1958135800 13.14083 13.1408335820 54.25307 54.2530735840 17.26002 17.2600235860 11.17730 11.1773035870 36.19220 36.1922035875 16.60070 16.6007035876 26.63156 26.6315635879 26.16003 26.1600335881 29.00975 29.0097535883 33.88985 33.8898535884 35.71243 35.7124335901 13.85194 13.8519435903 15.61317 15.6131735905 49.02184 49.0218435907 54.24069 54.2406936000 0.25936 0.6153636002 2.94714 4.2554436005 1.36531 8.1560136010 3.37709 13.8256936011 4.36714 22.1315436012 4.95105 21.2380536013 3.58794 19.2786436014 4.20720 20.1916036015 4.84623 22.0499336100 4.48804 13.0231436120 2.77741 10.8052136140 2.90547 11.7431736147 5.08212 19.3221236148 1.35850 6.0666036160 3.59338 12.7959836200 4.32438 15.8498836215 6.81035 27.8232536216 7.68653 30.4705336217 9.10487 49.0836736218 1.45245 4.6653536221 6.20419 30.7948936222 8.35047 38.5659736223 9.02896 42.0301636224 9.82630 45.6577036225 8.99130 41.6988036226 9.84410 46.5566036227 3.10725 6.8452536228 6.33807 32.0056736245 6.98975 30.02295

Page 56 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

36246 7.64821 30.0317136247 9.12547 46.8169736248 1.45245 4.0156536251 8.03705 39.0980536252 10.46887 43.0517736253 11.19661 59.7372136254 12.07897 62.1859736260 15.91443 15.9144336261 9.61433 9.6143336262 7.31295 7.3129536400 0.51354 0.7004436405 0.44543 0.6412336406 0.25046 0.4462636410 0.24156 0.4818636420 1.35043 1.3504336425 1.04966 1.0496636430 0.82086 0.8208636440 1.47537 1.4753736450 3.00713 3.0071336455 3.33045 3.3304536460 9.36050 9.3605036468 1.85210 1.8521036470 1.86660 3.4775036471 2.65853 4.3228336475 9.68568 43.4789836476 4.77742 9.8148236478 9.67332 35.6791236479 4.73836 10.1139636481 9.63788 20.3623836500 4.99077 4.9907736510 1.60289 2.7064936511 2.48866 2.4886636512 2.42974 2.4297436513 2.58796 2.5879636514 2.45306 12.3231636515 2.40444 45.4448436516 1.84376 50.3932636522 2.63753 31.8473336555 3.33274 6.6257436556 3.26308 5.8351836557 8.27484 21.6604436558 7.53300 19.6726036560 9.13479 26.8546936561 9.32854 28.1787436563 9.72520 29.0471036565 9.35944 24.1690436566 9.99518 95.2215836568 2.58024 7.3506436569 2.51854 6.3989436570 8.07514 27.5305436571 8.37904 29.95264

Page 57 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

36575 0.95113 3.8258336576 5.14158 9.1910836578 5.74770 12.4672036580 1.81349 5.4802936581 5.37436 18.3149636582 8.18310 26.1255036583 8.49817 27.6420736584 1.80708 5.3047836585 7.51380 26.2928036589 3.70696 4.3121636590 5.31915 7.0902536591 0.53606 0.5360636592 0.58946 0.5894636593 0.65176 0.6517636595 5.11921 14.5176136596 1.20697 3.2895736597 1.69427 3.1538736598 1.42452 2.7684236600 0.40448 0.7604836620 1.35587 1.3558736625 2.90899 2.9089936640 3.26416 3.2641636660 1.89430 1.8943036680 1.61680 1.6168036800 4.19935 4.1993536810 5.73542 5.7354236815 4.04676 4.0467636818 18.32387 18.3238736819 21.85317 21.8531736820 21.93805 21.9380536821 18.59545 18.5954536823 35.06546 35.0654636825 21.09213 21.0921336830 18.06577 18.0657736831 12.45444 12.4544436832 15.93383 15.9338336833 18.00616 18.0061636835 12.64869 12.6486936838 32.23359 32.2335936860 2.80477 4.9140736861 4.05280 4.0528036870 8.18654 44.1336437140 37.89567 37.8956737145 39.92876 39.9287637160 34.96516 34.9651637180 39.11812 39.1181237181 42.31357 42.3135737182 23.57913 23.5791337183 11.17851 122.2505137184 12.64476 57.6698637185 4.70608 19.16858

Page 58 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

37186 7.20770 38.2687037187 11.50239 55.0233937188 8.23299 46.2537937191 6.82537 70.4069737192 10.58693 47.7088337193 10.57803 45.5639337195 7.68508 7.6850837197 8.67619 44.9703937200 6.26211 6.2621137202 9.30541 9.3054137211 11.59474 11.5947437212 10.23776 10.2377637213 7.16242 7.1624237214 4.18000 4.1800037215 30.85398 30.8539837216 26.89325 26.8932537217 31.47144 31.4714437220 12.45697 84.4134737221 15.13894 124.4398437222 5.65485 24.5050537223 6.41759 122.8829937224 13.71336 101.3071637225 18.47646 284.3995637226 15.11831 237.9298137227 22.31754 384.2894437228 16.76460 143.9812037229 21.64277 282.2525737230 20.85366 222.0381637231 22.66494 355.4270437232 6.05246 32.5210637233 9.97092 39.9639237234 8.30834 102.6839437235 11.78910 109.9472037236 13.06012 72.2006237237 6.11565 31.4094537238 9.14755 104.7513537239 4.26897 52.0530737241 12.48880 116.0937037242 13.94663 194.9993337243 16.62923 246.0890337244 19.39774 172.9049437250 3.08138 3.0813837251 2.29360 2.2936037500 18.83137 18.8313737565 18.90807 18.9080737600 19.15716 19.1571637605 22.00724 22.0072437606 14.31071 14.3107137607 10.14367 10.1436737609 5.26961 7.4590137615 12.89658 12.89658

Page 59 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

37616 29.32375 29.3237537617 35.13681 35.1368137618 10.14593 10.1459337619 47.32354 47.3235437650 13.70771 13.7077137660 33.25942 33.2594237700 6.70626 6.7062637718 11.67161 11.6716137722 13.03606 13.0360637735 17.05446 17.0544637760 17.01912 17.0191237761 15.19719 15.1971937765 12.31399 12.3139937766 15.13372 15.1337237780 6.91325 6.9132537785 6.93105 9.0581537788 37.18189 37.1818937790 12.86087 12.8608738100 28.99331 28.9933138101 29.15903 29.1590338102 6.79163 6.7916338115 32.06560 32.0656038120 26.39453 26.3945338129 22.44000 22.4400038200 3.96082 3.9608238204 2.67860 2.6786038205 2.09692 2.0969238206 2.09898 2.0989838207 1.31031 1.3103138208 0.82696 0.8269638209 0.35128 0.3512838210 2.31839 2.3183938211 2.09918 2.0991838212 1.39662 1.3966238213 0.35128 0.3512838214 1.19687 1.1968738215 1.39662 1.3966238220 1.60338 3.6948838221 1.96837 4.0509738230 8.51983 8.5198338232 5.25117 5.2511738240 3.23664 3.2366438241 3.24348 3.2434838242 2.46351 2.4635138243 3.23641 3.2364138300 4.50982 6.4767238305 11.54378 11.5437838308 11.24381 11.2438138380 14.16424 14.1642438381 21.36558 21.3655838382 17.50261 17.50261

Page 60 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

38500 6.28613 7.8347338505 1.89316 3.0768638510 10.63338 12.6714838520 11.65639 11.6563938525 10.66385 10.6638538530 13.64730 13.6473038542 13.05745 13.0574538550 12.19365 12.1936538555 25.18507 25.1850738562 17.78708 17.7870838564 17.87470 17.8747038570 14.03340 14.0334038571 21.59304 21.5930438572 24.45534 24.4553438700 20.26883 20.2688338720 34.00025 34.0002538724 36.69657 36.6965738740 17.10420 17.1042038745 21.77379 21.7737938746 7.06206 7.0620638747 6.92782 6.9278238760 21.27854 21.2785438765 33.02995 33.0299538770 21.16674 21.1667438780 26.93996 26.9399638790 2.14459 2.1445938792 1.01878 1.0187838794 7.76996 7.7699638900 3.92118 3.9211839000 12.88161 12.8816139010 21.28339 21.2833939200 23.64095 23.6409539220 30.48661 30.4866139400 13.36859 13.3685939501 21.72268 21.7226839503 156.02709 156.0270939540 22.29683 22.2968339541 24.13587 24.1358739545 23.61219 23.6121939560 20.41532 20.4153239561 31.97243 31.9724340490 1.90598 3.1074840500 8.94063 11.8954340510 8.83552 11.5144240520 8.92821 11.7851140525 13.88930 13.8893040527 16.09646 16.0964640530 10.15298 13.0721840650 7.18140 9.8603040652 8.69363 11.5594340654 10.54100 13.62930

Page 61 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

40700 23.34269 23.3426940701 28.40011 28.4001140702 21.48917 21.4891740720 25.36256 25.3625640761 27.27054 27.2705440800 3.07271 4.6925140801 5.37361 7.2693140804 3.13192 4.8229240805 5.56077 7.5187740806 0.80621 2.3548140808 2.56767 4.1874740810 3.06776 4.6875640812 4.76323 6.6144340814 7.35760 8.9596040816 7.73163 9.4671340818 6.58759 8.2963940819 5.63131 7.0998140820 4.07180 6.0298040830 3.91658 5.7410840831 5.45491 7.5909140840 15.53533 19.2644340842 15.57983 19.4246340843 20.62349 25.5451940844 28.50318 33.6918840845 31.33054 36.1454441000 2.72667 3.7590741005 3.07045 5.2153541006 6.32872 8.4825241007 6.15484 8.4599441008 6.54544 8.7259441009 7.10431 9.2759141010 2.65813 4.6784341015 8.20236 10.0090641016 8.46275 10.2071541017 8.48945 10.3228541018 9.95518 11.8063841019 12.49094 12.4909441100 2.69894 3.9538441105 2.76745 3.9956541108 2.21230 3.4138041110 3.21992 4.9020241112 6.08919 7.7534941113 6.78053 8.5249341114 15.83724 15.8372441115 3.63473 5.6550341116 5.35830 7.6100041120 25.57826 25.5782641130 31.99590 31.9959041135 53.78312 53.7831241140 54.55865 54.5586541145 68.83095 68.83095

Page 62 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

41150 54.58412 54.5841241153 59.44935 59.4493541155 74.68712 74.6871241250 3.59206 5.5144641251 4.08952 5.7360241252 5.32250 7.3784041500 10.73614 10.7361441510 10.02265 10.0226541512 15.01292 15.0129241520 6.16039 8.0916941530 9.80915 71.1835541800 3.21365 5.4297541805 3.99854 5.5827441806 6.28381 8.1261141820 7.78690 7.7869041821 1.56560 1.5656041822 4.35715 6.6889541823 7.75899 9.9839941825 3.05411 4.7896141826 4.98015 6.8402541827 7.45453 10.1245341828 5.30436 7.1555641830 6.79381 9.0277141850 1.16650 1.1665041870 7.39810 7.3981041872 6.51089 8.6468941874 6.17181 8.5570142000 2.54286 3.6909642100 2.68300 3.5285042104 3.37517 4.9148742106 4.36705 6.2004542107 8.52634 10.8759442120 24.24624 24.2462442140 3.78540 5.8413042145 17.63808 17.6380842160 3.72187 5.5819742180 4.59333 5.8304342182 6.60551 7.9138142200 21.89613 21.8961342205 23.16068 23.1606842210 26.95815 26.9581542215 17.30847 17.3084742220 13.20854 13.2085442225 22.55005 22.5500542226 22.56399 22.5639942227 21.72630 21.7263042235 18.06341 18.0634142260 16.91744 20.1303442280 2.73571 3.8571142281 3.77032 4.8650242300 3.79018 4.96498

Page 63 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

42305 10.88439 10.8843942310 3.09263 3.8669342320 4.41862 5.9583242330 4.12014 5.5530442335 6.44339 8.8463942340 8.48144 11.1514442400 1.44976 2.5622642405 5.72558 7.2919842408 8.22520 10.8952042409 5.54403 7.8491342410 15.83183 15.8318342415 28.56034 28.5603442420 32.74636 32.7463642425 21.52920 21.5292042426 35.03464 35.0346442440 11.87467 11.8746742450 8.96782 10.9258242500 8.51678 10.4124842505 11.41098 13.5380842507 12.74017 12.7401742509 21.65248 21.6524842510 15.74615 15.7461542550 1.70443 3.4666342600 8.86872 11.6544242650 1.46673 1.9740342660 1.96559 2.5618942665 5.16273 7.3699342700 3.37557 4.4880742720 10.09023 11.3718342725 20.57581 20.5758142800 2.78960 3.7686042804 2.83739 4.6885942806 3.33459 5.3014942808 4.12761 5.4982142809 3.28182 4.1273242810 7.07074 9.2156442815 13.88049 13.8804942820 7.36164 7.3616442821 7.66218 7.6621842825 6.57835 6.5783542826 6.34197 6.3419742830 5.16439 5.1643942831 5.56243 5.5624342835 4.67300 4.6730042836 6.08178 6.0817842842 24.34131 24.3413142844 34.00076 34.0007642845 56.02216 56.0221642860 4.66636 4.6663642870 13.96456 13.9645642890 34.98237 34.98237

Page 64 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

42892 46.18001 46.1800142894 58.98930 58.9893042900 8.69925 8.6992542950 19.37211 19.3721142953 23.59973 23.5997342955 18.23251 18.2325142960 4.26566 4.2656642961 10.56293 10.5629342962 13.10748 13.1074842970 9.95372 9.9537242971 11.55610 11.5561042972 12.97401 12.9740143020 13.40439 13.4043943030 13.29415 13.2941543045 34.60588 34.6058843100 15.83716 15.8371643101 26.79725 26.7972543107 67.02352 67.0235243108 118.45159 118.4515943112 71.56298 71.5629843113 117.00838 117.0083843116 130.67555 130.6755543117 65.53979 65.5397943118 96.72553 96.7255343121 75.97443 75.9744343122 66.34976 66.3497643123 119.21928 119.2192843124 101.12767 101.1276743130 20.27171 20.2717143135 39.37947 39.3794743191 3.44886 3.4488643192 4.11951 4.1195143193 4.91622 4.9162243194 4.48902 4.4890243195 4.92512 4.9251243196 5.41562 5.4156243197 2.20964 4.8173443198 2.63232 5.3913243200 2.67473 5.1400343201 3.36049 7.0361943202 2.99473 6.7238343204 5.85224 5.8522443205 5.86074 5.8607443206 3.95985 8.6412543211 6.75025 6.7502543212 5.35114 5.3511443213 7.51711 31.6539143214 5.43462 5.4346243215 4.04230 4.0423043216 3.73950 5.0033043217 4.47116 9.06356

Page 65 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

43220 3.31888 3.3188843226 3.68112 3.6811243227 5.51567 5.5156743229 5.74506 18.7568643231 4.99157 4.9915743232 6.89297 6.8929743233 6.45217 6.4521743235 3.77427 7.1740743236 4.60492 8.9214243237 6.18612 6.1861243238 7.74786 7.7478643239 4.50493 8.3586343240 10.43979 10.4397943241 4.07501 4.0750143242 11.13096 11.1309643243 7.02982 7.0298243244 7.77210 7.7721043245 4.93256 4.9325643246 6.63132 6.6313243247 5.26272 5.2627243248 4.95949 4.9594943249 4.56972 4.5697243250 4.94312 4.9431243251 5.71087 5.7108743252 4.95960 9.6855043253 7.48420 7.4842043254 7.77810 7.7781043255 7.41959 7.4195943257 8.30118 8.3011843259 7.99337 7.9933743260 9.13203 9.1320343261 9.59114 9.5911443262 11.25536 11.2553643263 11.12040 11.1204043264 13.53391 13.5339143265 15.19936 15.1993643266 6.44055 6.4405543270 6.75643 18.7714343273 3.25238 3.2523843274 13.33094 13.3309443275 10.98992 10.9899243276 13.86746 13.8674643277 11.05554 11.0555443278 12.57275 12.5727543279 30.54296 30.5429643280 27.40504 27.4050443281 41.01634 41.0163443282 46.15082 46.1508243283 4.67605 4.6760543289 27.04000 27.0400043300 15.56329 15.56329

Page 66 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

43305 28.20606 28.2060643310 40.26812 40.2681243312 44.03005 44.0300543313 72.13323 72.1332343314 78.65137 78.6513743320 35.56727 35.5672743325 34.21504 34.2150443327 23.36459 23.3645943328 34.49385 34.4938543330 33.50733 33.5073343331 35.89312 35.8931243332 33.51288 33.5128843333 36.40292 36.4029243334 36.85556 36.8555643335 39.71973 39.7197343336 43.54657 43.5465743337 47.47041 47.4704143338 3.85533 3.8553343340 34.90057 34.9005743341 38.29409 38.2940943351 34.78637 34.7863743352 28.31835 28.3183543360 60.65473 60.6547343361 68.59114 68.5911443400 40.33278 40.3327843401 39.75915 39.7591543405 38.50519 38.5051943410 26.28371 26.2837143415 44.77737 44.7773743420 25.72012 25.7201243425 39.00402 39.0040243450 2.29924 3.8211443453 2.49899 7.0023943460 5.78147 5.7814743496 81.42000 81.4200043500 19.70415 19.7041543501 33.90626 33.9062643502 38.37547 38.3754743510 23.61850 23.6185043520 17.69549 17.6954943605 20.90966 20.9096643610 24.67368 24.6736843611 30.76630 30.7663043620 50.15460 50.1546043621 57.61439 57.6143943622 58.36179 58.3617943631 36.66993 36.6699343632 51.11612 51.1161243633 48.40522 48.4052243634 53.54110 53.5411043635 2.91374 2.91374

Page 67 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

43640 29.59456 29.5945643641 29.96109 29.9610943644 43.91898 43.9189843645 46.97343 46.9734343651 16.20999 16.2099943652 19.01879 19.0187943653 13.96836 13.9683643752 1.10309 1.1030943753 0.58643 0.5864343754 0.87329 2.1192943755 1.60750 3.2540043756 1.43591 5.8058143757 2.08796 7.4991643760 1.32556 8.5167643761 2.80065 3.1388543770 27.95126 27.9512643771 31.92453 31.9245343772 24.06324 24.0632443773 31.93343 31.9334343774 24.15516 24.1551643775 34.34290 34.3429043800 23.43423 23.4342343810 25.48876 25.4887643820 33.49583 33.4958343825 32.75478 32.7547843830 17.31929 17.3192943831 14.44979 14.4497943832 26.61068 26.6106843840 33.95617 33.9561743842 29.79209 29.7920943843 31.90945 31.9094543845 49.46120 49.4612043846 41.21097 41.2109743847 45.12174 45.1217443848 48.76989 48.7698943850 40.93484 40.9348443855 42.46613 42.4661343860 41.45007 41.4500743865 43.12041 43.1204143870 17.75376 17.7537643880 40.42096 40.4209643886 8.55506 8.5550643887 7.82606 7.8260643888 11.12064 11.1206444005 27.61292 27.6129244010 21.72746 21.7274644015 3.72636 3.7263644020 24.43092 24.4309244021 24.69583 24.6958344025 24.86167 24.8616744050 23.49782 23.49782

Page 68 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

44055 37.83715 37.8371544100 3.00675 3.0067544110 21.31892 21.3189244111 24.84676 24.8467644120 30.88226 30.8822644121 6.28058 6.2805844125 29.81429 29.8142944126 62.13471 62.1347144127 72.10210 72.1021044128 6.31140 6.3114044130 32.79133 32.7913344139 3.14351 3.1435144140 33.84717 33.8471744141 45.43253 45.4325344143 41.93737 41.9373744144 44.47133 44.4713344145 42.12408 42.1240844146 53.05634 53.0563444147 48.73625 48.7362544150 46.60370 46.6037044151 53.53646 53.5364644155 52.00208 52.0020844156 57.55340 57.5534044157 54.61382 54.6138244158 55.94018 55.9401844160 31.29607 31.2960744180 23.19771 23.1977144186 16.37932 16.3793244187 27.44938 27.4493844188 30.47933 30.4793344202 35.03917 35.0391744203 6.29360 6.2936044204 39.03294 39.0329444205 34.00503 34.0050344206 44.42503 44.4250344207 46.49826 46.4982644208 50.38969 50.3896944210 45.22481 45.2248144211 56.21548 56.2154844212 51.90098 51.9009844213 4.91264 4.9126444227 42.39654 42.3965444300 21.15657 21.1565744310 26.32603 26.3260344312 14.87557 14.8755744314 25.41806 25.4180644316 35.44951 35.4495144320 30.14525 30.1452544322 23.88532 23.8853244340 15.19316 15.1931644345 26.33570 26.33570

Page 69 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

44346 29.65435 29.6543544360 4.10649 4.1064944361 4.52751 4.5275144363 5.38549 5.3854944364 5.80319 5.8031944365 5.16173 5.1617344366 6.82346 6.8234644369 6.98801 6.9880144370 7.50487 7.5048744372 6.71806 6.7180644373 5.40741 5.4074144376 7.99769 7.9976944377 8.45620 8.4562044378 10.83806 10.8380644379 11.45096 11.4509644380 1.78301 1.7830144382 2.13675 2.1367544385 2.76024 5.9820444386 3.26920 8.2087044388 4.34470 8.3408044389 4.82639 9.5700944390 5.80176 11.1061644391 6.59555 12.3360544392 5.74893 10.5282344394 6.72656 12.2089644500 0.66985 0.6698544602 35.57346 35.5734644603 40.74194 40.7419444604 26.77532 26.7753244605 33.04900 33.0490044615 27.19774 27.1977444620 21.75451 21.7545144625 25.69848 25.6984844626 40.87438 40.8743844640 35.61304 35.6130444650 36.96012 36.9601244660 35.06273 35.0627344661 39.98365 39.9836544680 27.03536 27.0353644700 25.69234 25.6923444701 4.33102 4.3310244720 6.69650 6.6965044721 9.97732 9.9773244800 18.99839 18.9983944820 21.08915 21.0891544850 18.62001 18.6200144900 19.29289 19.2928944950 16.15934 16.1593444955 2.17481 2.1748144960 21.91788 21.9178844970 14.87871 14.87871

Page 70 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

45000 10.32706 10.3270645005 3.76548 5.9459845020 13.79898 13.7989845100 7.14414 7.1441445108 8.80512 8.8051245110 46.50384 46.5038445111 27.34541 27.3454145112 47.96108 47.9610845113 49.95502 49.9550245114 45.59885 45.5988545116 39.52092 39.5209245119 49.14768 49.1476845120 39.83656 39.8365645121 43.56790 43.5679045123 27.86558 27.8655845126 73.74362 73.7436245130 27.25992 27.2599245135 34.04926 34.0492645136 45.48880 45.4888045150 9.65839 9.6583945160 25.23561 25.2356145171 15.21325 15.2132545172 20.99443 20.9944345190 16.84940 16.8494045300 1.29534 2.6303445303 2.24418 19.4834845305 1.96121 4.2218145307 2.54698 4.8253845308 2.14688 4.4252845309 2.36194 4.8005445315 2.77984 5.2451445317 2.93678 5.1528845320 2.76722 5.0723245321 2.71133 2.7113345327 3.20246 3.2024645330 1.60644 3.2529445331 1.94673 4.0827345332 2.85087 6.7312745333 2.85293 6.8045345334 4.29133 4.2913345335 2.37024 5.8501445337 3.69580 3.6958045338 3.68112 7.5704245340 3.00569 10.3748945341 4.10048 4.1004845342 6.27203 6.2720345378 5.67049 9.6220945378 53 1.60644 3.2529445379 7.11032 12.2278245380 6.80337 11.5114745381 6.44797 11.18277

Page 71 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

45382 8.69610 15.1041045384 7.12211 11.4386145385 8.08878 13.0282845386 6.96563 15.7855345391 7.78721 7.7872145392 9.96700 9.9670045395 50.01226 50.0122645397 54.02708 54.0270845400 29.01476 29.0147645402 38.76501 38.7650145500 12.62905 12.6290545505 14.05070 14.0507045520 0.96581 3.0395145540 26.64098 26.6409845541 22.91819 22.9181945550 36.78474 36.7847445560 17.76122 17.7612245562 27.86588 27.8658845563 40.78720 40.7872045800 30.78679 30.7867945805 36.19316 36.1931645820 29.48217 29.4821745825 36.66217 36.6621745900 4.93187 4.9318745905 4.10849 4.1084945910 4.83669 4.8366945915 5.46055 7.4452545990 2.74218 2.7421846020 5.48038 6.2101846030 2.16674 3.0745446040 9.79185 12.0168546045 10.23253 10.2325346050 2.28968 4.2298846060 11.18389 11.1838946070 5.25331 5.2533146080 3.94806 5.6034646083 2.61383 4.0823346200 7.36621 9.4399146220 2.83799 4.4933946221 4.47422 5.9160246230 4.23020 6.1526046250 7.48543 10.2978346255 8.50836 11.4631646257 9.96868 9.9686846258 11.11609 11.1160946260 11.33499 11.3349946261 12.71856 12.7185646262 13.23559 13.2355946270 9.10134 11.2996446275 9.67684 11.9374446280 11.03285 11.03285

Page 72 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

46285 9.59946 11.6998646288 13.06363 13.0636346320 2.68918 4.0508846500 3.04521 4.9676146505 5.69730 6.6229046600 0.95691 1.9181146604 1.64991 11.9027146606 1.88586 4.9118646608 2.02082 5.0557246610 2.03012 4.9938246611 2.03656 3.9233646612 2.41468 5.9212846614 1.65426 2.9447646615 2.39276 3.4429646700 15.73819 15.7381946705 12.02261 12.0226146706 4.11118 4.1111846707 11.60921 11.6092146710 27.36772 27.3677246712 51.14877 51.1487746715 11.88914 11.8891446716 28.84918 28.8491846730 46.89427 46.8942746735 52.21156 52.2115646740 52.81636 52.8163646742 61.95828 61.9582846744 84.30150 84.3015046746 91.82104 91.8210446748 99.22328 99.2232846750 18.92981 18.9298146751 15.34736 15.3473646753 14.24599 14.2459946754 5.33807 6.7353746760 26.68641 26.6864146761 23.15455 23.1545546762 22.72106 22.7210646900 3.36335 5.3213546910 3.26957 5.5835746916 3.54407 5.4041746917 3.25861 10.1472146922 3.27163 5.8081346924 4.55541 11.7199146930 3.52321 4.8048146940 3.61075 5.0970546942 3.22739 4.7492946945 5.09433 6.5628346946 5.31065 6.9749546947 9.23407 9.2340747000 2.63404 7.9562447001 2.68958 2.6895847010 30.09740 30.09740

Page 73 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

47015 28.79450 28.7945047100 20.81359 20.8135947120 58.74801 58.7480147122 87.39542 87.3954247125 78.19578 78.1957847130 84.03259 84.0325947133 10.49800 10.4980047135 124.02666 124.0266647136 105.89008 105.8900847140 89.60900 89.6090047141 98.83354 98.8335447142 118.62732 118.6273247146 8.52842 8.5284247147 9.93076 9.9307647300 28.18950 28.1895047350 34.37905 34.3790547360 47.04895 47.0489547361 76.84594 76.8459447362 35.90948 35.9094847370 31.26256 31.2625647371 31.85416 31.8541647380 36.55690 36.5569047381 37.56262 37.5626247382 21.62232 106.8487247400 54.35512 54.3551247420 33.66241 33.6624147425 34.09851 34.0985147460 32.11638 32.1163847480 21.41075 21.4107547490 13.34599 13.3459947500 2.69036 2.6903647505 1.04348 1.0434847510 12.70101 12.7010147511 15.89839 15.8983947525 2.67602 12.1100247530 9.54413 34.0458347550 4.29496 4.2949647552 8.66549 8.6654947553 8.70696 8.7069647554 13.10433 13.1043347555 10.37931 10.3793147556 11.76723 11.7672347560 6.95864 6.9586447561 7.54959 7.5495947562 18.54234 18.5423447563 18.86855 18.8685547564 21.74088 21.7408847570 19.40710 19.4071047600 26.87496 26.8749647605 24.58216 24.5821647610 31.58138 31.58138

Page 74 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

47612 31.94711 31.9471147620 34.64433 34.6443347630 14.72861 14.7286147700 26.14796 26.1479647701 44.54521 44.5452147711 39.19596 39.1959647712 50.36010 50.3601047715 33.06937 33.0693747720 28.55254 28.5525447721 33.70565 33.7056547740 32.61627 32.6162747741 36.87231 36.8723147760 56.46294 56.4629447765 75.80571 75.8057147780 62.01552 62.0155247785 81.42743 81.4274347800 39.65109 39.6510947801 26.84604 26.8460447802 38.10967 38.1096747900 34.24552 34.2455248000 47.07241 47.0724148001 58.51017 58.5101748020 29.39807 29.3980748100 22.18906 22.1890648102 6.68602 13.1563248105 72.22602 72.2260248120 27.83061 27.8306148140 39.42324 39.4232448145 41.00189 41.0018948146 46.71610 46.7161048148 31.11357 31.1135748150 78.67074 78.6707448152 72.78405 72.7840548153 78.53993 78.5399348154 73.01608 73.0160848155 45.33757 45.3375748160 44.90000 44.9000048400 2.80391 2.8039148500 28.44654 28.4465448510 26.96313 26.9631348520 27.49819 27.4981948540 32.87380 32.8738048545 33.53801 33.5380148547 45.10952 45.1095248548 42.01303 42.0130348550 10.49800 10.4980048552 6.14436 6.1443648554 62.51134 62.5113448556 31.27125 31.2712549000 19.38484 19.3848449002 26.17129 26.17129

Page 75 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

49010 24.13960 24.1396049020 40.09985 40.0998549040 25.16576 25.1657649060 28.03901 28.0390149062 18.87422 18.8742249082 1.95008 4.4064849083 3.01548 8.2931849084 2.77518 2.7751849180 2.38441 4.1288149203 30.32709 30.3270949204 38.73701 38.7370149205 44.50253 44.5025349215 55.73095 55.7309549220 24.35757 24.3575749250 14.43683 14.4368349255 19.70072 19.7007249320 8.21320 8.2132049321 8.66670 8.6667049322 9.38975 9.3897549323 16.11421 16.1142149324 9.93382 9.9338249325 10.63260 10.6326049326 4.93184 4.9318449327 3.76742 3.7674249400 2.61186 4.3651649402 21.47643 21.4764349405 5.90247 22.4475749406 5.91137 22.4386749407 6.29430 19.0569049411 5.25466 12.8107649412 2.34900 2.3490049418 6.61815 40.4025549419 11.17986 11.1798649421 9.64968 9.6496849422 9.76495 9.7649549423 2.03748 13.2959849424 1.07018 3.6333849425 19.20566 19.2056649426 16.20101 16.2010149427 1.24735 1.2473549428 11.01055 11.0105549429 11.50566 11.5056649435 3.14039 3.1403949436 4.62672 4.6267249440 6.11298 25.8353849441 6.93081 28.2107149442 5.70982 24.6045249446 4.56741 23.6223149450 1.85118 17.1235849451 2.55786 16.8601649452 3.95428 21.17578

Page 76 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

49460 1.32436 18.7060649465 0.85180 4.0647049491 19.59629 19.5962949492 23.44107 23.4410749495 9.94644 9.9464449496 15.22752 15.2275249500 9.86860 9.8686049501 14.91780 14.9178049505 12.84072 12.8407249507 15.82815 15.8281549520 15.70747 15.7074749521 19.15338 19.1533849525 14.19607 14.1960749540 16.81794 16.8179449550 14.27637 14.2763749553 15.64620 15.6462049555 14.86483 14.8648349557 18.07476 18.0747649560 18.43308 18.4330849561 23.34174 23.3417449565 19.17221 19.1722149566 23.58287 23.5828749568 6.92988 6.9298849570 10.13251 10.1325149572 12.64429 12.6442949580 8.14523 8.1452349582 11.74347 11.7434749585 10.87705 10.8770549587 12.92062 12.9206249590 14.14908 14.1490849600 18.30035 18.3003549605 127.26409 127.2640949606 28.58754 28.5875449610 17.18739 17.1873949611 14.20424 14.2042449650 10.48688 10.4868849651 13.65540 13.6554049652 18.50454 18.5045449653 23.16599 23.1659949654 21.28459 21.2845949655 25.63159 25.6315949656 21.34214 21.3421449657 30.81969 30.8196949900 20.17777 20.1777749904 37.21271 37.2127149905 9.19006 9.1900649906 29.43800 29.4380050010 19.23900 19.2390050020 27.46916 27.4691650040 25.21870 25.2187050045 25.27342 25.27342

Page 77 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

50060 31.17615 31.1761550065 32.80566 32.8056650070 32.52701 32.5270150075 40.00685 40.0068550080 23.79398 23.7939850081 34.99790 34.9979050100 27.22575 27.2257550120 25.79257 25.7925750125 26.95504 26.9550450130 28.21630 28.2163050135 30.61499 30.6149950200 3.90371 13.5780150205 19.05663 19.0566350220 28.18844 28.1884450225 32.50840 32.5084050230 35.07299 35.0729950234 35.57145 35.5714550236 40.13680 40.1368050240 36.15911 36.1591150250 33.44706 33.4470650280 25.87375 25.8737550290 23.76777 23.7677750300 58.43700 58.4370050320 36.34131 36.3413150327 5.66276 5.6627650328 4.95508 4.9550850329 4.69936 4.6993650340 23.14894 23.1489450360 63.90462 63.9046250365 72.02557 72.0255750370 29.77414 29.7741450380 50.36407 50.3640750382 7.62602 30.8283250384 6.94644 26.2416450385 6.48438 30.0782850386 4.89588 19.6164850387 2.76694 14.1945450389 1.51192 8.0623250390 2.69036 2.6903650391 2.75472 3.3866250392 4.91949 4.9194950393 5.99133 5.9913350394 1.32828 2.5920850395 4.94619 4.9461950396 3.17491 3.1749150398 2.04638 12.7441850400 31.56011 31.5601150405 38.14866 38.1486650500 32.71128 32.7112850520 28.11654 28.1165450525 38.05727 38.05727

Page 78 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

50526 37.06775 37.0677550540 30.99486 30.9948650541 25.18436 25.1843650542 31.93248 31.9324850543 40.77557 40.7755750544 34.28813 34.2881350545 36.84038 36.8403850546 32.75125 32.7512550547 41.06012 41.0601250548 37.06586 37.0658650551 8.14697 9.8112750553 8.67436 10.3653650555 9.41816 11.1892650557 9.55229 11.4034950561 10.93088 12.9600850562 16.04680 16.0468050570 13.62725 13.6272550572 14.76511 14.7651150574 15.67446 15.6744650575 19.82600 19.8260050576 15.63431 15.6343150580 16.79990 16.7999050590 15.33339 24.0553950592 9.90626 84.0699650593 12.79371 111.9753150600 25.54895 25.5489550605 25.50141 25.5014150610 25.82259 25.8225950620 24.68513 24.6851350630 24.13765 24.1376550650 28.22866 28.2286650660 31.16416 31.1641650684 1.32828 4.3898850686 2.49693 2.8173350688 2.12748 2.1274850690 1.88386 2.5691650700 25.18047 25.1804750715 30.68736 30.6873650722 27.07525 27.0752550725 29.68850 29.6885050727 13.54674 13.5467450728 18.71698 18.7169850740 31.29031 31.2903150750 31.64768 31.6476850760 30.19901 30.1990150770 30.89118 30.8911850780 29.93285 29.9328550782 30.79686 30.7968650783 30.47488 30.4748850785 33.01525 33.0152550800 25.06897 25.06897

Page 79 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

50810 35.33315 35.3331550815 33.30592 33.3059250820 35.69985 35.6998550825 45.19594 45.1959450830 48.95769 48.9576950840 33.55017 33.5501750845 33.99208 33.9920850860 25.68182 25.6818250900 22.73356 22.7335650920 23.98257 23.9825750930 31.15993 31.1599350940 24.02129 24.0212950945 26.63341 26.6334150947 37.70592 37.7059250948 35.06896 35.0689650951 8.48935 10.2426550953 9.31877 10.8228750955 10.06354 11.8702450957 9.79096 11.6599650961 8.77584 10.5113450970 10.27119 10.2711950972 9.89922 9.8992250974 13.11182 13.1118250976 12.90317 12.9031750980 9.86920 9.8692051020 12.63513 12.6351351030 12.42737 12.4273751040 7.79889 7.7988951045 12.86907 12.8690751050 12.79187 12.7918751060 15.74883 15.7488351065 15.65093 15.6509351080 10.94899 10.9489951100 1.07390 1.6079051101 1.44026 3.2113651102 4.04096 6.0523651500 16.80685 16.8068551520 15.90803 15.9080351525 23.43128 23.4312851530 21.08561 21.0856151535 21.01156 21.0115651550 26.07581 26.0758151555 34.45184 34.4518451565 35.11832 35.1183251570 40.19578 40.1957851575 49.96322 49.9632251580 52.02551 52.0255151585 57.97752 57.9775251590 52.97681 52.9768151595 60.14080 60.1408051596 64.60078 64.60078

Page 80 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

51597 62.64442 62.6444251600 1.21570 4.7401051605 1.03146 1.0314651610 1.70357 2.8249751700 1.23556 2.2323651701 0.74394 1.5182451702 0.81514 1.9365451703 2.22727 3.5800751705 1.80147 2.8783751710 2.56962 4.0381251715 5.45123 7.6851351720 2.22770 2.9931051725 5.43459 5.4345951725 26 2.08613 2.0861351725 TC 3.34846 3.3484651726 7.91377 7.9137751726 26 2.35193 2.3519351726 TC 5.56184 5.5618451727 7.39929 7.3992951727 26 2.88493 2.8849351727 TC 4.51436 4.5143651728 7.38627 7.3862751728 26 2.84521 2.8452151728 TC 4.54106 4.5410651729 7.96237 7.9623751729 26 3.36791 3.3679151729 TC 4.59446 4.5944651736 1.38497 1.3849751736 26 0.84001 0.8400151736 TC 0.54496 0.5449651741 2.20054 2.2005451741 26 1.56658 1.5665851741 TC 0.63396 0.6339651784 5.06929 5.0692951784 26 2.09463 2.0946351784 TC 2.97466 2.9746651785 5.51635 5.5163551785 26 2.11449 2.1144951785 TC 3.40186 3.4018651792 5.59908 5.5990851792 26 1.52082 1.5208251792 TC 4.07826 4.0782651797 3.49636 3.4963651797 26 1.14470 1.1447051797 TC 2.35166 2.3516651798 0.46486 0.4648651800 28.45631 28.4563151820 28.88887 28.8888751840 17.53724 17.5372451841 20.86754 20.8675451845 15.85385 15.85385

Page 81 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

51860 19.72292 19.7229251865 24.12842 24.1284251880 12.54541 12.5454151900 22.14155 22.1415551920 20.37525 20.3752551925 27.45729 27.4572951940 44.01940 44.0194051960 37.95514 37.9551451980 19.31623 19.3162351990 20.17208 20.1720851992 22.38775 22.3877552000 3.42205 5.4156552001 7.90790 10.1240052005 3.63153 7.3339352007 4.53922 13.2345252010 4.44132 10.1373252204 3.86545 10.8074552214 5.80540 15.0970052224 4.65804 19.5655452234 6.77728 6.7772852235 7.96130 7.9613052240 13.94001 13.9400152250 6.67955 6.6795552260 5.77767 5.7776752265 4.40732 10.5216252270 4.98986 10.1785652275 6.86525 13.9140552276 7.32147 7.3214752277 9.01926 9.0192652281 4.23410 7.7585052282 9.28895 9.2889552283 5.52721 7.4407152285 5.35622 7.4744252287 4.69458 8.4859852290 6.73836 6.7383652300 7.79566 7.7956652301 8.07308 8.0730852305 7.68952 7.6895252310 4.16373 6.5044352315 7.58332 11.5171252317 9.62495 23.5534552318 13.12238 13.1223852320 6.81185 6.8118552325 8.85823 8.8582352327 7.28112 7.2811252330 7.29125 18.2560552332 4.27219 12.3177952334 7.06500 7.0650052341 7.98943 7.9894352342 8.68681 8.6868152343 9.67191 9.67191

Page 82 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

52344 10.48499 10.4849952345 11.19333 11.1933352346 12.63714 12.6371452351 8.65121 8.6512152352 10.14759 10.1475952353 11.68744 11.6874452354 10.79715 10.7971552355 12.88285 12.8828552356 11.34514 11.3451452400 12.94203 12.9420352402 7.42003 7.4200352450 12.66312 12.6631252500 13.19758 13.1975852601 22.72924 22.7292452630 12.04693 12.0469352640 8.03945 8.0394552647 17.54372 52.7343252648 18.74119 54.0296952649 26.53997 26.5399752700 11.80929 11.8092953000 4.00201 4.0020153010 7.88251 7.8825153020 2.66569 2.6656953025 1.76155 1.7615553040 10.56875 10.5687553060 4.31116 4.7917653080 11.60244 11.6024453085 17.08002 17.0800253200 3.84081 4.1790153210 20.95896 20.9589653215 25.40257 25.4025753220 12.21251 12.2125153230 16.40574 16.4057453235 17.25577 17.2557753240 11.53768 11.5376853250 11.26696 11.2669653260 4.79749 5.3403953265 5.01381 5.8682153270 5.07370 5.5899053275 7.17569 7.1756953400 21.76869 21.7686953405 23.88796 23.8879653410 26.75858 26.7585853415 30.91922 30.9192253420 22.23021 22.2302153425 25.70769 25.7076953430 26.09645 26.0964553431 31.53756 31.5375653440 23.96700 23.9670053442 21.10485 21.1048553444 21.67165 21.67165

Page 83 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

53445 23.94359 23.9435953446 17.46502 17.4650253447 22.10154 22.1015453448 35.04904 35.0490453449 16.63952 16.6395253450 11.05393 11.0539353460 12.40253 12.4025353500 20.21876 20.2187653502 13.10280 13.1028053505 13.18290 13.1829053510 17.15538 17.1553853515 21.62964 21.6296453520 15.07174 15.0717453600 1.76547 2.2727753601 1.47526 2.1872653605 1.78908 1.7890853620 2.39992 3.2187253621 1.98179 3.0141953660 1.11943 1.8759353661 1.10246 1.8589653665 1.06540 1.0654053850 15.46114 59.7297453852 16.86869 57.7285953855 2.19688 16.2321853860 6.60169 38.8908954000 2.86913 4.0261354001 3.72548 5.0070854015 8.41268 8.4126854050 2.60599 3.2022954055 2.35825 2.9990554056 2.71485 3.3823554057 2.45947 3.5363754060 3.44374 4.7787454065 4.33543 5.4568354100 3.20982 4.9008254105 5.79212 7.2250254110 16.94736 16.9473654111 21.89066 21.8906654112 25.68926 25.6892654115 11.40913 12.1211354120 17.16159 17.1615954125 22.18164 22.1816454130 32.66858 32.6685854135 41.52601 41.5260154150 2.68266 4.3291654160 3.92071 5.9944154161 5.33570 5.3357054162 5.34460 7.0623054163 5.84094 5.8409454164 5.14356 5.1435654200 2.24461 2.85871

Page 84 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

54205 14.51593 14.5159354220 3.67334 5.4978454230 2.15896 2.5772654231 3.17966 3.7403654235 1.97535 2.3847554240 2.62611 2.6261154240 26 1.80525 1.8052554240 TC 0.82086 0.8208654250 3.35068 3.3506854250 26 3.05492 3.0549254250 TC 0.29576 0.2957654300 17.56896 17.5689654304 20.60476 20.6047654308 19.61408 19.6140854312 22.49443 22.4944354316 27.44995 27.4499554318 19.31541 19.3154154322 21.47416 21.4741654324 26.69711 26.6971154326 25.35644 25.3564454328 25.61059 25.6105954332 27.83457 27.8345754336 31.54260 31.5426054340 15.35305 15.3530554344 26.08066 26.0806654348 27.74258 27.7425854352 39.10079 39.1007954360 19.78962 19.7896254380 21.93782 21.9378254385 27.52990 27.5299054390 32.75813 32.7581354400 14.45655 14.4565554401 17.67770 17.6777054405 22.10572 22.1057254406 19.89871 19.8987154408 21.50395 21.5039554410 23.47704 23.4770454411 27.95751 27.9575154415 14.29280 14.2928054416 19.22282 19.2228254417 24.49136 24.4913654420 19.26157 19.2615754430 17.43958 17.4395854435 11.27975 11.2797554440 14.00120 14.0012054450 1.60464 1.9428454500 2.04077 2.0407754505 5.72444 5.7244454512 14.55405 14.5540554520 8.76098 8.7609854522 15.75321 15.75321

Page 85 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

54530 13.70820 13.7082054535 20.02563 20.0256354550 13.25971 13.2597154560 18.20988 18.2098854600 12.25100 12.2510054620 8.19619 8.1961954640 12.71311 12.7131154650 19.15477 19.1547754660 9.56356 9.5635654670 10.90841 10.9084154680 21.24774 21.2477454690 18.59966 18.5996654692 20.78262 20.7826254700 5.73225 5.7322554800 3.76723 3.7672354830 10.00773 10.0077354840 8.69273 8.6927354860 11.30233 11.3023354861 15.31662 15.3166254865 9.61261 9.6126154900 20.75356 20.7535654901 28.68570 28.6857055000 2.28625 3.1584555040 9.10479 9.1047955041 13.75456 13.7545655060 10.22133 10.2213355100 4.37621 5.6756155110 10.40537 10.4053755120 9.55234 9.5523455150 13.19008 13.1900855175 9.76743 9.7674355180 18.62906 18.6290655200 7.43691 12.3408155250 6.04089 10.8023955300 4.96794 4.9679455400 13.59877 13.5987755450 6.92855 9.8744555500 10.35800 10.3580055520 11.11014 11.1101455530 9.51239 9.5123955535 11.55571 11.5557155540 13.40772 13.4077255550 11.41414 11.4141455600 11.39631 11.3963155605 13.71118 13.7111855650 19.39407 19.3940755680 9.15725 9.1572555700 3.77562 5.9739255705 7.28581 7.2858155706 10.20600 10.2060055720 12.23177 12.23177

Page 86 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

55725 15.94609 15.9460955801 29.70252 29.7025255810 36.02269 36.0226955812 44.07869 44.0786955815 48.36997 48.3699755821 23.87368 23.8736855831 25.86211 25.8621155840 36.64581 36.6458155842 39.26557 39.2655755845 44.92737 44.9273755860 23.91386 23.9138655862 30.09146 30.0914655865 36.61001 36.6100155866 47.73984 47.7398455870 3.91802 4.6834255873 23.83564 145.6944455875 20.75320 20.7532055876 2.76711 3.6215155920 11.88081 11.8808155970 85.00000 85.0000055980 99.99990 99.9999056405 2.71505 2.7595556420 2.37064 3.1093456440 4.70857 4.7085756441 3.56416 3.7332656442 1.22992 1.2299256501 2.87382 3.2565256515 5.06460 5.6431056605 1.57768 2.0938856606 0.78097 0.9767756620 12.69873 12.6987356625 15.39810 15.3981056630 22.65866 22.6586656631 28.79719 28.7971956632 33.34390 33.3439056633 29.56016 29.5601656634 31.19516 31.1951656637 36.82427 36.8242756640 36.59742 36.5974256700 4.78246 4.7824656740 7.67534 7.6753456800 6.23949 6.2394956805 29.82138 29.8213856810 6.72467 6.7246756820 2.20858 2.7870856821 2.98955 3.7282557000 4.90832 4.9083257010 11.11404 11.1140457020 2.12848 2.4132857022 4.32627 4.3262757023 8.05146 8.05146

Page 87 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

57061 2.45280 2.8266057065 4.38070 4.8613057100 1.71264 2.2199457105 3.15822 3.3985257106 12.26970 12.2697057107 36.40594 36.4059457109 41.75892 41.7589257110 23.31758 23.3175857111 42.07932 42.0793257112 42.82384 42.8238457120 13.18686 13.1868657130 4.11078 4.5557857135 4.42646 4.8803657150 0.78097 1.2348757155 10.67813 10.6781357156 2.89377 4.1397757160 1.25147 1.9100757170 1.27299 1.7001957180 2.72873 3.5386357200 7.58096 7.5809657210 9.41199 9.4119957220 8.20067 8.2006757230 10.31610 10.3161057240 17.34012 17.3401257250 17.27518 17.2751857260 21.42720 21.4272057265 23.64534 23.6453457267 6.88456 6.8845657268 12.35767 12.3576757270 20.72587 20.7258757280 25.00676 25.0067657282 12.94473 12.9447357283 17.93956 17.9395657284 21.56039 21.5603957285 17.60726 17.6072657287 17.93193 17.9319357288 18.76573 18.7657357289 19.31068 19.3106857291 13.92330 13.9233057292 21.48051 21.4805157295 12.50780 12.5078057296 24.75532 24.7553257300 13.96611 13.9661157305 23.45141 23.4514157307 26.54251 26.5425157308 16.43763 16.4376357310 12.28743 12.2874357311 14.01049 14.0104957320 14.12378 14.1237857330 19.82259 19.8225957335 30.34442 30.34442

Page 88 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

57400 3.48363 3.4836357410 2.74965 2.7496557415 4.08517 4.0851757420 2.33258 2.9199857421 3.20192 3.9584257423 24.08218 24.0821857425 25.31185 25.3118557426 22.56096 22.5609657452 2.35782 2.7494257454 3.53517 3.9356757455 2.89351 3.6233157456 2.69977 3.4206757460 4.24763 7.2291357461 4.92595 8.1655557500 1.92624 3.2078457505 2.29921 2.5395157510 2.98188 3.3556857511 3.35983 3.6713357513 3.36873 3.6268357520 6.95687 7.7400757522 6.20695 6.6786557530 8.80653 8.8065357531 44.29205 44.2920557540 20.18497 20.1849757545 21.32094 21.3209457550 10.45292 10.4529257555 15.49706 15.4970657556 14.69300 14.6930057558 2.89846 3.1654657700 7.87091 7.8709157720 7.85623 7.8562357800 1.24835 1.5064558100 2.27337 2.7806758110 1.08815 1.2483558120 5.60195 6.4029558140 23.77677 23.7767758145 13.99639 13.9963958146 30.11222 30.1122258150 25.76377 25.7637758152 32.42654 32.4265458180 24.79630 24.7963058200 34.00282 34.0028258210 45.42613 45.4261358240 72.17071 72.1707158260 21.43189 21.4318958262 23.93978 23.9397858263 25.79751 25.7975158267 27.42424 27.4242458270 22.90692 22.9069258275 25.55429 25.5542958280 27.33547 27.33547

Page 89 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

58285 34.23010 34.2301058290 29.98865 29.9886558291 32.56774 32.5677458292 34.32345 34.3234558293 35.67757 35.6775758294 31.74765 31.7476558300 1.35793 1.8563358301 1.78281 2.4147158321 1.23476 1.9022658322 1.54208 2.1828858323 0.32787 0.4613758340 1.50874 3.0395458345 7.27152 7.2715258346 11.48712 11.4871258350 1.98170 2.4000058353 5.67398 26.0282858356 9.10799 47.8852958400 11.41138 11.4113858410 20.84486 20.8448658520 20.95204 20.9520458540 23.55167 23.5516758541 22.24846 22.2484658542 24.86212 24.8621258543 25.28769 25.2876958544 27.34497 27.3449758545 23.22895 23.2289558546 29.37452 29.3745258548 46.21297 46.2129758550 22.86840 22.8684058552 25.41767 25.4176758553 29.54880 29.5488058554 34.13237 34.1323758555 4.94229 6.4107958558 6.97224 8.6276458559 8.98728 8.9872858560 10.16257 10.1625758561 14.38393 14.3839358562 7.61018 9.1142858563 8.97632 42.5293258565 11.19686 45.7288658570 23.91906 23.9190658571 26.47311 26.4731158572 29.74709 29.7470958573 33.98585 33.9858558600 9.35879 9.3587958605 8.48218 8.4821858611 2.03327 2.0332758615 6.36014 6.3601458660 17.44499 17.4449958661 16.73903 16.7390358662 18.29453 18.29453

Page 90 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

58670 9.41219 9.4121958671 9.39439 9.3943958672 19.16619 19.1661958673 20.87096 20.8709658700 19.94117 19.9411758720 18.60826 18.6082658740 22.69028 22.6902858750 23.45480 23.4548058752 22.34504 22.3450458760 21.10007 21.1000758770 21.90033 21.9003358800 7.68796 8.1774658805 10.40822 10.4082258820 7.99926 7.9992658822 18.81761 18.8176158825 18.00226 18.0022658900 11.03247 11.0324758920 18.10059 18.1005958925 19.05243 19.0524358940 13.10870 13.1087058943 29.15762 29.1576258950 27.78387 27.7838758951 35.82446 35.8244658952 40.41049 40.4104958953 50.10259 50.1025958954 54.34653 54.3465358956 34.13268 34.1326858957 38.89018 38.8901858958 42.88888 42.8888858960 23.93969 23.9396958970 4.92164 5.4734458974 8.82350 8.8235058976 5.45590 6.2035059000 2.11262 3.1895259001 4.80002 4.8000259012 5.33568 5.3356859015 3.47040 3.9866059020 1.68356 1.6835659020 26 0.96950 0.9695059020 TC 0.71406 0.7140659025 1.17025 1.1702559025 26 0.78549 0.7854959025 TC 0.38476 0.3847659030 2.64217 2.6421759050 1.33025 1.3302559051 1.10692 1.1069259070 8.23130 10.5898059072 13.87207 13.8720759074 8.22240 10.2783059076 13.68517 13.6851759100 21.53689 21.53689

Page 91 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

59120 20.57775 20.5777559121 20.64108 20.6410859130 21.50234 21.5023459135 21.66706 21.6670659136 22.80607 22.8060759140 9.23232 9.2323259150 19.91563 19.9156359151 19.46731 19.4673159160 4.61644 5.3729459200 1.18433 1.8340359300 3.83633 4.8598359320 3.98660 3.9866059325 5.66478 5.6647859350 7.33964 7.3396459400 46.31448 46.3144859409 20.13636 20.1363659410 23.50431 23.5043159412 2.70603 2.7060359414 2.41771 2.4177159425 9.45942 11.6577259426 16.78035 20.8832559430 3.28041 3.5919159510 52.52121 52.5212159514 23.94075 23.9407559515 28.42103 28.4210359525 12.81855 12.8185559610 48.83778 48.8377859612 22.66842 22.6684259614 25.43924 25.4392459618 54.91113 54.9111359620 26.32406 26.3240659622 30.81095 30.8109559812 7.56506 8.0901659820 8.99218 9.5706859821 9.09649 9.7016959830 11.25381 11.2538159840 5.30881 5.4868159841 9.30325 9.7838559850 8.98870 8.9887059851 10.27458 10.2745859852 12.93385 12.9338559855 10.73801 10.7380159856 12.67967 12.6796759857 13.55371 13.5537159866 5.60557 5.6055759870 12.06683 12.0668359871 3.48923 3.4892359898 9.30000 9.3000060000 3.59189 3.9211960100 2.13890 2.8598060200 16.55118 16.55118

Page 92 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

60210 17.79781 17.7978160212 25.52921 25.5292160220 19.44449 19.4444960225 23.39109 23.3910960240 24.75182 24.7518260252 33.56525 33.5652560254 43.02290 43.0229060260 27.89176 27.8917660270 35.46478 35.4647860271 26.99446 26.9944660280 11.00338 11.0033860281 14.71856 14.7185660300 1.32519 2.6601960500 25.81644 25.8164460502 32.48281 32.4828160505 35.53392 35.5339260512 6.31272 6.3127260520 26.47930 26.4793060521 30.32108 30.3210860522 36.69478 36.6947860540 27.54386 27.5438660545 31.58461 31.5846160600 37.66015 37.6601560605 46.81286 46.8128660650 30.94641 30.9464161000 2.72590 2.7259061001 3.08555 3.0855561020 3.28779 3.2877961026 3.18835 3.1883561050 2.65573 2.6557361055 3.50166 3.5016661070 2.01621 2.0162161105 10.97641 10.9764161107 8.17643 8.1764361108 22.11090 22.1109061120 18.21150 18.2115061140 31.29363 31.2936361150 33.77598 33.7759861151 24.52537 24.5253761154 31.34949 31.3494961156 31.24967 31.2496761210 9.56623 9.5662361215 12.07357 12.0735761250 21.21941 21.2194161253 21.34465 21.3446561304 41.18739 41.1873961305 50.47860 50.4786061312 52.44607 52.4460761313 49.71263 49.7126361314 45.80416 45.8041661315 52.13995 52.13995

Page 93 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

61316 2.26117 2.2611761320 48.03022 48.0302261321 53.20855 53.2085561322 59.36600 59.3660061323 60.11918 60.1191861330 43.67852 43.6785261332 49.26488 49.2648861333 50.86851 50.8685161340 35.96263 35.9626361343 55.48592 55.4859261345 51.35947 51.3594761450 48.32317 48.3231761458 50.60678 50.6067861460 52.58472 52.5847261480 39.89181 39.8918161500 33.52152 33.5215261501 28.73001 28.7300161510 54.75947 54.7594761512 64.54774 64.5477461514 47.93641 47.9364161516 46.55752 46.5575261517 2.26034 2.2603461518 69.61461 69.6146161519 74.78685 74.7868561520 95.63863 95.6386361521 80.65297 80.6529761522 55.19714 55.1971461524 52.27903 52.2790361526 91.42894 91.4289461530 77.59226 77.5922661531 30.26907 30.2690761533 38.13420 38.1342061534 41.14191 41.1419161535 24.61005 24.6100561536 65.42918 65.4291861537 61.91895 61.9189561538 66.80467 66.8046761539 59.43548 59.4354861540 55.10379 55.1037961541 54.07514 54.0751461543 54.36675 54.3667561544 46.07004 46.0700461545 80.34213 80.3421361546 58.15248 58.1524861548 39.45477 39.4547761550 23.70259 23.7025961552 30.98852 30.9885261556 42.25455 42.2545561557 42.14243 42.1424361558 47.13498 47.1349861559 51.26946 51.26946

Page 94 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

61563 49.93962 49.9396261564 60.79366 60.7936661566 56.92617 56.9261761567 64.95442 64.9544261570 46.62167 46.6216761571 50.12074 50.1207461575 62.58330 62.5833061576 90.06261 90.0626161580 60.74499 60.7449961581 67.16637 67.1663761582 72.49550 72.4955061583 71.77090 71.7709061584 70.42142 70.4214261585 78.12203 78.1220361586 56.20820 56.2082061590 77.55278 77.5527861591 78.62306 78.6230661592 78.93694 78.9369461595 59.17136 59.1713661596 63.47041 63.4704161597 73.40738 73.4073861598 67.29575 67.2957561600 53.17221 53.1722161601 58.72824 58.7282461605 55.11279 55.1127961606 75.48347 75.4834761607 72.86199 72.8619961608 81.23302 81.2330261610 48.53107 48.5310761611 10.37445 10.3744561612 38.35042 38.3504261613 81.47515 81.4751561615 58.95603 58.9560361616 82.95062 82.9506261618 32.63123 32.6312361619 37.58428 37.5842861623 14.68807 14.6880761624 29.38006 29.3800661626 23.30218 23.3021861630 33.46631 33.4663161635 36.21220 36.2122061640 16.48498 16.4849861641 5.79811 5.7981161642 11.59622 11.5962261680 57.10563 57.1056361682 107.16847 107.1684761684 71.64764 71.6476461686 114.93802 114.9380261690 54.93884 54.9388461692 93.02407 93.0240761697 107.08400 107.08400

Page 95 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

61698 116.99921 116.9992161700 87.15944 87.1594461702 101.63926 101.6392661703 33.95730 33.9573061705 65.30332 65.3033261708 52.92484 52.9248461710 48.68893 48.6889361711 65.84745 65.8474561720 30.85372 30.8537261735 38.61557 38.6155761750 35.25129 35.2512961751 34.22619 34.2261961760 39.09949 39.0994961770 39.88481 39.8848161781 6.92335 6.9233561782 5.65856 5.6585661783 5.71775 5.7177561790 21.29422 21.2942261791 27.47743 27.4774361796 20.82963 20.8296361797 4.84712 4.8471261798 27.18609 27.1860961799 6.67867 6.6786761800 3.34221 3.3422161850 24.45128 24.4512861860 39.36938 39.3693861863 37.54331 37.5433161864 7.40233 7.4023361867 57.70213 57.7021361868 13.01851 13.0185161870 29.66490 29.6649061880 13.66435 13.6643561885 15.85115 15.8511561886 20.16541 20.1654161888 9.73877 9.7387762000 24.29085 24.2908562005 31.48645 31.4864562010 38.03381 38.0338162100 40.45083 40.4508362115 31.62207 31.6220762117 44.30035 44.3003562120 42.91937 42.9193762121 43.21933 43.2193362140 25.96063 25.9606362141 28.59889 28.5988962142 21.91373 21.9137362143 25.75981 25.7598162145 35.56047 35.5604762146 30.84050 30.8405062147 36.56305 36.5630562148 3.26146 3.26146

Page 96 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

62160 4.92676 4.9267662161 37.99801 37.9980162162 47.59260 47.5926062163 30.48991 30.4899162164 51.86491 51.8649162165 39.42453 39.4245362180 40.16892 40.1689262190 22.72597 22.7259762192 24.20283 24.2028362194 9.33886 9.3388662200 34.44305 34.4430562201 29.68170 29.6817062220 25.27704 25.2770462223 26.04513 26.0451362225 12.44963 12.4496362230 20.86725 20.8672562252 2.43920 2.4392062252 26 1.19114 1.1911462252 TC 1.24806 1.2480662256 14.50590 14.5059062258 28.08128 28.0812862263 9.76824 16.2029462264 5.91856 9.7900662267 4.20480 6.3230062268 6.71933 10.9379362269 6.93499 11.7587962270 2.04237 3.7689762272 2.17083 4.5204362273 2.85949 4.0787962280 4.03045 7.4925562281 3.81102 6.9438262282 3.53855 7.0184562284 2.29060 5.2009062287 13.80957 13.8095762290 4.35066 7.8928662291 4.17887 7.4095762292 12.49266 12.4926662294 18.52703 18.5270362310 2.62185 5.3096562311 2.16872 4.6162262318 2.58814 5.5429462319 2.44053 5.0660362350 9.72575 9.7257562351 21.20922 21.2092262355 7.30543 7.3054362360 7.40241 7.4024162361 9.75213 9.7521362362 10.19278 10.1927862365 8.04719 8.0471962367 0.63548 0.9736862367 26 .63292 .63292

Page 97 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

62368 0.99131 1.4007162368 26 .97488 .9748862369 0.98055 3.3212562370 1.31526 3.4957663001 30.91149 30.9114963003 31.05438 31.0543863005 29.42829 29.4282963011 27.16583 27.1658363012 29.79863 29.7986363015 37.11249 37.1124963016 38.02981 38.0298163017 31.11479 31.1147963020 29.12234 29.1223463030 24.01724 24.0172463035 5.03019 5.0301963040 35.36061 35.3606163042 32.65938 32.6593863045 31.82493 31.8249363046 30.33847 30.3384763047 27.46349 27.4634963048 5.53603 5.5360363050 39.08501 39.0850163051 43.26795 43.2679563055 41.01805 41.0180563056 37.30618 37.3061863057 8.39439 8.3943963064 44.65808 44.6580863066 5.38312 5.3831263075 34.59850 34.5985063076 6.52822 6.5282263077 38.02192 38.0219263078 5.07378 5.0737863081 44.77338 44.7733863082 7.01692 7.0169263085 48.42141 48.4214163086 5.04241 5.0424163087 61.14863 61.1486363088 6.75196 6.7519663090 50.08197 50.0819763091 4.66893 4.6689363101 58.57976 58.5797663102 56.80778 56.8077863103 7.64934 7.6493463170 39.41451 39.4145163172 35.17634 35.1763463173 43.26895 43.2689563180 35.45739 35.4573963182 38.81074 38.8107463185 29.71913 29.7191363190 31.92423 31.9242363191 29.36122 29.36122

Page 98 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

63194 34.81552 34.8155263195 38.23476 38.2347663196 37.99257 37.9925763197 42.80140 42.8014063198 41.38110 41.3811063199 46.23599 46.2359963200 38.10922 38.1092263250 75.05954 75.0595463251 76.86126 76.8612663252 76.78923 76.7892363265 41.92312 41.9231263266 43.22352 43.2235263267 34.48411 34.4841163268 35.90448 35.9044863270 52.13394 52.1339463271 52.20134 52.2013463272 48.02376 48.0237663273 46.12679 46.1267963275 45.17216 45.1721663276 44.88553 44.8855363277 38.99361 38.9936163278 39.36732 39.3673263280 53.38575 53.3857563281 52.74667 52.7466763282 49.72305 49.7230563283 47.42702 47.4270263285 65.77565 65.7756563286 65.06472 65.0647263287 69.30182 69.3018263290 70.48612 70.4861263295 8.53695 8.5369563300 46.24624 46.2462463301 54.37399 54.3739963302 53.80917 53.8091763303 56.86839 56.8683963304 58.99237 58.9923763305 61.70366 61.7036663306 61.97215 61.9721563307 59.16888 59.1688863308 8.38400 8.3840063600 20.70284 20.7028463610 10.65236 28.8973663615 29.66218 29.6621863620 22.62364 22.6236463621 5.56190 5.5619063650 10.40226 10.4022663655 21.26470 21.2647063661 7.79290 13.6135063662 18.07424 18.0742463663 12.18497 20.3373763664 18.83286 18.83286

Page 99 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

63685 9.85447 9.8544763688 8.89876 8.8987663700 31.72097 31.7209763702 35.30263 35.3026363704 39.97501 39.9750163706 45.40721 45.4072163707 22.52033 22.5203363709 27.50115 27.5011563710 27.54970 27.5497063740 23.43297 23.4329763741 15.03146 15.0314663744 16.29918 16.2991863746 14.28131 14.2813164400 1.66545 2.6711564402 1.87493 2.7382364405 1.98894 2.6831464408 2.25995 2.9452564410 2.15283 3.5590364412 1.84242 3.4533264413 2.00514 2.8595464415 1.86798 3.1139864416 2.19319 2.1931964417 1.83796 3.1195664418 1.88346 3.2718664420 1.69178 3.8277864421 2.33988 5.6595864425 2.40799 3.1911964430 2.19084 3.6237464435 2.17773 3.4771364445 2.06106 3.2714664446 2.24659 2.2465964447 1.78064 1.7806464448 1.98723 1.9872364449 2.26439 2.2643964450 1.77729 2.4981964455 0.99609 1.2630964479 3.20118 6.6632864480 2.12974 3.4647464483 2.76342 6.3946264484 1.75557 3.2952764490 2.83210 4.6655064491 1.63672 2.3754264492 1.66342 2.4021264493 2.40052 4.1627264494 1.39682 2.1533264495 1.42352 2.1800264505 2.06750 2.4324064508 1.88128 3.6167864510 1.73548 3.2751864517 3.05738 4.2232864520 1.95303 4.41833

Page 100 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

64530 2.30760 4.5860064550 0.23060 0.3819064553 4.06070 5.0931064555 3.81634 5.0712464561 10.77471 25.9937164565 3.06885 4.2347564566 0.84330 3.4599064568 17.84330 17.8433064569 18.16040 18.1604064570 16.04066 16.0406664575 6.99208 6.9920864580 7.57975 7.5797564581 20.86037 20.8603764585 3.89887 7.4499764590 4.36731 7.2153164595 3.40044 7.1829464600 5.49641 9.7150164605 8.42027 14.4099764610 12.28904 17.3175464611 2.52153 2.7796364612 3.80585 4.1885564615 3.66805 4.0418564616 2.94787 3.3127764617 3.10648 5.0110864620 4.25937 6.6801764630 4.79709 5.6603964632 1.84995 2.1525564633 6.54550 12.2148064634 1.97452 5.5523264635 6.41386 12.0030664636 1.71682 4.9920264640 4.29789 5.4370964642 2.92421 3.7163164643 1.97108 2.4605864644 3.19164 4.2329464645 2.26043 2.9991364646 3.16328 3.9998864647 3.65321 4.6322164650 1.03784 1.6786464653 1.36502 2.0414264680 4.10077 7.3937764681 5.22736 9.0899664702 11.66352 11.6635264704 8.11471 8.1147164708 11.81974 11.8197464712 13.59251 13.5925164713 19.12788 19.1278864714 16.65063 16.6506364716 13.02285 13.0228564718 14.09356 14.0935664719 9.61073 9.61073

Page 101 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

64721 10.14679 10.1912964722 8.44466 8.4446664726 7.00015 7.0001564727 4.73152 4.7315264732 10.05971 10.0597164734 10.16675 10.1667564736 10.72741 10.7274164738 12.42954 12.4295464740 11.26712 11.2671264742 11.71447 11.7144764744 11.05296 11.0529664746 11.49146 11.4914664755 22.98983 22.9898364760 12.36567 12.3656764763 13.45582 13.4558264766 15.06201 15.0620164771 14.09879 14.0987964772 14.14664 14.1466464774 10.20818 10.2081864776 9.63970 9.6397064778 4.74537 4.7453764782 11.34084 11.3408464783 5.52901 5.5290164784 18.09494 18.0949464786 26.86987 26.8698764787 6.37551 6.3755164788 9.64072 9.6407264790 20.65670 20.6567064792 28.75072 28.7507264795 4.99937 4.9993764802 15.06889 15.0688964804 21.29063 21.2906364809 20.10861 20.1086164818 16.99704 16.9970464820 18.67582 18.6758264821 16.97113 16.9711364822 16.80203 16.8020364823 19.13000 19.1300064831 16.66324 16.6632464832 8.69641 8.6964164834 18.39955 18.3995564835 20.15273 20.1527364836 20.17053 20.1705364837 9.43621 9.4362164840 21.21856 21.2185664856 25.33887 25.3388764857 26.45272 26.4527264858 29.90446 29.9044664859 6.56395 6.5639564861 34.00365 34.0036564862 36.31385 36.31385

Page 102 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

64864 21.75631 21.7563164865 28.48069 28.4806964866 29.38423 29.3842364868 25.94736 25.9473664872 3.01465 3.0146564874 4.38806 4.3880664876 5.13119 5.1311964885 28.24326 28.2432664886 33.47622 33.4762264890 27.26064 27.2606464891 28.79193 28.7919364892 26.40578 26.4057864893 27.93873 27.9387364895 33.18027 33.1802764896 39.29034 39.2903464897 31.93936 31.9393664898 34.74215 34.7421564901 15.84604 15.8460464902 18.26985 18.2698564905 25.72975 25.7297564907 30.33959 30.3395964910 20.25307 20.2530764911 25.05103 25.0510365091 15.09514 15.0951465093 14.95500 14.9550065101 17.44214 17.4421465103 18.25104 18.2510465105 20.18801 20.1880165110 28.65162 28.6516265112 33.54655 33.5465565114 35.16587 35.1658765125 6.87001 10.3410165130 17.32272 17.3227265135 17.63754 17.6375465140 18.74454 18.7445465150 13.11301 13.1130165155 20.24184 20.2418465175 15.16132 15.1613265205 1.09891 1.3392165210 1.31646 1.6368665220 1.06331 1.3659165222 1.45265 1.8086565235 16.51779 16.5177965260 21.90554 21.9055465265 26.28612 26.2861265270 3.36049 5.9681965272 7.99584 11.1019465273 8.75678 8.7567865275 10.80057 13.0077765280 16.26740 16.2674065285 25.13429 25.13429

Page 103 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

65286 11.66267 16.0147765290 11.88799 11.8879965400 14.01402 15.5804265410 2.58129 3.3822965420 8.68362 11.6028265426 11.18593 14.7815365430 2.48265 2.7051565435 1.68528 1.8899865436 8.86296 9.1833665450 7.33359 7.4136965600 7.93576 8.9948665710 26.05859 26.0585965730 28.98567 28.9856765750 29.23668 29.2366865755 29.18379 29.1837965756 27.33626 27.3362665760 20.25720 20.2572065765 27.31000 27.3100065767 21.45700 21.4570065770 36.97792 36.9779265771 17.01600 17.0160065772 9.43503 10.3695365775 12.55177 12.5517765778 2.10275 33.1370565779 8.06802 30.2824265780 20.64371 20.6437165781 30.85632 30.8563265782 28.06553 28.0655365800 3.15247 3.5440765810 11.01076 11.0107665815 11.30374 14.6857465820 16.99257 16.9925765850 20.31949 20.3194965855 7.12351 7.9779165860 6.75037 7.8984765865 10.79145 10.7914565870 14.04403 14.0440365875 14.69563 14.6956365880 15.06284 15.0628465900 22.07215 22.0721565920 18.37163 18.3716365930 15.34641 15.3464166020 2.99170 4.1309066030 2.57328 3.7213866130 14.03827 16.6993766150 19.72245 19.7224566155 19.70382 19.7038266160 22.39833 22.3983366170 27.82220 27.8222066172 35.01946 35.0194666174 27.30857 27.30857

Page 104 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

66175 31.34866 31.3486666180 27.67454 27.6745466183 28.62466 28.6246666185 17.79692 17.7969266220 17.12591 17.1259166225 22.61749 22.6174966250 13.32238 17.3718866500 7.93093 7.9309366505 8.68832 8.6883266600 18.72450 18.7245066605 24.19062 24.1906266625 10.02346 10.0234666630 13.49060 13.4906066635 13.06577 13.0657766680 12.36727 12.3672766682 14.88735 14.8873566700 9.09612 10.2175266710 9.48384 10.4539466711 14.49793 14.4979366720 9.73428 10.7043866740 8.99542 9.8765266761 9.67504 10.5116466762 9.89932 10.9050266770 10.96579 11.8824966820 9.15371 9.1537166821 7.14188 7.5245866825 17.63095 17.6309566830 16.32433 16.3243366840 16.77450 16.7745066850 18.68997 18.6899766852 20.32799 20.3279966920 17.30199 17.3019966930 19.67315 19.6731566940 18.67379 18.6737966982 25.52072 25.5207266983 17.24547 17.2454766984 18.31788 18.3178866985 17.97920 17.9792066986 21.56016 21.5601666990 2.17991 2.1799167005 11.34125 11.3412567010 12.74106 12.7410667015 13.54186 13.5418667025 15.01233 16.9881367027 20.52960 20.5296067028 4.06986 4.9687667030 11.88083 11.8808367031 8.27651 8.9351167036 22.84494 22.8449467039 29.77964 29.7796467040 33.78997 33.78997

Page 105 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

67041 31.69117 31.6911767042 36.32242 36.3224267043 38.81162 38.8116267101 16.07604 18.2565467105 15.15251 16.6922167107 29.32325 29.3232567108 38.37343 38.3734367110 18.14607 20.0951767112 31.61951 31.6195167113 41.72631 41.7263167115 11.52293 11.5229367120 13.35798 15.4227867121 21.81767 21.8176767141 11.53185 12.2705567145 11.61502 12.2113267208 13.20883 13.6449367210 15.99575 16.4674567218 32.30240 32.3024067220 24.55865 25.5910567221 5.29589 6.8800967225 0.67503 0.7106367227 13.03661 13.8465167228 25.08350 28.1273067229 26.59106 26.5910667250 18.55863 18.5586367255 20.11827 20.1182767311 14.23783 14.2378367312 17.29362 17.2936267314 16.01151 16.0115167316 19.42971 19.4297167318 16.05086 16.0508667320 7.67722 7.6772267331 7.67351 7.6735167332 8.33360 8.3336067334 7.18125 7.1812567335 3.76617 3.7661767340 8.54310 8.5431067343 15.70023 15.7002367345 5.34235 5.7962567346 5.00135 5.0013567400 22.17890 22.1789067405 18.42308 18.4230867412 20.40422 20.4042267413 20.55540 20.5554067414 31.20576 31.2057667415 2.60190 2.6019067420 39.62771 39.6277167430 28.45287 28.4528767440 28.18996 28.1899667445 34.25914 34.2591467450 29.29777 29.29777

Page 106 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

67500 1.93380 2.1029067505 1.99369 2.1805967515 2.17358 2.3248867550 23.17999 23.1799967560 23.08704 23.0870467570 29.55696 29.5569667700 2.70140 5.8698067710 2.29131 4.9613167715 2.58999 5.2688967800 2.50165 2.9733567801 3.30245 3.8720567805 4.04573 4.7755367808 8.78858 8.7885867810 2.28974 5.0131467820 1.28581 1.2413167825 2.88123 3.0325367830 3.31859 6.0063967835 10.60178 10.6017867840 3.80071 6.2749167850 3.32114 5.0121467875 2.38303 3.9405367880 8.72282 10.6007267882 11.33284 13.2285467900 12.35088 15.0564867901 13.89573 16.6547367902 17.38428 17.3842867903 11.90413 14.2982367904 14.35653 17.1867367906 11.75243 11.7524367908 10.30908 11.5995867909 10.58687 12.6160767911 13.46444 13.4644467912 11.75324 20.2705467914 6.95369 9.0540967915 6.01470 7.9727067916 10.34042 12.5565267917 11.46743 13.7725367921 6.53679 8.6371967922 5.79798 7.7203867923 11.21823 13.3364367924 10.86117 13.7091767930 6.05061 8.5960167935 10.99962 14.0612267938 2.71754 5.3875467950 11.20229 13.4895967961 10.99570 13.4877067966 15.87457 18.2063767971 17.77797 17.7779767973 23.00271 23.0027167974 22.92902 22.9290267975 16.76809 16.76809

Page 107 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

68020 2.61200 2.7900068040 1.34127 1.5815768100 2.35699 3.8610968110 3.54896 5.1598668115 4.33045 6.9915568130 9.38370 12.0448068135 3.54035 3.6560568200 0.85609 1.0073968320 12.81588 16.6873868325 15.89563 15.8956368326 15.54272 15.5427268328 17.23235 17.2323568330 11.02194 14.0390468335 15.61040 15.6104068340 9.50599 12.5764968360 9.83137 12.3411768362 15.81387 15.8138768371 9.41847 9.4184768400 3.27326 6.3259668420 4.09201 7.1625168440 2.27165 2.4585568500 23.89381 23.8938168505 23.57477 23.5747768510 7.35090 10.6172068520 16.10842 16.1084268525 6.78688 6.7868868530 6.41282 9.9906268540 21.82324 21.8232468550 26.42490 26.4249068700 14.55499 14.5549968705 3.99957 5.4858768720 18.13106 18.1310668745 18.38772 18.3877268750 18.96024 18.9602468760 3.49224 4.6581468761 2.78233 3.3875368770 14.67341 14.6734168801 2.47512 2.8133268810 4.48143 5.5049368811 4.91919 4.9191968815 6.17006 10.0771668816 5.96530 15.3192068840 2.67942 2.9375268850 1.42266 1.5472669000 2.89454 4.2829469005 3.91398 5.1065869020 3.46663 5.3979369090 .49120 .4912069100 1.25851 2.4778169105 1.60003 3.2643369110 7.98077 10.77537

Page 108 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

69120 9.70394 9.7039469140 20.99546 20.9954669145 6.04280 9.0955069150 26.09567 26.0956769155 42.01537 42.0153769200 1.39553 2.8462369205 2.48159 2.4815969210 0.84619 1.2199969220 1.55387 3.1914769222 3.35113 5.1489369300 11.88809 15.7951969310 26.27887 26.2788769320 37.58076 37.5807669420 2.94276 4.4824669421 3.70510 3.7051069424 1.55553 3.0151369433 3.19405 4.6892569436 4.02201 4.0220169440 16.73293 16.7329369450 13.11949 13.1194969501 18.06997 18.0699769502 24.10244 24.1024469505 29.38833 29.3883369511 30.19500 30.1950069530 40.94100 40.9410069535 67.26210 67.2621069540 3.08121 4.8523169550 25.36137 25.3613769552 38.96783 38.9678369554 62.22319 62.2231969601 25.94263 25.9426369602 26.93574 26.9357469603 31.01904 31.0190469604 27.71714 27.7171469605 38.52703 38.5270369610 7.45977 9.5245769620 12.06809 16.5536969631 21.54707 21.5470769632 26.49686 26.4968669633 25.53371 25.5337169635 29.77667 29.7766769636 33.78915 33.7891569637 33.67940 33.6794069641 25.71197 25.7119769642 33.17214 33.1721469643 30.30885 30.3088569644 36.42107 36.4210769645 35.67753 35.6775369646 38.00685 38.0068569650 19.62444 19.6244469660 23.04995 23.04995

Page 109 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

69661 30.10690 30.1069069662 28.93224 28.9322469666 19.85853 19.8585369667 19.91276 19.9127669670 23.26601 23.2660169676 20.39645 20.3964569700 17.00271 17.0027169710 44.79700 44.7970069711 21.35548 21.3554869714 26.87393 26.8739369715 33.51616 33.5161669717 28.52035 28.5203569718 33.90593 33.9059369720 29.03357 29.0335769725 47.55560 47.5556069740 29.35415 29.3541569745 31.24642 31.2464269801 18.35760 18.3576069805 26.41697 26.4169769806 23.59065 23.5906569820 21.23832 21.2383269840 22.04884 22.0488469905 22.68476 22.6847669910 25.53309 25.5330969915 38.07587 38.0758769930 31.11507 31.1150769950 45.89047 45.8904769955 50.20160 50.2016069960 48.98230 48.9823069970 54.57475 54.5747569990 5.62906 5.6290670010 4.09907 4.0990770010 26 1.68511 1.6851170010 TC 2.41396 2.4139670015 3.56433 3.5643370015 26 1.60427 1.6042770015 TC 1.96006 1.9600670030 0.69463 0.6946370030 26 0.22977 0.2297770030 TC 0.46486 0.4648670100 0.75776 0.7577670100 26 0.23950 0.2395070100 TC 0.51826 0.5182670110 0.95937 0.9593770110 26 0.33431 0.3343170110 TC 0.62506 0.6250670120 0.82006 0.8200670120 26 0.23950 0.2395070120 TC 0.58056 0.5805670130 1.33174 1.3317470130 26 0.44858 0.44858

Page 110 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

70130 TC 0.88316 0.8831670134 1.13800 1.1380070134 26 0.45954 0.4595470134 TC 0.67846 0.6784670140 0.72299 0.7229970140 26 0.24923 0.2492370140 TC 0.47376 0.4737670150 1.03140 1.0314070150 26 0.34404 0.3440470150 TC 0.68736 0.6873670160 0.78363 0.7836370160 26 0.22977 0.2297770160 TC 0.55386 0.5538670170 1.29400 1.2940070170 26 0.41172 0.4117270170 TC 0.89635 0.8963570190 0.85815 0.8581570190 26 0.27759 0.2775970190 TC 0.58056 0.5805670200 1.06866 1.0686670200 26 0.37240 0.3724070200 TC 0.69626 0.6962670210 0.73023 0.7302370210 26 0.22977 0.2297770210 TC 0.50046 0.5004670220 0.94157 0.9415770220 26 0.32541 0.3254170220 TC 0.61616 0.6161670240 0.72299 0.7229970240 26 0.25813 0.2581370240 TC 0.46486 0.4648670250 0.87844 0.8784470250 26 0.31568 0.3156870250 TC 0.56276 0.5627670260 1.14484 1.1448470260 26 0.43968 0.4396870260 TC 0.70516 0.7051670300 0.35062 0.3506270300 26 0.14386 0.1438670300 TC 0.20676 0.2067670310 0.86290 0.8629070310 26 0.22894 0.2289470310 TC 0.63396 0.6339670320 1.17048 1.1704870320 26 0.30512 0.3051270320 TC 0.86536 0.8653670328 0.73996 0.7399670328 26 0.23950 0.2395070328 TC 0.50046 0.5004670330 1.13654 1.1365470330 26 0.32458 0.32458

Page 111 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

70330 TC 0.81196 0.8119670332 2.03570 2.0357070332 26 0.72534 0.7253470332 TC 1.31036 1.3103670336 11.10412 11.1041270336 26 1.98846 1.9884670336 TC 9.11566 9.1156670350 0.51663 0.5166370350 26 0.23867 0.2386770350 TC 0.27796 0.2779670355 0.54582 0.5458270355 26 0.27676 0.2767670355 TC 0.26906 0.2690670360 0.66793 0.6679370360 26 0.22977 0.2297770360 TC 0.43816 0.4381670370 1.83738 1.8373870370 26 0.42022 0.4202270370 TC 1.41716 1.4171670371 2.33650 2.3365070371 26 1.08844 1.0884470371 TC 1.24806 1.2480670373 1.93634 1.9363470373 26 0.55478 0.5547870373 TC 1.38156 1.3815670380 0.90823 0.9082370380 26 0.23867 0.2386770380 TC 0.66956 0.6695670390 2.37842 2.3784270390 26 0.51626 0.5162670390 TC 1.86216 1.8621670450 4.84235 4.8423570450 26 1.14679 1.1467970450 TC 3.69556 3.6955670460 6.30055 6.3005570460 26 1.51919 1.5191970460 TC 4.78136 4.7813670470 7.58487 7.5848770470 26 1.69991 1.6999170470 TC 5.88496 5.8849670480 7.55010 7.5501070480 26 1.70964 1.7096470480 TC 5.84046 5.8404670481 8.75306 8.7530670481 26 1.85350 1.8535070481 TC 6.89956 6.8995670482 9.95147 9.9514770482 26 1.93941 1.9394170482 TC 8.01206 8.0120670486 6.33492 6.3349270486 26 1.51796 1.51796

Page 112 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

70486 TC 4.81696 4.8169670487 7.65172 7.6517270487 26 1.74896 1.7489670487 TC 5.90276 5.9027670488 9.27258 9.2725870488 26 1.90132 1.9013270488 TC 7.37126 7.3712670490 6.28630 6.2863070490 26 1.71854 1.7185470490 TC 4.56776 4.5677670491 7.53376 7.5337670491 26 1.85350 1.8535070491 TC 5.68026 5.6802670492 9.08817 9.0881770492 26 1.93941 1.9394170492 TC 7.14876 7.1487670496 15.71209 15.7120970496 26 2.36003 2.3600370496 TC 13.35206 13.3520670498 15.73673 15.7367370498 26 2.35797 2.3579770498 TC 13.37876 13.3787670540 12.15927 12.1592770540 26 1.80651 1.8065170540 TC 10.35276 10.3527670542 13.51874 13.5187470542 26 2.16028 2.1602870542 TC 11.35846 11.3584670543 18.23251 18.2325170543 26 2.87795 2.8779570543 TC 15.35456 15.3545670544 14.34306 14.3430670544 26 1.60510 1.6051070544 TC 12.73796 12.7379670545 14.26296 14.2629670545 26 1.60510 1.6051070545 TC 12.65786 12.6578670546 22.66030 22.6603070546 26 2.40868 2.4086870546 TC 20.25162 20.2516270547 14.30746 14.3074670547 26 1.60510 1.6051070547 TC 12.70236 12.7023670548 14.93046 14.9304670548 26 1.60510 1.6051070548 TC 13.32536 13.3253670549 22.66030 22.6603070549 26 2.40868 2.4086870549 TC 20.25162 20.2516270551 12.50826 12.5082670551 26 1.97750 1.97750

Page 113 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

70551 TC 10.53076 10.5307670552 13.99688 13.9968870552 26 2.38922 2.3892270552 TC 11.60766 11.6076670553 18.09864 18.0986470553 26 3.16238 3.1623870553 TC 14.93626 14.9362670554 13.80589 13.8058970554 26 2.84587 2.8458770554 TC 10.96002 10.9600270555 26 3.49434 3.4943470557 26 4.71170 4.7117070558 26 4.36726 4.3672670559 26 4.43846 4.4384671010 0.58866 0.5886671010 26 0.23950 0.2395071010 TC 0.34916 0.3491671015 0.73355 0.7335571015 26 0.27759 0.2775971015 TC 0.45596 0.4559671020 0.76998 0.7699871020 26 0.29622 0.2962271020 TC 0.47376 0.4737671021 0.92543 0.9254371021 26 0.35377 0.3537771021 TC 0.57166 0.5716671022 1.12455 1.1245571022 26 0.41049 0.4104971022 TC 0.71406 0.7140671023 1.64656 1.6465671023 26 0.51420 0.5142071023 TC 1.13236 1.1323671030 1.12455 1.1245571030 26 0.41049 0.4104971030 TC 0.71406 0.7140671034 2.16940 2.1694071034 26 0.63654 0.6365471034 TC 1.53286 1.5328671035 0.84676 0.8467671035 26 0.24840 0.2484071035 TC 0.59836 0.5983671100 0.79668 0.7966871100 26 0.29622 0.2962271100 TC 0.50046 0.5004671101 0.96103 0.9610371101 26 0.35377 0.3537771101 TC 0.60726 0.6072671110 0.98773 0.9877371110 26 0.35377 0.3537771110 TC 0.63396 0.6339671111 1.25888 1.25888

Page 114 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

71111 26 0.42022 0.4202271111 TC 0.83866 0.8386671120 0.78612 0.7861271120 26 0.26786 0.2678671120 TC 0.51826 0.5182671130 0.91238 0.9123871130 26 0.29622 0.2962271130 TC 0.61616 0.6161671250 6.33864 6.3386471250 26 1.55728 1.5572871250 TC 4.78136 4.7813671260 7.59128 7.5912871260 26 1.66182 1.6618271260 TC 5.92946 5.9294671270 9.33156 9.3315671270 26 1.85350 1.8535071270 TC 7.47806 7.4780671275 12.43526 12.4352671275 26 2.57884 2.5788471275 TC 9.85642 9.8564271550 13.63006 13.6300671550 26 1.96010 1.9601071550 TC 11.66996 11.6699671551 15.30993 15.3099371551 26 2.31387 2.3138771551 TC 12.99606 12.9960671552 20.69120 20.6912071552 26 3.03838 3.0383871552 TC 17.65282 17.6528271555 14.53131 14.5313171555 26 2.43415 2.4341571555 TC 12.09716 12.0971672010 1.72563 1.7256372010 26 0.59327 0.5932772010 TC 1.13236 1.1323672020 0.58617 0.5861772020 26 0.21031 0.2103172020 TC 0.37586 0.3758672040 0.91444 0.9144472040 26 0.30718 0.3071872040 TC 0.60726 0.6072672050 1.26901 1.2690172050 26 0.42145 0.4214572050 TC 0.84756 0.8475672052 1.59356 1.5935672052 26 0.48790 0.4879072052 TC 1.10566 1.1056672069 0.87884 0.8788472069 26 0.30718 0.3071872069 TC 0.57166 0.5716672070 0.82338 0.82338

Page 115 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

72070 26 0.29622 0.2962272070 TC 0.52716 0.5271672072 0.92128 0.9212872072 26 0.29622 0.2962272072 TC 0.62506 0.6250672074 1.07258 1.0725872074 26 0.29622 0.2962272074 TC 0.77636 0.7763672080 0.86994 0.8699472080 26 0.30718 0.3071872080 TC 0.56276 0.5627672090 1.17068 1.1706872090 26 0.40322 0.4032272090 TC 0.76746 0.7674672100 0.95894 0.9589472100 26 0.30718 0.3071872100 TC 0.65176 0.6517672110 1.32241 1.3224172110 26 0.42145 0.4214572110 TC 0.90096 0.9009672114 1.74692 1.7469272114 26 0.49886 0.4988672114 TC 1.24806 1.2480672120 1.19034 1.1903472120 26 0.30718 0.3071872120 TC 0.88316 0.8831672125 6.35644 6.3564472125 26 1.55728 1.5572872125 TC 4.79916 4.7991672126 7.58278 7.5827872126 26 1.64442 1.6444272126 TC 5.93836 5.9383672127 9.17113 9.1711372127 26 1.70197 1.7019772127 TC 7.46916 7.4691672128 6.34754 6.3475472128 26 1.55728 1.5572872128 TC 4.79026 4.7902672129 7.58278 7.5827872129 26 1.64442 1.6444272129 TC 5.93836 5.9383672130 9.19577 9.1957772130 26 1.69991 1.6999172130 TC 7.49586 7.4958672131 6.33864 6.3386472131 26 1.55728 1.5572872131 TC 4.78136 4.7813672132 7.57388 7.5738872132 26 1.64442 1.6444272132 TC 5.92946 5.9294672133 9.18893 9.18893

Page 116 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

72133 26 1.71087 1.7108772133 TC 7.47806 7.4780672141 11.42764 11.4276472141 26 2.15178 2.1517872141 TC 9.27586 9.2758672142 14.17966 14.1796672142 26 2.58090 2.5809072142 TC 11.59876 11.5987672146 11.65904 11.6590472146 26 2.16068 2.1606872146 TC 9.49836 9.4983672147 12.89806 12.8980672147 26 2.58090 2.5809072147 TC 10.31716 10.3171672148 11.47792 11.4779272148 26 1.98846 1.9884672148 TC 9.48946 9.4894672149 13.97224 13.9722472149 26 2.40018 2.4001872149 TC 11.57206 11.5720672156 18.15579 18.1557972156 26 3.45093 3.4509372156 TC 14.70486 14.7048672157 17.18569 17.1856972157 26 3.45093 3.4509372157 TC 13.73476 13.7347672158 17.86246 17.8624672158 26 3.17540 3.1754072158 TC 14.68706 14.6870672159 15.87916 15.8791672159 26 2.38470 2.3847072159 TC 13.49446 13.4944672170 0.65219 0.6521972170 26 0.24073 0.2407372170 TC 0.41146 0.4114672190 0.97591 0.9759172190 26 0.29745 0.2974572190 TC 0.67846 0.6784672191 11.99415 11.9941572191 26 2.45813 2.4581372191 TC 9.53602 9.5360272192 6.00353 6.0035372192 26 1.47137 1.4713772192 TC 4.53216 4.5321672193 7.18414 7.1841472193 26 1.55728 1.5572872193 TC 5.62686 5.6268672194 9.14712 9.1471272194 26 1.63346 1.6334672194 TC 7.51366 7.5136672195 12.46416 12.46416

Page 117 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

72195 26 1.96010 1.9601072195 TC 10.50406 10.5040672196 13.82363 13.8236372196 26 2.32277 2.3227772196 TC 11.50086 11.5008672197 18.49084 18.4908472197 26 3.02948 3.0294872197 TC 15.46136 15.4613672198 14.47024 14.4702472198 26 2.41758 2.4175872198 TC 12.05266 12.0526672200 0.71243 0.7124372200 26 0.22977 0.2297772200 TC 0.48266 0.4826672202 0.83869 0.8386972202 26 0.25813 0.2581372202 TC 0.58056 0.5805672220 0.71243 0.7124372220 26 0.22977 0.2297772220 TC 0.48266 0.4826672240 3.61913 3.6191372240 26 1.21407 1.2140772240 TC 2.40506 2.4050672255 3.37883 3.3788372255 26 1.20517 1.2051772255 TC 2.17366 2.1736672265 3.41669 3.4166972265 26 1.11843 1.1184372265 TC 2.29826 2.2982672270 5.31145 5.3114572270 26 1.77609 1.7760972270 TC 3.53536 3.5353672275 2.56332 2.5633272275 26 0.98596 0.9859672275 TC 1.57736 1.5773672285 3.85554 3.8555472285 26 1.52168 1.5216872285 TC 2.33386 2.3338672295 3.37013 3.3701372295 26 1.08967 1.0896772295 TC 2.28046 2.2804673000 0.69586 0.6958673000 26 0.23100 0.2310073000 TC 0.46486 0.4648673010 0.71449 0.7144973010 26 0.24073 0.2407373010 TC 0.47376 0.4737673020 0.57727 0.5772773020 26 0.20141 0.2014173020 TC 0.37586 0.3758673030 0.73312 0.73312

Page 118 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

73030 26 0.25936 0.2593673030 TC 0.47376 0.4737673040 2.57176 2.5717673040 26 0.73630 0.7363073040 TC 1.83546 1.8354673050 0.89498 0.8949873050 26 0.28772 0.2877273050 TC 0.60726 0.6072673060 0.71449 0.7144973060 26 0.24073 0.2407373060 TC 0.47376 0.4737673070 0.66627 0.6662773070 26 0.20141 0.2014173070 TC 0.46486 0.4648673080 0.83703 0.8370373080 26 0.22977 0.2297773080 TC 0.60726 0.6072673085 2.32256 2.3225673085 26 0.72740 0.7274073085 TC 1.59516 1.5951673090 0.66710 0.6671073090 26 0.21114 0.2111473090 TC 0.45596 0.4559673092 0.69380 0.6938073092 26 0.21114 0.2111473092 TC 0.48266 0.4826673100 0.72256 0.7225673100 26 0.23100 0.2310073100 TC 0.49156 0.4915673110 0.84593 0.8459373110 26 0.22977 0.2297773110 TC 0.61616 0.6161673115 2.51836 2.5183673115 26 0.73630 0.7363073115 TC 1.78206 1.7820673120 0.65820 0.6582073120 26 0.21114 0.2111473120 TC 0.44706 0.4470673130 0.76583 0.7658373130 26 0.22977 0.2297773130 TC 0.53606 0.5360673140 0.72691 0.7269173140 26 0.18195 0.1819573140 TC 0.54496 0.5449673200 6.06583 6.0658373200 26 1.46247 1.4624773200 TC 4.60336 4.6033673201 7.25534 7.2553473201 26 1.55728 1.5572873201 TC 5.69806 5.6980673202 9.24502 9.24502

Page 119 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

73202 26 1.63346 1.6334673202 TC 7.61156 7.6115673206 11.43411 11.4341173206 26 2.43415 2.4341573206 TC 8.99996 8.9999673218 12.45297 12.4529773218 26 1.79761 1.7976173218 TC 10.65536 10.6553673219 13.71660 13.7166073219 26 2.18014 2.1801473219 TC 11.53646 11.5364673220 18.42831 18.4283173220 26 2.88685 2.8868573220 TC 15.54146 15.5414673221 11.80533 11.8053373221 26 1.81747 1.8174773221 TC 9.98786 9.9878673222 13.00460 13.0046073222 26 2.18014 2.1801473222 TC 10.82446 10.8244673223 17.58281 17.5828173223 26 2.87795 2.8779573223 TC 14.70486 14.7048673225 15.57075 15.5707573225 26 2.28989 2.2898973225 TC 13.28086 13.2808673500 0.63439 0.6343973500 26 0.24073 0.2407373500 TC 0.39366 0.3936673510 0.90471 0.9047173510 26 0.29745 0.2974573510 TC 0.60726 0.6072673520 0.97116 0.9711673520 26 0.35500 0.3550073520 TC 0.61616 0.6161673525 2.34926 2.3492673525 26 0.74520 0.7452073525 TC 1.60406 1.6040673530 0.86679 0.8667973530 26 0.40199 0.4019973530 TC 0.47914 0.4791473540 0.93948 0.9394873540 26 0.28772 0.2877273540 TC 0.65176 0.6517673550 0.69669 0.6966973550 26 0.24073 0.2407373550 TC 0.45596 0.4559673560 0.71449 0.7144973560 26 0.24073 0.2407373560 TC 0.47376 0.4737673562 0.84882 0.84882

Page 120 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

73562 26 0.25936 0.2593673562 TC 0.58946 0.5894673564 0.98564 0.9856473564 26 0.30718 0.3071873564 TC 0.67846 0.6784673565 0.77679 0.7767973565 26 0.24963 0.2496373565 TC 0.52716 0.5271673580 2.99212 2.9921273580 26 0.76506 0.7650673580 TC 2.22706 2.2270673590 0.66793 0.6679373590 26 0.22977 0.2297773590 TC 0.43816 0.4381673592 0.70270 0.7027073592 26 0.21114 0.2111473592 TC 0.49156 0.4915673600 0.66710 0.6671073600 26 0.21114 0.2111473600 TC 0.45596 0.4559673610 0.76583 0.7658373610 26 0.22977 0.2297773610 TC 0.53606 0.5360673615 2.42936 2.4293673615 26 0.73630 0.7363073615 TC 1.69306 1.6930673620 0.64930 0.6493073620 26 0.21114 0.2111473620 TC 0.43816 0.4381673630 0.75693 0.7569373630 26 0.22977 0.2297773630 TC 0.52716 0.5271673650 0.65820 0.6582073650 26 0.21114 0.2111473650 TC 0.44706 0.4470673660 0.68241 0.6824173660 26 0.17305 0.1730573660 TC 0.50936 0.5093673700 6.07473 6.0747373700 26 1.46247 1.4624773700 TC 4.61226 4.6122673701 7.29984 7.2998473701 26 1.55728 1.5572873701 TC 5.74256 5.7425673702 9.26282 9.2628273702 26 1.63346 1.6334673702 TC 7.62936 7.6293673706 12.52260 12.5226073706 26 2.56828 2.5682873706 TC 9.95432 9.9543273718 12.25923 12.25923

Page 121 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

73718 26 1.81747 1.8174773718 TC 10.44176 10.4417673719 13.55434 13.5543473719 26 2.16028 2.1602873719 TC 11.39406 11.3940673720 18.42831 18.4283173720 26 2.88685 2.8868573720 TC 15.54146 15.5414673721 12.01893 12.0189373721 26 1.81747 1.8174773721 TC 10.20146 10.2014673722 13.14016 13.1401673722 26 2.20000 2.2000073722 TC 10.94016 10.9401673723 17.54721 17.5472173723 26 2.88685 2.8868573723 TC 14.66036 14.6603673725 14.49860 14.4986073725 26 2.44594 2.4459473725 TC 12.05266 12.0526674000 0.62426 0.6242674000 26 0.23950 0.2395074000 TC 0.38476 0.3847674010 0.91321 0.9132174010 26 0.30595 0.3059574010 TC 0.60726 0.6072674020 0.97883 0.9788374020 26 0.36267 0.3626774020 TC 0.61616 0.6161674022 1.17878 1.1787874022 26 0.42912 0.4291274022 TC 0.74966 0.7496674150 6.09193 6.0919374150 26 1.59537 1.5953774150 TC 4.49656 4.4965674160 8.10107 8.1010774160 26 1.69991 1.6999174160 TC 6.40116 6.4011674170 10.63262 10.6326274170 26 1.88186 1.8818674170 TC 8.75076 8.7507674174 14.90740 14.9074074174 26 2.97044 2.9704474174 TC 11.93696 11.9369674175 12.72936 12.7293674175 26 2.56144 2.5614474175 TC 10.16792 10.1679274176 5.85418 5.8541874176 26 2.38112 2.3811274176 TC 3.47306 3.4730674177 9.10932 9.10932

Page 122 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

74177 26 2.49456 2.4945674177 TC 6.61476 6.6147674178 11.51647 11.5164774178 26 2.76365 2.7636574178 TC 8.75282 8.7528274181 11.24280 11.2428074181 26 1.94914 1.9491474181 TC 9.29366 9.2936674182 15.02513 15.0251374182 26 2.32277 2.3227774182 TC 12.70236 12.7023674183 18.51754 18.5175474183 26 3.02948 3.0294874183 TC 15.48806 15.4880674185 14.42574 14.4257474185 26 2.41758 2.4175874185 TC 12.00816 12.0081674190 1.86444 1.8644474190 26 0.65122 0.6512274190 TC 1.22462 1.2246274210 1.85166 1.8516674210 26 0.48790 0.4879074210 TC 1.36376 1.3637674220 2.13586 2.1358674220 26 0.62080 0.6208074220 TC 1.51506 1.5150674230 2.18823 2.1882374230 26 0.71767 0.7176774230 TC 1.47056 1.4705674235 4.05693 4.0569374235 26 1.65495 1.6549574235 TC 2.46496 2.4649674240 2.63761 2.6376174240 26 0.92675 0.9267574240 TC 1.71086 1.7108674241 2.81561 2.8156174241 26 0.91785 0.9178574241 TC 1.89776 1.8977674245 4.18873 4.1887374245 26 1.22297 1.2229774245 TC 2.96576 2.9657674246 3.00251 3.0025174246 26 0.92675 0.9267574246 TC 2.07576 2.0757674247 3.30511 3.3051174247 26 0.92675 0.9267574247 TC 2.37836 2.3783674249 4.49133 4.4913374249 26 1.22297 1.2229774249 TC 3.26836 3.2683674250 2.48379 2.48379

Page 123 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

74250 26 0.63053 0.6305374250 TC 1.85326 1.8532674251 8.02211 8.0221174251 26 0.92675 0.9267574251 TC 7.09536 7.0953674260 6.66038 6.6603874260 26 0.66862 0.6686274260 TC 5.99176 5.9917674261 10.30450 10.3045074261 26 2.94214 2.9421474261 TC 7.36236 7.3623674262 11.57082 11.5708274262 26 3.22946 3.2294674262 TC 8.34136 8.3413674263 17.62030 17.6203074263 26 3.06674 3.0667474263 TC 14.55356 14.5535674270 3.56321 3.5632174270 26 0.92675 0.9267574270 TC 2.63646 2.6364674280 4.94297 4.9429774280 26 1.32751 1.3275174280 TC 3.61546 3.6154674283 5.06406 5.0640674283 26 2.65010 2.6501074283 TC 2.41396 2.4139674290 1.59708 1.5970874290 26 0.42912 0.4291274290 TC 1.16796 1.1679674300 .77658 .7765874300 26 0.49886 0.4988674301 26 0.29745 0.2974574305 1.29869 1.2986974305 26 0.57504 0.5750474305 TC 0.73661 0.7366174320 2.64090 2.6409074320 26 0.72534 0.7253474320 TC 1.91556 1.9155674327 3.24710 3.2471074327 26 1.01114 1.0111474327 TC 2.23596 2.2359674328 3.88593 3.8859374328 26 0.95634 0.9563474328 TC 2.95507 2.9550774329 3.89734 3.8973474329 26 0.95634 0.9563474329 TC 2.96510 2.9651074330 4.14810 4.1481074330 26 1.23516 1.2351674330 TC 2.95507 2.9550774340 3.17567 3.17567

Page 124 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

74340 26 0.74726 0.7472674340 TC 2.45811 2.4581174355 3.46671 3.4667174355 26 1.04348 1.0434874355 TC 2.45811 2.4581174360 3.68150 3.6815074360 26 0.77396 0.7739674360 TC 2.95507 2.9550774363 6.91742 6.9174274363 26 1.20680 1.2068074363 TC 5.74265 5.7426574400 2.62785 2.6278574400 26 0.64999 0.6499974400 TC 1.97786 1.9778674410 2.74355 2.7435574410 26 0.65889 0.6588974410 TC 2.08466 2.0846674415 3.18855 3.1885574415 26 0.65889 0.6588974415 TC 2.52966 2.5296674420 2.94245 2.9424574420 26 0.49680 0.4968074420 TC 2.45811 2.4581174425 1.70896 1.7089674425 26 0.48790 0.4879074425 TC 1.22462 1.2246274430 1.89968 1.8996874430 26 0.42912 0.4291274430 TC 1.47056 1.4705674440 2.04912 2.0491274440 26 0.51626 0.5162674440 TC 1.53286 1.5328674445 2.58685 2.5868574445 26 1.58850 1.5885074445 TC 1.05601 1.0560174450 1.81209 1.8120974450 26 0.45871 0.4587174450 TC 1.36662 1.3666274455 2.15177 2.1517774455 26 0.45871 0.4587174455 TC 1.69306 1.6930674470 1.88896 1.8889674470 26 0.74726 0.7472674470 TC 1.17140 1.1714074475 2.78330 2.7833074475 26 0.72534 0.7253474475 TC 2.05796 2.0579674480 2.79220 2.7922074480 26 0.72534 0.7253474480 TC 2.06686 2.0668674485 2.71210 2.71210

Page 125 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

74485 26 0.72534 0.7253474485 TC 1.98676 1.9867674710 1.03120 1.0312074710 26 0.46844 0.4684474710 TC 0.56276 0.5627674740 1.87796 1.8779674740 26 0.50530 0.5053074740 TC 1.37266 1.3726674742 3.78055 3.7805574742 26 0.83317 0.8331774742 TC 2.96510 2.9651074775 2.19974 2.1997474775 26 0.84290 0.8429074775 TC 1.36662 1.3666275557 11.19619 11.1961975557 26 3.21973 3.2197375557 TC 7.97646 7.9764675559 16.38541 16.3854175559 26 4.11025 4.1102575559 TC 12.27516 12.2751675561 15.10830 15.1083075561 26 3.56294 3.5629475561 TC 11.54536 11.5453675563 18.56800 18.5680075563 26 4.21024 4.2102475563 TC 14.35776 14.3577675565 2.28547 2.2854775565 26 0.33431 0.3343175565 TC 1.95116 1.9511675571 2.27042 2.2704275571 26 0.74646 0.7464675571 TC 1.52396 1.5239675572 6.65461 6.6546175572 26 2.26485 2.2648575572 TC 4.38976 4.3897675573 9.45743 9.4574375573 26 3.24317 3.2431775573 TC 6.21426 6.2142675574 14.53372 14.5337275574 26 3.08626 3.0862675574 TC 11.44746 11.4474675600 6.88205 6.8820575600 26 0.69449 0.6944975600 TC 6.18756 6.1875675605 5.76944 5.7694475605 26 1.58438 1.5843875605 TC 4.18506 4.1850675625 5.73796 5.7379675625 26 1.57070 1.5707075625 TC 4.16726 4.1672675630 6.74421 6.74421

Page 126 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

75630 26 2.44345 2.4434575630 TC 4.30076 4.3007675635 14.29482 14.2948275635 26 3.25470 3.2547075635 TC 11.04012 11.0401275658 6.23061 6.2306175658 26 1.75185 1.7518575658 TC 4.47876 4.4787675705 7.43996 7.4399675705 26 2.91670 2.9167075705 TC 4.52326 4.5232675710 6.10352 6.1035275710 26 1.52686 1.5268675710 TC 4.57666 4.5766675716 6.97343 6.9734375716 26 1.78951 1.7895175716 TC 5.18392 5.1839275726 6.04534 6.0453475726 26 1.54878 1.5487875726 TC 4.49656 4.4965675731 6.14596 6.1459675731 26 1.57820 1.5782075731 TC 4.56776 4.5677675733 7.10553 7.1055375733 26 1.83261 1.8326175733 TC 5.27292 5.2729275736 6.06998 6.0699875736 26 1.54672 1.5467275736 TC 4.52326 4.5232675741 5.81915 5.8191575741 26 1.77649 1.7764975741 TC 4.04266 4.0426675743 6.49312 6.4931275743 26 2.26356 2.2635675743 TC 4.22956 4.2295675746 5.88308 5.8830875746 26 1.53782 1.5378275746 TC 4.34526 4.3452675756 6.34868 6.3486875756 26 1.72752 1.7275275756 TC 4.62116 4.6211675774 4.27246 4.2724675774 26 0.48790 0.4879075774 TC 3.78456 3.7845675791 7.70561 7.7056175791 26 2.21225 2.2122575791 TC 5.49336 5.4933675801 6.19705 6.1970575801 26 1.15995 1.1599575801 TC 5.07596 5.0759675803 6.62777 6.62777

Page 127 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

75803 26 1.60879 1.6087975803 TC 5.07596 5.0759675805 6.81803 6.8180375805 26 1.10993 1.1099375805 TC 5.72379 5.7237975807 7.29674 7.2967475807 26 1.60879 1.6087975807 TC 5.74265 5.7426575809 2.20789 2.2078975809 26 0.63053 0.6305375809 TC 1.57736 1.5773675810 13.30637 13.3063775810 26 1.57960 1.5796075810 TC 11.79343 11.7934375820 2.98760 2.9876075820 26 0.96524 0.9652475820 TC 2.02236 2.0223675822 3.66034 3.6603475822 26 1.42438 1.4243875822 TC 2.23596 2.2359675825 5.50450 5.5045075825 26 1.54194 1.5419475825 TC 3.96256 3.9625675827 5.50928 5.5092875827 26 1.50222 1.5022275827 TC 4.00706 4.0070675831 5.70310 5.7031075831 26 1.66044 1.6604475831 TC 4.04266 4.0426675833 6.37015 6.3701575833 26 1.98039 1.9803975833 TC 4.38976 4.3897675840 5.61410 5.6141075840 26 1.63374 1.6337475840 TC 3.98036 3.9803675842 6.38795 6.3879575842 26 2.00709 2.0070975842 TC 4.38086 4.3808675860 5.67154 5.6715475860 26 1.57548 1.5754875860 TC 4.09606 4.0960675870 5.66058 5.6605875870 26 1.53782 1.5378275870 TC 4.12276 4.1227675872 6.73748 6.7374875872 26 1.59122 1.5912275872 TC 5.14626 5.1462675880 3.02114 3.0211475880 26 0.92758 0.9275875880 TC 2.09356 2.0935675885 5.99014 5.99014

Page 128 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

75885 26 1.94748 1.9474875885 TC 4.04266 4.0426675887 6.03052 6.0305275887 26 1.92556 1.9255675887 TC 4.10496 4.1049675889 5.57158 5.5715875889 26 1.53782 1.5378275889 TC 4.03376 4.0337675891 5.57158 5.5715875891 26 1.53782 1.5378275891 TC 4.03376 4.0337675893 4.72144 4.7214475893 26 0.70548 0.7054875893 TC 4.01596 4.0159675894 24.36506 24.3650675894 26 1.82445 1.8244575894 TC 22.60205 22.6020575896 21.40975 21.4097575896 26 1.84019 1.8401975896 TC 19.65585 19.6558575898 3.18555 3.1855575898 26 2.31959 2.3195975898 TC 0.98505 0.9850575901 3.74035 3.7403575901 26 0.65889 0.6588975901 TC 3.08146 3.0814675902 1.83841 1.8384175902 26 0.53695 0.5369575902 TC 1.30146 1.3014675945 4.82837 4.8283775945 26 0.57750 0.5775075945 TC 4.26839 4.2683975946 2.73109 2.7310975946 26 0.57066 0.5706675946 TC 2.16132 2.1613275952 5.89010 5.8901075952 26 6.31209 6.3120975953 2.36210 2.3621075953 26 1.91422 1.9142275954 26 3.14995 3.1499575956 26 9.93348 9.9334875957 26 8.49142 8.4914275958 26 5.63334 5.6333475959 26 5.02430 5.0243075962 5.67580 5.6758075962 26 0.72534 0.7253475962 TC 4.95046 4.9504675964 3.47352 3.4735275964 26 0.49886 0.4988675964 TC 2.97466 2.9746675966 6.86729 6.86729

Page 129 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

75966 26 1.79223 1.7922375966 TC 5.07506 5.0750675968 3.42490 3.4249075968 26 0.48584 0.4858475968 TC 2.93906 2.9390675970 11.91375 11.9137575970 26 1.14925 1.1492575970 TC 10.79959 10.7995975978 5.62240 5.6224075978 26 0.71644 0.7164475978 TC 4.90596 4.9059675980 6.98655 6.9865575980 26 1.98242 1.9824275980 TC 5.07596 5.0759675982 7.65606 7.6560675982 26 1.98242 1.9824275982 TC 5.74265 5.7426575984 2.77360 2.7736075984 26 0.97374 0.9737475984 TC 1.79986 1.7998675989 3.43083 3.4308375989 26 1.59537 1.5953775989 TC 1.83546 1.8354676000 2.41233 2.4123376000 26 0.22977 0.2297776000 TC 2.18256 2.1825676001 3.36800 3.3680076001 26 0.95113 0.9511376001 TC 2.45811 2.4581176010 0.68656 0.6865676010 26 0.24840 0.2484076010 TC 0.43816 0.4381676080 1.54620 1.5462076080 26 0.72534 0.7253476080 TC 0.82086 0.8208676098 0.48910 0.4891076098 26 0.22004 0.2200476098 TC 0.26906 0.2690676100 3.11114 3.1111476100 26 0.80398 0.8039876100 TC 2.30716 2.3071676101 4.34552 4.3455276101 26 0.85466 0.8546676101 TC 3.49086 3.4908676102 5.79828 5.7982876102 26 0.85672 0.8567276102 TC 4.94156 4.9415676120 1.84648 1.8464876120 26 0.51832 0.5183276120 TC 1.32816 1.3281676125 1.09539 1.09539

Page 130 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

76125 26 0.38253 0.3825376125 TC 0.73661 0.7366176140 .54627 .5462776140 26 .54627 .5462776376 1.80072 1.8007276376 26 0.27676 0.2767676376 TC 1.52396 1.5239676377 2.42341 2.4234176377 26 1.05075 1.0507576377 TC 1.37266 1.3726676380 4.98458 4.9845876380 26 1.29792 1.2979276380 TC 3.68666 3.6866676390 11.01120 11.0112076390 26 1.84214 1.8421476390 TC 9.16906 9.1690676506 2.87293 2.8729376506 26 0.85057 0.8505776506 TC 2.02236 2.0223676510 3.99479 3.9947976510 26 2.33733 2.3373376510 TC 1.65746 1.6574676511 2.40504 2.4050476511 26 1.29048 1.2904876511 TC 1.11456 1.1145676512 2.27566 2.2756676512 26 1.33020 1.3302076512 TC 0.94546 0.9454676513 2.08810 2.0881076513 26 0.88454 0.8845476513 TC 1.20356 1.2035676514 0.34753 0.3475376514 26 0.24757 0.2475776514 TC 0.09996 0.0999676516 1.69544 1.6954476516 26 0.74998 0.7499876516 TC 0.94546 0.9454676519 1.82210 1.8221076519 26 0.76984 0.7698476519 TC 1.05226 1.0522676529 1.72875 1.7287576529 26 0.80999 0.8099976529 TC 0.91876 0.9187676536 2.74046 2.7404676536 26 0.73590 0.7359076536 TC 2.00456 2.0045676604 2.10773 2.1077376604 26 0.72617 0.7261776604 TC 1.38156 1.3815676700 3.35067 3.3506776700 26 1.07911 1.07911

Page 131 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

76700 TC 2.27156 2.2715676705 2.53825 2.5382576705 26 0.78289 0.7828976705 TC 1.75536 1.7553676770 3.18466 3.1846676770 26 0.98430 0.9843076770 TC 2.20036 2.2003676775 2.69968 2.6996876775 26 0.79302 0.7930276775 TC 1.90666 1.9066676776 3.56902 3.5690276776 26 1.01266 1.0126676776 TC 2.55636 2.5563676800 3.12803 3.1280376800 26 1.44387 1.4438776800 TC 1.68416 1.6841676801 3.17871 3.1787176801 26 1.30765 1.3076576801 TC 1.87106 1.8710676802 1.77497 1.7749776802 26 1.08761 1.0876176802 TC 0.68736 0.6873676805 3.56825 3.5682576805 26 1.29669 1.2966976805 TC 2.27156 2.2715676810 2.40152 2.4015276810 26 1.27806 1.2780676810 TC 1.12346 1.1234676811 4.82270 4.8227076811 26 2.47104 2.4710476811 TC 2.35166 2.3516676812 4.90174 4.9017476812 26 2.31868 2.3186876812 TC 2.58306 2.5830676813 3.13218 3.1321876813 26 1.52812 1.5281276813 TC 1.60406 1.6040676814 2.02855 2.0285576814 26 1.27889 1.2788976814 TC 0.74966 0.7496676815 2.20297 2.2029776815 26 0.83921 0.8392176815 TC 1.36376 1.3637676816 2.78233 2.7823376816 26 1.10707 1.1070776816 TC 1.67526 1.6752676817 2.49813 2.4981376817 26 0.98307 0.9830776817 TC 1.51506 1.5150676818 2.97693 2.9769376818 26 1.36397 1.36397

Page 132 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

76818 TC 1.61296 1.6129676819 2.26839 2.2683976819 26 1.01143 1.0114376819 TC 1.25696 1.2569676820 1.22932 1.2293276820 26 0.64876 0.6487676820 TC 0.58056 0.5805676821 2.35158 2.3515876821 26 0.91662 0.9166276821 TC 1.43496 1.4349676825 5.21301 5.2130176825 26 2.17605 2.1760576825 TC 3.03696 3.0369676826 2.93197 2.9319776826 26 1.07871 1.0787176826 TC 1.85326 1.8532676827 1.68096 1.6809676827 26 0.75330 0.7533076827 TC 0.92766 0.9276676828 1.26100 1.2610076828 26 0.72494 0.7249476828 TC 0.53606 0.5360676830 2.94705 2.9470576830 26 0.90689 0.9068976830 TC 2.04016 2.0401676831 2.95844 2.9584476831 26 0.93608 0.9360876831 TC 2.02236 2.0223676856 2.96691 2.9669176856 26 0.92675 0.9267576856 TC 2.04016 2.0401676857 2.42292 2.4229276857 26 0.52516 0.5251676857 TC 1.89776 1.8977676870 2.92716 2.9271676870 26 0.86030 0.8603076870 TC 2.06686 2.0668676872 3.41191 3.4119176872 26 0.94455 0.9445576872 TC 2.46736 2.4673676873 4.41507 4.4150776873 26 2.09011 2.0901176873 TC 2.32496 2.3249676881 3.08527 3.0852776881 26 0.81371 0.8137176881 TC 2.27156 2.2715676882 0.83437 0.8343776882 26 0.56531 0.5653176882 TC 0.26906 0.2690676885 3.37156 3.3715676885 26 0.98430 0.98430

Page 133 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

76885 TC 2.38726 2.3872676886 2.58318 2.5831876886 26 0.81002 0.8100276886 TC 1.77316 1.7731676930 2.30253 2.3025376930 26 0.92987 0.9298776930 TC 1.37266 1.3726676932 2.34739 2.3473976932 26 0.96275 0.9627576932 TC 1.43774 1.4377476936 7.57829 7.5782976936 26 2.74353 2.7435376936 TC 4.83476 4.8347676937 0.85878 0.8587876937 26 0.41172 0.4117276937 TC 0.44706 0.4470676940 4.46179 4.4617976940 26 2.77930 2.7793076940 TC 1.60779 1.6077976941 3.24825 3.2482576941 26 1.82076 1.8207676941 TC 1.42871 1.4287176942 4.54945 4.5494576942 26 0.89839 0.8983976942 TC 3.65106 3.6510676945 2.32070 2.3207076945 26 0.88949 0.8894976945 TC 1.42871 1.4287176946 1.00576 1.0057676946 26 0.49640 0.4964076946 TC 0.50936 0.5093676948 1.03452 1.0345276948 26 0.50736 0.5073676948 TC 0.52716 0.5271676965 3.25844 3.2584476965 26 1.82348 1.8234876965 TC 1.43496 1.4349676970 2.17950 2.1795076970 26 0.54874 0.5487476970 TC 1.63076 1.6307676975 2.53190 2.5319076975 26 1.13869 1.1386976975 TC 1.43774 1.4377476977 0.29307 0.2930776977 26 0.07741 0.0774176977 TC 0.21566 0.2156676998 26 1.72088 1.7208877001 2.60982 2.6098277001 26 0.51626 0.5162677001 TC 2.09356 2.0935677002 1.76870 1.76870

Page 134 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

77002 26 0.71644 0.7164477002 TC 1.05226 1.0522677003 1.47998 1.4799877003 26 0.75702 0.7570277003 TC 0.72296 0.7229677011 16.94747 16.9474777011 26 1.60181 1.6018177011 TC 15.34566 15.3456677012 4.30532 4.3053277012 26 1.53536 1.5353677012 TC 2.76996 2.7699677013 26 5.47759 5.4775977014 4.56439 4.5643977014 26 1.13583 1.1358377014 TC 3.42856 3.4285677021 10.44240 10.4424077021 26 2.03874 2.0387477021 TC 8.40366 8.4036677022 5.64338 5.6433877022 26 5.73180 5.7318077051 0.29390 0.2939077051 26 0.08714 0.0871477051 TC 0.20676 0.2067677052 0.29390 0.2939077052 26 0.08714 0.0871477052 TC 0.20676 0.2067677053 1.71816 1.7181677053 26 0.48790 0.4879077053 TC 1.23026 1.2302677054 2.29523 2.2952377054 26 0.60217 0.6021777054 TC 1.69306 1.6930677055 2.10444 2.1044477055 26 0.93648 0.9364877055 TC 1.16796 1.1679677056 2.68131 2.6813177056 26 1.16625 1.1662577056 TC 1.51506 1.5150677057 1.99764 1.9976477057 26 0.93648 0.9364877057 TC 1.06116 1.0611677058 18.28313 18.2831377058 26 2.17891 2.1789177058 TC 16.10422 16.1042277059 19.26213 19.2621377059 26 2.17891 2.1789177059 TC 17.08322 17.0832277071 1.06783 1.0678377072 0.58059 0.5805977072 26 0.25813 0.2581377072 TC 0.32246 0.32246

Page 135 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

77073 0.93845 0.9384577073 26 0.38459 0.3845977073 TC 0.55386 0.5538677074 1.68113 1.6811377074 26 0.60217 0.6021777074 TC 1.07896 1.0789677075 2.43620 2.4362077075 26 0.71644 0.7164477075 TC 1.71976 1.7197677076 2.35364 2.3536477076 26 0.90978 0.9097877076 TC 1.44386 1.4438677077 1.03967 1.0396777077 26 0.44131 0.4413177077 TC 0.59836 0.5983677078 3.74507 3.7450777078 26 0.33431 0.3343177078 TC 3.41076 3.4107677080 1.54262 1.5426277080 26 0.26786 0.2678677080 TC 1.27476 1.2747677081 0.71658 0.7165877081 26 0.28732 0.2873277081 TC 0.42926 0.4292677084 12.76058 12.7605877084 26 2.14972 2.1497277084 TC 10.61086 10.6108677261 1.92075 1.9207577262 2.88765 2.8876577263 4.30476 4.3047677263 TC 3.04090 3.0409077280 4.49854 4.4985477280 26 0.94538 0.9453877280 TC 3.55316 3.5531677285 7.78705 7.7870577285 26 1.41259 1.4125977285 TC 6.37446 6.3744677290 12.30130 12.3013077290 26 2.09094 2.0909477290 TC 10.21036 10.2103677293 10.93096 10.9309677293 26 2.76760 2.7676077293 TC 8.16336 8.1633677295 15.08004 15.0800477295 26 6.10950 6.1095077295 TC 8.97054 8.9705477300 1.75754 1.7575477300 26 0.82988 0.8298877300 TC 0.92766 0.9276677301 54.20243 54.2024377301 26 10.71077 10.71077

Page 136 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

77301 TC 43.49166 43.4916677321 2.82145 2.8214577321 26 1.27969 1.2796977321 TC 1.54176 1.5417677331 1.62015 1.6201577331 26 1.16419 1.1641977331 TC 0.45596 0.4559677332 1.92890 1.9289077332 26 0.72534 0.7253477332 TC 1.20356 1.2035677333 1.62656 1.6265677333 26 1.12610 1.1261077333 TC 0.50046 0.5004677334 3.85328 3.8532877334 26 1.66182 1.6618277334 TC 2.19146 2.1914677336 1.31926 1.3192677338 12.18359 12.1835977338 26 5.96043 5.9604377338 TC 6.22316 6.2231677370 2.75628 2.7562877371 26.86625 26.8662577372 19.89084 19.8908477373 36.91860 36.9186077401 0.64286 0.6428677401 26 .88530 .8853077402 3.35736 3.3573677402 26 .83610 .8361077407 5.45776 5.4577677407 26 1.13120 1.1312077412 5.19076 5.1907677412 26 1.42630 1.4263077417 0.36696 0.3669677422 4.96826 4.9682677423 5.64466 5.6446677427 5.14952 5.1495277431 2.61149 2.6114977432 10.87348 10.8734877435 18.02096 18.0209677469 8.35267 8.3526777470 5.58541 5.5854177470 26 2.80655 2.8065577470 TC 2.77886 2.7788677520 2.45000 2.4500077520 26 2.45000 2.4500077523 2.45000 2.4500077523 26 2.45000 2.4500077600 9.47522 9.4752277600 26 2.09094 2.0909477600 TC 7.38428 7.3842877605 18.92115 18.92115

Page 137 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

77605 26 2.90799 2.9079977605 TC 16.01316 16.0131677610 15.45396 15.4539677610 26 2.04438 2.0443877610 TC 13.40958 13.4095877615 22.31881 22.3188177615 26 2.79765 2.7976577615 TC 19.52116 19.5211677620 10.36110 10.3611077620 26 2.00672 2.0067277620 TC 8.35438 8.3543877750 8.97350 8.9735077750 26 6.68208 6.6820877750 TC 2.29142 2.2914277761 9.12107 9.1210777761 26 5.10989 5.1098977761 TC 4.01118 4.0111877762 12.41998 12.4199877762 26 7.70364 7.7036477762 TC 4.71634 4.7163477763 17.67146 17.6714677763 26 11.57150 11.5715077763 TC 6.09996 6.0999677776 10.59856 10.5985677776 26 6.27382 6.2738277776 TC 4.32474 4.3247477777 14.84866 14.8486677777 26 10.18572 10.1857277777 TC 4.66294 4.6629477778 21.44820 21.4482077778 26 15.16134 15.1613477778 TC 6.28686 6.2868677785 4.99646 4.9964677785 26 1.89720 1.8972077785 TC 3.09926 3.0992677786 13.83137 13.8313777786 26 4.27549 4.2754977786 TC 9.55588 9.5558877787 21.30867 21.3086777787 26 6.54011 6.5401177787 TC 14.76856 14.7685677789 2.74822 2.7482277789 26 1.53576 1.5357677789 TC 1.21246 1.2124677790 2.29575 2.2957577790 26 1.41259 1.4125977790 TC 0.88316 0.8831678012 2.20039 2.2003978012 26 0.25813 0.2581378012 TC 1.94226 1.9422678013 5.54805 5.54805

Page 138 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

78013 26 0.49557 0.4955778013 TC 5.05248 5.0524878014 6.43516 6.4351678014 26 0.67068 0.6706878014 TC 5.76448 5.7644878015 4.93421 4.9342178015 26 0.88949 0.8894978015 TC 4.04472 4.0447278016 7.26956 7.2695678016 26 1.06008 1.0600878016 TC 6.20948 6.2094878018 7.40638 7.4063878018 26 1.13666 1.1366678018 TC 6.26972 6.2697278020 2.12968 2.1296878020 26 0.79262 0.7926278020 TC 1.33706 1.3370678070 4.04776 4.0477678070 26 1.08884 1.0888478070 TC 2.95892 2.9589278071 9.62334 9.6233478071 26 1.58936 1.5893678071 TC 8.03398 8.0339878072 11.23662 11.2366278072 26 2.19010 2.1901078072 TC 9.10198 9.1019878075 9.74808 9.7480878075 26 0.98430 0.9843078075 TC 8.76378 8.7637878102 3.87199 3.8719978102 26 0.73507 0.7350778102 TC 3.13692 3.1369278103 5.16335 5.1633578103 26 0.99403 0.9940378103 TC 4.16932 4.1693278104 5.88156 5.8815678104 26 1.08034 1.0803478104 TC 4.80122 4.8012278110 1.88205 1.8820578110 26 0.25813 0.2581378110 TC 1.62392 1.6239278111 2.17824 2.1782478111 26 0.29622 0.2962278111 TC 1.88202 1.8820278120 2.01887 2.0188778120 26 0.30595 0.3059578120 TC 1.71292 1.7129278121 2.32004 2.3200478121 26 0.41132 0.4113278121 TC 1.90872 1.9087278122 2.84703 2.84703

Page 139 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

78122 26 0.59121 0.5912178122 TC 2.25582 2.2558278130 3.65859 3.6585978130 26 0.82221 0.8222178130 TC 2.83638 2.8363878135 7.73728 7.7372878135 26 0.86030 0.8603078135 TC 6.87698 6.8769878140 3.38953 3.3895378140 26 0.82221 0.8222178140 TC 2.56732 2.5673278185 4.51608 4.5160878185 26 0.52476 0.5247678185 TC 3.99132 3.9913278190 8.96723 8.9672378190 26 1.43165 1.4316578190 TC 7.53558 7.5355878191 4.37949 4.3794978191 26 0.81331 0.8133178191 TC 3.56618 3.5661878195 8.12814 8.1281478195 26 1.61606 1.6160678195 TC 6.51208 6.5120878201 4.22982 4.2298278201 26 0.59450 0.5945078201 TC 3.63532 3.6353278202 4.72991 4.7299178202 26 0.65849 0.6584978202 TC 4.07142 4.0714278205 5.46263 5.4626378205 26 0.94621 0.9462178205 TC 4.51642 4.5164278206 8.09314 8.0931478206 26 1.26956 1.2695678206 TC 6.82358 6.8235878215 4.40991 4.4099178215 26 0.64999 0.6499978215 TC 3.75992 3.7599278216 3.19725 3.1972578216 26 0.75453 0.7545378216 TC 2.44272 2.4427278226 8.66434 8.6643478226 26 0.98636 0.9863678226 TC 7.67798 7.6779878227 11.84808 11.8480878227 26 1.18654 1.1865478227 TC 10.66154 10.6615478230 3.79249 3.7924978230 26 0.60217 0.6021778230 TC 3.19032 3.1903278231 3.08424 3.08424

Page 140 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

78231 26 0.67712 0.6771278231 TC 2.40712 2.4071278232 2.99315 2.9931578232 26 0.61273 0.6127378232 TC 2.38042 2.3804278258 5.33846 5.3384678258 26 0.99114 0.9911478258 TC 4.34732 4.3473278261 5.75467 5.7546778261 26 0.92675 0.9267578261 TC 4.82792 4.8279278262 5.67168 5.6716878262 26 0.88826 0.8882678262 TC 4.78342 4.7834278264 6.57204 6.5720478264 26 1.04102 1.0410278264 TC 5.53102 5.5310278270 1.88288 1.8828878270 26 0.26786 0.2678678270 TC 1.61502 1.6150278271 1.95408 1.9540878271 26 0.25896 0.2589678271 TC 1.69512 1.6951278272 2.12899 2.1289978272 26 0.34487 0.3448778272 TC 1.78412 1.7841278278 7.94639 7.9463978278 26 1.31861 1.3186178278 TC 6.62778 6.6277878282 4.19980 4.1998078282 26 0.52722 0.5272278290 7.24220 7.2422078290 26 0.91702 0.9170278290 TC 6.32518 6.3251878291 5.82590 5.8259078291 26 1.17598 1.1759878291 TC 4.64992 4.6499278300 4.07566 4.0756678300 26 0.83194 0.8319478300 TC 3.24372 3.2437278305 5.38359 5.3835978305 26 1.09857 1.0985778305 TC 4.28502 4.2850278306 5.91118 5.9111878306 26 1.14556 1.1455678306 TC 4.76562 4.7656278315 7.94888 7.9488878315 26 1.35670 1.3567078315 TC 6.59218 6.5921878320 5.89258 5.8925878320 26 1.38506 1.38506

Page 141 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

78320 TC 4.50752 4.5075278350 0.80558 0.8055878350 26 0.28732 0.2873278350 TC 0.51826 0.5182678351 0.41172 0.4117278414 26 0.58437 0.5843778428 4.67428 4.6742878428 26 1.05676 1.0567678428 TC 3.61752 3.6175278445 3.96491 3.9649178445 26 0.64999 0.6499978445 TC 3.31492 3.3149278451 5.61820 5.6182078451 26 1.78024 1.7802478451 TC 3.83796 3.8379678452 9.52058 9.5205878452 26 2.10482 2.1048278452 TC 7.41576 7.4157678453 4.87260 4.8726078453 26 1.29274 1.2927478453 TC 3.57986 3.5798678454 4.72488 4.7248878454 26 1.71462 1.7146278454 TC 3.01026 3.0102678456 8.19436 8.1943678456 26 1.39748 1.3974878456 TC 6.79688 6.7968878457 4.55775 4.5577578457 26 1.02239 1.0223978457 TC 3.53536 3.5353678458 4.83966 4.8396678458 26 1.19544 1.1954478458 TC 3.64422 3.6442278459 21.26500 21.2650078459 26 2.07228 2.0722878459 TC 52.74585 52.7458578466 4.27521 4.2752178466 26 0.94249 0.9424978466 TC 3.33272 3.3327278468 5.29894 5.2989478468 26 1.11182 1.1118278468 TC 4.18712 4.1871278469 6.02980 6.0298078469 26 1.25528 1.2552878469 TC 4.77452 4.7745278472 6.07244 6.0724478472 26 1.33352 1.3335278472 TC 4.73892 4.7389278473 8.19777 8.1977778473 26 2.01705 2.0170578473 TC 6.18072 6.18072

Page 142 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

78481 5.23378 5.2337878481 26 1.37802 1.3780278481 TC 3.85576 3.8557678483 7.34337 7.3433778483 26 2.07935 2.0793578483 TC 5.26402 5.2640278491 20.00000 20.0000078491 26 2.09898 2.0989878491 TC 53.21486 53.2148678492 25.00000 25.0000078492 26 2.63015 2.6301578492 TC 66.33326 66.3332678494 6.57937 6.5793778494 26 1.62685 1.6268578494 TC 4.95252 4.9525278496 2.33292 2.3329278496 26 0.69326 0.6932678496 TC 1.63966 1.6396678579 4.61667 4.6166778579 26 0.65205 0.6520578579 TC 3.96462 3.9646278580 4.95576 4.9557678580 26 0.98224 0.9822478580 TC 3.97352 3.9735278582 8.51579 8.5157978582 26 1.40741 1.4074178582 TC 7.10838 7.1083878597 5.21469 5.2146978597 26 0.96527 0.9652778597 TC 4.24942 4.2494278598 7.98611 7.9861178598 26 1.10023 1.1002378598 TC 6.88588 6.8858878600 4.12780 4.1278078600 26 0.58148 0.5814878600 TC 3.54632 3.5463278601 4.90107 4.9010778601 26 0.67835 0.6783578601 TC 4.22272 4.2227278605 4.56453 4.5645378605 26 0.71561 0.7156178605 TC 3.84892 3.8489278606 7.35046 7.3504678606 26 0.83838 0.8383878606 TC 6.51208 6.5120878607 8.51811 8.5181178607 26 1.62333 1.6233378607 TC 6.89478 6.8947878608 21.26500 21.2650078608 26 2.02984 2.0298478609 2.00108 2.00108

Page 143 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

78609 26 2.00108 2.0010878610 4.12508 4.1250878610 26 0.40966 0.4096678610 TC 3.71542 3.7154278630 7.66734 7.6673478630 26 0.90606 0.9060678630 TC 6.76128 6.7612878635 7.17887 7.1788778635 26 0.80919 0.8091978635 TC 6.36968 6.3696878645 7.17077 7.1707778645 26 0.77439 0.7743978645 TC 6.39638 6.3963878647 7.69862 7.6986278647 26 1.16874 1.1687478647 TC 6.52988 6.5298878650 7.47669 7.4766978650 26 0.82221 0.8222178650 TC 6.65448 6.6544878660 3.97713 3.9771378660 26 0.71561 0.7156178660 TC 3.26152 3.2615278700 4.05949 4.0594978700 26 0.60217 0.6021778700 TC 3.45732 3.4573278701 4.89941 4.8994178701 26 0.64999 0.6499978701 TC 4.24942 4.2494278707 5.64564 5.6456478707 26 1.28052 1.2805278707 TC 4.36512 4.3651278708 4.50255 4.5025578708 26 1.61483 1.6148378708 TC 2.88772 2.8877278709 8.51731 8.5173178709 26 1.87173 1.8717378709 TC 6.64558 6.6455878710 5.32976 5.3297678710 26 0.85784 0.8578478710 TC 4.47192 4.4719278725 2.38732 2.3873278725 26 0.49640 0.4964078725 TC 1.89092 1.8909278730 1.76097 1.7609778730 26 0.21921 0.2192178730 TC 1.54176 1.5417678740 4.98615 4.9861578740 26 0.76343 0.7634378740 TC 4.22272 4.2227278761 4.91083 4.9108378761 26 0.95511 0.95511

Page 144 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

78761 TC 3.95572 3.9557278800 4.39048 4.3904878800 26 0.87976 0.8797678800 TC 3.51072 3.5107278801 5.82527 5.8252778801 26 1.05075 1.0507578801 TC 4.77452 4.7745278802 7.58644 7.5864478802 26 1.13666 1.1366678802 TC 6.44978 6.4497878803 8.29289 8.2928978803 26 1.44261 1.4426178803 TC 6.85028 6.8502878804 13.46419 13.4641978804 26 1.43205 1.4320578804 TC 12.03214 12.0321478805 4.35179 4.3517978805 26 0.97457 0.9745778805 TC 3.37722 3.3772278806 7.88904 7.8890478806 26 1.13666 1.1366678806 TC 6.75238 6.7523878807 8.29289 8.2928978807 26 1.45151 1.4515178807 TC 6.84138 6.8413878808 1.07816 1.0781678811 54.84824 54.8482478811 26 2.13040 2.1304078811 TC 52.86923 52.8692378812 54.84804 54.8480478812 26 2.62351 2.6235178812 TC 52.86903 52.8690378813 54.84704 54.8470478813 26 2.72928 2.7292878813 TC 52.86807 52.8680778814 59.43442 59.4344278814 26 2.99714 2.9971478814 TC 56.15385 56.1538578815 59.43596 59.4359678815 26 3.31282 3.3128278815 TC 56.15531 56.1553178816 59.43630 59.4363078816 26 3.38900 3.3890078816 TC 56.15563 56.1556379005 3.70396 3.7039679005 26 2.36690 2.3669079005 TC 1.33706 1.3370679101 4.16224 4.1622479101 26 2.70948 2.7094879101 TC 1.45276 1.4527679200 4.29757 4.29757

Page 145 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

79200 26 2.68461 2.6846179200 TC 1.61296 1.6129679300 26 2.17576 2.1757679403 5.28925 5.2892579403 26 3.01563 3.0156379403 TC 2.27362 2.2736279440 3.91553 3.9155379440 26 2.64077 2.6407779440 TC 1.27476 1.2747679445 5.72252 5.7225279445 26 3.25404 3.2540479445 TC 2.48286 2.4828680500 0.48873 0.5510380502 1.68915 1.7336583020 26 0.50653 0.5065384165 26 0.49763 0.4976384166 26 0.49763 0.4976384181 26 0.49763 0.4976384182 26 0.50653 0.5065385060 0.60217 0.6021785097 1.24326 2.1688685390 26 0.50653 0.5065385396 0.48873 0.4887385576 26 0.50653 0.5065386077 1.26106 1.3144686078 1.26106 1.3322686079 1.26996 1.3411686153 26 0.94249 0.9424986255 26 0.50653 0.5065386256 26 0.50653 0.5065386320 26 0.49557 0.4955786325 26 0.49763 0.4976386327 26 0.57298 0.5729886334 26 0.50653 0.5065386335 26 0.49763 0.4976386486 0.11776 0.1177686490 0.15336 0.1533686510 0.15336 0.1533686580 0.17116 0.1711687164 26 0.49763 0.4976387207 26 0.50653 0.5065388104 1.55470 1.5547088104 26 0.72494 0.7249488104 TC 0.82976 0.8297688106 1.91960 1.9196088106 26 0.72494 0.7249488106 TC 1.19466 1.1946688108 1.80596 1.8059688108 26 0.72700 0.7270088108 TC 1.07896 1.0789688112 2.56258 2.56258

Page 146 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

88112 26 1.50142 1.5014288112 TC 1.06116 1.0611688120 12.09820 12.0982088120 26 1.47638 1.4763888120 TC 10.62182 10.6218288121 10.20848 10.2084888121 26 1.29752 1.2975288121 TC 8.91096 8.9109688125 0.55080 0.5508088125 26 0.34404 0.3440488125 TC 0.20676 0.2067688141 0.71538 0.7153888160 1.29162 1.2916288160 26 0.63986 0.6398688160 TC 0.65176 0.6517688161 1.33612 1.3361288161 26 0.63096 0.6309688161 TC 0.70516 0.7051688162 1.89376 1.8937688162 26 0.97500 0.9750088162 TC 0.91876 0.9187688172 1.33552 1.3355288172 26 0.78166 0.7816688172 TC 0.55386 0.5538688173 3.36321 3.3632188173 26 1.80365 1.8036588173 TC 1.55956 1.5595688177 0.76878 0.7687888177 26 0.59762 0.5976288177 TC 0.17116 0.1711688182 2.51965 2.5196588182 26 0.93133 0.9313388182 TC 1.58832 1.5883288184 1.91556 1.9155688185 1.14126 1.1412688187 1.77174 1.7717488188 2.19485 2.1948588189 2.77779 2.7777988291 0.75038 0.7503888300 0.58926 0.5892688300 26 0.11550 0.1155088300 TC 0.47376 0.4737688302 1.20751 1.2075188302 26 0.17305 0.1730588302 TC 1.03446 1.0344688304 1.52648 1.5264888304 26 0.28732 0.2873288304 TC 1.23916 1.2391688305 2.57617 2.5761788305 26 0.97211 0.9721188305 TC 1.60406 1.60406

Page 147 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

88307 5.28441 5.2844188307 26 2.07835 2.0783588307 TC 3.20606 3.2060688309 8.06308 8.0630888309 26 3.63566 3.6356688309 TC 4.42742 4.4274288311 0.46904 0.4690488311 26 0.31568 0.3156888311 TC 0.15336 0.1533688312 2.46974 2.4697488312 26 0.68768 0.6876888312 TC 1.78206 1.7820688313 1.79514 1.7951488313 26 0.30678 0.3067888313 TC 1.48836 1.4883688314 2.15077 2.1507788314 26 0.59121 0.5912188314 TC 1.55956 1.5595688319 3.39657 3.3965788319 26 0.69781 0.6978188319 TC 2.69876 2.6987688321 2.13441 2.3391188323 3.62429 3.6242988323 26 2.26053 2.2605388323 TC 1.36376 1.3637688325 3.32530 4.9540088329 0.89839 1.2899988331 2.27655 2.2765588331 26 1.57139 1.5713988331 TC 0.70516 0.7051688332 1.02319 1.0231988332 26 0.77193 0.7719388332 TC 0.25126 0.2512688333 2.35064 2.3506488333 26 1.58318 1.5831888333 TC 0.76746 0.7674688334 1.43737 1.4373788334 26 0.95471 0.9547188334 TC 0.48266 0.4826688342 2.49753 2.4975388342 26 1.08927 1.0892788342 TC 1.40826 1.4082688346 2.48946 2.4894688346 26 1.10790 1.1079088346 TC 1.38156 1.3815688347 1.95340 1.9534088347 26 1.04354 1.0435488347 TC 0.90986 0.9098688348 15.44297 15.4429788348 26 1.93821 1.9382188348 TC 13.50476 13.50476

Page 148 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

88355 5.54835 5.5483588355 26 2.26219 2.2621988355 TC 3.28616 3.2861688356 7.18384 7.1838488356 26 3.62656 3.6265688356 TC 3.55728 3.5572888358 1.87393 1.8739388358 26 1.14207 1.1420788358 TC 0.73186 0.7318688360 3.00984 3.0098488360 26 1.40578 1.4057888360 TC 1.60406 1.6040688361 3.66618 3.6661888361 26 1.48362 1.4836288361 TC 2.18256 2.1825688362 6.69087 6.6908788362 26 2.83099 2.8309988362 TC 3.85988 3.8598888363 0.48189 1.0336988365 3.95264 3.9526488365 26 1.52978 1.5297888365 TC 2.42286 2.4228688367 5.91210 5.9121088367 26 1.62024 1.6202488367 TC 4.29186 4.2918688368 5.20634 5.2063488368 26 1.68878 1.6887888368 TC 3.51756 3.5175688371 26 0.49763 0.4976388372 26 0.49763 0.4976388380 4.85472 4.8547288380 26 2.02246 2.0224688380 TC 2.83226 2.8322688381 4.85878 4.8587888381 26 1.48362 1.4836288381 TC 3.37516 3.3751688387 1.02568 1.0256888387 26 0.82782 0.8278288387 TC 0.19786 0.1978688388 0.61997 0.6199788388 26 0.52001 0.5200188388 TC 0.09996 0.0999689049 1.81478 6.0066889060 26 0.50653 0.5065389220 0.35806 0.3580689230 0.10886 0.1088689250 16.94900 16.9490089251 16.94900 16.9490089253 8.78220 8.7822089254 1.17100 1.1710089255 2.34190 2.34190

Page 149 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

89257 1.17100 1.1710089258 7.94120 7.9412089259 1.75640 1.7564089260 3.51290 3.5129089261 3.51290 3.5129089264 1.17100 1.1710090460 0.62137 0.6213790461 0.31711 0.3171190471 0.54127 0.5412790472 0.21031 0.2815190473 0.22087 0.3721790474 0.20141 0.2459190785 0.13579 0.1357990791 3.31666 4.1977690792 3.42784 3.5168490832 1.39565 1.7516590833 1.16648 1.1753890834 2.09369 2.2805990836 1.90736 1.9073690837 3.15895 3.3458590838 3.06328 3.0721890839 3.59325 3.6199590840 1.72996 1.7388690845 2.13467 2.1791790846 2.24479 2.2981990847 2.68779 2.8568990849 0.78289 0.8629990853 0.78289 0.8362990865 3.48496 4.0901690867 4.86206 9.3921690868 0.66696 4.4850690869 3.30178 11.3295890870 2.27770 3.5860090875 1.61606 1.8919690876 2.56350 2.8216090880 2.58823 2.7662390882 .05320 .0532090885 1.31011 1.3101190887 1.98846 2.2465690889 1.13770 1.1377090901 0.52765 0.8836590911 1.20557 2.1667790935 1.77586 1.7758690937 2.93487 2.9348790945 1.85204 1.8520490947 2.99242 2.9924290951 26.02966 26.0296690954 21.51820 21.5182090955 12.09651 12.0965190956 8.15625 8.1562590957 17.25124 17.25124

Page 150 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

90958 11.58334 11.5833490959 7.56298 7.5629890960 7.59254 7.5925490961 6.11954 6.1195490962 4.41511 4.4151190963 14.58486 14.5848690964 12.29878 12.2987890965 11.72331 11.7233190966 6.09284 6.0928490967 0.53157 0.5315790968 0.42062 0.4206290969 0.39993 0.3999390970 0.20948 0.2094890989 14.34300 14.3430090993 .53160 .5316090997 2.39420 2.3942091010 4.55721 4.5572191010 26 1.76055 1.7605591010 TC 2.79666 2.7966691013 0.62426 0.6242691013 26 0.27510 0.2751091013 TC 0.34916 0.3491691020 5.59648 5.5964891020 26 2.00772 2.0077291020 TC 3.58876 3.5887691022 4.50862 4.5086291022 26 2.04126 2.0412691022 TC 2.46736 2.4673691030 3.35897 3.3589791030 26 1.29211 1.2921191030 TC 2.06686 2.0668691034 4.72565 4.7256591034 26 1.35049 1.3504991034 TC 3.37516 3.3751691035 11.28029 11.2802991035 26 2.23583 2.2358391035 TC 9.04446 9.0444691037 3.87537 3.8753791037 26 1.38131 1.3813191037 TC 2.49406 2.4940691038 3.43226 3.4322691038 26 1.56120 1.5612091038 TC 1.87106 1.8710691040 8.55949 8.5594991040 26 1.35733 1.3573391040 TC 7.20216 7.2021691065 1.60492 1.6049291065 26 0.27676 0.2767691065 TC 1.32816 1.3281691110 21.61564 21.6156491110 26 5.13078 5.13078

Page 151 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

91110 TC 16.48486 16.4848691111 16.80544 16.8054491111 26 1.42418 1.4241891111 TC 15.38126 15.3812691112 31.28260 31.2826091112 26 3.12094 3.1209491112 TC 28.16166 28.1616691117 4.25993 4.0107391120 9.35093 9.3509391120 26 1.31217 1.3121791120 TC 8.03876 8.0387691122 5.58349 5.5834991122 26 2.36853 2.3685391122 TC 3.21496 3.2149691132 3.77160 3.7716091132 26 0.73258 0.7325891132 TC 2.98356 2.9835691133 4.61298 4.6129891133 26 0.95096 0.9509691133 TC 3.58876 3.5887692002 1.20474 1.8277492004 2.50140 3.4359092012 1.28816 1.9289692014 1.97664 2.8221492015 0.50736 0.7476692018 3.53206 3.5320692019 1.75869 1.7586992020 0.52433 0.6489392025 0.83417 0.8341792025 26 0.48501 0.4850192025 TC 0.34916 0.3491692060 1.44295 1.4429592060 26 0.95139 0.9513992060 TC 0.49156 0.4915692065 1.13843 1.1384392065 26 0.47777 0.4777792065 TC 0.66066 0.6606692071 0.92901 1.0358192072 2.68707 3.3100792081 1.27316 1.2731692081 26 0.49680 0.4968092081 TC 0.77636 0.7763692082 1.70016 1.7001692082 26 0.62120 0.6212092082 TC 1.07896 1.0789692083 1.92558 1.9255892083 26 0.69532 0.6953292083 TC 1.23026 1.2302692100 1.25940 2.1583092132 0.98959 0.9895992132 26 0.58703 0.58703

Page 152 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

92132 TC 0.40256 0.4025692133 1.21564 1.2156492133 26 0.81308 0.8130892133 TC 0.40256 0.4025692134 1.21564 1.2156492134 26 0.81308 0.8130892134 TC 0.40256 0.4025692136 1.92684 1.9268492136 26 0.75888 0.7588892136 TC 1.16796 1.1679692140 0.67752 1.3806292225 0.53406 0.6319692226 0.46555 0.5634592227 0.30466 0.3046692228 0.81222 0.8122292228 26 0.48086 0.4808692228 TC 0.33136 0.3313692230 0.83028 1.4265892235 3.01041 3.0104192235 26 1.13935 1.1393592235 TC 1.87106 1.8710692240 5.51074 5.5107492240 26 1.55708 1.5570892240 TC 3.95366 3.9536692250 1.70494 1.7049492250 26 0.59928 0.5992892250 TC 1.10566 1.1056692260 0.28566 0.4369692265 1.86025 1.8602592265 26 1.07499 1.0749992265 TC 0.78526 0.7852692270 2.10261 2.1026192270 26 1.06815 1.0681592270 TC 1.03446 1.0344692275 3.24267 3.2426792275 26 1.41611 1.4161192275 TC 1.82656 1.8265692283 1.10403 1.1040392283 26 0.23867 0.2386792283 TC 0.86536 0.8653692284 1.40354 1.4035492284 26 0.31568 0.3156892284 TC 1.08786 1.0878692285 1.00178 1.0017892285 26 0.29662 0.2966292285 TC 0.70516 0.7051692286 2.79326 2.7932692286 26 0.91330 0.9133092286 TC 1.87996 1.8799692287 1.13251 2.7078192287 26 1.27491 1.27491

Page 153 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

92287 TC 2.24486 2.2448692310 1.57797 2.3255792311 1.45480 2.3181092312 1.67032 2.6226292313 1.27926 2.2404692314 0.92675 1.8167592315 0.60423 1.6010392316 0.95262 2.1185292317 0.55561 1.7749192325 0.71406 0.7140692326 0.83866 0.8386692340 0.49763 0.8803392341 0.63053 1.0132392342 0.71767 1.1003792352 0.49763 0.9782392353 0.67958 1.1512892354 1.74646 1.7464692355 1.10566 1.1056692358 0.36696 0.3669692370 0.43118 0.7604892371 0.31356 0.3135692502 2.45169 2.4516992504 0.25730 0.7112092507 0.69698 1.6225892508 0.36184 0.7979492511 1.49990 3.7160092512 0.74397 1.4826792516 0.60051 1.5439192520 1.03853 1.5814392521 2.99259 2.9925992522 2.43578 2.4357892523 5.05162 5.0516292524 2.54398 2.5439892526 1.56604 2.5628492531 .78618 .7861892532 1.27590 1.2759092533 .53160 .5316092534 .42530 .4253092540 2.47344 2.4734492540 26 2.06198 2.0619892540 TC 0.41146 0.4114692541 1.27442 1.2744292541 26 0.53366 0.5336692541 TC 0.74076 0.7407692542 1.29531 1.2953192542 26 0.44775 0.4477592542 TC 0.84756 0.8475692543 0.60872 0.6087292543 26 0.14386 0.1438692543 TC 0.46486 0.4648692544 1.04920 1.04920

Page 154 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

92544 26 0.35294 0.3529492544 TC 0.69626 0.6962692545 0.98441 0.9844192545 26 0.31485 0.3148592545 TC 0.66956 0.6695692546 2.09299 2.0929992546 26 0.39103 0.3910392546 TC 1.70196 1.7019692547 0.10886 0.1088692548 2.29732 2.2973292548 26 0.66656 0.6665692548 TC 1.63076 1.6307692550 0.53841 0.5384192551 0.26016 0.2601692552 0.53606 0.5360692553 0.68736 0.6873692555 0.38476 0.3847692556 0.58946 0.5894692557 0.97952 1.0507292560 .40398 .4039892561 0.68736 0.6873692562 0.62506 0.6250692563 0.51826 0.5182692564 0.48266 0.4826692565 0.29576 0.2957692567 0.34796 0.4013692568 0.43553 0.4355392570 0.77957 0.8240792571 0.40256 0.4025692572 0.56276 0.5627692575 0.95436 0.9543692576 0.53606 0.5360692577 0.36696 0.3669692579 1.04328 1.1322892582 1.03446 1.0344692583 0.79416 0.7941692584 1.47056 1.4705692585 2.48422 2.4842292585 26 0.66656 0.6665692585 TC 1.81766 1.8176692586 1.47946 1.4794692587 0.86931 0.8693192587 26 0.18195 0.1819592587 TC 0.68736 0.6873692588 1.51140 1.5114092588 26 0.48584 0.4858492588 TC 1.02556 1.0255692590 1.06330 1.0633092591 1.59490 1.5949092592 .42530 .4253092593 .63800 .63800

Page 155 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

92594 .53160 .5316092595 .63800 .6380092596 0.92766 0.9276692597 1.62376 2.6917692601 3.57364 3.9296492602 2.08510 2.4500092603 3.29359 3.6317992604 1.85845 2.1343592605 2.43329 2.5400992606 1.92496 2.2008692607 3.91946 3.9194692608 0.79416 0.7941692609 2.12438 2.1243892610 1.78316 2.8689692611 3.07698 3.0769892612 1.76221 3.9605192613 0.99961 0.9996192614 1.77111 3.5422192615 0.87521 0.8841192616 2.60222 4.8450292617 1.09525 1.0952592618 0.89673 0.9145392620 1.98806 2.0414692621 0.44941 0.4672192625 1.54549 1.5810992626 2.04890 2.1201092627 0.49225 0.5100592640 2.32880 2.4000092920 15.51164 15.5116492924 18.43393 18.4339392928 17.22373 17.2237392933 19.27176 19.2717692937 17.21400 17.2140092941 19.31108 19.3110892943 19.31108 19.3110892950 4.68323 7.0239392953 0.30595 0.3059592960 3.46681 6.2436192961 6.84805 6.8480592970 4.78525 4.7852592971 2.68415 2.6841592973 4.73740 4.7374092974 4.34926 4.3492692975 10.41852 10.4185292977 2.51392 2.5139292978 6.75186 6.7518692978 26 2.59764 2.5976492978 TC 4.26839 4.2683992979 4.14687 4.1468792979 26 2.08304 2.0830492979 TC 2.15645 2.15645

Page 156 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

92986 35.51941 35.5194192987 36.63501 36.6350192990 28.36003 28.3600392992 35.38500 35.3850092993 35.93700 35.9370092997 16.78672 16.7867292998 8.48681 8.4868193000 0.50773 0.5077393005 0.26906 0.2690693010 0.23867 0.2386793015 2.35573 2.3557393016 0.62681 0.6268193017 1.31036 1.3103693018 0.41856 0.4185693024 2.98005 2.9800593024 26 1.62519 1.6251993024 TC 1.35486 1.3548693025 4.88333 4.8833393025 26 1.05427 1.0542793025 TC 3.82906 3.8290693040 0.34670 0.3467093041 0.13556 0.1355693042 0.21114 0.2111493224 2.64814 2.6481493225 0.76746 0.7674693226 1.15016 1.1501693227 0.73052 0.7305293228 0.69904 0.6990493229 17.92666 17.9266693268 6.10340 6.1034093270 0.41146 0.4114693271 4.98812 4.9881293272 0.70382 0.7038293278 0.89707 0.8970793278 26 0.34321 0.3432193278 TC 0.55386 0.5538693279 1.37733 1.3773393279 26 0.93027 0.9302793279 TC 0.44706 0.4470693280 1.62759 1.6275993280 26 1.10933 1.1093393280 TC 0.51826 0.5182693281 1.89854 1.8985493281 26 1.30018 1.3001893281 TC 0.59836 0.5983693282 1.74103 1.7410393282 26 1.20497 1.2049793282 TC 0.53606 0.5360693283 2.23969 2.2396993283 26 1.62353 1.6235393283 TC 0.61616 0.61616

Page 157 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

93284 2.51705 2.5170593284 26 1.81189 1.8118993284 TC 0.70516 0.7051693285 1.15978 1.1597893285 26 0.74832 0.7483293285 TC 0.41146 0.4114693286 0.68762 0.6876293286 26 0.39186 0.3918693286 TC 0.29576 0.2957693287 0.91367 0.9136793287 26 0.59121 0.5912193287 TC 0.32246 0.3224693288 1.03661 1.0366193288 26 0.61625 0.6162593288 TC 0.42036 0.4203693289 1.78244 1.7824493289 26 1.26418 1.2641893289 TC 0.51826 0.5182693290 0.80521 0.8052193290 26 0.56285 0.5628593290 TC 0.24236 0.2423693291 1.00101 1.0010193291 26 0.61625 0.6162593291 TC 0.38476 0.3847693292 0.90311 0.9031193292 26 0.61625 0.6162593292 TC 0.28686 0.2868693293 1.38348 1.3834893293 26 0.43802 0.4380293293 TC 0.94546 0.9454693294 0.94123 0.9412393295 1.84603 1.8460393296 0.84756 0.8475693297 0.69904 0.6990493298 0.77024 0.7702493303 5.15354 5.1535493303 26 1.78728 1.7872893303 TC 3.36626 3.3662693304 3.24573 3.2457393304 26 1.01867 1.0186793304 TC 2.22706 2.2270693306 6.01000 6.0100093306 26 1.85164 1.8516493306 TC 4.15836 4.1583693307 3.88284 3.8828493307 26 1.28198 1.2819893307 TC 2.60086 2.6008693308 2.60241 2.6024193308 26 0.74025 0.7402593308 TC 1.86216 1.8621693312 7.87978 7.87978

Page 158 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

93312 26 2.98956 2.9895693312 TC 4.89022 4.8902293313 1.11265 1.1126593314 6.76235 6.7623593314 26 1.70303 1.7030393314 TC 5.05932 5.0593293315 7.24162 7.2416293315 26 3.93050 3.9305093315 TC 3.44748 3.4474893316 1.20165 1.2016593317 5.93019 5.9301993317 26 2.51665 2.5166593317 TC 3.44748 3.4474893318 26 3.06702 3.0670293320 1.69106 1.6910693320 26 0.53200 0.5320093320 TC 1.15906 1.1590693321 0.76417 0.7641793321 26 0.21921 0.2192193321 TC 0.54496 0.5449693325 1.00673 1.0067393325 26 0.10577 0.1057793325 TC 0.90096 0.9009693350 5.15998 5.1599893350 26 2.06072 2.0607293350 TC 3.09926 3.0992693351 6.14937 6.1493793351 26 2.51405 2.5140593351 TC 3.63532 3.6353293352 0.90783 0.9078393451 20.41202 20.4120293451 26 4.23454 4.2345493451 TC 16.17748 16.1774893452 22.89549 22.8954993452 26 7.42795 7.4279593452 TC 15.46754 15.4675493453 29.96684 29.9668493453 26 9.74464 9.7446493453 TC 20.22220 20.2222093454 23.61287 23.6128793454 26 7.49563 7.4956393454 TC 16.11724 16.1172493455 27.52412 27.5241293455 26 8.63692 8.6369293455 TC 18.88720 18.8872093456 29.56159 29.5615993456 26 9.59749 9.5974993456 TC 19.96410 19.9641093457 33.47201 33.4720193457 26 10.74001 10.7400193457 TC 22.73200 22.73200

Page 159 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

93458 28.48303 28.4830393458 26 9.13303 9.1330393458 TC 19.35000 19.3500093459 31.47758 31.4775893459 26 10.28528 10.2852893459 TC 21.19230 21.1923093460 33.71769 33.7176993460 26 11.45739 11.4573993460 TC 22.26030 22.2603093461 38.59838 38.5983893461 26 12.64252 12.6425293461 TC 25.95586 25.9558693462 5.82329 5.8232993463 3.07654 3.0765493464 6.84516 6.8451693464 26 2.71350 2.7135093464 TC 4.13166 4.1316693503 3.71401 3.7140193505 18.68179 18.6817993505 26 6.26217 6.2621793505 TC 12.41962 12.4196293530 22.17473 22.1747393530 26 6.04230 6.0423093530 TC 15.97440 15.9744093531 57.72164 57.7216493531 26 11.76612 11.7661293531 TC 45.67821 45.6782193532 58.99615 58.9961593532 26 13.99325 13.9932593532 TC 44.59335 44.5933593533 54.18652 54.1865293533 26 9.39659 9.3965993533 TC 44.59335 44.5933593561 1.17476 1.1747693561 26 0.65288 0.6528893561 TC 0.51494 0.5149493562 0.53294 0.5329493562 26 0.20224 0.2022493562 TC 0.31964 0.3196493563 1.58123 1.5812393564 1.60959 1.6095993565 1.22706 1.2270693566 1.21610 4.5269093567 1.36969 3.7726993568 1.25542 4.1123293571 6.72525 6.7252593571 26 2.58874 2.5887493571 TC 4.26839 4.2683993572 4.09257 4.0925793572 26 2.06936 2.0693693572 TC 2.16132 2.16132

Page 160 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

93580 26.01635 26.0163593581 34.31635 34.3163593582 18.91050 18.9105093583 21.04982 21.0498293600 4.85428 4.8542893600 26 3.04662 3.0466293600 TC 1.85487 1.8548793602 4.04671 4.0467193602 26 3.05074 3.0507493602 TC 1.04722 1.0472293603 4.58818 4.5881893603 26 3.06170 3.0617093603 TC 1.58861 1.5886193609 9.61543 9.6154393609 26 7.17627 7.1762793609 TC 2.57366 2.5736693610 5.55067 5.5506793610 26 4.33930 4.3393093610 TC 1.28695 1.2869593612 5.79919 5.7991993612 26 4.33246 4.3324693612 TC 1.52652 1.5265293613 10.07737 10.0773793613 26 9.79104 9.7910493615 1.55808 1.5580893615 26 1.40967 1.4096793615 TC 0.30174 0.3017493616 2.25820 2.2582093616 26 1.83115 1.8311593616 TC 0.30366 0.3036693618 9.73598 9.7359893618 26 6.14541 6.1454193618 TC 3.73619 3.7361993619 17.86427 17.8642793619 26 10.60439 10.6043993619 TC 7.26829 7.2682993620 1.85270 1.8527093620 26 16.70819 16.7081993620 TC 8.05588 8.0558893621 .93680 .9368093621 26 3.02716 3.0271693621 TC .64870 .6487093622 26 4.43766 4.4376693623 5.91569 5.9156993623 26 4.10129 4.1012993624 8.92823 8.9282393624 26 6.97154 6.9715493624 TC 1.88148 1.8814893631 16.88911 16.8891193631 26 11.02449 11.0244993631 TC 6.04685 6.04685

Page 161 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

93640 11.68455 11.6845593640 26 5.07829 5.0782993640 TC 6.75343 6.7534393641 15.09822 15.0982293641 26 8.53852 8.5385293641 TC 6.75343 6.7534393642 11.21178 11.2117893642 26 6.95346 6.9534693642 TC 4.25832 4.2583293650 15.33349 15.3334993653 23.42102 23.4210293654 31.25176 31.2517693655 11.70948 11.7094893656 31.26232 31.2623293657 11.72044 11.7204493660 4.25639 4.2563993660 26 2.67903 2.6790393660 TC 1.57736 1.5773693662 7.56300 7.5630093662 26 4.02594 4.0259493662 TC 3.64550 3.6455093668 0.42036 0.4203693701 0.65382 0.6538293701 26 0.24326 0.2432693701 TC 0.61616 0.6161693724 8.14128 8.1412893724 26 6.88432 6.8843293724 TC 1.25696 1.2569693740 0.25770 0.2577093740 26 0.21114 0.2111493740 TC 0.04656 0.0465693750 1.20600 1.3662093770 0.23100 0.2310093770 26 0.21114 0.2111493770 TC 0.01986 0.0198693784 1.63082 1.6308293786 0.72296 0.7229693788 0.40256 0.4025693790 0.50530 0.5053093797 0.25730 0.4531093798 0.39020 0.6572093880 5.85194 5.8519493880 26 0.81248 0.8124893880 TC 5.03946 5.0394693882 3.96840 3.9684093882 26 0.54874 0.5487493882 TC 3.41966 3.4196693886 7.40412 7.4041293886 26 1.23230 1.2323093886 TC 6.17182 6.1718293888 4.92800 4.92800

Page 162 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

93888 26 0.83194 0.8319493888 TC 4.09606 4.0960693890 6.49034 6.4903493890 26 1.31738 1.3173893890 TC 5.17296 5.1729693892 7.45715 7.4571593892 26 1.50989 1.5098993892 TC 5.94726 5.9472693893 7.29695 7.2969593893 26 1.51879 1.5187993893 TC 5.77816 5.7781693922 2.89957 2.8995793922 26 0.32541 0.3254193922 TC 2.57416 2.5741693923 4.46889 4.4688993923 26 0.60423 0.6042393923 TC 3.86466 3.8646693924 5.48764 5.4876493924 26 0.67958 0.6795893924 TC 4.80806 4.8080693925 7.35644 7.3564493925 26 0.77522 0.7752293925 TC 6.58122 6.5812293926 4.74187 4.7418793926 26 0.53901 0.5390193926 TC 4.20286 4.2028693930 5.76912 5.7691293930 26 0.62286 0.6228693930 TC 5.14626 5.1462693931 3.86987 3.8698793931 26 0.42351 0.4235193931 TC 3.44636 3.4463693965 2.96333 2.9633393965 26 0.46927 0.4692793965 TC 2.49406 2.4940693970 5.99620 5.9962093970 26 0.92114 0.9211493970 TC 5.07506 5.0750693971 3.96365 3.9636593971 26 0.62409 0.6240993971 TC 3.33956 3.3395693975 9.07618 9.0761893975 26 2.44156 2.4415693975 TC 6.63462 6.6346293976 5.20565 5.2056593976 26 1.62579 1.6257993976 TC 3.57986 3.5798693978 5.64661 5.6466193978 26 0.88305 0.8830593978 TC 4.76356 4.7635693979 3.90736 3.90736

Page 163 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

93979 26 0.59450 0.5945093979 TC 3.31286 3.3128693980 4.31897 4.3189793980 26 1.70921 1.7092193980 TC 2.60976 2.6097693981 2.91740 2.9174093981 26 0.59244 0.5924493981 TC 2.32496 2.3249693982 1.04774 1.0477493990 4.72819 4.7281993990 26 0.33843 0.3384393990 TC 4.38976 4.3897694002 2.39503 2.3950394003 1.73219 1.7321994004 1.25920 1.2592094005 2.35708 2.3570894010 0.82813 0.8281394010 26 0.22087 0.2208794010 TC 0.60726 0.6072694011 2.56356 2.5635694012 3.94264 3.9426494013 0.83526 0.8352694014 1.23098 1.2309894014 26 .74000 .7400094014 TC .45000 .4500094015 0.57166 0.5716694015 26 .74000 .7400094015 TC .45000 .4500094016 0.65932 0.6593294060 1.42715 1.4271594060 26 0.39269 0.3926994060 TC 1.03446 1.0344694070 1.46218 1.4621894070 26 0.75702 0.7570294070 TC 0.70516 0.7051694150 0.57063 0.5706394150 26 0.10577 0.1057794150 TC 0.46486 0.4648694200 0.56505 0.5650594200 26 0.14469 0.1446994200 TC 0.42036 0.4203694250 0.60065 0.6006594250 26 0.14469 0.1446994250 TC 0.45596 0.4559694375 0.93765 0.9376594375 26 0.39269 0.3926994375 TC 0.54496 0.5449694400 1.28332 1.2833294400 26 0.49806 0.4980694400 TC 0.78526 0.7852694450 1.35452 1.35452

Page 164 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

94450 26 0.49806 0.4980694450 TC 0.85646 0.8564694452 1.36485 1.3648594452 26 0.38379 0.3837994452 TC 0.98106 0.9810694453 1.83512 1.8351294453 26 0.49806 0.4980694453 TC 1.33706 1.3370694610 1.53948 1.5394894620 1.65240 1.6524094620 26 0.81374 0.8137494620 TC 0.83866 0.8386694621 3.99076 3.9907694621 26 1.84380 1.8438094621 TC 2.14696 2.1469694640 0.34026 0.3402694642 .47850 .4785094644 0.86536 0.8653694645 0.32246 0.3224694660 0.97022 1.4686294662 0.96132 0.9613294664 0.34916 0.3491694667 0.48266 0.4826694668 0.47376 0.4737694669 0.88316 0.8831694680 1.38740 1.3874094680 26 0.33514 0.3351494680 TC 1.05226 1.0522694681 1.41802 1.4180294681 26 0.25896 0.2589694681 TC 1.15906 1.1590694690 1.20253 1.2025394690 26 0.09687 0.0968794690 TC 1.10566 1.1056694726 1.43396 1.4339694726 26 0.34404 0.3440494726 TC 1.08992 1.0899294727 1.12930 1.1293094727 26 0.34404 0.3440494727 TC 0.78526 0.7852694728 1.12930 1.1293094728 26 0.34404 0.3440494728 TC 0.78526 0.7852694729 1.41553 1.4155394729 26 0.22977 0.2297794729 TC 1.18576 1.1857694750 1.76761 1.7676194750 26 0.28815 0.2881594750 TC 1.47946 1.4794694760 0.06436 0.0643694761 0.09996 0.09996

Page 165 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

94762 0.55386 0.5538694770 0.86207 0.8620794770 26 0.19251 0.1925194770 TC 0.66956 0.6695694772 1.83548 1.8354894772 26 1.10129 1.1012994772 TC .73419 .7341994780 0.66012 1.3721294781 0.22977 0.5323795004 0.14529 0.1452995012 0.47376 0.4737695017 0.10577 2.2506795018 0.20058 0.7790895024 0.17199 0.1719995027 0.11859 0.1185995028 0.27796 0.2779695044 0.14446 0.1444695052 0.16226 0.1622695056 0.88316 0.8831695060 0.60726 0.6072695065 0.53606 0.5360695070 0.95436 0.9543695071 1.17686 1.1768695076 2.00380 3.1786095079 1.85144 2.2697495115 0.24236 0.2423695117 0.29576 0.2957695120 .21710 .2171095125 .20367 .2036795130 .89310 .8931095131 1.24400 1.2440095132 1.43540 1.4354095133 1.61610 1.6161095134 1.79690 1.7969095144 0.08714 0.2918495145 0.08714 0.3808495146 0.08714 0.6211495147 0.08714 0.6033495148 0.08714 0.8525495149 0.08714 1.1106495165 0.08714 0.3007495170 0.08714 0.2295495180 2.79579 3.6056995250 3.22386 3.2238695251 1.10229 1.1022995782 28.17704 28.1770495782 26 3.57390 3.5739095782 TC 24.60314 24.6031495783 29.52157 29.5215795783 26 3.89971 3.8997195783 TC 25.62186 25.62186

Page 166 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

95800 34.46035 34.4603595800 26 1.61729 1.6172995800 TC 32.84306 32.8430695801 58.27260 58.2726095801 26 1.43514 1.4351495801 TC 56.83746 56.8374695803 3.00360 3.0036095803 26 1.30164 1.3016495803 TC 1.70196 1.7019695805 9.72428 9.7242895805 26 2.41120 2.4112095805 TC 7.31308 7.3130895806 5.08280 5.0828095806 26 2.13278 2.1327895806 TC 2.95002 2.9500295807 11.73456 11.7345695807 26 2.11498 2.1149895807 TC 9.61958 9.6195895808 16.39751 16.3975195808 26 3.39593 3.3959395808 TC 13.00158 13.0015895810 18.89876 18.8987695810 26 4.48002 4.4800295810 TC 14.41874 14.4187495811 20.82783 20.8278395811 26 4.80503 4.8050395811 TC 16.02280 16.0228095812 6.56340 6.5634095812 26 1.42398 1.4239895812 TC 5.13942 5.1394295813 7.90513 7.9051395813 26 2.27415 2.2741595813 TC 5.63098 5.6309895816 6.02940 6.0294095816 26 1.42398 1.4239895816 TC 4.60542 4.6054295819 6.60996 6.6099695819 26 1.42398 1.4239895819 TC 5.18598 5.1859895822 6.35870 6.3587095822 26 1.42398 1.4239895822 TC 4.93472 4.9347295824 1.48450 1.4845095824 26 0.99526 0.9952695824 TC .39630 .3963095827 11.16610 11.1661095827 26 1.42398 1.4239895827 TC 9.74212 9.7421295829 32.26716 32.2671695829 26 8.09542 8.0954295829 TC 24.17174 24.17174

Page 167 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

95830 2.27100 4.6651095831 0.38336 0.6859695832 0.41295 0.6621595833 0.61067 0.9043795834 0.77482 1.1130295851 0.21114 0.4247495852 0.15359 0.3404995857 0.73547 1.1181795860 2.13492 2.1349295860 26 1.29626 1.2962695860 TC 0.83866 0.8386695861 3.11072 3.1107295861 26 2.06736 2.0673695861 TC 1.04336 1.0433695863 3.73853 3.7385395863 26 2.49047 2.4904795863 TC 1.24806 1.2480695864 4.16679 4.1667995864 26 2.66063 2.6606395864 TC 1.50616 1.5061695865 2.92425 2.9242595865 26 2.12119 2.1211995865 TC 0.80306 0.8030695866 2.46365 2.4636595866 26 1.68729 1.6872995866 TC 0.77636 0.7763695867 1.86955 1.8695595867 26 1.05759 1.0575995867 TC 0.81196 0.8119695868 2.55368 2.5536895868 26 1.57262 1.5726295868 TC 0.98106 0.9810695869 1.26303 1.2630395869 26 0.49557 0.4955795869 TC 0.76746 0.7674695870 1.22743 1.2274395870 26 0.49557 0.4955795870 TC 0.73186 0.7318695872 4.44264 4.4426495872 26 3.73748 3.7374895872 TC 0.70516 0.7051695873 1.26303 1.2630395873 26 0.52227 0.5222795873 TC 0.74076 0.7407695874 1.20073 1.2007395874 26 0.50447 0.5044795874 TC 0.69626 0.6962695875 2.45120 2.4512095875 26 1.46124 1.4612495875 TC 0.98996 0.9899695885 1.49277 1.49277

Page 168 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

95885 26 0.49391 0.4939195885 TC 0.99886 0.9988695886 2.37190 2.3719095886 26 1.31964 1.3196495886 TC 1.05226 1.0522695887 2.10487 2.1048795887 26 1.03481 1.0348195887 TC 1.07006 1.0700695905 1.88617 1.8861795905 26 0.07741 0.0774195905 TC 1.80876 1.8087695907 2.56956 2.5695695907 26 1.44198 1.4419895907 TC 1.12758 1.1275895908 3.17087 3.1708795908 26 1.81189 1.8118995908 TC 1.35898 1.3589895909 3.80094 3.8009495909 26 2.16194 2.1619495909 TC 1.63900 1.6390095910 5.00562 5.0056295910 26 2.89286 2.8928695910 TC 2.11276 2.1127695911 6.05900 6.0590095911 26 3.60392 3.6039295911 TC 2.45508 2.4550895912 7.11238 7.1123895912 26 4.33484 4.3348495912 TC 2.77754 2.7775495913 8.24194 8.2419495913 26 5.13098 5.1309895913 TC 3.11096 3.1109695921 1.91428 1.9142895921 26 1.17352 1.1735295921 TC 0.74076 0.7407695922 2.30196 2.3019695922 26 1.24970 1.2497095922 TC 1.05226 1.0522695923 3.13564 3.1356495923 26 1.19338 1.1933895923 TC 1.94226 1.9422695924 4.01583 4.0158395924 26 2.42067 2.4206795924 TC 1.59516 1.5951695925 3.23926 3.2392695925 26 0.71644 0.7164495925 TC 2.52282 2.5228295926 3.16806 3.1680695926 26 0.71644 0.7164495926 TC 2.45162 2.4516295927 3.09686 3.09686

Page 169 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

95927 26 0.72534 0.7253495927 TC 2.37152 2.3715295928 5.13182 5.1318295928 26 1.97710 1.9771095928 TC 3.15472 3.1547295929 5.41662 5.4166295929 26 1.98600 1.9860095929 TC 3.43062 3.4306295930 2.80107 2.8010795930 26 0.46721 0.4672195930 TC 2.33386 2.3338695933 1.68385 1.6838595933 26 0.78289 0.7828995933 TC 0.90096 0.9009695937 1.49715 1.4971595937 26 0.88099 0.8809995937 TC 0.61616 0.6161695938 7.81990 7.8199095938 26 1.21882 1.2188295938 TC 6.60108 6.6010895939 12.32165 12.3216595939 26 3.20871 3.2087195939 TC 9.11294 9.1129495940 0.88368 0.8836895950 6.19175 6.1917595950 26 1.98683 1.9868395950 TC 4.20492 4.2049295951 21.10316 21.1031695951 26 8.07197 8.0719795951 TC 12.63676 12.6367695953 10.55554 10.5555495953 26 4.34812 4.3481295953 TC 6.20742 6.2074295954 6.67851 6.6785195954 26 2.99663 2.9966395954 TC 3.68188 3.6818895955 3.61853 3.6185395955 26 1.32027 1.3202795955 TC 2.29826 2.2982695956 18.06742 18.0674295956 26 4.06080 4.0608095956 TC 14.00662 14.0066295957 7.18718 7.1871895957 26 2.61736 2.6173695957 TC 4.56982 4.5698295958 10.31250 10.3125095958 26 5.59822 5.5982295958 TC 4.71428 4.7142895961 5.91177 5.9117795961 26 3.96061 3.9606195961 TC 1.95116 1.95116

Page 170 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

95962 5.50655 5.5065595962 26 4.24069 4.2406995962 TC 1.26586 1.2658695965 26 10.91967 10.9196795966 26 5.46935 5.4693595967 26 4.70967 4.7096795970 0.59533 1.3340395971 1.05404 1.4545495972 2.02506 2.6658695973 1.21902 1.4860295974 4.00628 4.6114895975 2.27784 2.5092495978 4.78722 5.5615295979 2.22152 2.4618295980 1.15912 1.1591295981 0.42952 0.7232295982 0.89195 1.1767595990 1.56162 1.5616295991 0.99091 2.3704195992 1.00499 1.1028996000 2.32858 2.3285896001 2.76225 2.7622596002 0.54545 0.5454596003 0.47983 0.4798396004 2.93258 2.9325896020 26 4.71977 4.7197796040 0.99886 0.9988696101 2.20278 2.2116896102 0.62618 1.3559896103 0.64275 1.2746596105 1.84848 1.8484896110 0.18006 0.1800696111 3.36442 3.4534296116 2.30480 2.4294096118 2.19388 2.6477896119 0.66387 1.7229796120 0.63385 1.8442596125 2.10940 2.4654096150 0.58646 0.5953696151 0.56700 0.5759096152 0.53864 0.5475496153 0.12606 0.1349696154 0.52891 0.5378196155 0.59244 0.5924496360 1.34433 1.3443396361 0.38333 0.3833396365 1.67011 1.6701196366 0.52430 0.5243096367 0.81883 0.8188396368 0.48787 0.4878796369 3.61715 3.61715

Page 171 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

96370 0.38190 0.3819096371 1.86216 1.8621696372 0.54127 0.5412796373 0.46117 0.4611796374 1.31846 1.3184696375 0.55326 0.5532696401 1.66599 1.6659996402 0.88113 0.8811396405 0.75928 2.0764896406 1.12278 2.8938896409 2.68036 2.6803696411 1.50702 1.5070296413 3.50454 3.5045496415 0.76543 0.7654396416 3.81913 3.8191396417 1.73035 1.7303596420 2.58967 2.5896796422 4.13827 4.1382796423 1.88929 1.8892996425 4.16703 4.1670396440 3.75011 16.4148196446 0.60583 4.6998396450 2.28153 5.0494396521 3.07837 3.0783796522 2.61557 2.6155796523 0.61058 0.6105896542 1.14533 3.1834396567 2.90346 2.9034696570 1.56878 1.5687896571 0.72823 0.7282396900 0.47376 0.4737696902 0.54545 0.5632596904 1.55066 1.5506696910 1.54176 1.5417696912 1.96896 1.9689696913 2.72546 2.7254696920 1.70363 4.0888396921 1.70735 4.0658596922 3.06136 5.9805697001 1.85224 1.8522497002 0.99732 0.9973297003 1.98780 1.9878097004 1.15752 1.1575297010 0.13164 0.1316497012 0.38771 0.3877197014 0.35520 0.3552097016 0.40860 0.4086097018 0.21174 0.2117497022 0.47007 0.4700797024 0.14944 0.1494497026 0.13164 0.13164

Page 172 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

97028 0.16890 0.1689097032 0.43221 0.4322197033 0.65554 0.6555497034 0.40219 0.4021997035 0.31319 0.3131997036 0.69486 0.6948697039 0.29825 0.2982597110 0.74251 0.7425197112 0.78017 0.7801797113 0.91968 0.9196897116 0.65826 0.6582697124 0.60071 0.6007197139 0.39755 0.3975597140 0.69635 0.6963597150 0.47837 0.4783797530 0.79508 0.7950897532 0.64378 0.6437897533 0.69718 0.6971897535 0.79591 0.7959197537 0.71581 0.7158197542 0.72471 0.7247197545 .68050 .6805097546 .34020 .3402097597 0.81288 1.5782897598 1.10020 1.9635097605 0.73441 0.9747197606 0.81388 1.0541897750 0.77127 0.7712797755 0.89218 0.8921897760 0.85137 0.8513797761 0.76237 0.7623797762 0.89501 0.8950197802 0.73341 0.7690197803 0.62887 0.6733797804 0.34321 0.3432197810 0.81248 0.9281897811 0.67958 0.7151897813 0.87893 0.9946397814 0.74603 0.8083398925 0.58437 0.7445798926 0.85223 1.0302398927 1.12175 1.3442598928 1.32193 1.5622398929 1.53307 1.8000798940 0.54450 0.6404498941 0.79828 0.8942298942 1.06911 1.1650598943 0.53572 0.6158298960 0.58946 0.5894698961 0.28686 0.2868698962 0.21566 0.21566

Page 173 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

98966 0.32541 0.3610198967 0.67958 0.7062898968 1.00499 1.0316999001 .30830 .3083099002 .31900 .3190099024 .23633 .2363399050 .72000 .7200099051 0.72000 0.7200099053 0.72000 0.7200099056 .60610 .6061099058 .72000 .7200099060 0.72000 0.7200099071 .15808 .1580899075 1.53110 1.5311099078 1.22745 1.2274599080 .22330 .2233099082 1.53110 1.5311099090 .60610 .6061099091 1.47426 1.4742699170 2.48669 3.6436999173 0.06436 0.0643699174 0.63396 0.6339699175 0.55386 0.5538699183 3.08820 5.0373099190 3.38110 3.3811099191 2.08400 2.0840099192 1.55230 1.5523099195 1.82384 1.8238499201 0.66012 1.0072299202 1.28215 1.7538599203 1.93626 2.5503699204 3.26955 3.9726599205 4.23811 5.0035199211 0.23950 0.4887099212 0.65122 1.0072299213 1.28341 1.7106199214 1.98328 2.5706899215 2.79659 3.4729999217 1.79180 1.7918099218 1.69596 1.6959699219 2.80592 2.8059299220 3.92601 3.9260199221 2.53574 2.5357499222 3.43373 3.4337399223 5.04298 5.0429899224 0.78286 0.7828699225 1.38048 1.3804899226 2.06730 2.0673099231 1.01472 1.0147299232 1.82969 1.8296999233 2.62520 2.62520

Page 174 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

99234 3.43848 3.4384899235 4.50995 4.5099599236 5.59238 5.5923899238 1.79180 1.7918099239 2.61278 2.6127899241 0.89112 1.2649299242 1.86732 2.3924299243 2.60362 3.2711299244 4.12842 4.8582299245 5.12657 5.9453799251 1.31260 1.3126099252 2.02094 2.0209499253 3.07687 3.0768799254 4.43835 4.4383599255 5.37088 5.3708899281 0.55973 0.5597399282 1.08014 1.0801499283 1.64960 1.6496099284 3.10028 3.1002899285 4.57932 4.5793299288 2.88140 2.8814099291 5.75610 6.7974099292 2.87257 3.0861799304 2.25712 2.2571299305 3.16979 3.1697999306 4.05164 4.0516499307 1.07496 1.0749699308 1.65518 1.6551899309 2.19007 2.1900799310 3.24165 3.2416599315 1.57259 1.5725999316 2.06132 2.0613299318 2.30125 2.3012599324 1.43803 1.4380399325 2.10064 2.1006499326 3.52711 3.5271199327 4.59898 4.5989899328 5.39409 5.3940999334 1.50531 1.5053199335 2.34864 2.3486499336 3.30624 3.3062499337 4.75340 4.7534099339 1.95841 1.9584199340 2.75784 2.7578499341 1.44899 1.4489999342 2.09174 2.0917499343 3.41407 3.4140799344 4.51224 4.5122499345 5.43175 5.4317599347 1.41940 1.4194099348 2.14846 2.14846

Page 175 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

99349 3.15305 3.1530599350 4.37728 4.3772899354 2.34389 2.4684999355 2.32815 2.4616599356 2.27661 2.2766199357 2.27661 2.2766199358 2.84916 2.8491699359 1.36600 1.3660099360 1.60716 1.6071699363 2.20043 3.1082399364 0.84167 1.0730799366 1.09090 1.1087099374 1.48316 1.7679699375 2.48503 2.7609399377 1.48316 1.7679699378 2.54733 2.8321399379 1.48316 1.7679699380 2.33373 2.6719399381 1.59743 2.3539399382 1.82720 2.5837099383 1.82720 2.5659099384 2.06587 2.7956799385 2.06587 2.7956799386 2.52418 3.2717899387 2.77258 3.6002899391 1.36766 1.9817699392 1.59743 2.2115399393 1.59743 2.2026399394 1.82720 2.4324099395 1.82720 2.4413099396 2.06587 2.6710799397 2.31427 3.0084799401 0.64026 0.9161699402 1.31984 1.6046499403 1.96010 2.2538099404 2.62995 2.9236599406 0.31568 0.3512899407 0.65082 0.6775299408 0.87003 0.9056399409 1.75102 1.7866299411 0.20141 0.3794199412 0.33431 0.5123199420 0.23346 0.2334699441 0.32541 0.3610199442 0.67958 0.7062899443 1.00499 1.0316999450 .91440 .9144099455 1.46730 1.4673099456 1.46730 1.4673099460 1.53347 1.5334799461 1.68334 2.25294

Page 176 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

99462 0.81414 0.8141499463 2.06338 2.0633899464 1.92988 1.9298899465 3.91419 3.9141999466 6.27651 6.2765199467 3.15202 3.1520299468 23.62666 23.6266699469 10.31307 10.3130799471 20.67270 20.6727099472 10.33977 10.3397799475 14.26767 14.2676799476 8.56019 8.5601999477 9.02042 9.0204299478 3.69249 3.6924999479 3.27808 3.2780899480 3.14312 3.1431299485 2.08118 2.0811899486 1.81538 1.8153899487 2.24026 2.2402699489 1.12458 1.1245899495 3.72837 4.4937799496 5.46525 6.33745G0008 0.56840 0.56840G0009 0.56840 0.56840G0010 .09004 .09004G0101 0.90477 0.90477G0102 0.22977 0.47897G0104 1.55164 3.19814G0105 5.47321 9.42481G0105 53 1.54068 3.18718G0106 4.93201 4.93201G0106 26 1.31655 1.31655G0106 TC 3.61546 3.61546G0108 0.58056 0.58056G0109 0.32246 0.32246G0117 1.17177 1.17177G0118 0.80827 0.80827G0120 4.93201 4.93201G0120 26 1.31655 1.31655G0120 TC 3.61546 3.61546G0121 5.48417 9.43577G0121 53 1.57356 3.22006G0122 6.03561 6.03561G0122 26 1.30765 1.30765G0122 TC 4.72796 4.72796G0124 0.71538 0.71538G0124 26 .60000 .60000G0127 0.22087 0.49677G0128 0.22230 0.22230G0130 0.79668 0.79668G0130 26 0.28732 0.28732

Page 177 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

G0130 TC 0.50936 0.50936G0141 0.71538 0.71538G0151 .24870 .24870G0152 .24870 .24870G0153 .24870 .24870G0154 .24870 .24870G0155 .24870 .24870G0156 .11710 .11710G0166 3.59457 3.59457G0168 0.67543 1.99263G0179 1.00267 1.00267G0180 1.34545 1.34545G0181 2.66987 2.66987G0182 2.71437 2.71437G0202 3.25254 3.25254G0202 26 0.92758 0.92758G0202 TC 2.32496 2.32496G0204 3.88281 3.88281G0204 26 1.15735 1.15735G0204 TC 2.72546 2.72546G0206 3.06564 3.06564G0206 26 0.92758 0.92758G0206 TC 2.13806 2.13806G0219 54.77243 54.77243G0219 26 2.02658 2.02658G0219 TC 52.74585 52.74585G0237 0.24236 0.24236G0238 0.26016 0.26016G0239 0.27796 0.27796G0245 1.21158 1.68328G0246 0.61107 0.96707G0247 0.67068 1.10678G0248 3.42856 3.42856G0249 2.98356 2.98356G0250 0.25730 0.25730G0252 55.01568 55.01568G0252 26 2.08118 2.08118G0252 TC 52.98010 52.98010G0268 0.82905 1.23845G0270 0.62887 0.67337G0271 0.34321 0.34321G0278 0.36101 0.36101G0281 0.31070 0.31070G0283 0.31070 0.31070G0288 2.50296 2.50296G0289 2.28430 2.28430G0329 0.21174 0.21174G0337 1.92118 1.92118G0341 20.04454 20.04454G0342 17.34656 17.34656G0343 28.99855 28.99855

Page 178 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

G0364 0.22894 0.30904G0365 4.72819 4.72819G0365 26 0.33843 0.33843G0365 TC 4.38976 4.38976G0372 0.22087 0.28317G0389 2.68872 2.68872G0389 26 0.78206 0.78206G0389 TC 1.90666 1.90666G0396 0.82553 0.86113G0397 1.68872 1.72432G0402 3.48942 3.48942G0403 0.48993 0.50773G0404 0.26906 0.26906G0405 0.22087 0.23867G0406 1.01472 1.01472G0407 1.82969 1.82969G0408 2.62520 2.62520G0409 0.21566 0.21566G0412 17.03213 17.03213G0413 25.06017 25.06017G0414 23.73409 23.73409G0415 32.52705 32.52705G0416 15.54057 15.54057G0416 26 4.72501 4.72501G0416 TC 10.81556 10.81556G0420 2.85008 2.85008G0421 0.67546 0.67546G0422 1.26226 1.26226G0423 1.26226 1.26226G0424 0.25936 0.60646G0425 2.64254 2.64254G0426 3.58503 3.58503G0427 5.26548 5.26548G0429 1.87135 2.51215G0436 0.33348 0.38688G0437 0.73298 0.78638G0438 4.44501 4.44501G0439 2.94308 2.94308G0442 0.25730 0.47090G0443 0.64873 0.70213G0444 0.25730 0.47090G0445 0.64873 0.70213G0446 0.64873 0.70213G0447 0.64873 0.70213G0451 0.26016 0.26016G0452 26 0.52639 0.52639G0453 0.73298 0.73298G0454 0.24840 0.24840G0455 3.26061 3.26061G0459 1.29749 1.29749G9157 2.97382 2.97382

Page 179 of 181 Posted 05/2015

Procedure Code Modifier Facility RVU Non-Facility RVU

BCBSNM RVUs effective 5/1/15

G9187 1.21850 1.21850P2038 26 .12110 .12110P3000 26 .07270 .07270P3001 0.71538 0.71538P7001 .56680 .56680P9023 3.51290 3.51290Q0035 0.47213 0.47213Q0035 26 0.22087 0.22087Q0035 TC 0.25126 0.25126Q0091 0.48873 1.04053Q0092 0.44706 0.44706Q0144 .47660 .47660