156
Ryan White Part A Outpatient Medical Billing Rates CPT Code Fee Allowable Units 10021 $238.25 1 10022 $225.54 1 10030 $1,224.81 10040 $161.55 1 10060 $185.30 1 10061 $330.24 1 10080 $285.27 1 10081 $429.23 1 10120 $242.19 1 10121 $438.41 1 10140 $259.65 1 10160 $207.71 1 10180 $400.80 1 11000 $85.95 1 11001 $32.85 1 11004 $981.93 1 11005 $1,343.10 1 11006 $1,190.13 1 11008 $473.19 1 11010 $790.50 1 11011 $854.10 1 11012 $1,151.66 1 11042 $185.63 1 11043 $368.31 1 11044 $512.97 1 11045 $66.41 1 11046 $118.94 1 11047 $204.60 1 11055 $74.75 1 11056 $91.44 1 11057 $102.62 1 11100 $163.68 1 11101 $52.01 6 11200 $139.91 1 11201 $29.91 1 11300 $152.97 1 11301 $189.32 1 11302 $223.32 1 11303 $246.38 1 11305 $154.49 1 11306 $191.61 1 11307 $226.94 1 11308 $238.13 1 11310 $179.16 1 11311 $176.84 1 3/1/2015 1 of 156

A Outpatient Medical Allowable CPT Code Fee Units · PDF fileRyan White Part A Outpatient Medical Billing Rates CPT Code Fee Allowable Units 10021 $238.25 1 10022 $225.54 1 10030 $1,224.81

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Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

10021 $238.25 1

10022 $225.54 1

10030 $1,224.81

10040 $161.55 1

10060 $185.30 1

10061 $330.24 1

10080 $285.27 1

10081 $429.23 1

10120 $242.19 1

10121 $438.41 1

10140 $259.65 1

10160 $207.71 1

10180 $400.80 1

11000 $85.95 1

11001 $32.85 1

11004 $981.93 1

11005 $1,343.10 1

11006 $1,190.13 1

11008 $473.19 1

11010 $790.50 1

11011 $854.10 1

11012 $1,151.66 1

11042 $185.63 1

11043 $368.31 1

11044 $512.97 1

11045 $66.41 1

11046 $118.94 1

11047 $204.60 1

11055 $74.75 1

11056 $91.44 1

11057 $102.62 1

11100 $163.68 1

11101 $52.01 6

11200 $139.91 1

11201 $29.91 1

11300 $152.97 1

11301 $189.32 1

11302 $223.32 1

11303 $246.38 1

11305 $154.49 1

11306 $191.61 1

11307 $226.94 1

11308 $238.13 1

11310 $179.16 1

11311 $176.84 1

3/1/2015 1 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

11312 $253.85 1

11313 $294.66 1

11400 $196.86 1

11401 $237.12 1

11402 $264.27 1

11403 $307.83 1

11404 $349.38 1

11406 $510.60 1

11420 $193.52 1

11421 $249.89 1

11422 $280.11 1

11423 $324.42 1

11424 $376.22 1

11426 $542.64 1

11440 $212.64 1

11441 $268.58 1

11442 $300.41 1

11443 $359.13 1

11444 $452.96 1

11446 $632.64 1

11450 $621.38 1

11451 $785.51 1

11462 $599.82 1

11463 $800.04 1

11470 $665.46 1

11471 $818.82 1

11600 $305.79 1

11601 $363.63 1

11602 $393.32 1

11603 $451.91 1

11604 $504.00 1

11606 $727.85 1

11620 $309.45 1

11621 $366.20 1

11622 $408.00 1

11623 $480.89 1

11624 $543.41 1

11626 $660.75 1

11640 $318.24 1

11641 $378.57 1

11642 $431.97 1

11643 $512.61 1

11644 $635.04 1

11646 $835.58 1

11719 $21.65 1

3/1/2015 2 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

11720 $50.49 1

11721 $69.84 1

11730 $154.92 1

11732 $56.19 4

11740 $77.85 1

11750 $351.53 1

11752 $519.09 1

11755 $209.82 1

11760 $362.87 1

11762 $447.86 1

11765 $262.64 1

11770 $449.01 1

11771 $939.30 1

11772 $1,141.28 1

11900 $87.54 1

11901 $110.30 1

11920 $274.34 1

11921 $317.64 1

11922 $97.35 1

11950 $125.88 1

11951 $172.08 1

11952 $209.01 1

11954 $257.00 1

11960 $1,540.43 1

11970 $997.91 1

11971 $751.46 1

11976 $228.95 1

11980 $149.58 1

11981 $229.05 1

11982 $259.32 1

11983 $359.99 1

12001 $142.46 1

12002 $174.74 1

12004 $206.48 1

12005 $268.22 1

12006 $320.57 1

12007 $374.99 1

12011 $175.04 1

12013 $192.11 1

12014 $228.00 1

12015 $275.94 1

12016 $344.04 1

12017 $258.53 1

12018 $294.29 1

12020 $449.94 1

3/1/2015 3 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

12021 $265.22 1

12031 $376.44 1

12032 $480.56 1

12034 $498.24 1

12035 $612.65 1

12036 $677.57 1

12037 $780.35 1

12041 $384.39 1

12042 $459.14 1

12044 $572.84 1

12045 $648.33 1

12046 $786.06 1

12047 $897.92 1

12051 $409.98 1

12052 $468.03 1

12053 $550.40 1

12054 $586.88 1

12055 $762.39 1

12056 $803.25 1

12057 $937.46 1

13100 $532.44 1

13101 $628.86 1

13102 $196.31 3

13120 $556.94 1

13121 $677.96 1

13122 $214.95 3

13131 $613.58 1

13132 $759.56 1

13133 $287.75 3

13151 $674.82 1

13152 $809.10 1

13153 $313.22 2

13160 $1,343.04 1

14000 $1,002.23 1

14001 $1,293.66 1

14020 $1,118.52 1

14021 $1,400.79 1

14040 $1,222.53 1

14041 $1,512.80 1

14060 $1,247.85 1

14061 $1,627.20 1

14301 $1,741.11 1

14302 $369.95 1

14350 $1,123.22 1

15002 $561.39 1

3/1/2015 4 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

15003 $123.54 1

15004 $646.64 1

15005 $203.82 1

15040 $409.04 1

15050 $913.86 1

15100 $1,403.24 1

15101 $302.31 20

15110 $1,335.59 1

15111 $196.22 1

15115 $1,346.90 1

15116 $277.49 1

15120 $1,381.31 1

15121 $337.77 20

15130 $1,108.41 1

15131 $155.55 4

15135 $1,361.85 1

15136 $157.40 4

15150 $1,167.77 1

15151 $205.55 2

15152 $254.27 4

15155 $1,098.57 1

15156 $278.16 2

15157 $250.19 4

15200 $1,343.15 1

15201 $238.71 10

15220 $1,240.65 1

15221 $220.70 10

15240 $1,503.53 1

15241 $298.59 10

15260 $1,623.63 1

15261 $344.96 10

15271 $226.64 1

15272 $43.85 1

15273 $484.31 1

15274 $116.18 1

15275 $238.26 1

15276 $54.62 1

15277 $526.40 1

15278 $139.05 1

15570 $1,482.11 1

15572 $1,436.60 1

15574 $1,479.12 1

15576 $1,296.78 1

15600 $515.45 1

15610 $569.67 1

3/1/2015 5 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

15620 $703.40 1

15630 $736.56 1

15650 $815.72 1

15731 $1,835.34 1

15732 $2,072.43 1

15734 $2,478.21 1

15736 $2,160.96 1

15738 $2,303.91 1

15740 $1,643.25 1

15750 $1,525.32 1

15756 $3,858.83 1

15757 $3,816.33 1

15758 $3,810.66 1

15760 $1,373.88 1

15770 $1,102.43 1

15775 $461.88 1

15776 $774.33 1

15777 $359.40 1

15780 $1,362.45 1

15781 $887.49 1

15782 $1,023.23 1

15783 $771.93 1

15786 $383.69 1

15787 $76.44 1

15788 $726.17 1

15789 $887.31 1

15792 $683.27 1

15793 $782.61 1

15819 $1,299.84 1

15820 $901.17 1

15821 $960.63 1

15822 $707.72 1

15823 $957.74 1

15824 $0.00 1

15825 $0.00 1

15826 $0.00 1

15828 $0.00 1

15829 $0.00 1

15830 $1,945.40 1

15832 $1,505.07 1

15833 $1,432.04 1

15834 $1,458.48 1

15835 $1,539.83 1

15836 $1,295.12 1

15837 $1,465.62 1

3/1/2015 6 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

15838 $934.37 1

15839 $1,435.41 1

15840 $1,646.91 1

15841 $2,640.17 1

15842 $4,037.52 1

15845 $1,607.75 1

15851 $156.60 1

15852 $79.26 1

15860 $186.50 1

15876 $0.00 1

15877 $0.00 1

15878 $0.00 1

15879 $0.00 1

15920 $1,001.66 1

15922 $1,281.68 1

15931 $1,153.97 1

15933 $1,412.88 1

15934 $1,557.08 1

15935 $1,830.44 1

15936 $1,480.05 1

15937 $1,709.58 1

15940 $1,167.03 1

15941 $1,492.70 1

15944 $1,479.95 1

15945 $1,607.10 1

15946 $2,711.43 1

15950 $983.66 1

15951 $1,441.58 1

15952 $1,482.75 1

15953 $1,634.46 1

15956 $1,908.90 1

15958 $1,948.74 1

16000 $110.33 1

16020 $130.32 1

16025 $239.69 1

16030 $295.85 1

16035 $322.25 1

16036 $136.77 1

17000 $104.90 1

17003 $9.14 13

17004 $237.71 1

17106 $545.88 1

17107 $689.75 1

17108 $1,031.72 1

17110 $173.79 1

3/1/2015 7 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

17111 $206.87 1

17250 $125.15 1

17260 $150.36 1

17261 $227.64 1

17262 $277.43 1

17263 $303.06 1

17264 $326.57 1

17266 $369.38 1

17270 $239.19 1

17271 $259.91 1

17272 $295.35 1

17273 $330.62 1

17274 $389.40 1

17276 $450.66 1

17280 $223.22 1

17281 $282.36 1

17282 $325.11 1

17283 $388.59 1

17284 $445.95 1

17286 $576.63 1

17311 $1,050.03 1

17312 $616.11 1

17313 $981.83 1

17314 $590.18 1

17315 $126.93 1

17340 $83.27 1

17360 $205.16 1

17380 $0.00 1

19000 $180.02 1

19001 $43.70 1

19020 $765.48 1

19030 $263.60 1

19081 $1,048.68

19082 $857.25

19083 $1,032.21

19084 $825.00

19085 $1,632.53

19086 $1,290.42

19100 $247.07 1

19101 $557.46 1

19105 $3,925.16 1

19110 $792.84 1

19112 $753.54 1

19120 $817.50 1

19125 $911.07 1

3/1/2015 8 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

19126 $279.53 1

19260 $2,035.38 1

19271 $2,741.73 1

19272 $3,013.44 1

19281 $379.40

19282 $265.74

19283 $431.88

19284 $319.34

19285 $701.39

19286 $595.59

19287 $1,376.52

19288 $1,099.80

19296 $6,153.09 1

19297 $163.29 1

19298 $1,660.94 1

19300 $859.92 1

19301 $1,105.62 1

19302 $1,526.90 1

19303 $1,714.44 1

19304 $964.82 1

19305 $1,909.40 1

19306 $2,032.59 1

19307 $2,028.38 1

19316 $1,274.99 1

19318 $1,818.09 1

19324 $826.19 1

19325 $1,054.89 1

19328 $814.22 1

19330 $1,043.99 1

19340 $1,651.82 1

19342 $1,515.56 1

19350 $1,337.69 1

19355 $1,169.37 1

19357 $2,465.19 1

19361 $2,601.84 1

19364 $4,568.33 1

19366 $2,344.83 1

19367 $2,959.76 1

19368 $3,646.83 1

19369 $3,383.85 1

19370 $1,126.94 1

19371 $1,290.50 1

19380 $1,270.76 1

19396 $467.69 1

20005 $498.36 1

3/1/2015 9 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

20100 $1,031.96 1

20101 $734.42 1

20102 $798.02 1

20103 $940.92 1

20150 $1,456.26 1

20200 $337.73 1

20205 $474.92 1

20206 $372.75 1

20220 $266.97 1

20225 $830.01 1

20240 $356.88 1

20245 $1,019.94 1

20250 $671.91 1

20251 $718.01 1

20500 $167.70 1

20501 $186.96 1

20520 $327.08 1

20525 $775.35 1

20526 $125.90 1

20527 $137.58 1

20550 $94.91 2

20551 $97.11 1

20552 $87.32 1

20553 $101.36 1

20555 $546.38 1

20600 $76.08 1

20604 $115.49

20605 $79.37 1

20606 $128.19

20610 $97.23 1

20611 $149.21

20612 $97.74 1

20615 $396.35 1

20650 $331.98 1

20660 $439.61 1

20661 $870.44 1

20662 $775.52 1

20663 $644.01 1

20664 $1,553.93 1

20665 $166.47 1

20670 $605.48 1

20680 $1,003.44 1

20690 $996.26 1

20692 $1,857.84 1

20693 $739.77 1

3/1/2015 10 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

20694 $693.68 1

20696 $2,026.04 1

20697 $3,313.73 1

20802 $4,668.09 1

20805 $5,435.81 1

20808 $6,583.80 1

20816 $3,487.97 1

20822 $2,978.76 1

20824 $3,382.44 1

20827 $3,062.13 1

20838 $3,425.42 1

20900 $677.16 1

20902 $482.36 1

20910 $749.48 1

20912 $785.42 1

20920 $645.68 1

20922 $1,004.58 1

20924 $842.43 1

20926 $712.22 1

20931 $203.09 1

20937 $293.93 1

20938 $330.92 1

20950 $394.22 1

20955 $4,194.27 1

20956 $4,489.98 1

20957 $3,398.64 1

20962 $3,266.96 1

20969 $4,575.36 1

20970 $4,858.25 1

20972 $3,700.14 1

20973 $4,071.51 1

20974 $125.13 1

20975 $307.50 1

20979 $82.79 1

20982 $5,884.10 1

20983 $10,858.41

20985 $250.59 1

21010 $1,262.01 1

21011 $563.21 1

21012 $561.00 1

21013 $843.57 1

21014 $862.32 1

21015 $1,170.87 1

21016 $1,700.01 1

21025 $1,467.50 1

3/1/2015 11 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

21026 $1,009.94 1

21029 $1,247.72 1

21030 $848.82 1

21031 $644.28 1

21032 $653.42 1

21034 $2,177.19 1

21040 $856.92 1

21044 $1,456.56 1

21045 $2,031.96 1

21046 $1,856.22 1

21047 $2,201.00 1

21048 $1,906.05 1

21049 $2,006.69 1

21050 $1,395.63 1

21060 $1,345.92 1

21070 $1,023.62 1

21073 $644.40 1

21076 $1,668.44 1

21077 $4,187.97 1

21079 $2,814.39 1

21080 $3,146.91 1

21081 $2,913.69 1

21082 $2,758.22 1

21083 $2,625.24 1

21084 $3,005.61 1

21085 $1,261.10 1

21086 $3,111.09 1

21087 $3,111.09 1

21100 $1,860.56 1

21110 $1,316.99 1

21116 $236.40 1

21120 $975.38 1

21121 $1,309.97 1

21122 $1,025.94 1

21123 $1,238.24 1

21125 $5,018.97 1

21127 $6,932.61 1

21137 $1,175.04 1

21138 $1,411.43 1

21139 $1,855.46 1

21141 $2,242.68 1

21142 $2,395.65 1

21143 $2,419.62 1

21145 $2,718.75 1

21146 $2,831.04 1

3/1/2015 12 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

21147 $2,993.43 1

21150 $2,776.29 1

21151 $3,407.46 1

21154 $3,666.17 1

21155 $3,783.47 1

21159 $3,872.13 1

21160 $4,202.57 1

21172 $2,841.71 1

21175 $4,164.95 1

21179 $2,104.74 1

21180 $2,532.74 1

21181 $1,220.52 1

21182 $3,172.31 1

21183 $3,580.32 1

21184 $4,007.81 1

21188 $2,578.49 1

21193 $1,964.28 1

21194 $2,487.98 1

21195 $2,224.94 1

21196 $2,435.49 1

21198 $1,920.09 1

21199 $1,663.43 1

21206 $2,045.30 1

21208 $3,083.24 1

21209 $1,313.48 1

21210 $3,704.63 1

21215 $6,575.73 1

21230 $1,262.54 1

21235 $1,176.81 1

21240 $1,864.98 1

21242 $1,708.29 1

21243 $2,833.07 1

21244 $1,758.50 1

21245 $1,804.80 1

21246 $1,491.53 1

21247 $2,521.62 1

21248 $1,834.49 1

21249 $2,525.52 1

21255 $2,166.81 1

21256 $1,914.48 1

21260 $1,837.32 1

21261 $3,261.83 1

21263 $3,013.95 1

21267 $2,520.74 1

21268 $3,038.18 1

3/1/2015 13 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

21270 $1,536.75 1

21275 $1,381.82 1

21280 $910.26 1

21282 $610.31 1

21295 $306.09 1

21296 $684.60 1

21310 $208.79 1

21315 $447.98 1

21320 $413.10 1

21325 $774.69 1

21330 $935.58 1

21335 $1,186.49 1

21336 $1,049.46 1

21337 $656.10 1

21338 $1,224.41 1

21339 $1,391.52 1

21340 $1,279.79 1

21343 $1,995.62 1

21344 $2,294.72 1

21345 $1,271.69 1

21346 $1,479.20 1

21347 $1,869.48 1

21348 $1,998.35 1

21355 $786.96 1

21356 $816.54 1

21360 $881.96 1

21365 $1,839.20 1

21366 $1,929.56 1

21385 $1,118.94 1

21386 $1,148.57 1

21387 $1,169.25 1

21390 $1,294.14 1

21395 $1,668.35 1

21400 $312.99 1

21401 $796.31 1

21406 $942.15 1

21407 $1,052.09 1

21408 $1,485.48 1

21421 $1,365.72 1

21422 $1,110.90 1

21423 $1,308.72 1

21431 $1,288.65 1

21432 $1,052.76 1

21433 $2,885.45 1

21435 $2,083.98 1

3/1/2015 14 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

21436 $3,384.02 1

21440 $935.36 1

21445 $1,262.58 1

21450 $1,013.18 1

21451 $1,337.24 1

21452 $926.18 1

21453 $1,491.41 1

21454 $949.25 1

21461 $3,436.35 1

21462 $3,660.26 1

21465 $1,548.65 1

21470 $2,005.13 1

21480 $158.10 1

21485 $1,146.42 1

21490 $1,528.85 1

21495 $1,021.13 1

21497 $1,196.16 1

21501 $737.99 1

21502 $864.00 1

21510 $745.41 1

21550 $422.12 1

21552 $752.67 1

21554 $1,231.80 1

21555 $679.28 1

21556 $884.48 1

21557 $1,608.57 1

21558 $2,267.15 1

21600 $932.07 1

21610 $2,183.99 1

21615 $1,067.91 1

21616 $1,257.59 1

21620 $851.19 1

21627 $910.28 1

21630 $2,001.72 1

21632 $2,062.65 1

21685 $1,641.14 1

21700 $632.16 1

21705 $945.57 1

21720 $790.29 1

21725 $904.01 1

21740 $1,773.87 1

21750 $1,170.39 1

21805 $449.94 1

21811 $1,034.40

21812 $1,240.73

3/1/2015 15 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

21813 $1,687.85

21820 $232.20 1

21825 $913.94 1

21920 $411.62 1

21925 $734.72 1

21930 $776.01 1

21931 $792.74 1

21932 $1,116.81 1

21933 $1,249.65 1

21935 $1,730.34 1

21936 $2,392.79 1

22010 $1,637.69 1

22015 $1,546.74 1

22100 $1,657.89 1

22101 $1,381.95 1

22102 $1,346.04 1

22103 $245.87 1

22110 $1,818.45 1

22112 $2,022.59 1

22114 $1,673.93 1

22116 $250.68 1

22206 $4,275.63 1

22207 $4,164.18 1

22208 $995.72 1

22210 $3,133.52 1

22212 $2,563.16 1

22214 $2,557.04 1

22216 $639.23 1

22220 $2,764.89 1

22222 $2,641.23 1

22224 $2,706.90 1

22226 $634.46 1

22305 $313.44 1

22310 $511.10 1

22315 $1,493.06 1

22318 $2,944.20 1

22319 $3,348.42 1

22325 $2,493.66 1

22326 $2,648.70 1

22327 $2,638.55 1

22328 $508.23 1

22505 $222.53 1

22510 $2,793.59

22511 $2,767.26

22512 $1,555.91

3/1/2015 16 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

22513 $11,575.28

22514 $11,510.42

22515 $6,980.00

22532 $3,115.05 1

22533 $2,828.79 1

22534 $633.78 1

22548 $3,595.44 1

22551 $3,042.21 1

22552 $718.71 1

22554 $2,207.55 1

22556 $2,935.61 1

22558 $2,666.93 1

22585 $583.35 1

22586 $3,662.19 1

22590 $2,812.14 1

22595 $2,686.74 1

22600 $2,274.84 1

22610 $2,209.71 1

22612 $2,761.53 1

22614 $700.25 1

22630 $2,776.29 1

22632 $577.37 1

22633 $3,256.37 1

22634 $885.60 1

22800 $2,332.67 1

22802 $3,621.51 1

22804 $4,215.72 1

22808 $3,234.66 1

22810 $3,518.42 1

22812 $3,754.97 1

22818 $3,693.33 1

22819 $5,060.03 1

22830 $1,404.50 1

22840 $1,354.83 1

22842 $1,358.09 1

22843 $1,452.59 1

22844 $1,736.10 1

22845 $1,315.43 1

22846 $1,364.76 1

22847 $1,374.06 1

22848 $632.85 1

22849 $2,273.87 1

22850 $1,253.21 1

22851 $726.69 1

22852 $1,198.70 1

3/1/2015 17 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

22855 $1,943.94 1

22856 $2,790.84 1

22857 $3,013.07 1

22858 $880.43

22861 $3,292.76 1

22862 $2,832.17 1

22864 $3,818.07 1

22865 $3,480.24 1

22900 $952.25 1

22901 $1,126.47 1

22902 $721.98 1

22903 $741.98 1

22904 $1,785.45 1

22905 $2,256.44 1

23000 $955.38 1

23020 $1,149.08 1

23030 $718.01 1

23031 $689.84 1

23035 $1,136.13 1

23040 $1,200.54 1

23044 $955.83 1

23065 $349.82 1

23066 $905.76 1

23071 $704.64 1

23073 $1,166.78 1

23075 $766.16 1

23076 $903.83 1

23077 $1,925.49 1

23078 $2,416.37 1

23100 $832.70 1

23101 $748.05 1

23105 $1,060.83 1

23106 $826.37 1

23107 $1,098.68 1

23120 $970.53 1

23125 $1,187.82 1

23130 $1,016.49 1

23140 $882.21 1

23145 $1,164.65 1

23146 $1,037.72 1

23150 $1,107.81 1

23155 $1,330.02 1

23156 $1,135.29 1

23170 $935.28 1

23172 $944.33 1

3/1/2015 18 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

23174 $1,267.82 1

23180 $1,117.44 1

23182 $1,100.19 1

23184 $1,227.18 1

23190 $954.00 1

23195 $1,265.84 1

23200 $2,562.12 1

23210 $3,014.40 1

23220 $3,306.72 1

23330 $391.70 1

23333 $755.52

23334 $1,791.86

23335 $2,137.13

23350 $208.11 1

23395 $2,146.35 1

23397 $1,924.20 1

23400 $1,631.90 1

23405 $1,039.92 1

23406 $1,286.52 1

23410 $1,373.73 1

23412 $1,422.93 1

23415 $1,165.85 1

23420 $1,618.44 1

23430 $1,244.24 1

23440 $1,262.45 1

23450 $1,595.90 1

23455 $1,677.93 1

23460 $1,834.95 1

23462 $1,794.05 1

23465 $1,887.39 1

23466 $1,885.80 1

23470 $2,018.13 1

23472 $2,445.99 1

23473 $2,734.83 1

23474 $2,959.01 1

23480 $1,378.44 1

23485 $1,599.44 1

23490 $1,447.97 1

23491 $1,702.25 1

23500 $352.91 1

23505 $577.31 1

23515 $1,199.36 1

23520 $379.10 1

23525 $631.50 1

23530 $956.94 1

3/1/2015 19 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

23532 $1,042.68 1

23540 $365.36 1

23545 $551.63 1

23550 $941.30 1

23552 $1,084.59 1

23570 $377.88 1

23575 $659.15 1

23585 $1,639.79 1

23600 $528.02 1

23605 $759.81 1

23615 $1,476.66 1

23616 $2,083.08 1

23620 $438.71 1

23625 $623.09 1

23630 $1,301.96 1

23650 $507.27 1

23655 $661.59 1

23660 $963.47 1

23665 $694.73 1

23670 $1,467.84 1

23675 $909.75 1

23680 $1,556.28 1

23700 $327.63 1

23800 $1,725.87 1

23802 $2,162.54 1

23900 $2,344.40 1

23920 $1,897.44 1

23921 $754.70 1

23930 $571.85 1

23931 $460.85 1

23935 $838.13 1

24000 $791.66 1

24006 $1,181.24 1

24065 $410.85 1

24066 $1,022.64 1

24071 $680.67 1

24073 $1,166.22 1

24075 $798.69 1

24076 $904.94 1

24077 $1,742.85 1

24079 $2,237.78 1

24100 $693.68 1

24101 $827.76 1

24102 $1,020.68 1

24105 $577.20 1

3/1/2015 20 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

24110 $980.34 1

24115 $1,236.03 1

24116 $1,448.58 1

24120 $872.58 1

24125 $1,036.88 1

24126 $1,084.16 1

24130 $840.09 1

24134 $1,252.62 1

24136 $980.09 1

24138 $1,125.05 1

24140 $1,173.26 1

24145 $989.00 1

24147 $1,035.17 1

24149 $1,949.42 1

24150 $2,631.06 1

24152 $2,281.70 1

24155 $1,432.98 1

24160 $2,106.98 1

24164 $1,213.04 1

24200 $334.95 1

24201 $909.90 1

24220 $255.48 1

24300 $681.56 1

24301 $1,235.63 1

24305 $947.90 1

24310 $779.09 1

24320 $1,310.69 1

24330 $1,202.51 1

24331 $1,319.19 1

24332 $1,021.79 1

24340 $1,016.55 1

24341 $1,237.25 1

24342 $1,292.10 1

24343 $1,170.57 1

24344 $1,843.31 1

24345 $1,182.17 1

24346 $1,843.31 1

24357 $709.29 1

24358 $863.64 1

24359 $1,090.97 1

24360 $1,510.85 1

24361 $1,691.42 1

24362 $1,783.10 1

24363 $2,437.92 1

24365 $1,069.25 1

3/1/2015 21 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

24366 $1,132.88 1

24370 $2,602.23 1

24371 $3,034.19 1

24400 $1,366.46 1

24410 $1,777.55 1

24420 $1,664.90 1

24430 $1,768.14 1

24435 $1,798.38 1

24470 $1,122.14 1

24495 $913.05 1

24498 $1,457.72 1

24500 $582.59 1

24505 $818.57 1

24515 $1,462.04 1

24516 $1,439.09 1

24530 $618.05 1

24535 $1,008.56 1

24538 $1,242.30 1

24545 $1,554.27 1

24546 $1,737.20 1

24560 $517.19 1

24565 $878.69 1

24566 $1,195.77 1

24575 $1,222.52 1

24576 $551.12 1

24577 $906.48 1

24579 $1,392.06 1

24582 $1,345.92 1

24586 $1,813.13 1

24587 $1,831.32 1

24600 $592.28 1

24605 $777.45 1

24615 $1,181.82 1

24620 $900.11 1

24635 $1,117.20 1

24640 $225.93 1

24650 $421.79 1

24655 $707.49 1

24665 $1,080.92 1

24666 $1,219.52 1

24670 $471.62 1

24675 $745.32 1

24685 $1,085.49 1

24800 $1,389.71 1

24802 $1,683.09 1

3/1/2015 22 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

24900 $1,211.81 1

24920 $1,228.28 1

24925 $854.85 1

24930 $1,300.43 1

24931 $1,234.85 1

24935 $1,556.94 1

25000 $550.14 1

25001 $562.64 1

25020 $938.45 1

25023 $1,819.07 1

25024 $1,295.90 1

25025 $2,066.46 1

25028 $859.25 1

25031 $602.75 1

25035 $963.86 1

25040 $929.12 1

25065 $408.05 1

25066 $592.97 1

25071 $710.91 1

25073 $884.78 1

25075 $774.86 1

25076 $855.21 1

25077 $1,485.38 1

25078 $1,958.42 1

25085 $750.02 1

25100 $572.39 1

25101 $664.07 1

25105 $789.74 1

25107 $1,017.18 1

25109 $883.26 1

25110 $561.12 1

25111 $525.12 1

25112 $633.02 1

25115 $1,251.20 1

25116 $984.27 1

25118 $624.26 1

25119 $827.72 1

25120 $819.71 1

25125 $997.50 1

25126 $996.11 1

25130 $730.67 1

25135 $929.97 1

25136 $820.28 1

25145 $859.77 1

25150 $946.05 1

3/1/2015 23 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

25151 $979.26 1

25170 $2,498.67 1

25210 $798.42 1

25215 $1,018.49 1

25230 $711.98 1

25240 $699.75 1

25246 $258.39 1

25248 $687.95 1

25250 $883.16 1

25251 $1,167.32 1

25259 $678.06 1

25260 $1,038.90 1

25263 $1,044.78 1

25265 $1,253.19 1

25270 $803.87 1

25272 $924.78 1

25274 $1,121.03 1

25275 $1,106.28 1

25280 $923.96 1

25290 $716.49 1

25295 $860.24 1

25300 $1,143.72 1

25301 $1,062.14 1

25310 $1,020.06 1

25312 $1,188.48 1

25315 $1,293.48 1

25316 $1,532.94 1

25320 $1,627.49 1

25332 $1,388.46 1

25335 $1,583.15 1

25337 $1,465.26 1

25350 $1,113.26 1

25355 $1,283.61 1

25360 $1,084.53 1

25365 $1,534.58 1

25370 $1,687.68 1

25375 $1,599.45 1

25390 $1,272.68 1

25391 $1,673.76 1

25392 $1,659.17 1

25393 $1,854.27 1

25394 $1,331.33 1

25400 $1,333.04 1

25405 $1,722.14 1

25415 $1,625.57 1

3/1/2015 24 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

25420 $1,966.83 1

25425 $1,616.30 1

25426 $1,892.30 1

25430 $1,223.25 1

25431 $1,283.81 1

25440 $1,271.04 1

25441 $1,528.86 1

25442 $1,306.46 1

25443 $1,308.99 1

25444 $1,383.62 1

25445 $1,197.03 1

25446 $1,942.16 1

25447 $1,366.05 1

25449 $1,704.77 1

25450 $796.64 1

25455 $944.60 1

25490 $1,113.84 1

25491 $1,239.66 1

25492 $1,516.38 1

25500 $440.46 1

25505 $818.28 1

25515 $1,113.53 1

25520 $938.28 1

25525 $1,305.68 1

25526 $1,603.05 1

25530 $423.56 1

25535 $802.41 1

25545 $1,032.44 1

25560 $447.86 1

25565 $849.86 1

25574 $1,120.52 1

25575 $1,499.87 1

25600 $529.29 1

25605 $892.85 1

25606 $1,101.80 1

25607 $1,217.43 1

25608 $1,368.18 1

25609 $1,739.36 1

25622 $489.87 1

25624 $785.31 1

25628 $1,191.86 1

25630 $494.09 1

25635 $731.99 1

25645 $950.40 1

25650 $516.23 1

3/1/2015 25 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

25651 $794.30 1

25652 $1,034.63 1

25660 $668.61 1

25670 $1,000.34 1

25671 $879.98 1

25675 $709.64 1

25676 $1,048.98 1

25680 $765.29 1

25685 $1,233.32 1

25690 $797.21 1

25695 $1,058.75 1

25800 $1,210.35 1

25805 $1,416.08 1

25810 $1,433.06 1

25820 $1,010.66 1

25825 $1,244.49 1

25830 $1,577.46 1

25900 $1,172.24 1

25905 $1,174.83 1

25907 $1,023.89 1

25909 $1,147.49 1

25915 $1,561.91 1

25920 $1,162.49 1

25922 $1,017.98 1

25924 $1,134.86 1

25927 $1,341.56 1

25929 $923.96 1

25931 $1,228.73 1

26010 $420.02 1

26011 $622.61 1

26020 $712.08 1

26025 $694.23 1

26030 $808.34 1

26034 $887.81 1

26035 $1,432.49 1

26037 $931.77 1

26040 $507.75 1

26045 $772.89 1

26055 $892.80 1

26060 $428.18 1

26070 $516.95 1

26075 $546.24 1

26080 $637.77 1

26100 $554.16 1

26105 $557.42 1

3/1/2015 26 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

26110 $525.30 1

26111 $690.54 1

26113 $902.46 1

26115 $813.53 1

26116 $868.11 1

26117 $1,233.27 1

26118 $1,754.51 1

26121 $985.46 1

26123 $1,374.39 1

26125 $460.41 1

26130 $767.96 1

26135 $901.19 1

26140 $827.52 1

26145 $843.66 1

26160 $919.85 1

26170 $664.49 1

26180 $724.55 1

26185 $881.93 1

26200 $736.94 1

26205 $1,005.00 1

26210 $724.22 1

26215 $938.87 1

26230 $819.03 1

26235 $810.60 1

26236 $722.88 1

26250 $1,775.61 1

26260 $1,347.95 1

26262 $1,058.37 1

26320 $566.93 1

26340 $538.47 1

26341 $160.56 1

26350 $1,137.81 1

26352 $1,312.43 1

26356 $1,761.32 1

26357 $1,417.40 1

26358 $1,438.94 1

26370 $1,216.92 1

26372 $1,441.49 1

26373 $1,326.32 1

26390 $1,369.55 1

26392 $1,590.98 1

26410 $901.14 1

26412 $1,120.79 1

26415 $1,071.00 1

26416 $1,447.77 1

3/1/2015 27 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

26418 $919.31 1

26420 $1,134.60 1

26426 $824.24 1

26428 $1,179.54 1

26432 $798.65 1

26433 $848.78 1

26434 $1,049.52 1

26437 $999.51 1

26440 $986.51 1

26442 $1,551.71 1

26445 $914.75 1

26449 $1,140.59 1

26450 $650.48 1

26455 $646.29 1

26460 $627.06 1

26471 $980.34 1

26474 $972.51 1

26476 $944.57 1

26477 $915.92 1

26478 $987.59 1

26479 $973.89 1

26480 $1,196.37 1

26483 $1,352.15 1

26485 $1,291.98 1

26489 $1,526.46 1

26490 $1,299.63 1

26492 $1,443.63 1

26494 $1,254.83 1

26496 $1,369.20 1

26497 $1,416.51 1

26498 $1,895.39 1

26499 $1,308.51 1

26500 $998.37 1

26502 $1,155.35 1

26508 $1,020.00 1

26510 $946.76 1

26516 $1,119.08 1

26517 $1,349.31 1

26518 $1,319.94 1

26520 $1,037.75 1

26525 $1,038.24 1

26530 $884.28 1

26531 $1,026.42 1

26535 $688.17 1

26536 $1,134.86 1

3/1/2015 28 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

26540 $1,052.48 1

26541 $1,291.95 1

26542 $1,089.66 1

26545 $1,150.70 1

26546 $1,606.86 1

26548 $1,220.73 1

26550 $2,729.52 1

26551 $5,534.87 1

26553 $4,335.77 1

26554 $5,073.69 1

26555 $2,264.88 1

26556 $4,785.75 1

26560 $955.89 1

26561 $1,501.10 1

26562 $2,156.78 1

26565 $1,103.15 1

26567 $1,089.05 1

26568 $1,467.21 1

26580 $2,506.17 1

26587 $1,624.76 1

26590 $2,335.22 1

26591 $688.71 1

26593 $958.16 1

26596 $1,212.99 1

26600 $473.61 1

26605 $521.34 1

26607 $757.64 1

26608 $780.56 1

26615 $949.34 1

26641 $612.36 1

26645 $704.06 1

26650 $786.21 1

26665 $1,039.43 1

26670 $545.46 1

26675 $748.38 1

26676 $820.76 1

26685 $949.89 1

26686 $1,040.70 1

26700 $520.41 1

26705 $683.94 1

26706 $708.78 1

26715 $939.45 1

26720 $318.27 1

26725 $546.39 1

26727 $769.35 1

3/1/2015 29 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

26735 $982.65 1

26740 $369.51 1

26742 $595.28 1

26746 $1,223.13 1

26750 $295.76 1

26755 $507.03 1

26756 $680.31 1

26765 $821.67 1

26770 $443.27 1

26775 $620.84 1

26776 $725.49 1

26785 $897.99 1

26820 $1,284.96 1

26841 $1,166.16 1

26842 $1,267.97 1

26843 $1,203.00 1

26844 $1,292.43 1

26850 $1,108.32 1

26852 $1,279.23 1

26860 $900.96 1

26861 $174.12 1

26862 $1,165.08 1

26863 $381.30 1

26910 $1,158.44 1

26951 $1,048.23 1

26952 $1,035.00 1

26990 $1,042.35 1

26991 $1,148.76 1

26992 $1,589.10 1

27000 $687.08 1

27001 $899.13 1

27003 $995.63 1

27005 $1,210.16 1

27006 $1,226.66 1

27025 $1,516.77 1

27027 $1,483.19 1

27030 $1,572.05 1

27033 $1,628.75 1

27035 $1,725.47 1

27036 $1,692.95 1

27040 $555.96 1

27041 $1,145.72 1

27043 $792.56 1

27045 $1,260.90 1

27047 $773.81 1

3/1/2015 30 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

27048 $1,025.60 1

27049 $2,259.65 1

27050 $666.23 1

27052 $966.42 1

27054 $1,139.55 1

27057 $1,709.01 1

27059 $3,077.78 1

27060 $774.32 1

27062 $760.16 1

27065 $859.76 1

27066 $1,358.57 1

27067 $1,739.70 1

27070 $1,415.07 1

27071 $1,526.40 1

27075 $3,562.65 1

27076 $4,318.47 1

27077 $4,822.98 1

27078 $3,513.75 1

27080 $861.96 1

27086 $477.29 1

27087 $1,043.69 1

27090 $1,381.16 1

27091 $2,688.56 1

27093 $297.86 1

27095 $384.08 1

27096 $253.92 1

27097 $1,141.85 1

27098 $1,162.38 1

27100 $1,383.92 1

27105 $1,453.13 1

27110 $1,627.08 1

27111 $1,510.59 1

27120 $2,194.52 1

27122 $1,842.26 1

27125 $1,904.52 1

27130 $2,281.64 1

27132 $2,819.33 1

27134 $3,230.40 1

27137 $2,480.04 1

27138 $2,576.57 1

27140 $1,507.53 1

27146 $2,162.09 1

27147 $2,486.01 1

27151 $2,692.04 1

27156 $2,904.23 1

3/1/2015 31 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

27158 $2,370.21 1

27161 $2,042.81 1

27165 $2,300.93 1

27170 $1,981.56 1

27175 $1,120.67 1

27176 $1,542.11 1

27177 $1,875.57 1

27178 $1,542.11 1

27179 $1,641.86 1

27181 $1,890.71 1

27185 $937.83 1

27187 $1,662.81 1

27193 $780.96 1

27194 $1,186.58 1

27200 $294.45 1

27202 $892.40 1

27220 $880.67 1

27222 $1,640.90 1

27226 $1,779.39 1

27227 $2,799.33 1

27228 $3,195.29 1

27230 $784.37 1

27232 $1,265.12 1

27235 $1,527.80 1

27236 $2,010.11 1

27238 $762.36 1

27240 $1,605.30 1

27244 $2,070.69 1

27245 $2,069.76 1

27246 $638.28 1

27248 $1,246.38 1

27250 $305.91 1

27252 $1,274.51 1

27253 $1,578.24 1

27254 $2,146.59 1

27256 $497.76 1

27257 $572.21 1

27258 $1,869.72 1

27259 $2,625.32 1

27265 $651.81 1

27266 $971.37 1

27267 $717.84 1

27268 $900.44 1

27269 $2,096.60 1

27275 $302.45 1

3/1/2015 32 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

27279 $913.97

27280 $1,852.23 1

27282 $1,260.09 1

27284 $2,593.47 1

27286 $2,797.86 1

27290 $2,747.69 1

27295 $2,127.18 1

27301 $1,085.87 1

27303 $1,062.42 1

27305 $797.39 1

27306 $587.27 1

27307 $799.23 1

27310 $1,220.39 1

27323 $435.20 1

27324 $662.60 1

27325 $861.44 1

27326 $855.09 1

27327 $749.25 1

27328 $1,044.38 1

27329 $1,744.89 1

27330 $690.12 1

27331 $790.28 1

27332 $1,074.30 1

27333 $977.63 1

27334 $1,139.96 1

27335 $1,274.37 1

27337 $702.44 1

27339 $1,268.63 1

27340 $614.61 1

27345 $798.45 1

27347 $878.81 1

27350 $1,084.29 1

27355 $1,005.99 1

27356 $1,237.19 1

27357 $1,360.65 1

27358 $476.76 1

27360 $1,420.20 1

27364 $2,646.51 1

27365 $3,490.01 1

27370 $245.55 1

27372 $989.55 1

27380 $985.53 1

27381 $1,325.40 1

27385 $950.66 1

27386 $1,379.31 1

3/1/2015 33 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

27390 $745.77 1

27391 $963.56 1

27392 $1,192.82 1

27393 $850.11 1

27394 $1,084.26 1

27395 $1,473.98 1

27396 $1,029.14 1

27397 $1,537.38 1

27400 $1,163.84 1

27403 $1,069.44 1

27405 $1,128.17 1

27407 $1,328.01 1

27409 $1,621.29 1

27412 $2,793.41 1

27415 $2,318.13 1

27416 $1,649.28 1

27418 $1,380.39 1

27420 $1,234.16 1

27422 $1,239.21 1

27424 $1,253.69 1

27425 $744.35 1

27427 $1,191.45 1

27428 $1,871.61 1

27429 $2,102.46 1

27430 $1,226.04 1

27435 $1,342.16 1

27437 $1,106.67 1

27438 $1,404.59 1

27440 $1,338.86 1

27441 $1,383.98 1

27442 $1,455.00 1

27443 $1,370.37 1

27445 $2,106.36 1

27446 $1,948.46 1

27447 $2,281.08 1

27448 $1,267.73 1

27450 $1,690.73 1

27454 $2,192.99 1

27455 $1,584.30 1

27457 $1,616.72 1

27465 $2,107.37 1

27466 $1,996.46 1

27468 $2,267.00 1

27470 $1,972.95 1

27472 $2,125.61 1

3/1/2015 34 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

27475 $1,107.78 1

27477 $1,229.37 1

27479 $1,548.90 1

27485 $1,123.65 1

27486 $2,362.19 1

27487 $2,958.08 1

27488 $2,015.66 1

27495 $1,894.37 1

27496 $907.07 1

27497 $995.82 1

27498 $1,095.33 1

27499 $1,172.88 1

27500 $860.36 1

27501 $835.98 1

27502 $1,278.78 1

27503 $1,342.43 1

27506 $2,248.20 1

27507 $1,633.31 1

27508 $865.49 1

27509 $1,067.64 1

27510 $1,140.81 1

27511 $1,678.13 1

27513 $2,093.25 1

27514 $1,626.86 1

27516 $840.87 1

27517 $1,147.98 1

27519 $1,505.30 1

27520 $525.00 1

27524 $1,259.19 1

27530 $490.65 1

27532 $1,024.59 1

27535 $1,508.18 1

27536 $2,000.16 1

27538 $778.73 1

27540 $1,356.38 1

27550 $827.18 1

27552 $1,040.51 1

27556 $1,478.27 1

27557 $1,770.56 1

27558 $2,022.45 1

27560 $585.89 1

27562 $805.07 1

27566 $1,501.76 1

27570 $251.01 1

27580 $2,409.72 1

3/1/2015 35 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

27590 $1,385.22 1

27591 $1,626.08 1

27592 $1,172.01 1

27594 $858.36 1

27596 $1,231.16 1

27598 $1,227.59 1

27600 $697.64 1

27601 $749.90 1

27602 $839.63 1

27603 $866.88 1

27604 $796.67 1

27605 $543.63 1

27606 $473.81 1

27607 $1,017.33 1

27610 $1,083.54 1

27612 $929.01 1

27613 $401.87 1

27614 $929.87 1

27615 $1,714.89 1

27616 $2,139.39 1

27618 $734.16 1

27619 $781.49 1

27620 $756.57 1

27625 $963.62 1

27626 $1,018.79 1

27630 $907.52 1

27632 $694.16 1

27634 $1,148.73 1

27635 $977.24 1

27637 $1,279.73 1

27638 $1,304.58 1

27640 $1,397.58 1

27641 $1,110.57 1

27645 $3,014.40 1

27646 $2,612.51 1

27647 $1,652.31 1

27648 $258.08 1

27650 $1,086.20 1

27652 $1,128.59 1

27654 $1,162.88 1

27656 $1,035.29 1

27658 $613.53 1

27659 $786.36 1

27664 $596.85 1

27665 $671.16 1

3/1/2015 36 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

27675 $788.36 1

27676 $976.13 1

27680 $711.35 1

27681 $913.44 1

27685 $1,071.69 1

27686 $935.72 1

27687 $748.61 1

27690 $1,030.85 1

27691 $1,243.01 1

27692 $175.02 1

27695 $782.76 1

27696 $901.62 1

27698 $1,054.43 1

27700 $936.38 1

27702 $1,620.54 1

27703 $1,857.30 1

27704 $957.89 1

27705 $1,251.60 1

27707 $666.17 1

27709 $1,971.11 1

27712 $1,861.20 1

27715 $1,770.29 1

27720 $1,463.49 1

27722 $1,495.55 1

27724 $2,132.37 1

27725 $2,054.43 1

27726 $1,621.76 1

27727 $1,370.13 1

27730 $979.59 1

27732 $743.49 1

27734 $1,097.82 1

27740 $1,187.33 1

27742 $1,304.43 1

27745 $1,268.76 1

27750 $564.98 1

27752 $885.99 1

27756 $960.30 1

27758 $1,492.47 1

27759 $1,674.96 1

27760 $540.02 1

27762 $775.35 1

27766 $1,019.63 1

27767 $457.16 1

27768 $731.13 1

27769 $1,216.67 1

3/1/2015 37 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

27780 $495.51 1

27781 $693.54 1

27784 $1,197.72 1

27786 $513.08 1

27788 $687.95 1

27792 $1,089.30 1

27808 $541.41 1

27810 $765.29 1

27814 $1,289.73 1

27816 $520.55 1

27818 $790.65 1

27822 $1,398.33 1

27823 $1,596.42 1

27824 $509.10 1

27825 $900.60 1

27826 $1,385.07 1

27827 $1,806.08 1

27828 $2,168.61 1

27829 $1,136.55 1

27830 $613.56 1

27831 $663.48 1

27832 $1,266.69 1

27840 $601.20 1

27842 $825.11 1

27846 $1,222.89 1

27848 $1,359.65 1

27860 $286.50 1

27870 $1,721.67 1

27871 $1,140.32 1

27880 $1,583.58 1

27881 $1,475.10 1

27882 $1,032.35 1

27884 $985.23 1

27886 $1,127.54 1

27888 $1,158.30 1

27889 $1,115.30 1

27892 $915.87 1

27893 $1,017.95 1

27894 $1,454.31 1

28001 $450.87 1

28002 $712.82 1

28003 $1,147.05 1

28005 $941.13 1

28008 $697.64 1

28010 $373.23 1

3/1/2015 38 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

28011 $521.91 1

28020 $888.39 1

28022 $793.02 1

28024 $748.20 1

28035 $856.23 1

28039 $826.47 1

28041 $748.02 1

28043 $643.79 1

28045 $797.52 1

28046 $1,196.00 1

28047 $1,794.80 1

28050 $771.44 1

28052 $705.50 1

28054 $602.99 1

28055 $611.30 1

28060 $836.45 1

28062 $939.71 1

28070 $857.51 1

28072 $837.90 1

28080 $850.40 1

28086 $899.45 1

28088 $703.61 1

28090 $762.33 1

28092 $682.56 1

28100 $994.65 1

28102 $1,013.85 1

28103 $628.73 1

28104 $864.48 1

28106 $688.22 1

28107 $830.22 1

28108 $715.41 1

28110 $749.79 1

28111 $804.44 1

28112 $795.35 1

28113 $961.62 1

28114 $1,765.38 1

28116 $1,224.81 1

28118 $965.81 1

28119 $849.09 1

28120 $1,103.84 1

28122 $970.88 1

28124 $767.69 1

28126 $637.67 1

28130 $980.46 1

28140 $971.36 10

3/1/2015 39 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

28150 $691.77 1

28153 $665.22 1

28160 $681.29 1

28171 $1,367.22 1

28173 $1,236.60 1

28175 $787.43 1

28190 $412.16 1

28192 $759.20 1

28193 $861.62 1

28200 $791.30 1

28202 $956.76 1

28208 $769.20 1

28210 $936.86 1

28220 $727.89 1

28222 $809.91 1

28225 $657.51 1

28226 $708.20 1

28230 $705.93 1

28232 $624.81 1

28234 $661.40 1

28238 $1,099.31 1

28240 $712.17 1

28250 $946.40 1

28260 $1,118.27 1

28261 $1,627.35 1

28262 $2,454.89 1

28264 $1,358.30 1

28270 $796.16 1

28272 $635.94 1

28280 $832.14 1

28285 $864.27 1

28286 $723.24 1

28288 $976.13 1

28289 $1,193.19 1

28290 $962.25 1

28292 $1,276.71 1

28293 $1,680.29 1

28294 $1,229.16 1

28296 $1,152.83 1

28297 $1,319.54 1

28298 $1,166.97 1

28299 $1,456.95 1

28300 $1,081.11 1

28302 $1,199.45 1

28304 $1,356.20 1

3/1/2015 40 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

28305 $1,049.12 1

28306 $999.53 1

28307 $1,173.60 1

28308 $914.39 1

28309 $1,509.78 1

28310 $886.64 1

28312 $839.43 1

28313 $862.07 1

28315 $781.13 1

28320 $999.41 1

28322 $1,294.26 1

28340 $931.23 1

28341 $1,080.60 1

28344 $911.49 1

28345 $840.87 1

28360 $1,317.51 1

28400 $402.83 1

28405 $649.49 1

28406 $870.99 1

28415 $1,839.56 1

28420 $2,109.12 1

28430 $384.38 1

28435 $534.12 1

28436 $744.23 1

28445 $1,780.95 1

28446 $2,063.34 1

28450 $348.78 1

28455 $465.59 1

28456 $524.93 1

28465 $1,015.61 1

28470 $354.68 1

28475 $414.77 1

28476 $574.01 1

28485 $859.83 1

28490 $234.54 1

28495 $289.32 1

28496 $721.10 1

28505 $1,100.87 1

28510 $199.92 1

28515 $261.71 1

28525 $905.15 1

28530 $185.10 1

28531 $548.27 1

28540 $307.29 1

28545 $485.21 1

3/1/2015 41 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

28546 $941.85 1

28555 $1,450.07 1

28570 $281.63 1

28575 $596.82 1

28576 $657.98 1

28585 $1,382.91 1

28600 $350.64 1

28605 $537.59 1

28606 $648.92 1

28615 $1,303.07 1

28630 $253.31 1

28635 $276.17 1

28636 $574.79 1

28645 $1,063.13 1

28660 $189.24 1

28665 $250.74 1

28666 $321.41 1

28675 $962.21 1

28705 $2,089.37 1

28715 $1,559.94 1

28725 $1,288.05 1

28730 $1,206.60 1

28735 $1,287.72 1

28737 $1,134.27 1

28740 $1,383.27 1

28750 $1,332.69 1

28755 $822.56 1

28760 $1,285.58 1

28800 $898.16 1

28805 $1,219.17 1

28810 $720.80 1

28820 $924.32 1

28825 $881.24 1

28890 $521.24 1

29000 $513.35 1

29010 $364.37 1

29015 $451.46 1

29035 $364.29 1

29040 $349.41 1

29044 $407.58 1

29046 $376.91 1

29049 $121.19 1

29055 $363.17 1

29058 $205.94 1

29065 $156.95 1

3/1/2015 42 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

29075 $141.45 1

29085 $155.48 1

29086 $123.29 1

29105 $143.51 1

29125 $102.50 1

29126 $124.29 1

29130 $65.48 1

29131 $82.34 1

29200 $47.06 1

29240 $45.41 1

29260 $45.77 1

29280 $46.32 1

29305 $404.75 1

29325 $448.47 1

29345 $224.21 1

29355 $231.00 1

29358 $263.94 1

29365 $200.63 1

29405 $132.39 1

29425 $126.12 1

29435 $193.08 1

29440 $69.60 1

29445 $220.11 1

29450 $231.23 1

29505 $134.04 1

29515 $115.38 1

29520 $48.72 1

29530 $44.30 1

29540 $40.44 1

29550 $30.17 1

29580 $83.63 1

29581 $98.48 1

29582 $111.57 1

29583 $70.31 1

29584 $111.57 1

29700 $99.06 1

29705 $110.54 1

29710 $205.71 1

29720 $139.76 1

29730 $103.92 1

29740 $165.00 1

29750 $157.41 1

29800 $855.44 1

29804 $1,061.88 1

29805 $787.50 1

3/1/2015 43 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

29806 $1,782.66 1

29807 $1,740.71 1

29819 $980.75 1

29820 $883.74 1

29821 $961.28 1

29822 $933.39 1

29823 $1,016.12 1

29824 $1,097.06 1

29825 $951.86 1

29826 $298.58 1

29827 $1,742.22 1

29828 $1,502.91 1

29830 $762.71 1

29834 $799.04 1

29835 $841.04 1

29836 $966.30 1

29837 $864.74 1

29838 $970.31 1

29840 $754.37 1

29843 $808.11 1

29844 $811.23 1

29845 $947.97 1

29846 $856.65 1

29847 $910.41 1

29848 $843.45 1

29850 $1,045.14 1

29851 $1,569.92 1

29855 $1,313.07 1

29856 $1,678.73 1

29860 $1,118.54 1

29861 $1,184.91 1

29862 $1,331.03 1

29863 $1,327.73 1

29866 $1,765.94 1

29867 $2,156.69 1

29868 $2,831.87 1

29870 $957.90 1

29871 $858.60 1

29873 $872.42 1

29874 $897.02 1

29875 $825.68 1

29876 $1,102.73 1

29877 $1,038.11 1

29879 $1,106.96 1

29880 $937.58 1

3/1/2015 44 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

29881 $900.60 1

29882 $1,174.08 1

29883 $1,414.17 1

29884 $1,016.06 1

29885 $1,263.14 1

29886 $1,067.61 1

29887 $1,246.29 1

29888 $1,650.36 1

29889 $2,060.51 1

29891 $1,125.39 1

29892 $1,005.74 1

29893 $982.29 1

29894 $829.02 1

29895 $797.34 1

29897 $840.30 1

29898 $934.91 1

29899 $1,748.55 1

29900 $668.69 1

29901 $859.91 1

29902 $794.55 1

29904 $1,071.59 1

29905 $1,043.22 1

29906 $1,185.60 1

29907 $1,472.79 1

29914 $1,642.44 1

29915 $1,671.92 1

29916 $1,676.34 1

30000 $368.09 1

30020 $372.50 1

30100 $226.80 1

30110 $370.34 1

30115 $698.22 1

30117 $1,392.86 1

30118 $1,246.71 1

30120 $838.47 1

30124 $461.24 1

30125 $985.44 1

30130 $612.33 1

30140 $707.19 1

30150 $1,251.00 1

30160 $1,257.47 1

30200 $181.77 1

30210 $241.41 1

30220 $482.07 1

30300 $366.33 1

3/1/2015 45 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

30310 $330.95 1

30320 $730.50 1

30400 $1,625.63 1

30410 $1,912.76 1

30420 $2,230.47 1

30430 $1,400.42 1

30435 $2,022.14 1

30450 $2,431.31 1

30460 $1,329.65 1

30462 $2,324.39 1

30465 $1,594.64 1

30520 $1,008.75 1

30540 $1,113.15 1

30545 $1,357.83 1

30560 $428.03 1

30580 $1,064.01 1

30600 $922.67 1

30620 $1,006.08 1

30630 $1,014.92 1

30801 $364.22 1

30802 $465.99 1

30901 $154.37 1

30903 $330.24 1

30905 $413.33 1

30906 $450.84 1

30915 $936.60 1

30920 $1,358.72 1

30930 $198.96 1

31000 $293.78 1

31002 $310.77 1

31020 $779.27 1

31030 $1,117.71 1

31032 $931.92 1

31040 $1,247.88 1

31050 $783.81 1

31051 $1,043.16 1

31070 $707.51 1

31075 $1,265.06 1

31080 $1,671.18 1

31081 $2,610.71 1

31084 $1,872.18 1

31085 $2,378.36 1

31086 $1,819.92 1

31087 $1,759.92 1

31090 $1,653.29 1

3/1/2015 46 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

31200 $902.06 1

31201 $1,198.23 1

31205 $1,423.95 1

31225 $3,066.95 1

31230 $3,396.12 1

31231 $333.90 1

31233 $422.01 1

31235 $480.56 1

31237 $416.54 1

31238 $416.87 1

31239 $991.49 1

31240 $265.53 1

31254 $452.27 1

31255 $663.59 1

31256 $327.77 1

31267 $526.64 1

31276 $836.19 1

31287 $383.85 1

31288 $446.30 1

31290 $1,921.82 1

31291 $2,063.31 1

31292 $1,644.51 1

31293 $1,785.96 1

31294 $2,045.60 1

31295 $3,234.77 1

31296 $3,282.06 1

31297 $3,220.32 1

31300 $2,061.20 1

31320 $1,056.30 1

31360 $3,406.62 1

31365 $4,223.57 1

31367 $3,602.22 1

31368 $3,995.93 1

31370 $3,381.89 1

31375 $3,210.86 1

31380 $3,163.05 1

31382 $3,471.59 1

31390 $4,678.83 1

31395 $4,920.72 1

31400 $1,622.03 1

31420 $1,362.12 1

31500 $182.03 1

31502 $56.76 1

31505 $131.96 1

31510 $342.33 1

3/1/2015 47 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

31511 $342.30 1

31512 $335.09 1

31513 $219.95 1

31515 $333.69 1

31520 $260.27 1

31525 $409.13 1

31526 $260.81 1

31527 $326.15 1

31528 $240.51 1

31529 $270.02 1

31530 $327.08 1

31531 $354.18 1

31535 $316.56 1

31536 $351.47 1

31540 $404.49 1

31541 $441.60 1

31545 $604.25 1

31546 $920.55 1

31560 $523.86 1

31561 $572.90 1

31570 $554.06 1

31571 $417.35 1

31575 $184.74 1

31576 $360.11 1

31577 $391.52 1

31578 $449.66 1

31579 $341.04 1

31580 $1,987.17 1

31582 $3,088.05 1

31584 $2,469.03 1

31587 $1,646.09 1

31588 $1,860.51 1

31590 $1,435.50 1

31595 $1,242.21 1

31600 $672.78 1

31601 $468.75 1

31603 $376.65 1

31605 $311.66 1

31610 $1,173.75 1

31611 $877.26 1

31612 $143.07 1

31613 $740.13 1

31614 $1,232.79 1

31615 $294.54 1

31620 $455.87 1

3/1/2015 48 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

31622 $499.67 1

31623 $525.84 1

31624 $498.23 1

31625 $530.22 1

31626 $715.82 1

31627 $2,221.32 1

31628 $590.84 1

31629 $933.59 1

31630 $330.98 1

31631 $387.35 1

31632 $113.06 4

31633 $140.57 4

31634 $2,966.96 1

31635 $559.55 1

31636 $367.02 1

31637 $120.08 1

31638 $421.86 1

31640 $421.43 1

31641 $423.50 1

31643 $287.87 1

31645 $514.89 1

31646 $463.13 1

31647 $367.04 1

31648 $328.71 1

31649 $110.00 1

31651 $120.08 1

31660 $337.83 1

31661 $353.64 1

31717 $413.46 1

31720 $82.80 1

31725 $145.07 1

31730 $1,941.51 1

31750 $2,251.49 1

31755 $2,789.94 1

31760 $2,377.97 1

31766 $2,730.98 1

31770 $2,316.74 1

31775 $1,996.08 1

31780 $1,992.53 1

31781 $2,411.09 1

31785 $1,779.02 1

31786 $2,714.36 1

31800 $1,158.39 1

31805 $1,407.95 1

31820 $704.52 1

3/1/2015 49 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

31825 $981.03 1

31830 $722.42 1

32035 $1,241.82 1

32036 $1,330.05 1

32096 $1,384.59 1

32097 $1,384.22 1

32098 $1,310.82 1

32100 $1,391.58 1

32110 $2,515.92 1

32120 $1,490.72 1

32124 $1,594.31 1

32140 $1,719.20 1

32141 $2,629.20 1

32150 $1,730.36 1

32151 $1,744.14 1

32160 $1,349.37 1

32200 $1,971.11 1

32215 $1,377.98 1

32220 $2,720.10 1

32225 $1,705.07 1

32310 $1,543.23 1

32320 $2,748.95 1

32400 $243.53 1

32405 $710.96 1

32440 $2,696.42 1

32442 $5,352.86 1

32445 $6,163.38 1

32480 $2,547.26 1

32482 $2,731.14 1

32484 $2,484.26 1

32486 $4,078.35 1

32488 $4,188.99 1

32491 $2,553.71 1

32501 $426.93 1

32503 $3,136.40 1

32504 $3,599.96 1

32505 $1,603.40 1

32506 $273.90 1

32507 $272.97 1

32540 $2,991.20 1

32550 $1,249.41 1

32551 $287.25 1

32552 $305.61 1

32553 $937.74 1

32554 $319.49 1

3/1/2015 50 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

32555 $457.59 1

32556 $876.87 1

32557 $808.10 1

32560 $390.45 1

32561 $150.95 1

32562 $137.75 1

32601 $530.57 1

32604 $840.84 1

32606 $796.91 1

32607 $532.41 1

32608 $655.07 1

32609 $445.89 1

32650 $1,138.74 1

32651 $1,889.57 1

32652 $2,867.97 1

32653 $1,821.89 1

32654 $1,945.55 1

32655 $1,642.67 1

32656 $1,379.85 1

32658 $1,234.14 1

32659 $1,257.17 1

32661 $1,381.94 1

32662 $1,538.70 1

32663 $2,418.81 1

32664 $1,468.97 1

32665 $2,143.98 1

32666 $1,497.71 1

32667 $274.44 1

32668 $273.90 1

32669 $2,323.02 1

32670 $2,772.66 1

32671 $3,099.47 1

32672 $2,625.81 1

32673 $2,100.27 1

32674 $376.67 1

32701 $368.28 1

32800 $1,644.33 1

32810 $1,560.86 1

32815 $4,848.00 1

32820 $2,414.34 1

32851 $5,711.01 1

32852 $6,272.09 1

32853 $7,997.45 1

32854 $8,483.61 1

32900 $2,460.66 1

3/1/2015 51 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

32905 $2,322.84 1

32906 $2,872.83 1

32940 $2,145.95 1

32960 $201.60 1

32997 $553.68 1

32998 $4,654.44 1

33010 $206.82 1

33011 $209.96 1

33015 $863.73 1

33020 $1,517.42 1

33025 $1,375.28 1

33030 $3,464.97 1

33031 $4,264.95 1

33050 $1,737.29 1

33120 $3,632.24 1

33130 $2,403.72 1

33140 $2,751.95 1

33141 $227.51 1

33202 $1,339.44 1

33203 $1,392.51 1

33206 $788.96 1

33207 $842.19 1

33208 $911.55 1

33210 $307.85 1

33211 $313.95 1

33212 $568.14 1

33213 $594.03 1

33214 $832.61 1

33215 $529.11 1

33216 $650.39 1

33217 $638.84 1

33218 $681.18 1

33220 $683.07 1

33221 $634.11 1

33222 $590.69 1

33223 $715.74 1

33224 $886.62 1

33225 $805.83 1

33226 $850.94 1

33227 $598.50 1

33228 $623.12 1

33229 $653.24 1

33230 $673.40 1

33231 $709.79 1

33233 $411.00 1

3/1/2015 52 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

33234 $849.06 1

33235 $1,103.75 1

33236 $1,346.64 1

33237 $1,448.15 1

33238 $1,603.23 1

33240 $643.46 1

33241 $387.77 1

33243 $2,363.84 1

33244 $1,486.40 1

33249 $1,585.74 1

33250 $2,561.28 1

33251 $2,813.79 1

33254 $2,357.15 1

33255 $2,842.13 1

33256 $3,383.70 1

33257 $998.72 1

33258 $1,134.39 1

33259 $1,448.40 1

33261 $2,813.79 1

33262 $655.23 1

33263 $683.15 1

33264 $711.44 1

33265 $2,339.87 1

33266 $3,202.98 1

33270 $1,004.19

33271 $843.47

33272 $620.55

33273 $686.18

33282 $404.93 1

33284 $358.59 1

33300 $4,238.10 1

33305 $7,117.31 1

33310 $2,070.78 1

33315 $3,319.67 1

33320 $1,844.84 1

33321 $2,083.47 1

33322 $2,393.76 1

33330 $2,484.77 1

33335 $3,284.04 1

33361 $2,355.05 1

33362 $2,580.02 1

33363 $2,706.03 1

33364 $2,810.75 1

33365 $3,086.12 1

33366 $3,346.22

3/1/2015 53 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

33367 $1,087.11 1

33368 $1,308.21 1

33369 $1,726.07 1

33400 $3,941.42 1

33401 $2,500.74 1

33403 $2,565.81 1

33404 $3,077.54 1

33405 $3,922.19 1

33406 $4,977.20 1

33410 $4,386.03 1

33411 $5,809.11 1

33412 $5,533.62 1

33413 $5,701.41 1

33414 $3,734.19 1

33415 $3,508.98 1

33416 $3,511.58 1

33417 $2,870.96 1

33418 $3,190.86

33419 $751.80

33420 $2,400.77 1

33422 $2,906.01 1

33425 $4,725.30 1

33426 $4,114.55 1

33427 $4,225.64 1

33430 $4,834.59 1

33460 $4,248.45 1

33463 $5,354.88 1

33464 $4,217.52 1

33465 $4,770.84 1

33468 $4,260.27 1

33470 $2,139.17 1

33471 $2,032.80 1

33474 $3,777.60 1

33475 $4,076.16 1

33476 $2,637.92 1

33478 $2,718.08 1

33496 $2,908.59 1

33500 $2,724.60 1

33501 $1,944.35 1

33502 $2,204.40 1

33503 $2,286.00 1

33504 $2,531.25 1

33505 $3,588.65 1

33506 $3,753.98 1

33507 $2,992.04 1

3/1/2015 54 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

33508 $27.12 1

33510 $3,335.37 1

33511 $3,665.58 1

33512 $4,172.52 1

33513 $4,298.04 1

33514 $4,547.36 1

33516 $4,776.23 1

33517 $325.56 1

33518 $715.89 1

33519 $945.95 1

33521 $1,134.21 1

33522 $1,274.39 1

33523 $1,463.45 1

33530 $916.52 1

33533 $3,226.71 1

33534 $3,798.23 1

33535 $4,237.38 1

33536 $4,575.35 1

33542 $4,541.81 1

33545 $5,387.25 1

33548 $5,120.30 1

33572 $400.82 1

33600 $2,998.61 1

33602 $2,906.28 1

33606 $2,738.93 1

33608 $3,115.73 1

33610 $3,098.66 1

33611 $3,017.27 1

33612 $3,480.23 1

33615 $3,490.35 1

33617 $3,751.95 1

33619 $4,203.35 1

33620 $2,644.28 1

33621 $1,619.07 1

33622 $5,920.07 1

33641 $2,826.36 1

33645 $3,002.15 1

33647 $3,153.50 1

33660 $3,076.77 1

33665 $3,323.75 1

33670 $3,457.67 1

33675 $3,453.06 1

33676 $3,130.49 1

33677 $3,253.46 1

33681 $3,190.85 1

3/1/2015 55 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

33684 $3,307.23 1

33688 $3,276.23 1

33690 $2,085.12 1

33692 $3,031.98 1

33694 $3,389.06 1

33697 $3,646.16 1

33702 $2,676.39 1

33710 $3,643.14 1

33720 $2,698.46 1

33722 $2,835.78 1

33724 $2,668.95 1

33726 $3,561.27 1

33730 $3,505.05 1

33732 $2,875.22 1

33735 $2,255.39 1

33736 $2,427.60 1

33737 $1,993.26 1

33750 $2,297.90 1

33755 $2,020.13 1

33762 $1,972.07 1

33764 $2,020.13 1

33766 $2,425.88 1

33767 $2,462.10 1

33768 $648.68 1

33770 $3,278.43 1

33771 $3,379.20 1

33774 $3,140.28 1

33775 $2,857.19 1

33776 $3,018.96 1

33777 $2,920.65 1

33778 $3,631.19 1

33779 $3,605.91 1

33780 $3,671.31 1

33781 $3,585.87 1

33782 $5,657.07 1

33783 $5,410.70 1

33786 $3,522.68 1

33788 $2,677.94 1

33800 $1,798.10 1

33802 $1,970.52 1

33803 $1,769.54 1

33813 $1,904.09 1

33814 $2,655.02 1

33820 $1,673.48 1

33822 $1,571.73 1

3/1/2015 56 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

33824 $2,035.25 1

33840 $1,902.47 1

33845 $2,302.64 1

33851 $1,954.28 1

33852 $2,416.23 1

33853 $3,172.71 1

33860 $5,562.39 1

33863 $5,462.57 1

33864 $5,602.43 1

33870 $4,368.17 1

33875 $4,773.95 1

33877 $6,364.49 1

33880 $3,157.77 1

33881 $2,713.86 1

33883 $1,960.40 1

33884 $731.46 1

33886 $1,695.89 1

33889 $1,401.84 1

33891 $1,723.70 1

33910 $4,561.70 1

33915 $2,241.33 1

33916 $7,345.85 1

33917 $2,537.96 1

33920 $3,161.48 1

33922 $2,399.96 1

33924 $499.08 1

33925 $3,007.49 1

33926 $4,409.70 1

33935 $8,652.30 1

33945 $8,440.25 1

33946 $528.48

33947 $583.80

33948 $415.46

33949 $404.45

33951 $771.50

33952 $749.04

33953 $859.98

33954 $837.15

33955 $1,549.02

33956 $1,471.68

33957 $343.59

33958 $333.09

33959 $436.67

33962 $411.81

33963 $872.51

3/1/2015 57 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

33964 $896.18

33965 $343.59

33966 $414.89

33967 $449.33 1

33968 $56.97 1

33969 $504.87

33970 $617.12 1

33971 $1,224.12 1

33973 $893.94 1

33974 $1,544.16 1

33975 $2,285.82 1

33976 $2,795.52 1

33977 $1,965.18 1

33978 $2,340.50 1

33979 $3,412.07 1

33980 $3,102.80 1

33981 $1,464.69 1

33982 $3,441.12 1

33983 $4,056.68 1

33984 $497.85

33985 $952.26

33986 $908.99

33987 $364.64

33988 $1,354.01

33989 $860.64

33990 $761.75 1

33991 $1,106.09 1

33992 $371.88 1

33993 $326.66 1

34001 $1,735.44 1

34051 $1,576.14 1

34101 $1,057.92 1

34111 $1,052.94 1

34151 $2,473.56 1

34201 $1,822.70 1

34203 $1,681.34 1

34401 $2,568.74 1

34421 $1,280.61 1

34451 $2,885.88 1

34471 $1,915.05 1

34490 $1,071.21 1

34501 $1,580.79 1

34502 $2,666.81 1

34510 $2,066.70 1

34520 $1,753.76 1

3/1/2015 58 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

34530 $1,915.98 1

34800 $1,985.07 1

34802 $2,194.08 1

34803 $2,266.98 1

34804 $2,191.88 1

34805 $2,122.23 1

34806 $178.20 1

34808 $371.69 1

34812 $598.50 1

34813 $420.68 1

34820 $870.00 1

34825 $1,217.48 1

34826 $363.77 1

34830 $3,139.01 1

34831 $3,376.11 1

34832 $3,376.11 1

34833 $1,083.45 1

34834 $480.92 1

34900 $1,571.22 1

35001 $1,993.43 1

35002 $2,016.53 1

35005 $2,013.57 1

35011 $1,765.97 1

35013 $2,196.83 1

35021 $2,208.66 1

35022 $2,531.97 1

35045 $1,741.50 1

35081 $3,088.76 1

35082 $3,879.11 1

35091 $3,183.93 1

35092 $4,628.43 1

35102 $3,347.18 1

35103 $3,986.91 1

35111 $2,361.81 1

35112 $3,281.25 1

35121 $2,911.56 1

35122 $3,789.08 1

35131 $2,455.53 1

35132 $2,910.03 1

35141 $1,956.99 1

35142 $2,333.07 1

35151 $2,197.68 1

35152 $2,485.50 1

35180 $1,515.99 1

35182 $2,869.46 1

3/1/2015 59 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

35184 $1,948.61 1

35188 $1,857.69 1

35189 $2,685.93 1

35190 $1,331.72 1

35201 $1,668.32 1

35206 $1,353.14 1

35207 $1,256.45 1

35211 $2,384.85 1

35216 $3,560.46 1

35221 $2,540.97 1

35226 $1,461.98 1

35231 $2,097.72 1

35236 $1,719.02 1

35241 $2,509.52 1

35246 $2,756.36 1

35251 $3,000.06 1

35256 $1,794.11 1

35261 $1,881.54 1

35266 $1,520.58 1

35271 $2,408.58 1

35276 $2,552.94 1

35281 $2,856.50 1

35286 $1,642.47 1

35301 $1,998.20 1

35302 $1,990.34 1

35303 $2,193.65 1

35304 $2,270.28 1

35305 $2,166.02 1

35306 $797.15 1

35311 $2,741.21 1

35321 $1,567.22 1

35331 $2,570.67 1

35341 $2,407.59 1

35351 $2,263.44 1

35355 $1,831.47 1

35361 $2,707.79 1

35363 $3,094.91 1

35371 $1,445.94 1

35372 $1,735.04 1

35390 $283.35 1

35400 $265.43 1

35450 $888.66 1

35452 $607.28 1

35458 $867.12 1

35460 $552.90 1

3/1/2015 60 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

35471 $4,083.45 1

35472 $2,990.75 1

35475 $2,478.63 1

35476 $2,262.87 1

35500 $567.33 1

35501 $2,662.91 1

35506 $2,269.08 1

35508 $2,361.93 1

35509 $2,517.77 1

35510 $2,189.22 1

35511 $1,994.48 1

35512 $2,422.41 1

35515 $2,676.80 1

35516 $2,172.02 1

35518 $2,032.77 1

35521 $2,180.81 1

35522 $2,152.76 1

35523 $2,280.06 1

35525 $2,029.20 1

35526 $3,052.56 1

35531 $3,586.40 1

35533 $2,681.24 1

35535 $3,390.23 1

35536 $3,009.80 1

35537 $4,176.44 1

35538 $4,160.51 1

35539 $3,907.85 1

35540 $4,544.93 1

35556 $2,477.06 1

35558 $2,164.41 1

35560 $3,035.63 1

35563 $2,666.99 1

35565 $2,347.31 1

35566 $2,960.67 1

35570 $2,693.54 1

35571 $2,355.32 1

35572 $612.02 1

35583 $2,569.89 1

35585 $2,975.96 1

35587 $2,428.40 1

35600 $445.11 1

35601 $2,484.98 1

35606 $2,084.46 1

35612 $1,855.70 1

35616 $1,961.40 1

3/1/2015 61 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

35621 $1,949.81 1

35623 $2,336.24 1

35626 $2,767.59 1

35631 $3,282.99 1

35632 $3,218.75 1

35633 $3,576.08 1

35634 $3,250.61 1

35636 $2,838.83 1

35637 $3,084.74 1

35638 $3,123.08 1

35642 $2,009.18 1

35645 $1,680.03 1

35646 $3,040.86 1

35647 $2,741.42 1

35650 $1,926.54 1

35654 $2,431.79 1

35656 $1,917.20 1

35661 $1,917.95 1

35663 $2,238.21 1

35665 $2,073.05 1

35666 $2,234.61 1

35671 $1,971.59 1

35681 $141.57 1

35682 $627.98 1

35683 $732.47 1

35685 $354.33 1

35686 $288.26 1

35691 $1,678.04 1

35693 $1,476.54 1

35694 $1,753.41 1

35695 $1,821.56 1

35697 $262.85 1

35700 $271.74 1

35701 $968.34 1

35721 $796.52 1

35741 $890.51 1

35761 $672.02 1

35800 $1,226.70 1

35820 $3,481.40 1

35840 $2,052.65 1

35860 $1,473.65 1

35870 $2,211.87 1

35875 $1,046.48 1

35876 $1,667.42 1

35879 $1,629.60 1

3/1/2015 62 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

35881 $1,798.05 1

35883 $2,139.87 1

35884 $2,208.14 1

35901 $864.48 1

35903 $988.56 1

35905 $3,113.99 1

35907 $3,390.71 1

36002 $265.85 1

36005 $511.10 1

36010 $799.44 1

36011 $1,325.85 1

36012 $1,369.26 1

36013 $1,234.61 1

36014 $1,287.56 1

36015 $1,364.66 1

36100 $792.57 1

36120 $671.42 1

36140 $698.66 1

36147 $1,326.93 1

36148 $415.08 1

36160 $786.23 1

36200 $1,002.68 1

36215 $1,790.15 1

36216 $1,872.02 1

36217 $3,013.29 1

36218 $295.37 3

36221 $1,745.09 1

36222 $2,028.84 1

36223 $2,429.85 1

36224 $3,030.98 1

36225 $2,348.64 1

36226 $2,960.27 1

36227 $428.03 1

36228 $2,014.16 1

36245 $2,175.35 1

36246 $1,433.96 1

36247 $2,512.08 1

36248 $243.08 3

36251 $2,268.69 1

36252 $2,475.38 1

36253 $3,587.27 1

36254 $3,518.66 1

36260 $1,104.69 1

36261 $619.65 1

36262 $517.73 1

3/1/2015 63 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

36400 $44.31 1

36405 $41.67 1

36406 $32.85 1

36410 $26.96 1

36420 $81.23 1

36425 $65.99 1

36430 $54.87 1

36440 $96.65 1

36450 $196.73 1

36455 $222.90 1

36460 $571.40 1

36468 $0.00 1

36470 $241.83 1

36471 $284.03 1

36475 $2,444.07 1

36476 $482.73 1

36478 $1,918.01 1

36479 $499.49 1

36481 $3,256.40 1

36500 $306.78 1

36510 $149.60 1

36511 $149.84 1

36512 $152.60 1

36513 $161.24 1

36514 $841.26 1

36515 $3,221.42 1

36516 $3,257.60 1

36522 $2,180.99 1

36555 $403.17 1

36556 $374.36 1

36557 $1,646.64 1

36558 $1,250.00 1

36560 $1,699.17 1

36561 $1,880.72 1

36563 $2,146.26 1

36565 $1,560.86 1

36566 $8,735.85 1

36568 $481.17 1

36569 $396.63 1

36570 $1,875.44 1

36571 $2,087.90 1

36575 $263.52 1

36576 $631.11 1

36578 $836.13 1

36580 $342.41 1

3/1/2015 64 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

36581 $1,219.43 1

36582 $1,753.49 1

36583 $2,188.68 1

36584 $323.61 1

36585 $1,844.01 1

36589 $270.66 1

36590 $481.79 1

36591 $36.83 1

36592 $41.25 1

36593 $48.42 1

36595 $930.89 1

36596 $212.39 1

36597 $205.38 1

36598 $173.93 1

36600 $49.94 1

36620 $83.03 1

36625 $172.98 1

36640 $192.17 1

36660 $98.46 1

36680 $98.96 1

36800 $207.08 1

36810 $363.68 1

36815 $241.74 1

36818 $1,215.00 1

36819 $1,289.58 1

36820 $1,280.18 1

36821 $1,166.45 1

36823 $2,393.88 1

36825 $1,406.18 1

36830 $1,173.42 1

36831 $1,084.86 1

36832 $1,329.75 1

36833 $1,422.39 1

36835 $864.44 1

36838 $2,019.62 1

36860 $329.67 1

36861 $229.20 1

36870 $2,900.01 1

37140 $4,000.16 1

37145 $3,708.41 1

37160 $3,808.97 1

37180 $3,664.85 1

37181 $4,000.16 1

37182 $1,383.03 1

37183 $9,301.82 1

3/1/2015 65 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

37184 $3,632.73 1

37185 $1,153.25 1

37186 $2,198.13 1

37187 $3,285.96 1

37188 $2,796.62 1

37191 $4,160.85 1

37192 $2,657.36 1

37193 $2,551.08 1

37197 $2,421.87 1

37200 $365.52 1

37202 $522.18 1

37211 $688.01 1

37212 $600.98 1

37213 $419.64 1

37214 $231.80 1

37215 $1,898.42 1

37217 $1,966.50

37218 $1,419.59

37220 $5,018.45 1

37221 $7,386.20 1

37222 $1,417.49 1

37223 $4,108.17 1

37224 $6,081.02 1

37225 $17,411.94 1

37226 $14,322.02 1

37227 $23,502.06 1

37228 $8,638.91 1

37229 $17,191.52 1

37230 $13,165.04 1

37231 $21,105.26 1

37232 $1,937.24 1

37233 $2,353.74 1

37234 $6,134.58 1

37235 $6,596.90 1

37236 $6,567.53

37237 $3,936.36

37238 $6,496.07

37239 $3,208.91

37241 $7,247.78

37242 $12,200.82

37243 $15,399.45

37244 $10,794.24

37250 $187.35 1

37251 $141.02 1

37500 $1,125.95 1

3/1/2015 66 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

37565 $1,226.15 1

37600 $1,256.57 1

37605 $1,385.19 1

37606 $847.22 1

37607 $654.74 1

37609 $510.44 1

37615 $841.92 1

37616 $1,919.27 1

37617 $2,322.06 1

37618 $656.94 1

37619 $2,834.34 1

37650 $812.57 1

37660 $2,264.46 1

37700 $430.19 1

37718 $757.89 1

37722 $833.00 1

37735 $1,030.71 1

37760 $1,069.22 1

37761 $961.97 1

37765 $1,091.16 1

37766 $1,297.91 1

37780 $446.03 1

37785 $598.86 1

37788 $2,060.66 1

37790 $792.69 1

38100 $1,977.26 1

38101 $2,004.68 1

38102 $451.44 1

38115 $2,185.41 1

38120 $1,800.84 1

38200 $221.12 1

38205 $131.63 1

38206 $132.74 1

38220 $261.38 1

38221 $264.42 1

38230 $325.41 1

38232 $343.80 1

38240 $357.77 1

38241 $268.97 1

38242 $191.04 1

38243 $190.64 1

38300 $447.11 1

38305 $784.95 1

38308 $752.34 1

38380 $923.90 1

3/1/2015 67 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

38381 $1,379.30 1

38382 $1,160.57 1

38500 $549.74 1

38505 $203.10 1

38510 $861.48 1

38520 $781.82 1

38525 $740.43 1

38530 $924.60 1

38542 $863.03 1

38550 $860.30 1

38555 $1,718.18 1

38562 $1,185.17 1

38564 $1,197.51 1

38570 $900.18 1

38571 $1,317.33 1

38572 $1,667.79 1

38700 $1,338.51 1

38720 $2,243.42 1

38724 $2,417.88 1

38740 $1,181.48 1

38745 $1,492.29 1

38746 $375.18 1

38747 $461.42 1

38760 $1,429.56 1

38765 $2,195.16 1

38770 $1,340.18 1

38780 $1,709.16 1

38790 $140.06 1

38792 $64.34 1

38794 $490.07 1

38900 $237.69 1

39000 $845.57 1

39010 $1,354.20 1

39200 $1,520.85 1

39220 $1,958.49 1

39400 $874.05 1

39501 $1,452.53 1

39503 $10,640.10 1

39540 $1,491.33 1

39541 $1,625.85 1

39545 $1,532.60 1

39560 $1,363.98 1

39561 $2,121.09 1

40490 $207.20 1

40500 $822.11 1

3/1/2015 68 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

40510 $792.26 1

40520 $800.58 1

40525 $912.75 1

40527 $1,022.13 1

40530 $882.42 1

40650 $710.72 1

40652 $801.54 1

40654 $927.44 1

40700 $1,670.49 1

40701 $1,575.81 1

40702 $1,586.31 1

40720 $1,708.64 1

40761 $1,619.01 1

40800 $345.84 1

40801 $522.36 1

40804 $345.72 1

40805 $533.70 1

40806 $174.24 1

40808 $304.77 1

40810 $337.89 1

40812 $475.28 1

40814 $637.47 1

40816 $664.88 1

40818 $587.60 1

40819 $517.59 1

40820 $432.39 1

40830 $434.55 1

40831 $552.48 1

40840 $1,338.20 1

40842 $1,357.70 1

40843 $1,805.31 1

40844 $2,134.34 1

40845 $2,427.36 1

41000 $267.39 1

41005 $368.91 1

41006 $632.43 1

41007 $621.98 1

41008 $626.72 1

41009 $665.52 1

41010 $328.35 1

41015 $749.63 1

41016 $728.64 1

41017 $739.88 1

41018 $837.63 1

41019 $749.70 1

3/1/2015 69 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

41100 $275.93 1

41105 $280.64 1

41108 $242.57 1

41110 $346.59 1

41112 $551.69 1

41113 $604.89 1

41114 $1,061.04 1

41115 $403.11 1

41116 $541.88 1

41120 $1,725.89 1

41130 $2,142.68 1

41135 $3,574.37 1

41140 $3,583.34 1

41145 $4,538.58 1

41150 $3,603.92 1

41153 $3,938.88 1

41155 $4,969.61 1

41250 $438.57 1

41251 $480.51 1

41252 $519.33 1

41500 $747.14 1

41510 $643.41 1

41512 $1,046.00 1

41520 $584.82 1

41530 $5,123.84 1

41800 $435.63 1

41805 $406.79 1

41806 $586.73 1

41820 $0.00 1

41821 $0.00 1

41822 $511.31 1

41823 $749.94 1

41825 $347.03 1

41826 $520.14 1

41827 $731.99 1

41828 $511.22 1

41830 $653.24 1

41850 $0.00 1

41870 $0.00 1

41872 $616.76 1

41874 $624.75 1

42000 $257.55 1

42100 $247.49 1

42104 $353.57 1

42106 $449.85 1

3/1/2015 70 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

42107 $758.97 1

42120 $1,641.50 1

42140 $411.74 1

42145 $1,168.32 1

42160 $380.19 1

42180 $398.94 1

42182 $525.89 1

42200 $1,408.58 1

42205 $1,473.21 1

42210 $1,796.34 1

42215 $1,193.34 1

42220 $891.02 1

42225 $1,446.20 1

42226 $1,472.15 1

42227 $1,381.17 1

42235 $1,207.65 1

42260 $1,429.43 1

42280 $272.52 1

42281 $335.04 1

42300 $342.60 1

42305 $715.26 1

42310 $264.75 1

42320 $407.84 1

42330 $380.63 1

42335 $613.17 1

42340 $765.90 1

42400 $171.65 1

42405 $489.36 1

42408 $741.51 1

42409 $544.19 1

42410 $1,035.15 1

42415 $1,757.55 1

42420 $1,975.04 1

42425 $1,388.90 1

42426 $2,252.97 1

42440 $684.42 1

42450 $744.33 1

42500 $712.80 1

42505 $914.30 1

42507 $845.18 1

42509 $1,397.12 1

42510 $1,038.24 1

42550 $216.74 1

42600 $785.07 1

42650 $136.49 1

3/1/2015 71 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

42660 $213.96 1

42665 $507.45 1

42700 $310.70 1

42720 $749.88 1

42725 $1,360.16 1

42800 $259.88 1

42804 $316.47 1

42806 $355.88 1

42808 $370.55 1

42809 $284.97 1

42810 $633.84 1

42815 $927.05 1

42820 $480.02 1

42821 $498.20 1

42825 $431.82 1

42826 $415.34 1

42830 $342.26 1

42831 $367.95 1

42835 $318.38 1

42836 $397.97 1

42842 $1,641.44 1

42844 $2,259.80 1

42845 $3,669.14 1

42860 $310.97 1

42870 $946.91 1

42890 $2,328.68 1

42892 $3,099.71 1

42894 $3,882.95 1

42900 $562.61 1

42950 $1,301.33 1

42953 $1,566.41 1

42955 $1,233.62 1

42960 $282.47 1

42961 $699.39 1

42962 $860.25 1

42970 $685.31 1

42971 $757.52 1

42972 $848.72 1

43020 $963.62 1

43030 $864.63 1

43045 $2,255.54 1

43100 $1,040.36 1

43101 $1,827.35 1

43107 $4,423.32 1

43108 $8,131.71 1

3/1/2015 72 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

43112 $4,670.94 1

43113 $7,611.69 1

43116 $8,726.94 1

43117 $4,271.54 1

43118 $6,625.64 1

43121 $4,988.39 1

43122 $4,416.33 1

43123 $8,231.28 1

43124 $6,653.28 1

43130 $1,319.24 1

43135 $2,586.44 1

43180 $936.59

43191 $254.67

43192 $283.10

43193 $282.54

43194 $319.86

43195 $308.97

43196 $326.64

43197 $303.39

43198 $341.75

43200 $434.49 1

43201 $444.87 1

43202 $582.23 1

43204 $242.07 1

43205 $249.08 1

43206 $532.34

43211 $419.30

43212 $337.37

43213 $1,970.33

43214 $336.45

43215 $659.69 1

43216 $674.10 1

43217 $721.71 1

43220 $1,803.17 1

43226 $612.51 1

43227 $637.97 1

43229 $1,167.50

43231 $650.09 1

43232 $771.81 1

43233 $396.68

43235 $505.22 1

43236 $627.92 1

43237 $344.45 1

43238 $411.08 1

43239 $643.38 1

3/1/2015 73 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

43240 $684.09 1

43241 $252.86 1

43242 $462.27 1

43243 $416.99 1

43244 $431.69 1

43245 $990.84 1

43246 $353.31 1

43247 $659.72 1

43248 $664.83 1

43249 $1,724.73 1

43250 $738.75 1

43251 $809.94 1

43252 $597.72

43253 $462.27

43254 $474.56

43255 $698.21 1

43257 $410.18 1

43259 $397.47 1

43260 $563.76 1

43261 $590.15 1

43262 $623.28 1

43263 $625.67 1

43264 $635.40 1

43265 $753.72 1

43266 $399.08

43270 $1,217.42

43273 $205.92 1

43274 $804.39

43275 $656.03

43276 $837.14

43277 $659.28

43278 $753.18

43279 $2,225.18 1

43280 $1,854.78 1

43281 $2,655.72 1

43282 $2,987.55 1

43283 $276.18 1

43300 $1,019.34 1

43305 $1,815.87 1

43310 $2,562.72 1

43312 $2,790.23 1

43313 $4,202.55 1

43314 $4,536.65 1

43320 $2,403.29 1

43325 $2,312.01 1

3/1/2015 74 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

43327 $1,400.33 1

43328 $1,966.35 1

43330 $2,294.45 1

43331 $2,330.22 1

43332 $1,996.47 1

43333 $2,173.56 1

43334 $2,169.54 1

43335 $2,337.39 1

43336 $2,624.40 1

43337 $2,819.91 1

43338 $201.90 1

43340 $2,371.22 1

43341 $2,545.97 1

43351 $2,388.59 1

43352 $1,850.82 1

43360 $4,106.04 1

43361 $4,445.54 1

43400 $2,620.52 1

43401 $2,705.24 1

43405 $2,646.05 1

43410 $1,803.75 1

43415 $4,429.92 1

43420 $1,692.99 1

43425 $2,511.14 1

43450 $343.58 1

43453 $1,547.99 1

43460 $366.54 1

43500 $1,337.73 1

43501 $2,312.01 1

43502 $2,626.07 1

43510 $1,620.95 1

43520 $1,174.80 1

43605 $1,428.65 1

43610 $1,681.79 1

43611 $2,091.92 1

43620 $3,388.43 1

43621 $3,910.16 1

43622 $3,993.84 1

43631 $2,491.01 1

43632 $3,495.47 1

43633 $3,302.25 1

43634 $3,670.14 1

43635 $194.96 1

43640 $2,017.02 1

43641 $2,065.58 1

3/1/2015 75 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

43644 $2,972.67 1

43645 $3,178.01 1

43651 $1,119.24 1

43652 $1,309.88 1

43653 $973.52 1

43752 $67.74 1

43753 $35.36 1

43754 $207.90 1

43755 $226.80 1

43756 $328.17 1

43757 $469.71 1

43760 $775.97 1

43761 $190.46 1

43770 $1,912.38 1

43771 $2,174.10 1

43772 $1,628.33 1

43773 $2,195.63 1

43774 $1,641.68 1

43800 $1,592.49 1

43810 $1,751.24 1

43820 $2,300.34 1

43825 $2,251.50 1

43830 $1,189.52 1

43831 $1,010.51 1

43832 $1,781.45 1

43840 $2,328.59 1

43843 $2,202.68 1

43845 $3,374.16 1

43846 $2,768.21 1

43847 $3,103.79 1

43848 $3,305.28 1

43850 $2,805.47 1

43855 $2,912.30 1

43860 $2,810.15 1

43865 $2,946.15 1

43870 $1,216.55 1

43880 $2,735.25 1

43886 $610.58 1

43887 $552.18 1

43888 $778.16 1

44005 $1,872.06 1

44010 $1,476.21 1

44015 $247.26 1

44020 $1,668.74 1

44021 $1,668.05 1

3/1/2015 76 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

44025 $1,685.03 1

44050 $1,600.46 1

44055 $2,549.42 1

44100 $186.59 1

44110 $1,455.20 1

44111 $1,678.76 1

44120 $2,095.62 1

44121 $417.95 1

44125 $2,016.45 1

44126 $4,254.68 1

44127 $4,923.54 1

44128 $423.45 1

44130 $2,243.97 1

44132 $0.00 1

44133 $0.00 1

44135 $0.00 1

44136 $0.00 1

44139 $208.86 1

44140 $2,295.66 1

44141 $3,116.40 1

44143 $2,846.24 1

44144 $3,029.85 1

44145 $2,826.75 1

44146 $3,611.84 1

44147 $3,330.12 1

44150 $3,184.11 1

44151 $3,694.85 1

44155 $3,520.14 1

44156 $3,972.87 1

44157 $3,749.93 1

44158 $3,506.87 1

44160 $2,120.57 1

44180 $1,570.11 1

44186 $1,115.34 1

44187 $1,871.61 1

44188 $2,077.05 1

44202 $2,370.05 1

44203 $423.45 1

44204 $2,621.09 1

44205 $2,278.53 1

44206 $2,991.42 1

44207 $3,097.55 1

44208 $3,379.97 1

44210 $3,008.31 1

44211 $3,652.16 1

3/1/2015 77 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

44212 $3,453.83 1

44213 $323.18 1

44227 $2,853.92 1

44300 $1,437.44 1

44310 $1,775.73 1

44312 $992.27 1

44314 $1,696.29 1

44316 $2,433.21 1

44320 $2,047.95 1

44322 $1,693.34 1

44340 $1,056.38 1

44345 $1,787.75 1

44346 $2,010.50 1

44360 $254.88 1

44361 $281.69 1

44363 $337.94 1

44364 $359.46 1

44365 $309.51 1

44366 $422.64 1

44369 $432.23 1

44370 $467.67 1

44372 $422.45 1

44373 $338.67 1

44376 $494.91 1

44377 $525.23 1

44378 $671.24 1

44379 $715.61 1

44380 $112.10 1

44382 $133.28 1

44385 $425.36 1

44386 $565.91 1

44388 $568.46 1

44389 $635.16 1

44390 $743.79 1

44391 $801.00 1

44392 $706.07 1

44394 $799.91 1

44500 $39.90 1

44602 $2,422.37 1

44603 $2,779.34 1

44604 $1,813.44 1

44605 $2,232.24 1

44615 $1,829.84 1

44620 $1,477.23 1

44625 $1,727.82 1

3/1/2015 78 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

44626 $2,742.59 1

44640 $2,395.62 1

44650 $2,485.44 1

44660 $2,250.35 1

44661 $2,637.09 1

44680 $1,824.08 1

44700 $1,722.92 1

44701 $288.84 1

44720 $477.42 1

44721 $667.13 1

44800 $1,302.84 1

44820 $1,454.94 1

44850 $1,283.22 1

44900 $1,328.87 1

44950 $1,098.23 1

44955 $143.90 1

44960 $1,495.86 1

44970 $1,023.69 1

45000 $702.56 1

45005 $442.14 1

45020 $957.59 1

45100 $499.26 1

45108 $625.26 1

45110 $3,125.04 1

45111 $1,845.02 1

45112 $3,176.94 1

45113 $3,128.96 1

45114 $3,132.24 1

45116 $2,568.71 1

45119 $3,285.29 1

45120 $2,736.14 1

45121 $2,727.44 1

45123 $1,882.73 1

45126 $4,502.48 1

45130 $1,823.30 1

45135 $2,363.96 1

45136 $2,984.07 1

45150 $586.02 1

45160 $1,753.43 1

45171 $1,002.11 1

45172 $1,351.74 1

45190 $1,156.02 1

45300 $198.12 1

45303 $1,531.79 1

45305 $314.31 1

3/1/2015 79 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

45307 $360.92 1

45308 $356.79 1

45309 $354.42 1

45315 $405.48 1

45317 $390.99 1

45320 $400.17 1

45321 $180.56 1

45327 $203.36 1

45330 $219.96 1

45331 $260.72 1

45332 $467.39 1

45333 $475.11 1

45334 $268.83 1

45335 $438.65 1

45337 $235.73 1

45338 $510.68 1

45340 $773.63 1

45341 $255.78 1

45342 $387.68 1

45378 $625.61 1

45379 $806.10 1

45380 $745.20 2

45381 $747.42 1

45382 $966.71 1

45384 $749.37 1

45385 $842.48 1

45386 $1,065.74 1

45391 $483.95 1

45392 $616.74 1

45395 $3,334.31 1

45397 $3,621.42 1

45400 $1,908.68 1

45402 $2,560.26 1

45500 $862.13 1

45505 $992.54 1

45520 $251.57 1

45540 $1,783.58 1

45541 $1,584.83 1

45550 $2,454.57 1

45560 $1,135.35 1

45562 $1,959.36 1

45563 $2,826.95 1

45800 $2,125.52 1

45805 $2,281.59 1

45820 $1,841.36 1

3/1/2015 80 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

45825 $2,389.22 1

45900 $343.52 1

45905 $282.51 1

45910 $323.51 1

45915 $537.11 1

45990 $181.95 1

46020 $452.90 1

46030 $226.83 1

46040 $880.10 1

46045 $726.63 1

46050 $324.65 1

46060 $791.37 1

46070 $352.17 1

46080 $405.42 1

46083 $283.80 1

46200 $725.01 1

46220 $334.35 1

46221 $436.82 1

46230 $444.48 1

46250 $757.44 1

46255 $831.23 1

46257 $700.31 1

46258 $788.15 1

46260 $795.39 1

46261 $866.28 1

46262 $921.83 1

46270 $833.69 1

46275 $880.02 1

46280 $777.92 1

46285 $870.27 1

46288 $913.89 1

46320 $298.40 1

46500 $385.61 1

46505 $465.30 1

46600 $140.90 1

46604 $990.83 1

46606 $360.26 1

46608 $384.39 1

46610 $364.71 1

46611 $281.64 1

46612 $444.45 1

46614 $207.20 1

46615 $236.03 1

46700 $1,085.58 1

46705 $775.19 1

3/1/2015 81 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

46706 $297.45 1

46707 $790.79 1

46710 $1,726.86 1

46712 $3,227.97 1

46715 $917.28 1

46716 $1,716.92 1

46730 $3,353.06 1

46735 $3,264.56 1

46740 $3,668.72 1

46742 $3,589.37 1

46744 $6,055.17 1

46746 $5,711.67 1

46748 $6,131.30 1

46750 $1,246.41 1

46751 $922.79 1

46753 $949.17 1

46754 $471.32 1

46760 $1,801.29 1

46761 $1,528.77 1

46762 $1,520.88 1

46900 $391.14 1

46910 $412.50 1

46916 $365.91 1

46917 $717.24 1

46922 $431.28 1

46924 $858.30 1

46930 $332.34 1

46940 $372.38 1

46942 $351.66 1

46945 $499.83 1

46946 $512.24 1

46947 $640.76 1

47000 $575.67 1

47001 $180.30 1

47010 $2,055.03 1

47015 $1,991.66 1

47100 $1,439.54 1

47120 $3,998.48 1

47122 $5,911.79 1

47125 $5,286.47 1

47130 $5,686.64 1

47135 $8,400.08 1

47136 $7,224.54 1

47140 $5,182.16 1

47141 $7,339.49 1

3/1/2015 82 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

47142 $8,096.06 1

47146 $573.38 1

47147 $662.54 1

47300 $1,940.33 1

47350 $2,344.25 1

47360 $3,215.18 1

47361 $5,205.47 1

47362 $2,489.27 1

47370 $2,138.00 1

47371 $2,158.61 1

47380 $2,465.54 1

47381 $2,199.59 1

47382 $7,899.33 1

47383 $11,924.10

47400 $3,712.02 1

47420 $2,298.59 1

47425 $2,346.54 1

47460 $2,175.63 1

47480 $1,490.91 1

47490 $541.02 1

47500 $158.51 1

47505 $61.01 1

47510 $770.70 1

47511 $944.15 1

47525 $820.61 1

47530 $2,179.59 1

47550 $286.94 1

47552 $518.16 1

47553 $513.80 1

47554 $806.21 1

47555 $610.17 1

47556 $692.15 1

47560 $466.38 1

47561 $510.47 1

47562 $1,122.38 1

47563 $1,219.62 1

47564 $1,900.79 1

47570 $1,329.98 1

47600 $1,825.40 1

47605 $1,922.66 1

47610 $2,151.60 1

47612 $2,178.02 1

47620 $2,371.82 1

47630 $878.55 1

47700 $1,800.47 1

3/1/2015 83 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

47701 $2,983.68 1

47711 $2,660.73 1

47712 $3,442.16 1

47715 $2,282.60 1

47720 $1,977.20 1

47721 $2,324.24 1

47740 $2,252.91 1

47741 $2,535.68 1

47760 $3,879.54 1

47765 $5,243.46 1

47780 $4,248.48 1

47785 $5,591.42 1

47800 $2,712.59 1

47801 $1,665.33 1

47802 $2,621.24 1

47900 $2,354.99 1

48000 $3,238.62 1

48001 $3,984.83 1

48020 $2,020.71 1

48100 $1,503.86 1

48102 $852.14 1

48105 $4,895.28 1

48120 $1,895.70 1

48140 $2,682.87 1

48145 $2,810.94 1

48146 $3,226.28 1

48148 $2,143.80 1

48150 $5,351.06 1

48152 $4,971.00 1

48153 $5,320.95 1

48154 $4,993.83 1

48155 $3,108.47 1

48400 $186.48 1

48500 $1,971.03 1

48510 $1,878.15 1

48520 $1,871.27 1

48540 $2,255.45 1

48545 $2,311.32 1

48547 $3,090.00 1

48548 $2,868.72 1

48552 $410.43 1

48554 $4,348.65 1

48556 $2,176.43 1

49000 $1,312.91 1

49002 $1,789.26 1

3/1/2015 84 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

49010 $1,590.57 1

49020 $2,723.58 1

49040 $1,709.49 1

49060 $1,874.72 1

49062 $1,262.61 1

49082 $308.63 1

49083 $464.48 1

49084 $187.52 1

49180 $261.99 1

49203 $2,040.42 1

49204 $2,611.23 1

49205 $3,002.81 1

49215 $3,728.22 1

49220 $1,666.65 1

49250 $991.82 1

49255 $1,338.66 1

49320 $547.73 1

49321 $582.23 1

49322 $618.32 1

49323 $1,079.52 1

49324 $665.12 1

49325 $710.16 1

49326 $328.32 1

49327 $226.11 1

49400 $222.33 1

49402 $1,460.64 1

49405 $1,383.36

49406 $1,385.01

49407 $1,160.52

49411 $870.32 1

49412 $142.11 1

49418 $2,261.01 1

49419 $750.63 1

49421 $398.06 1

49422 $647.49 1

49423 $866.03 1

49424 $231.15 1

49425 $1,231.34 1

49426 $1,044.78 1

49427 $74.24 1

49428 $950.43 1

49429 $786.47 1

49435 $206.43 1

49436 $317.07 1

49440 $1,644.95 1

3/1/2015 85 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

49441 $1,845.80 1

49442 $1,528.86 1

49446 $1,578.41 1

49450 $1,050.87 1

49451 $1,146.96 1

49452 $1,420.22 1

49460 $1,153.91 1

49465 $256.05 1

49491 $1,282.16 1

49492 $1,381.70 1

49495 $595.80 1

49496 $879.69 1

49500 $696.27 1

49501 $1,034.69 1

49505 $884.33 1

49507 $996.29 1

49520 $1,077.12 1

49521 $1,221.83 1

49525 $973.89 1

49540 $1,148.27 1

49550 $980.24 1

49553 $1,075.76 1

49555 $1,014.39 1

49557 $1,233.75 1

49560 $1,256.28 1

49561 $1,591.85 1

49565 $1,309.31 1

49566 $1,605.05 1

49568 $462.33 1

49570 $702.02 1

49572 $876.92 1

49580 $561.33 1

49582 $820.31 1

49585 $753.80 1

49587 $805.67 1

49590 $974.67 1

49600 $1,190.03 1

49605 $8,534.72 1

49606 $1,948.86 1

49610 $1,175.97 1

49611 $868.77 1

49650 $725.82 1

49651 $945.14 1

49652 $1,269.72 1

49653 $1,585.01 1

3/1/2015 86 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

49654 $1,444.59 1

49655 $1,765.50 1

49656 $1,571.70 1

49657 $2,261.45 1

49900 $1,382.91 1

49904 $2,406.93 1

49905 $604.19 1

50010 $1,242.12 1

50020 $1,648.95 1

50040 $1,511.64 1

50045 $1,519.34 1

50060 $1,859.39 1

50065 $1,972.98 1

50070 $1,933.41 1

50075 $2,378.28 1

50080 $1,418.15 1

50081 $2,083.40 1

50100 $1,848.45 1

50120 $1,548.17 1

50125 $1,602.78 1

50130 $1,685.31 1

50135 $1,831.79 1

50200 $972.96 1

50205 $1,277.24 1

50220 $1,722.51 1

50225 $1,968.89 1

50230 $2,099.09 1

50234 $2,125.59 1

50236 $2,395.28 1

50240 $2,161.05 1

50250 $1,983.83 1

50280 $1,563.63 1

50290 $1,463.34 1

50320 $2,558.66 1

50327 $373.37 1

50328 $327.03 1

50329 $317.34 1

50340 $1,612.25 1

50360 $4,129.85 1

50365 $4,818.87 1

50370 $2,033.61 1

50380 $3,412.86 1

50382 $1,876.29 1

50384 $1,494.65 1

50385 $1,803.62 1

3/1/2015 87 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

50386 $1,174.43 1

50387 $857.79 1

50389 $468.51 1

50390 $159.06 1

50391 $197.91 1

50392 $293.40 1

50393 $356.96 1

50394 $164.87 1

50395 $294.14 1

50396 $194.39 1

50398 $787.22 1

50400 $1,885.94 1

50405 $2,279.55 1

50500 $1,881.59 1

50520 $1,689.65 1

50525 $2,478.77 1

50526 $2,286.47 1

50540 $1,872.03 1

50541 $1,499.01 1

50542 $1,901.43 1

50543 $2,426.19 1

50544 $2,032.79 1

50545 $2,188.77 1

50546 $1,968.90 1

50547 $2,716.80 1

50548 $2,201.18 1

50551 $581.66 1

50553 $622.65 1

50555 $667.62 1

50557 $678.53 1

50561 $768.29 1

50562 $949.44 1

50570 $804.72 1

50572 $870.81 1

50574 $925.34 1

50575 $1,169.69 1

50576 $923.18 1

50580 $994.70 1

50590 $1,157.33 1

50592 $4,950.20 1

50593 $7,292.70 1

50600 $1,531.85 1

50605 $1,653.87 1

50610 $1,542.03 1

50620 $1,474.85 1

3/1/2015 88 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

50630 $1,455.87 1

50650 $1,689.18 1

50660 $1,865.16 1

50684 $167.63 1

50686 $252.41 1

50688 $129.17 1

50690 $157.40 1

50700 $1,509.24 1

50715 $2,051.79 1

50722 $1,690.94 1

50725 $1,823.37 1

50727 $829.38 1

50728 $1,135.92 1

50740 $2,099.76 1

50750 $1,881.59 1

50760 $1,870.50 1

50770 $1,881.59 1

50780 $1,825.98 1

50782 $1,826.67 1

50783 $1,839.71 1

50785 $1,985.45 1

50800 $1,515.75 1

50810 $2,395.04 1

50815 $1,993.70 1

50820 $2,157.95 1

50825 $2,700.96 1

50830 $2,942.16 1

50840 $2,003.81 1

50845 $2,034.99 1

50860 $1,541.93 1

50900 $1,383.93 1

50920 $1,436.27 1

50930 $1,798.92 1

50940 $1,445.84 1

50945 $1,588.55 1

50947 $2,269.91 1

50948 $2,081.96 1

50951 $608.16 1

50953 $644.34 1

50955 $688.80 1

50957 $695.37 1

50961 $626.24 1

50970 $608.45 1

50972 $587.87 1

50974 $774.57 1

3/1/2015 89 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

50976 $763.55 1

50980 $585.17 1

51020 $759.09 1

51030 $763.13 1

51040 $467.99 1

51045 $807.29 1

51050 $766.37 1

51060 $944.54 1

51065 $940.67 1

51080 $662.16 1

51100 $99.83 1

51101 $198.87 1

51102 $363.54 1

51500 $1,035.00 1

51520 $966.21 1

51525 $1,402.10 1

51530 $1,275.42 1

51535 $1,269.77 1

51550 $1,583.82 1

51555 $2,081.49 1

51565 $2,132.99 1

51570 $2,420.21 1

51575 $2,976.47 1

51580 $3,095.16 1

51585 $3,447.32 1

51590 $3,161.00 1

51595 $3,576.44 1

51596 $3,838.13 1

51597 $3,757.88 1

51600 $289.14 1

51605 $61.38 1

51610 $170.28 1

51700 $132.63 1

51701 $86.10 1

51702 $110.42 1

51703 $206.81 1

51705 $144.75 1

51710 $204.98 1

51715 $467.01 1

51720 $174.71 1

51725 $296.42 1

51726 $413.57 1

51727 $490.08 1

51728 $493.20 1

51729 $535.65 1

3/1/2015 90 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

51736 $24.77 1

51741 $25.32 1

51784 $303.56 1

51785 $402.24 1

51792 $331.52 1

51797 $175.85 1

51798 $29.64 1

51800 $1,703.99 1

51820 $2,077.91 1

51840 $1,070.04 1

51841 $1,260.74 1

51845 $953.24 1

51860 $1,231.50 1

51865 $1,474.92 1

51880 $767.61 1

51900 $1,356.60 1

51920 $1,242.75 1

51925 $1,910.57 1

51940 $2,679.45 1

51960 $2,269.05 1

51980 $1,159.97 1

51990 $1,226.45 1

51992 $1,380.14 1

52000 $326.36 1

52001 $597.56 1

52005 $420.96 1

52007 $699.80 1

52010 $579.56 1

52204 $583.02 1

52214 $1,035.81 1

52224 $1,087.04 1

52234 $402.41 1

52235 $472.71 1

52240 $642.09 1

52250 $392.31 1

52260 $345.56 1

52265 $579.51 1

52270 $563.91 1

52275 $761.18 1

52276 $433.11 1

52277 $530.28 1

52281 $432.32 1

52282 $553.29 1

52283 $442.16 1

52285 $446.78 1

3/1/2015 91 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

52287 $494.75 1

52290 $399.71 1

52300 $459.50 1

52301 $476.30 1

52305 $456.18 1

52310 $387.84 1

52315 $660.92 1

52317 $1,272.75 1

52318 $776.55 1

52320 $403.77 1

52325 $525.89 1

52327 $430.05 1

52330 $783.27 1

52332 $768.99 1

52334 $418.85 1

52341 $464.39 1

52342 $507.03 1

52343 $564.27 1

52344 $606.36 1

52345 $646.25 1

52346 $733.71 1

52351 $495.96 1

52352 $581.63 1

52353 $642.09 1

52354 $682.35 1

52355 $764.70 1

52356 $680.70

52400 $779.57 1

52402 $437.09 1

52441 $1,939.77

52442 $1,477.59

52450 $762.08 1

52500 $793.53 1

52601 $1,378.05 1

52630 $648.80 1

52640 $509.49 1

52647 $2,803.41 1

52648 $2,886.56 1

52649 $1,340.33 1

52700 $715.59 1

53000 $241.50 1

53010 $476.52 1

53020 $157.70 1

53025 $110.87 1

53040 $637.19 1

3/1/2015 92 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

53060 $298.38 1

53080 $682.10 1

53085 $1,055.97 1

53200 $255.08 1

53210 $1,258.28 1

53215 $1,513.95 1

53220 $742.97 1

53230 $987.56 1

53235 $1,028.66 1

53240 $689.36 1

53250 $642.21 1

53260 $325.07 1

53265 $351.72 1

53270 $332.07 1

53275 $427.91 1

53400 $1,305.48 1

53405 $1,423.98 1

53410 $1,597.13 1

53415 $1,843.58 1

53420 $1,369.73 1

53425 $1,526.30 1

53430 $1,573.77 1

53431 $1,882.76 1

53440 $1,226.45 1

53442 $1,273.56 1

53444 $1,291.95 1

53445 $1,225.92 1

53446 $1,043.90 1

53447 $1,316.48 1

53448 $2,087.73 1

53449 $994.74 1

53450 $665.19 1

53460 $743.34 1

53500 $1,221.50 1

53502 $791.49 1

53505 $790.38 1

53510 $1,026.50 1

53515 $1,296.69 1

53520 $903.87 1

53600 $134.12 1

53601 $129.53 1

53605 $106.20 1

53620 $186.30 1

53621 $175.14 1

53660 $111.36 1

3/1/2015 93 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

53661 $109.14 1

53665 $63.96 1

53850 $3,254.13 1

53852 $3,003.96 1

53855 $1,211.00 1

53860 $2,448.48 1

54000 $236.63 1

54001 $295.97 1

54015 $498.06 1

54050 $211.52 1

54055 $190.22 1

54056 $226.43 1

54057 $215.57 1

54060 $286.44 1

54065 $349.91 1

54100 $316.77 1

54105 $424.41 1

54110 $1,015.14 1

54111 $1,305.39 1

54112 $1,528.65 1

54115 $730.64 1

54120 $1,029.72 1

54125 $1,323.95 1

54130 $1,945.59 1

54135 $2,468.04 1

54150 $247.91 1

54160 $351.29 1

54161 $319.82 1

54162 $410.96 1

54163 $354.06 1

54164 $312.89 1

54200 $170.55 1

54205 $864.36 1

54220 $329.00 1

54230 $155.82 1

54231 $226.13 1

54235 $145.76 1

54240 $158.27 1

54250 $194.54 1

54300 $1,044.71 1

54304 $1,221.80 1

54308 $1,163.21 1

54312 $1,332.32 1

54316 $1,627.46 1

54318 $1,151.22 1

3/1/2015 94 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

54322 $1,271.85 1

54324 $1,580.58 1

54326 $1,541.85 1

54328 $1,531.74 1

54332 $1,653.45 1

54336 $1,939.68 1

54340 $927.06 1

54344 $1,544.54 1

54348 $1,639.61 1

54352 $2,311.52 1

54360 $1,174.73 1

54380 $1,301.91 1

54385 $1,711.76 1

54390 $2,004.56 1

54400 $861.65 1

54401 $1,062.69 1

54405 $1,316.82 1

54406 $1,190.39 1

54408 $1,286.88 1

54410 $1,398.99 1

54411 $1,672.28 1

54415 $861.20 1

54416 $1,153.02 1

54417 $1,464.53 1

54420 $1,146.27 1

54430 $1,041.06 1

54435 $675.99 1

54450 $112.53 1

54500 $122.18 1

54505 $340.34 1

54512 $884.40 1

54520 $533.15 1

54522 $960.06 1

54530 $821.36 1

54535 $1,213.10 1

54550 $800.46 1

54560 $1,071.32 1

54600 $735.05 1

54620 $488.55 1

54640 $783.14 1

54650 $1,157.31 1

54660 $579.39 1

54670 $657.29 1

54680 $1,282.07 1

54690 $1,070.78 1

3/1/2015 95 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

54692 $1,237.80 1

54700 $352.16 1

54800 $206.70 1

54830 $605.48 1

54840 $520.86 1

54860 $680.37 1

54861 $921.00 1

54865 $581.55 1

54900 $1,295.30 1

54901 $1,707.03 1

55000 $188.45 1

55040 $551.69 1

55041 $831.18 1

55060 $619.61 1

55100 $346.44 1

55110 $630.92 1

55120 $580.53 1

55150 $804.02 1

55175 $589.13 1

55180 $1,123.49 1

55200 $693.83 1

55250 $609.20 1

55300 $305.52 1

55400 $810.81 1

55450 $573.78 1

55500 $651.69 1

55520 $764.93 1

55530 $574.59 1

55535 $698.94 1

55540 $940.85 1

55550 $695.61 1

55600 $684.14 1

55605 $845.78 1

55650 $1,165.92 1

55680 $560.57 1

55700 $347.90 1

55705 $434.28 1

55706 $605.96 1

55720 $733.61 1

55725 $1,030.37 1

55801 $1,780.95 1

55810 $2,156.49 1

55812 $2,626.02 1

55815 $2,878.31 1

55821 $1,424.19 1

3/1/2015 96 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

55831 $1,542.12 1

55840 $1,911.20 1

55842 $1,908.80 1

55845 $2,225.40 1

55860 $1,426.28 1

55862 $1,771.80 1

55865 $2,177.78 1

55866 $2,827.82 1

55870 $283.26 1

55873 $11,111.07 1

55875 $1,239.74 1

55876 $216.51 1

55920 $723.11 1

56405 $177.68 1

56420 $195.80 1

56440 $295.65 1

56441 $234.81 1

56442 $76.05 1

56501 $210.68 1

56515 $367.88 1

56605 $133.01 1

56606 $60.80 1

56620 $859.47 1

56625 $1,052.43 1

56630 $1,557.29 1

56631 $1,980.60 1

56632 $2,325.78 1

56633 $2,044.02 1

56634 $2,222.91 1

56637 $2,560.44 1

56640 $2,608.77 1

56700 $301.62 1

56740 $492.93 1

56800 $391.92 1

56805 $1,854.27 1

56810 $422.46 1

56820 $182.63 1

56821 $240.66 1

57000 $298.76 1

57010 $699.69 1

57020 $149.49 1

57022 $272.15 1

57023 $504.24 1

57061 $183.50 1

57065 $319.76 1

3/1/2015 97 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

57100 $145.37 1

57105 $221.46 1

57106 $813.12 1

57107 $2,435.42 1

57109 $2,983.67 1

57110 $1,451.15 1

57111 $2,599.85 1

57112 $3,194.18 1

57120 $824.22 1

57130 $285.30 1

57135 $309.95 1

57150 $72.03 1

57155 $679.76 1

57156 $312.00 1

57160 $122.48 1

57170 $97.59 1

57180 $226.43 1

57200 $493.13 1

57210 $596.93 1

57220 $515.46 1

57230 $637.59 1

57240 $1,088.78 1

57250 $1,097.61 1

57260 $1,353.39 1

57265 $1,481.88 1

57267 $417.63 1

57268 $783.20 1

57270 $1,296.45 1

57280 $1,551.33 1

57282 $808.71 1

57283 $1,119.26 1

57284 $1,324.67 1

57285 $1,090.26 1

57287 $1,100.58 1

57288 $1,159.94 1

57289 $1,187.40 1

57291 $856.97 1

57292 $1,322.79 1

57295 $772.31 1

57296 $1,517.52 1

57300 $935.82 1

57305 $1,570.22 1

57307 $1,833.99 1

57308 $1,034.09 1

57310 $747.00 1

3/1/2015 98 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

57311 $851.21 1

57320 $858.62 1

57330 $1,204.79 1

57335 $1,778.46 1

57400 $216.36 1

57410 $177.44 1

57415 $259.28 1

57420 $193.50 1

57421 $256.98 1

57423 $1,486.26 1

57425 $1,574.03 1

57426 $1,369.10 1

57452 $176.55 1

57454 $247.58 1

57455 $231.56 1

57456 $217.41 1

57460 $450.60 1

57461 $511.86 1

57500 $204.47 1

57505 $163.61 1

57510 $211.26 1

57511 $234.56 1

57513 $235.67 1

57520 $496.95 1

57522 $424.74 1

57530 $568.53 1

57531 $3,148.89 1

57540 $1,301.49 1

57545 $1,330.74 1

57550 $656.31 1

57555 $972.35 1

57556 $918.60 1

57558 $201.42 1

57700 $498.96 1

57720 $493.76 1

57800 $98.37 1

58100 $175.22 1

58110 $78.12 1

58120 $418.07 1

58140 $1,509.17 1

58145 $892.80 1

58146 $1,868.07 1

58150 $1,670.39 1

58152 $2,048.07 1

58180 $1,577.46 1

3/1/2015 99 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

58200 $2,294.72 1

58210 $3,104.52 1

58240 $4,899.92 1

58260 $1,340.97 1

58262 $1,499.01 1

58263 $1,604.46 1

58267 $1,716.78 1

58270 $1,432.65 1

58275 $1,607.16 1

58280 $1,704.50 1

58285 $2,438.90 1

58290 $1,862.85 1

58291 $2,018.49 1

58292 $2,129.09 1

58293 $2,213.69 1

58294 $1,972.73 1

58301 $152.43 1

58321 $121.88 1

58322 $137.61 1

58323 $25.04 1

58340 $187.88 1

58345 $451.26 1

58346 $704.63 1

58350 $154.80 1

58353 $1,576.64 1

58356 $2,943.54 1

58400 $709.70 1

58410 $1,301.04 1

58520 $1,297.88 1

58540 $1,471.77 1

58541 $1,162.25 1

58542 $1,330.65 1

58543 $1,344.45 1

58544 $1,475.61 1

58545 $1,485.80 1

58546 $1,822.70 1

58548 $3,201.11 1

58550 $1,432.05 1

58552 $1,618.02 1

58553 $1,842.20 1

58554 $2,172.15 1

58555 $484.97 1

58558 $636.06 1

58559 $555.14 1

58560 $627.26 1

3/1/2015 100 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

58561 $889.95 1

58562 $660.72 1

58563 $2,606.79 1

58565 $2,930.42 1

58570 $1,268.22 1

58571 $1,489.23 1

58572 $1,662.41 1

58573 $2,008.13 1

58600 $587.76 1

58605 $532.62 1

58611 $125.81 1

58615 $393.93 1

58660 $1,102.05 1

58661 $1,065.05 1

58662 $1,160.43 1

58670 $590.16 1

58671 $588.32 1

58672 $1,190.70 1

58673 $1,295.49 1

58700 $1,289.85 1

58720 $1,215.81 1

58740 $1,454.63 1

58750 $1,478.69 1

58752 $1,382.10 1

58760 $1,311.32 1

58770 $1,380.48 1

58800 $511.59 1

58805 $652.13 1

58820 $502.08 1

58822 $1,132.46 1

58825 $1,285.04 1

58900 $666.39 1

58920 $1,156.73 1

58925 $1,231.22 1

58940 $870.50 1

58943 $1,970.18 1

58950 $1,900.77 1

58951 $2,439.02 1

58952 $2,771.40 1

58953 $3,424.28 1

58954 $3,713.64 1

58956 $2,325.56 1

58957 $2,682.17 1

58958 $2,938.23 1

58960 $1,645.16 1

3/1/2015 101 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

58970 $359.99 1

58976 $387.15 1

59000 $209.82 1

59001 $314.03 1

59012 $354.74 1

59015 $266.36 1

59020 $117.87 1

59025 $80.16 1

59030 $161.60 1

59050 $89.15 1

59051 $73.19 1

59070 $694.67 1

59072 $751.67 1

59074 $668.15 1

59076 $751.67 1

59100 $1,444.82 1

59120 $1,374.33 1

59121 $1,375.70 1

59130 $1,347.27 1

59135 $1,330.59 1

59136 $1,522.76 1

59140 $689.28 1

59150 $1,332.98 1

59151 $1,294.97 1

59160 $347.19 1

59200 $120.80 1

59300 $327.89 1

59320 $265.53 1

59325 $422.78 1

59350 $493.16 1

59400 $3,600.06 1

59409 $1,422.95 1

59410 $1,814.19 1

59412 $180.98 1

59414 $160.70 1

59425 $774.68 1

59426 $1,384.01 1

59430 $314.34 1

59510 $3,984.54 1

59514 $1,600.34 1

59515 $2,195.78 1

59525 $850.79 1

59610 $3,782.67 1

59612 $1,603.34 1

59614 $1,992.74 1

3/1/2015 102 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

59618 $4,044.63 1

59620 $1,660.41 1

59622 $2,256.77 1

59812 $542.03 1

59820 $643.02 1

59821 $649.25 1

59830 $751.38 1

59840 $371.46 1

59841 $656.43 1

59850 $556.32 1

59851 $683.61 1

59852 $803.91 1

59855 $715.56 1

59856 $843.15 1

59857 $829.01 1

59866 $347.46 1

59870 $804.81 1

59871 $231.12 1

60000 $258.90 1

60100 $182.72 1

60200 $1,102.89 1

60210 $1,188.02 1

60212 $1,698.27 1

60220 $1,184.78 1

60225 $1,568.18 1

60240 $1,549.73 1

60252 $2,226.69 1

60254 $2,819.16 1

60260 $1,838.75 1

60270 $2,316.63 1

60271 $1,780.50 1

60280 $731.52 1

60281 $969.90 1

60300 $190.11 1

60500 $1,630.92 1

60502 $2,183.13 1

60505 $2,337.87 1

60512 $417.21 1

60520 $1,785.98 1

60521 $1,930.91 1

60522 $2,341.53 1

60540 $1,778.57 1

60545 $2,055.74 1

60600 $2,413.11 1

60605 $3,425.33 1

3/1/2015 103 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

60650 $2,016.27 1

61000 $196.46 1

61001 $131.10 1

61020 $186.27 1

61026 $172.74 1

61050 $140.63 1

61055 $204.66 1

61070 $97.07 1

61105 $834.00 1

61107 $583.05 1

61108 $1,648.01 1

61120 $1,358.58 1

61140 $2,291.58 1

61150 $2,491.17 1

61151 $1,820.81 1

61154 $2,302.71 1

61156 $2,291.19 1

61210 $687.92 1

61215 $900.74 1

61250 $1,583.61 1

61253 $1,704.80 1

61304 $2,984.10 1

61305 $3,704.97 1

61312 $3,810.77 1

61313 $3,618.27 1

61314 $3,326.90 1

61315 $3,786.03 1

61316 $163.80 1

61320 $3,461.78 1

61321 $3,930.02 1

61322 $4,355.15 1

61323 $4,413.11 1

61330 $2,477.94 1

61332 $2,864.82 1

61333 $2,927.63 1

61340 $2,656.56 1

61343 $4,017.00 1

61345 $3,765.87 1

61450 $3,552.42 1

61458 $3,672.83 1

61460 $3,885.56 1

61480 $3,586.08 1

61500 $2,336.40 1

61501 $2,049.72 1

61510 $3,986.82 1

3/1/2015 104 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

61512 $4,666.41 1

61514 $3,495.75 1

61516 $3,399.26 1

61517 $164.19 1

61518 $5,038.08 1

61519 $5,409.53 1

61520 $6,833.25 1

61521 $5,801.99 1

61522 $4,040.49 1

61524 $3,843.23 1

61526 $6,770.93 1

61530 $5,706.66 1

61531 $2,233.98 1

61533 $2,798.15 1

61534 $3,025.40 1

61535 $1,822.83 1

61536 $4,774.40 1

61537 $4,510.85 1

61538 $4,949.06 1

61539 $4,365.39 1

61540 $4,031.28 1

61541 $3,968.93 1

61543 $4,012.88 1

61544 $3,512.09 1

61545 $5,890.83 1

61546 $4,266.98 1

61548 $2,823.15 1

61550 $1,627.68 1

61552 $1,795.89 1

61556 $3,138.71 1

61557 $3,086.78 1

61558 $3,107.48 1

61559 $4,407.62 1

61563 $3,655.22 1

61564 $4,445.48 1

61566 $4,154.81 1

61567 $4,381.35 1

61570 $3,442.23 1

61571 $3,668.70 1

61575 $4,636.74 1

61576 $5,671.55 1

61580 $4,274.79 1

61581 $4,361.52 1

61582 $5,398.28 1

61583 $5,218.44 1

3/1/2015 105 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

61584 $5,145.74 1

61585 $5,862.77 1

61586 $4,320.80 1

61590 $5,134.74 1

61591 $5,341.94 1

61592 $5,741.99 1

61595 $4,052.87 1

61596 $4,057.58 1

61597 $5,297.22 1

61598 $5,158.44 1

61600 $3,624.44 1

61601 $4,310.64 1

61605 $3,623.96 1

61606 $5,561.64 1

61607 $4,632.95 1

61608 $5,906.79 1

61610 $3,485.15 1

61611 $601.20 1

61612 $2,256.20 1

61613 $6,022.59 1

61615 $4,908.90 1

61616 $5,935.91 1

61618 $2,313.05 1

61619 $2,518.61 1

61623 $984.74 1

61624 $2,001.68 1

61626 $1,454.63 1

61630 $2,305.46 1

61635 $2,408.36 1

61680 $4,113.63 1

61682 $7,715.16 1

61684 $5,267.13 1

61686 $8,366.46 1

61690 $4,035.29 1

61692 $6,798.81 1

61697 $7,787.93 1

61698 $8,619.65 1

61700 $6,272.72 1

61702 $7,479.80 1

61703 $2,495.39 1

61705 $4,820.73 1

61708 $4,712.46 1

61710 $3,979.95 1

61711 $4,761.65 1

61720 $2,333.63 1

3/1/2015 106 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

61735 $2,926.68 1

61750 $2,571.78 1

61751 $2,517.51 1

61760 $2,912.99 1

61770 $2,996.01 1

61781 $436.68 1

61782 $294.98 1

61783 $426.38 1

61790 $1,595.96 1

61791 $2,061.08 1

61796 $1,853.24 1

61797 $413.73 1

61798 $2,536.95 1

61799 $568.98 1

61800 $285.39 1

61850 $1,798.40 1

61860 $2,885.96 1

61863 $2,749.86 1

61864 $533.97 1

61867 $4,180.95 1

61868 $931.41 1

61870 $2,172.05 1

61880 $1,017.15 1

61885 $909.63 1

61886 $1,505.73 1

61888 $710.27 1

62000 $1,885.08 1

62005 $2,334.72 1

62010 $2,816.79 1

62100 $2,895.95 1

62115 $2,286.27 1

62117 $3,625.73 1

62120 $2,746.65 1

62121 $2,791.28 1

62140 $1,856.52 1

62141 $2,060.97 1

62142 $1,594.14 1

62143 $1,892.30 1

62145 $2,565.32 1

62146 $2,255.39 1

62147 $2,685.47 1

62148 $237.38 1

62160 $356.52 1

62161 $2,793.74 1

62162 $3,481.16 1

3/1/2015 107 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

62163 $2,241.33 1

62164 $3,845.46 1

62165 $2,734.52 1

62180 $2,947.29 1

62190 $952.94 1

62192 $1,767.68 1

62194 $876.18 1

62200 $2,532.15 1

62201 $2,192.99 1

62220 $1,858.13 1

62223 $1,886.76 1

62225 $941.06 1

62230 $1,524.27 1

62252 $144.62 1

62256 $1,079.60 1

62258 $2,036.97 1

62263 $1,001.91 1

62264 $665.51 1

62267 $400.98 1

62268 $429.86 1

62269 $440.82 1

62270 $257.42 1

62272 $326.85 1

62273 $276.41 1

62280 $479.66 1

62281 $375.75 1

62282 $470.37 1

62284 $291.95 1

62287 $938.84 1

62290 $531.72 5

62291 $535.74 1

62292 $941.66 1

62294 $1,287.11 1

62302 $390.17

62303 $405.08

62304 $385.25

62305 $420.26

62310 $380.10 1

62311 $350.13 1

62318 $362.76 1

62319 $266.37 1

62350 $673.86 1

62351 $1,503.00 1

62355 $455.48 1

62360 $512.60 1

3/1/2015 108 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

62361 $767.16 1

62362 $656.72 1

62365 $507.15 1

62367 $64.77 1

62368 $90.06 1

62369 $190.61 1

62370 $201.83 1

63001 $2,231.36 1

63003 $2,211.66 1

63005 $2,100.02 1

63011 $1,922.34 1

63012 $2,102.48 1

63015 $2,669.06 1

63016 $2,715.23 1

63017 $2,238.27 1

63020 $2,060.09 1

63030 $1,694.39 1

63035 $341.76 1

63040 $2,462.16 1

63042 $2,261.64 1

63045 $2,274.09 1

63046 $2,129.10 1

63047 $1,935.71 1

63048 $379.17 1

63050 $2,608.20 1

63051 $3,015.29 1

63055 $2,933.66 1

63056 $2,616.89 1

63057 $570.53 1

63064 $3,157.13 1

63066 $386.30 1

63075 $2,390.78 1

63076 $443.24 1

63077 $2,639.37 1

63078 $327.21 1

63081 $3,105.45 1

63082 $477.69 1

63085 $3,384.63 1

63086 $340.41 1

63087 $4,258.62 1

63088 $468.92 1

63090 $3,357.41 1

63091 $306.99 1

63101 $4,151.96 1

63102 $4,011.05 1

3/1/2015 109 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

63103 $527.40 1

63170 $2,928.57 1

63172 $2,606.69 1

63173 $3,177.56 1

63180 $2,729.16 1

63182 $3,000.12 1

63185 $1,988.97 1

63190 $2,168.15 1

63191 $2,527.61 1

63194 $2,933.54 1

63195 $1,879.70 1

63196 $2,185.04 1

63197 $3,149.96 1

63198 $2,573.82 1

63199 $2,699.45 1

63200 $2,778.17 1

63250 $5,505.06 1

63251 $5,623.65 1

63252 $5,623.13 1

63265 $3,009.62 1

63266 $3,104.13 1

63267 $2,439.59 1

63268 $2,644.01 1

63270 $3,832.88 1

63271 $3,789.09 1

63272 $3,409.43 1

63273 $3,438.06 1

63275 $3,271.58 1

63276 $3,236.15 1

63277 $2,772.29 1

63278 $2,920.07 1

63280 $3,883.49 1

63281 $3,817.53 1

63282 $3,583.22 1

63283 $3,496.88 1

63285 $4,840.14 1

63286 $4,785.80 1

63287 $5,082.08 1

63290 $5,169.60 1

63295 $625.89 1

63300 $3,313.91 1

63301 $3,984.45 1

63302 $4,019.96 1

63303 $4,279.86 1

63304 $4,341.62 1

3/1/2015 110 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

63305 $4,625.30 1

63306 $3,456.32 1

63307 $3,738.53 1

63308 $588.93 1

63600 $1,476.99 1

63610 $633.15 1

63615 $1,749.27 1

63620 $2,033.90 1

63621 $471.06 1

63650 $2,098.83 1

63655 $1,456.11 1

63661 $932.88 1

63662 $1,476.60 1

63663 $1,263.33 1

63664 $1,506.69 1

63685 $622.04 1

63688 $627.38 1

63700 $1,977.92 1

63702 $2,564.72 1

63704 $2,518.58 1

63706 $2,856.68 1

63707 $1,608.17 1

63709 $1,933.04 1

63710 $1,892.58 1

63740 $1,740.09 1

63741 $1,203.66 1

63744 $1,213.50 1

63746 $1,083.54 1

64400 $206.82 1

64402 $212.85 1

64405 $164.57 1

64408 $186.27 1

64410 $190.67 1

64412 $227.70 1

64413 $209.12 1

64415 $186.53 1

64416 $128.00 1

64417 $204.83 1

64418 $233.75 1

64420 $178.92 1

64421 $238.14 1

64425 $210.03 1

64430 $223.40 1

64435 $216.96 1

64445 $215.63 1

3/1/2015 111 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

64446 $128.55 1

64447 $189.26 1

64448 $113.93 1

64449 $135.92 1

64450 $127.32 1

64455 $75.21 6

64479 $374.15 1

64480 $179.43 2

64483 $346.43 1

64484 $137.96 2

64486 $196.64

64487 $239.75

64488 $241.58

64489 $335.72

64490 $302.18 1

64491 $149.85 1

64492 $150.41 1

64493 $273.38 1

64494 $138.15 1

64495 $138.69 1

64505 $167.94 1

64508 $107.55 1

64510 $201.69 1

64517 $286.65 1

64520 $293.91 1

64530 $302.01 1

64550 $24.93 1

64553 $339.60 1

64555 $337.82 1

64561 $1,295.99 1

64565 $303.84 1

64566 $191.27 1

64568 $1,161.15 1

64569 $1,385.10 1

64570 $1,170.20 1

64575 $535.28 1

64580 $508.20 1

64581 $1,087.46 1

64585 $392.10 1

64590 $424.34 1

64595 $392.09 1

64600 $619.85 1

64605 $951.47 1

64610 $1,230.39 1

64611 $198.09 1

3/1/2015 112 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

64612 $215.36 1

64615 $254.57 1

64616 $213.12

64617 $307.01

64620 $328.43 1

64630 $379.53 1

64632 $136.11 8

64633 $659.82 1

64634 $293.78 1

64635 $654.39 1

64636 $268.80 1

64640 $211.07 1

64642 $234.48

64643 $157.11

64644 $270.11

64645 $189.98

64646 $255.78

64647 $295.05

64650 $125.91 1

64653 $157.11 1

64680 $499.67 1

64681 $640.22 1

64702 $821.58 1

64704 $511.86 1

64708 $826.74 1

64712 $952.31 1

64713 $1,206.35 1

64714 $1,066.55 1

64716 $877.85 1

64718 $981.80 1

64719 $661.62 1

64721 $710.97 1

64722 $617.85 1

64726 $445.16 1

64727 $315.17 1

64732 $624.93 1

64734 $888.53 1

64736 $656.06 1

64738 $761.03 1

64740 $748.56 1

64742 $752.13 1

64744 $883.46 1

64746 $737.27 1

64755 $1,577.27 1

64760 $873.87 1

3/1/2015 113 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

64763 $866.19 1

64766 $931.67 1

64771 $983.69 1

64772 $957.63 1

64774 $693.98 1

64776 $636.87 1

64778 $229.94 1

64782 $737.58 1

64783 $365.39 1

64784 $1,208.73 1

64786 $1,827.62 1

64787 $408.83 1

64788 $686.21 1

64790 $1,441.01 1

64792 $1,795.71 1

64795 $331.88 1

64802 $1,071.30 1

64804 $1,612.14 1

64809 $1,986.54 1

64818 $893.34 1

64820 $1,200.81 1

64821 $1,128.53 1

64822 $1,128.53 1

64823 $1,323.08 1

64831 $1,132.65 1

64832 $566.43 1

64834 $1,221.50 1

64835 $1,372.43 1

64836 $1,357.01 1

64837 $634.52 1

64840 $1,604.45 1

64856 $1,696.44 1

64857 $1,756.17 1

64858 $1,992.45 1

64859 $421.59 1

64861 $2,116.98 1

64862 $1,850.21 1

64864 $1,437.72 1

64865 $1,827.42 1

64866 $1,896.38 1

64868 $1,673.57 1

64872 $202.07 1

64874 $275.61 1

64876 $273.15 1

64885 $1,849.46 1

3/1/2015 114 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

64886 $2,146.04 1

64890 $1,813.89 1

64891 $1,933.25 1

64892 $1,775.79 1

64893 $1,883.76 1

64895 $2,243.19 1

64896 $2,905.04 1

64897 $2,096.99 1

64898 $2,286.81 1

64901 $934.71 1

64902 $1,081.98 1

64905 $1,699.73 1

64907 $2,641.23 1

64910 $1,368.78 1

64911 $1,679.90 1

65091 $996.80 1

65093 $986.10 1

65101 $1,159.73 1

65103 $1,208.76 1

65105 $1,334.97 1

65110 $1,921.89 1

65112 $2,229.09 1

65114 $2,338.65 1

65125 $715.61 1

65130 $1,149.96 1

65135 $1,166.61 1

65140 $1,269.08 1

65150 $906.80 1

65155 $1,329.17 1

65175 $1,031.73 1

65205 $87.62 1

65210 $107.66 1

65220 $91.47 1

65222 $104.90 1

65235 $1,122.12 1

65260 $1,509.56 1

65265 $1,700.36 1

65270 $418.34 1

65272 $788.01 1

65273 $599.69 1

65275 $908.87 1

65280 $1,060.65 1

65285 $1,748.79 1

65286 $1,105.16 1

65290 $773.33 1

3/1/2015 115 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

65400 $1,067.85 1

65410 $224.48 1

65420 $809.61 1

65426 $1,024.34 1

65430 $180.29 1

65435 $124.10 1

65436 $609.99 1

65450 $511.64 1

65600 $619.65 2

65710 $1,743.27 1

65730 $1,934.28 1

65750 $1,945.35 1

65755 $1,934.67 1

65756 $1,869.41 1

65770 $2,219.55 1

65772 $708.81 1

65775 $869.01 1

65778 $2,150.64 1

65779 $1,914.59 1

65780 $1,400.15 1

65781 $2,102.45 1

65782 $1,813.86 1

65800 $187.74 1

65810 $734.33 1

65815 $1,001.40 1

65820 $1,176.98 1

65850 $1,322.67 1

65855 $531.78 1

65860 $486.39 1

65865 $745.64 1

65870 $930.66 1

65875 $991.29 1

65880 $1,044.74 1

65900 $1,518.99 1

65920 $1,242.06 1

65930 $1,005.83 1

66020 $291.42 1

66030 $260.12 1

66130 $1,093.46 1

66150 $1,372.49 1

66155 $1,379.13 1

66160 $1,555.10 1

66170 $1,891.13 1

66172 $2,383.94 1

66174 $1,494.32 1

3/1/2015 116 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

66175 $1,565.10 1

66179 $1,698.69

66180 $1,793.39 1

66183 $1,623.20

66184 $1,236.11

66185 $1,330.98 1

66220 $1,171.34 1

66225 $1,469.09 1

66250 $1,175.12 1

66500 $556.53 1

66505 $610.04 1

66600 $1,309.80 1

66605 $1,665.93 1

66625 $675.51 1

66630 $896.78 1

66635 $905.84 1

66680 $815.72 1

66682 $1,002.57 1

66700 $707.99 1

66710 $691.97 1

66711 $1,009.89 1

66720 $746.52 1

66740 $687.56 1

66761 $465.08 1

66762 $746.09 1

66770 $831.42 1

66820 $617.93 1

66821 $518.90 1

66825 $1,195.77 1

66830 $1,122.66 1

66840 $1,099.01 1

66850 $1,249.26 1

66852 $1,331.30 1

66920 $1,189.19 1

66930 $1,350.12 1

66940 $1,233.17 1

66982 $1,253.94 1

66983 $1,151.88 1

66984 $1,008.57 1

66985 $1,212.99 1

66986 $1,431.20 1

66990 $143.58 1

67005 $744.35 1

67010 $855.33 1

67015 $914.12 1

3/1/2015 117 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

67025 $1,142.18 1

67027 $1,342.92 1

67028 $160.46 1

67030 $838.08 1

67031 $610.56 1

67036 $1,419.99 1

67039 $1,522.67 1

67040 $1,645.41 1

67041 $1,819.97 1

67042 $1,819.97 1

67043 $1,920.62 1

67101 $1,232.39 1

67105 $1,131.56 1

67107 $1,915.65 1

67108 $2,531.55 1

67110 $1,366.86 1

67112 $2,092.26 1

67113 $2,752.77 1

67115 $787.26 1

67120 $1,032.59 1

67121 $1,431.77 1

67141 $824.76 1

67145 $829.82 1

67208 $943.13 1

67210 $816.87 1

67218 $2,181.90 1

67220 $842.28 1

67221 $452.01 1

67225 $46.76 1

67227 $961.74 1

67228 $1,576.73 1

67229 $1,839.90 1

67250 $1,228.88 1

67255 $1,076.19 1

67311 $942.38 1

67312 $1,122.54 1

67314 $1,061.16 1

67316 $1,264.67 1

67318 $1,110.90 1

67320 $510.18 1

67331 $484.28 1

67332 $525.57 1

67334 $477.41 1

67335 $236.28 1

67340 $568.31 1

3/1/2015 118 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

67343 $1,030.74 1

67345 $390.29 1

67346 $307.47 1

67400 $1,464.02 1

67405 $1,251.44 1

67412 $1,341.00 1

67413 $1,345.34 1

67414 $2,090.43 1

67415 $165.65 1

67420 $2,564.28 1

67430 $1,961.22 1

67440 $1,898.24 1

67445 $2,213.73 1

67450 $1,979.42 1

67500 $124.37 1

67505 $140.48 1

67515 $152.78 1

67550 $1,520.00 1

67560 $1,557.83 1

67570 $1,844.01 1

67700 $417.95 1

67710 $347.76 1

67715 $372.12 1

67800 $199.73 1

67801 $255.08 1

67805 $316.92 1

67808 $581.43 1

67810 $270.62 1

67820 $78.21 1

67825 $202.46 1

67830 $416.64 1

67835 $691.43 1

67840 $430.64 1

67850 $337.47 1

67875 $267.77 1

67880 $719.36 1

67882 $885.74 1

67900 $1,008.90 1

67901 $1,188.30 1

67902 $1,145.66 1

67903 $932.45 1

67904 $1,152.15 1

67906 $801.59 1

67908 $774.39 1

67909 $844.85 1

3/1/2015 119 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

67911 $886.85 1

67912 $1,387.13 1

67914 $737.49 1

67915 $456.89 1

67916 $929.87 1

67917 $946.46 1

67921 $720.45 1

67922 $452.46 1

67923 $927.12 1

67924 $989.18 1

67930 $572.66 1

67935 $936.92 1

67938 $374.88 1

67950 $900.51 1

67961 $904.04 1

67966 $1,210.38 1

67971 $1,143.15 1

67973 $1,471.22 1

67974 $1,467.21 1

67975 $1,083.45 1

68020 $188.10 1

68040 $97.70 1

68100 $265.56 1

68110 $353.00 1

68115 $486.29 1

68130 $843.59 1

68135 $246.83 1

68200 $64.40 1

68320 $1,135.89 1

68325 $1,043.37 1

68326 $1,019.04 1

68328 $1,118.46 1

68330 $947.81 1

68335 $1,022.28 1

68340 $853.73 1

68360 $831.68 1

68362 $1,036.22 1

68371 $649.70 1

68400 $444.09 1

68420 $502.58 1

68440 $159.71 1

68500 $1,537.17 1

68505 $1,530.12 1

68510 $700.20 1

68520 $1,083.63 1

3/1/2015 120 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

68525 $418.77 1

68530 $670.55 1

68540 $1,463.91 1

68550 $1,792.71 1

68700 $952.71 1

68705 $370.40 1

68720 $1,192.95 1

68745 $1,197.11 1

68750 $1,240.05 1

68760 $314.21 1

68761 $231.39 1

68770 $992.91 1

68801 $194.13 1

68810 $378.24 1

68811 $324.72 1

68815 $704.15 1

68816 $1,158.06 1

68840 $200.64 1

68850 $96.86 1

69000 $298.46 1

69005 $346.91 1

69020 $371.87 1

69100 $159.81 1

69105 $224.55 1

69110 $736.71 1

69120 $651.95 1

69140 $1,423.62 1

69145 $637.89 1

69150 $1,721.33 1

69155 $2,738.18 1

69200 $195.78 1

69205 $165.60 1

69210 $78.93 1

69220 $218.70 1

69222 $352.11 1

69300 $1,181.43 1

69310 $1,774.59 1

69320 $2,493.89 1

69420 $307.67 1

69421 $244.59 1

69424 $204.30 1

69433 $325.22 1

69436 $263.55 1

69440 $1,123.44 1

69450 $886.41 1

3/1/2015 121 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

69501 $1,198.16 1

69502 $1,597.64 1

69505 $1,963.64 1

69511 $2,011.76 1

69530 $2,705.61 1

69535 $4,420.61 1

69540 $333.29 1

69550 $1,697.33 1

69552 $2,571.93 1

69554 $4,149.36 1

69601 $1,716.06 1

69602 $1,783.32 1

69603 $2,058.08 1

69604 $1,822.76 1

69605 $2,552.75 1

69610 $625.26 1

69620 $1,120.82 1

69631 $1,445.01 1

69632 $1,763.27 1

69633 $1,706.31 1

69635 $2,012.97 1

69636 $2,253.66 1

69637 $2,302.61 1

69641 $1,704.83 1

69642 $2,193.93 1

69643 $2,009.79 1

69644 $2,423.28 1

69645 $2,381.21 1

69646 $2,524.55 1

69650 $1,315.79 1

69660 $1,525.02 1

69661 $1,982.93 1

69662 $1,908.68 1

69666 $1,327.05 1

69667 $1,325.93 1

69670 $1,544.66 1

69676 $1,359.23 1

69700 $1,121.07 1

69711 $1,411.31 1

69714 $1,773.36 1

69715 $2,187.72 1

69717 $1,857.59 1

69718 $2,209.97 1

69720 $1,962.80 1

69725 $3,100.22 1

3/1/2015 122 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

69740 $1,920.48 1

69745 $2,040.99 1

69801 $317.97 1

69805 $1,733.00 1

69806 $1,552.41 1

69820 $1,401.90 1

69840 $1,459.55 1

69905 $1,501.41 1

69910 $1,671.12 1

69915 $2,536.01 1

69930 $2,018.48 1

69950 $2,946.66 1

69955 $3,264.35 1

69960 $3,180.38 1

69970 $3,537.18 1

69990 $406.22 1

70010 $120.89 1

70015 $240.77 1

70030 $42.99 1

70100 $51.27 1

70110 $58.89 1

70120 $52.92 1

70130 $85.08 1

70134 $79.74 1

70140 $46.28 1

70150 $64.40 1

70160 $50.73 1

70170 $0.00 1

70190 $54.54 1

70200 $65.48 1

70210 $46.31 1

70220 $57.78 1

70240 $47.21 1

70250 $55.59 1

70260 $69.80 1

70300 $23.78 1

70310 $60.14 1

70320 $83.97 1

70328 $48.51 1

70330 $73.64 1

70332 $128.76 1

70336 $496.07 1

70350 $31.22 1

70355 $32.27 1

70360 $43.55 1

3/1/2015 123 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

70370 $125.81 1

70371 $139.88 1

70373 $118.61 1

70380 $56.63 1

70390 $145.77 1

70450 $180.00 1

70460 $251.55 1

70470 $297.18 1

70480 $361.23 1

70481 $427.19 1

70482 $467.40 1

70486 $217.02 1

70487 $261.50 1

70488 $317.61 1

70490 $298.82 1

70491 $365.31 1

70492 $430.38 1

70496 $458.99 1

70498 $456.23 1

70540 $554.84 1

70542 $625.11 1

70543 $763.10 1

70544 $608.66 1

70545 $598.35 1

70546 $930.66 1

70547 $610.50 1

70548 $641.25 1

70549 $934.53 1

70551 $356.31 1

70552 $497.06 1

70553 $585.92 1

70554 $701.66 1

70555 $0.00 1

70557 $0.00 1

70558 $0.00 1

70559 $0.00 1

71010 $35.25 1

71015 $42.93 1

71020 $43.47 1

71021 $52.79 1

71022 $64.88 1

71023 $99.18 1

71030 $64.32 1

71034 $131.10 1

71035 $50.72 1

3/1/2015 124 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

71100 $47.34 1

71101 $56.10 1

71110 $57.75 1

71111 $73.14 1

71120 $45.71 1

71130 $56.54 1

71250 $278.99 1

71260 $355.23 1

71270 $426.08 1

71275 $466.05 1

71550 $642.30 1

71551 $710.73 1

71552 $900.47 1

71555 $617.99 1

72010 $109.58 2

72020 $34.19 1

72040 $52.13 1

72050 $69.66 1

72052 $87.62 1

72069 $50.46 1

72070 $49.37 1

72072 $53.42 1

72074 $60.60 1

72080 $53.04 1

72090 $67.68 1

72100 $54.89 1

72110 $76.65 1

72114 $97.62 1

72120 $63.54 1

72125 $285.53 1

72126 $355.62 1

72127 $418.71 1

72128 $279.02 1

72129 $355.26 1

72130 $419.25 1

72131 $277.35 1

72132 $354.53 1

72133 $419.63 1

72141 $345.81 1

72142 $502.22 1

72146 $345.81 1

72147 $498.90 1

72148 $344.16 1

72149 $496.14 1

72156 $589.23 1

3/1/2015 125 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

72157 $591.62 1

72158 $588.30 1

72159 $649.13 1

72170 $43.37 1

72190 $59.87 1

72191 $472.70 1

72192 $226.94 1

72193 $349.83 1

72194 $403.32 1

72195 $582.65 1

72196 $638.55 1

72197 $786.11 1

72198 $624.08 1

72200 $44.10 1

72202 $51.26 1

72220 $43.55 1

72240 $153.57 1

72255 $152.10 1

72265 $143.39 1

72270 $198.02 1

72275 $179.60 1

72285 $178.40 1

72295 $152.42 1

73000 $43.94 1

73010 $47.24 1

73020 $36.77 2

73030 $45.56 1

73040 $156.75 1

73050 $56.03 1

73060 $42.26 1

73070 $43.40 2

73080 $49.44 1

73085 $153.06 1

73090 $40.25 2

73092 $42.47 2

73100 $46.14 1

73110 $55.52 1

73115 $166.70 1

73120 $40.80 2

73130 $47.42 1

73140 $48.59 2

73200 $277.35 1

73201 $344.85 1

73202 $430.38 1

73206 $506.96 1

3/1/2015 126 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

73218 $564.23 1

73219 $627.50 1

73220 $775.07 1

73221 $365.36 1

73222 $587.18 1

73223 $728.10 1

73225 $627.32 1

73500 $41.70 2

73510 $58.22 1

73520 $62.37 1

73525 $158.40 1

73530 $0.00 1

73540 $61.55 1

73550 $42.81 2

73560 $46.13 2

73562 $53.85 1

73564 $62.99 1

73565 $51.65 1

73580 $178.47 1

73590 $41.34 2

73592 $42.47 2

73600 $42.47 1

73610 $49.44 1

73615 $154.35 1

73620 $40.25 2

73630 $45.21 1

73650 $41.91 2

73660 $43.62 1

73700 $277.35 1

73701 $349.83 1

73702 $422.84 1

73706 $544.56 1

73718 $565.34 2

73719 $627.87 1

73720 $780.03 1

73721 $364.80 1

73722 $592.52 1

73723 $731.42 1

73725 $625.71 1

74000 $36.90 1

74010 $54.50 1

74020 $57.75 1

74022 $68.16 1

74150 $232.67 1

74160 $357.39 1

3/1/2015 127 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

74170 $406.71 1

74174 $605.39 1

74175 $476.55 1

74176 $311.70 1

74177 $484.29 1

74178 $547.52 1

74181 $515.43 1

74182 $705.95 1

74183 $787.77 1

74185 $625.74 1

74190 $0.00 1

74210 $120.39 1

74220 $137.73 1

74230 $199.49 1

74235 $0.00 1

74240 $177.32 1

74241 $182.10 1

74245 $265.89 1

74246 $199.77 1

74247 $218.93 1

74249 $284.69 1

74250 $162.02 1

74251 $648.71 1

74260 $542.03 1

74261 $755.87 1

74262 $845.01 1

74270 $232.74 1

74280 $329.67 1

74283 $325.23 1

74290 $108.86 1

74300 $0.00 1

74301 $0.00 1

74305 $0.00 1

74320 $144.78 1

74327 $208.97 1

74328 $0.00 1

74329 $0.00 1

74330 $0.00 1

74340 $0.00 1

74355 $0.00 1

74360 $0.00 1

74363 $0.00 1

74400 $169.35 1

74410 $164.57 1

74415 $211.34 1

3/1/2015 128 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

74420 $0.00 1

74425 $0.00 1

74430 $57.68 1

74440 $123.32 1

74445 $0.00 1

74450 $0.00 1

74455 $126.15 1

74470 $0.00 1

74475 $143.67 1

74480 $143.67 1

74485 $141.84 1

74710 $62.43 1

74740 $117.42 1

74742 $0.00 1

74775 $0.00 1

75557 $493.74 1

75559 $670.85 1

75561 $658.70 1

75563 $781.05 1

75565 $85.95 1

75571 $156.32 1

75572 $442.05 1

75573 $602.99 1

75574 $649.44 1

75600 $313.71 1

75605 $219.48 1

75625 $220.95 1

75630 $273.50 1

75635 $590.70 1

75658 $265.98 1

75705 $367.34 1

75710 $251.72 1

75716 $294.15 1

75726 $236.25 1

75731 $265.53 1

75733 $284.40 1

75736 $259.07 1

75741 $238.01 1

75743 $266.34 1

75746 $238.10 1

75756 $270.68 1

75774 $137.70 1

75791 $499.20 1

75801 $0.00 1

75803 $0.00 1

3/1/2015 129 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

75805 $0.00 1

75807 $0.00 1

75809 $153.92 1

75810 $0.00 1

75820 $181.35 1

75822 $215.75 1

75825 $216.90 1

75827 $217.83 1

75831 $219.86 1

75833 $271.76 1

75840 $232.56 1

75842 $282.83 1

75860 $226.86 1

75870 $232.01 1

75872 $233.12 1

75880 $226.47 1

75885 $247.55 1

75887 $250.86 1

75889 $225.39 1

75891 $228.15 1

75893 $185.10 1

75894 $0.00 1

75896 $0.00 1

75898 $0.00 1

75901 $271.55 1

75902 $111.87 1

75945 $0.00 1

75946 $0.00 1

75952 $0.00 1

75953 $0.00 1

75954 $0.00 1

75956 $0.00 1

75957 $0.00 1

75958 $0.00 1

75959 $0.00 1

75962 $215.85 1

75964 $134.94 1

75966 $269.30 1

75968 $138.08 1

75970 $0.00 1

75978 $213.65 1

75980 $0.00 1

75982 $0.00 1

75984 $165.86 1

75989 $190.13 1

3/1/2015 130 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

76000 $73.74 1

76001 $0.00 1

76010 $40.77 1

76080 $86.22 1

76098 $25.89 1

76100 $144.90 1

76101 $207.50 1

76102 $272.51 1

76120 $142.10 1

76125 $0.00 1

76376 $35.76 1

76377 $100.01 1

76380 $227.67 1

76506 $185.88 2

76510 $263.40 1

76511 $159.42 1

76512 $143.96 1

76513 $149.37 1

76514 $24.21 1

76516 $122.51 1

76519 $131.34 2

76529 $124.11 1

76536 $181.40 1

76604 $138.14 1

76641 $170.07

76642 $140.33

76700 $192.23 1

76705 $143.60 1

76770 $176.51 1

76775 $89.66 1

76776 $244.79 1

76800 $214.91 1

76801 $196.53 1

76802 $104.36 3

76805 $225.26 1

76810 $150.69 3

76811 $288.96 1

76812 $326.91 3

76813 $193.10 1

76814 $130.25 3

76815 $133.74 1

76816 $181.65 1

76817 $153.83 1

76818 $192.93 4

76819 $140.54 1

3/1/2015 131 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

76820 $75.06 4

76821 $146.73 1

76825 $436.83 1

76826 $258.11 1

76827 $120.23 4

76828 $84.90 1

76830 $192.23 1

76831 $187.02 1

76856 $171.60 1

76857 $73.40 1

76870 $103.92 1

76872 $145.83 1

76873 $258.80 1

76881 $182.21 1

76882 $57.03 1

76885 $224.93 1

76886 $167.12 1

76930 $0.00 1

76932 $0.00 1

76936 $436.49 1

76937 $51.26 1

76940 $0.00 1

76941 $0.00 1

76942 $94.67 1

76945 $0.00 1

76946 $52.23 1

76948 $52.23 1

76965 $140.36 1

76970 $146.85 1

76975 $0.00 1

76977 $11.70 1

76998 $0.00 1

77001 $109.32 1

77002 $143.67 1

77003 $133.08 1

77011 $341.10 1

77012 $194.06 1

77013 $0.00 1

77014 $181.67 1

77021 $639.30 1

77022 $0.00 1

77051 $14.45 1

77052 $14.45 1

77053 $90.57 1

77054 $118.97 1

3/1/2015 132 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

77055 $139.92 1

77056 $179.79 1

77057 $128.31 1

77058 $840.35 1

77059 $831.51 1

77063 $87.24

77071 $77.04 1

77072 $36.33 1

77073 $57.38 1

77074 $99.26 1

77075 $135.39 1

77076 $148.20 1

77077 $59.90 1

77078 $176.55 1

77080 $64.50 1

77081 $44.03 1

77084 $608.19 1

77085 $87.54

77086 $55.70

77261 $118.74 1

77262 $177.23 1

77263 $260.09 1

77280 $419.63 1

77285 $660.83 1

77290 $789.45 1

77293 $718.77

77295 $758.34 1

77300 $98.25 10

77301 $3,009.69 1

77306 $225.15

77307 $441.86

77316 $289.41

77317 $379.13

77318 $547.55

77321 $142.83 1

77331 $99.32 1

77332 $127.85 1

77333 $82.25 1

77334 $235.53 1

77336 $119.51 1

77338 $784.31 1

77370 $182.12 1

77372 $1,644.53 1

77373 $2,087.93 1

77401 $32.40 1

3/1/2015 133 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

77417 $16.94 8

77422 $52.29 1

77423 $101.82 1

77427 $292.86 1

77431 $160.22 1

77432 $656.91 1

77435 $991.17 1

77469 $503.16 1

77470 $241.89 1

77600 $625.76 1

77605 $1,183.38 1

77610 $1,595.24 1

77615 $1,569.71 1

77620 $731.43 1

77750 $576.20 1

77761 $602.73 1

77762 $885.53 1

77763 $1,136.33 1

77776 $728.40 1

77777 $913.34 1

77778 $1,354.10 1

77785 $371.13 1

77786 $761.31 1

77787 $1,214.22 1

77789 $183.96 1

77790 $150.23 1

78012 $128.40 1

78013 $304.89 1

78014 $387.17 1

78015 $353.75 1

78016 $454.05 1

78018 $500.21 1

78020 $134.19 1

78070 $482.99 1

78071 $575.33 1

78072 $658.28 1

78075 $727.43 1

78102 $272.75 1

78103 $353.81 1

78104 $392.40 1

78110 $165.42 1

78111 $154.88 1

78120 $150.99 1

78121 $169.07 1

78122 $153.95 1

3/1/2015 134 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

78130 $252.75 1

78135 $564.27 1

78140 $217.59 1

78185 $340.92 1

78190 $630.93 1

78191 $268.77 1

78195 $572.39 1

78201 $303.11 1

78202 $322.16 1

78205 $338.03 1

78206 $552.89 1

78215 $312.06 1

78216 $202.37 1

78226 $532.80 1

78227 $721.83 1

78230 $277.14 1

78231 $207.78 1

78232 $159.44 1

78258 $352.71 1

78261 $406.94 1

78262 $391.29 1

78264 $465.32 1

78270 $163.19 1

78271 $145.52 1

78272 $155.90 1

78278 $562.23 1

78282 $0.00 1

78290 $535.47 1

78291 $400.37 1

78300 $290.12 1

78305 $370.80 1

78306 $405.00 1

78315 $558.50 1

78320 $366.41 1

78414 $0.00 1

78428 $290.42 1

78445 $288.86 1

78451 $547.97 1

78452 $758.79 1

78453 $488.37 1

78454 $699.39 1

78456 $514.71 1

78457 $281.60 1

78458 $329.45 1

78459 $0.00 1

3/1/2015 135 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

78466 $312.84 1

78468 $310.26 1

78469 $365.31 1

78472 $369.45 1

78473 $462.95 1

78481 $279.78 1

78483 $380.82 1

78491 $0.00 1

78492 $0.00 1

78494 $359.18 1

78496 $71.01 1

78579 $295.86 1

78580 $382.92 1

78582 $538.16 1

78597 $324.71 1

78598 $492.30 1

78600 $295.76 1

78601 $345.54 1

78605 $319.17 1

78606 $534.81 1

78607 $566.45 1

78608 $0.00 1

78610 $279.96 1

78630 $546.53 1

78635 $548.30 1

78645 $520.92 1

78647 $563.30 1

78650 $537.80 1

78660 $282.53 1

78700 $274.92 1

78701 $338.03 1

78707 $372.80 1

78708 $279.23 1

78709 $579.96 1

78710 $316.94 1

78725 $173.76 1

78730 $123.14 1

78740 $351.15 1

78761 $338.96 1

78800 $306.08 1

78801 $418.74 1

78802 $522.30 1

78803 $547.89 1

78804 $916.56 1

78805 $292.16 1

3/1/2015 136 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

78806 $536.30 1

78807 $547.71 1

78808 $70.97 1

78811 $0.00 1

78812 $0.00 1

78813 $0.00 1

78814 $0.00 1

78815 $0.00 1

78816 $0.00 1

79005 $213.27 1

79101 $222.41 1

79200 $210.77 1

79300 $0.00 1

79403 $298.35 1

79440 $201.56 1

79445 $0.00 1

80500 $36.05 1

80502 $113.31 1

85060 $38.69 1

85097 $138.06 1

85396 $32.18 1

86077 $87.60 1

86078 $87.06 1

86079 $85.40 1

86486 $8.10 1

86490 $10.86 1

86510 $9.77 1

86580 $12.53 1

88104 $115.85 1

88106 $136.04 1

88108 $130.95 1

88112 $99.83 1

88120 $962.39 1

88121 $855.74 1

88125 $41.57 1

88141 $50.33 1

88160 $103.79 1

88161 $93.84 1

88162 $154.56 1

88172 $87.47 1

88173 $233.09 1

88177 $47.57 1

88182 $168.17 1

88184 $145.65 1

88185 $88.76 25

3/1/2015 137 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

88187 $111.60 8

88188 $142.56 15

88189 $175.20 25

88291 $49.07 1

88300 $24.36 1

88302 $50.25 1

88304 $71.09 1

88305 $112.22 1

88307 $471.78 1

88309 $715.65 1

88311 $32.94 1

88312 $150.68 1

88313 $105.30 1

88314 $115.47 1

88319 $137.25 1

88321 $149.10 1

88323 $233.49 1

88325 $333.50 1

88329 $91.17 1

88331 $158.46 1

88332 $69.95 1

88333 $167.66 1

88334 $103.23 1

88341 $104.46

88342 $139.37 1

88344 $180.14

88346 $170.04 1

88347 $142.98 1

88348 $535.25 1

88355 $268.26 1

88356 $314.60 1

88358 $129.57 1

88360 $208.88 1

88361 $260.69 1

88362 $459.78 1

88363 $35.49 1

88364 $150.14

88365 $241.28 1

88366 $229.65

88367 $165.29 1

88368 $167.25 1

88369 $113.69

88373 $93.41

88374 $315.21

88375 $74.40

3/1/2015 138 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

88377 $328.83

88380 $203.85 1

88381 $192.50 1

88387 $66.03 1

88388 $53.04 1

89049 $375.59 1

89220 $24.68 1

89230 $4.23 1

90460 $39.32 1

90461 $20.01 1

90471 $39.32 1

90472 $20.01 1

90473 $39.32 1

90474 $20.01 1

90785 $21.93 1

90791 $201.59 1

90792 $227.51 1

90832 $98.31 1

90833 $101.07 1

90834 $129.92 1

90836 $128.22 1

90837 $195.51 1

90838 $169.80 1

90839 $204.14

90840 $97.76

90845 $140.06 1

90846 $157.25 1

90847 $164.46 1

90849 $54.84 1

90853 $39.56 1

90865 $260.40 1

90870 $274.94 1

90880 $155.94 1

90901 $59.19 1

90911 $132.24 1

90935 $114.17 1

90937 $163.43 1

90945 $134.48 1

90947 $194.81 1

90951 $1,476.08 1

90954 $1,286.18 1

90955 $718.68 1

90956 $502.67 1

90957 $1,013.16 1

90958 $682.58 1

3/1/2015 139 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

90959 $464.18 1

90960 $445.17 1

90961 $375.02 1

90962 $288.24 1

90963 $856.32 1

90964 $745.92 1

90965 $711.29 1

90966 $372.63 1

90967 $28.35 29

90968 $24.56 29

90969 $24.02 29

90970 $12.30 29

90997 $148.58 1

91010 $279.48 1

91013 $38.01 1

91020 $366.51 1

91022 $266.15 1

91030 $214.53 1

91034 $294.17 1

91035 $757.92 1

91037 $254.01 1

91038 $713.96 1

91040 $687.66 1

91065 $127.47 1

91110 $1,398.54 1

91111 $1,147.04 1

91112 $1,701.54 1

91117 $224.37 1

91120 $676.05 1

91122 $354.00 1

91132 $233.39 1

91133 $270.17 1

91200 $56.04

92002 $125.64 1

92004 $229.64 1

92012 $132.20 1

92014 $191.24 1

92018 $226.14 1

92019 $111.87 1

92020 $41.21 1

92025 $59.28 1

92060 $100.71 1

92065 $83.55 1

92071 $58.86 1

92072 $208.40 1

3/1/2015 140 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

92081 $53.28 1

92082 $74.67 1

92083 $99.92 1

92100 $124.61 1

92132 $54.32 1

92133 $68.43 1

92134 $70.08 1

92136 $140.18 1

92140 $97.71 1

92145 $24.77

92225 $41.75 2

92226 $38.51 2

92227 $23.01 1

92228 $55.38 1

92230 $90.18 2

92235 $170.13 2

92240 $395.04 1

92250 $122.66 1

92260 $28.77 1

92265 $133.11 1

92270 $143.24 1

92275 $227.63 1

92283 $87.74 1

92284 $97.58 1

92285 $32.70 1

92286 $59.75 1

92287 $213.77 1

92311 $156.62 1

92312 $182.30 1

92313 $150.98 1

92315 $112.89 1

92316 $142.16 1

92317 $117.86 1

92325 $66.11 1

92326 $55.05 1

92502 $153.15 1

92504 $47.04 1

92507 $122.57 1

92508 $36.30 1

92511 $213.17 1

92512 $95.79 1

92516 $109.98 1

92520 $117.74 1

92521 $167.69

92522 $143.42

3/1/2015 141 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

92523 $293.46

92524 $141.95

92526 $132.99 1

92540 $157.97 1

92541 $34.89 1

92542 $40.85 1

92543 $25.43 1

92544 $24.60 1

92545 $22.98 1

92546 $160.47 1

92547 $10.31 1

92548 $161.06 1

92550 $32.40 1

92552 $48.98 1

92553 $57.83 1

92555 $36.27 1

92556 $58.37 1

92557 $57.77 1

92561 $58.92 1

92562 $72.18 1

92563 $48.42 1

92564 $44.57 1

92565 $24.68 1

92567 $22.70 1

92568 $24.21 1

92570 $49.56 1

92571 $42.90 1

92572 $48.98 1

92575 $110.85 1

92576 $55.05 1

92577 $25.23 1

92579 $69.77 1

92582 $111.41 1

92583 $79.37 1

92584 $115.28 1

92585 $210.41 2

92586 $130.19 2

92587 $33.87 2

92588 $51.23 2

92596 $65.55 1

92597 $112.32 1

92601 $216.51 1

92602 $138.59 1

92603 $232.25 1

92604 $137.57 1

3/1/2015 142 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

92607 $193.68 1

92608 $82.47 1

92609 $171.41 1

92610 $131.78 1

92611 $135.95 1

92612 $270.11 1

92613 $61.28 1

92614 $225.36 1

92615 $52.94 1

92616 $321.42 1

92617 $65.39 1

92620 $145.82 1

92621 $34.61 1

92625 $108.45 1

92626 $139.35 1

92627 $34.08 4

92640 $175.77 1

92920 $942.90 1

92924 $1,118.61 1

92928 $1,046.24 1

92933 $1,170.93 1

92937 $1,045.70 1

92941 $1,172.57 1

92943 $1,170.72 1

92950 $484.26 1

92953 $18.05 1

92960 $324.87 1

92961 $444.77 1

92970 $309.18 1

92971 $173.15 1

92973 $306.41 1

92974 $279.06 1

92975 $676.70 1

92977 $93.53 1

92978 $0.00 1

92979 $0.00 1

92986 $2,288.24 1

92987 $2,351.99 1

92990 $1,868.31 1

92997 $1,145.88 1

92998 $560.88 1

93000 $26.97 1

93005 $13.62 1

93010 $13.35 4

93015 $119.03 1

3/1/2015 143 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

93016 $34.82 1

93017 $61.68 1

93018 $22.53 1

93024 $175.44 1

93025 $254.93 1

93040 $20.39 1

93041 $9.21 1

93042 $11.18 1

93224 $143.70 1

93225 $42.35 1

93226 $59.48 1

93227 $41.88 1

93228 $41.15 1

93229 $1,052.52 1

93260 $104.51

93261 $95.85

93268 $320.30 1

93270 $14.73 1

93271 $265.89 1

93272 $39.68 1

93278 $47.84 1

93279 $77.40 1

93280 $91.38 1

93281 $106.08 1

93282 $98.99 1

93283 $127.04 1

93284 $139.59 1

93285 $66.00 1

93286 $42.80 1

93287 $56.73 1

93288 $58.97 1

93289 $101.64 1

93290 $48.11 1

93291 $55.83 1

93292 $50.31 1

93293 $83.64 1

93294 $53.46 1

93295 $106.74 1

93296 $40.70 1

93297 $41.70 1

93298 $41.70 1

93303 $369.68 1

93304 $240.75 1

93306 $353.66 1

93307 $202.73 1

3/1/2015 144 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

93308 $194.15 1

93312 $476.85 1

93313 $36.00 1

93314 $456.23 1

93315 $0.00 1

93316 $60.50 1

93317 $0.00 1

93318 $0.00 1

93320 $85.20 1

93321 $43.58 1

93325 $41.51 2

93350 $374.76 1

93351 $421.07 1

93352 $53.46 1

93355 $359.46

93451 $1,243.10 1

93452 $1,415.46 1

93453 $1,824.39 1

93454 $1,432.71 1

93455 $1,668.65 1

93456 $1,795.08 1

93457 $2,025.53 1

93458 $1,716.77 1

93459 $1,897.29 1

93460 $2,039.33 1

93461 $2,330.88 1

93462 $357.60 1

93463 $157.71 1

93464 $428.72 1

93503 $209.27 1

93505 $1,224.59 1

93530 $0.00 1

93531 $0.00 1

93532 $0.00 1

93533 $0.00 1

93561 $0.00 1

93562 $0.00 1

93563 $100.76 1

93564 $106.98 1

93565 $78.89 1

93566 $273.51 1

93567 $228.59 1

93568 $246.42 1

93571 $0.00 1

93572 $0.00 1

3/1/2015 145 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

93580 $1,676.22 1

93581 $2,306.15 1

93582 $1,156.74

93583 $1,289.55

93600 $0.00 1

93602 $0.00 1

93603 $0.00 1

93609 $0.00 1

93610 $0.00 1

93612 $0.00 1

93613 $682.26 1

93615 $0.00 1

93616 $0.00 1

93618 $0.00 1

93619 $0.00 1

93620 $0.00 1

93621 $0.00 1

93622 $0.00 1

93623 $0.00 1

93624 $0.00 1

93631 $0.00 1

93640 $0.00 1

93641 $0.00 1

93642 $699.69 1

93644 $488.87

93650 $1,035.99 1

93653 $1,460.07 1

93654 $1,942.46 1

93655 $729.48 1

93656 $1,950.17 1

93657 $728.93 1

93660 $246.65 1

93662 $0.00 1

93701 $38.49 1

93702 $177.14

93724 $428.16 1

93750 $89.48 1

93784 $84.45 1

93786 $46.77 1

93788 $8.66 1

93790 $29.04 1

93797 $25.49 1

93798 $39.51 1

93880 $316.71 1

93882 $202.47 1

3/1/2015 146 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

93886 $449.30 1

93888 $233.78 1

93890 $454.68 1

93892 $527.18 1

93893 $540.98 1

93922 $140.46 1

93923 $217.67 1

93924 $271.53 1

93925 $408.78 1

93926 $241.88 1

93930 $328.68 1

93931 $204.69 1

93965 $188.91 1

93970 $310.07 1

93971 $190.59 1

93975 $441.71 1

93976 $256.13 1

93978 $300.32 1

93979 $189.77 1

93980 $186.18 1

93981 $112.53 1

93982 $68.94 1

93990 $254.78 1

94002 $147.96 1

94003 $106.80 1

94004 $76.83 1

94010 $56.81 1

94011 $158.07 1

94012 $262.91 1

94013 $49.02 1

94014 $87.54 1

94015 $47.88 1

94016 $39.68 1

94060 $95.31 1

94070 $92.94 1

94200 $40.34 1

94250 $41.43 1

94375 $61.56 1

94400 $88.47 1

94450 $103.95 1

94452 $90.29 1

94453 $125.31 1

94610 $89.82 1

94620 $87.36 1

94621 $256.05 1

3/1/2015 147 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

94640 $29.10 3

94644 $68.31 1

94645 $21.92 1

94660 $98.39 1

94662 $54.93 1

94664 $27.44 1

94667 $41.61 1

94668 $45.12 1

94669 $55.98

94680 $89.81 1

94681 $83.82 1

94690 $77.96 1

94726 $82.62 1

94727 $66.06 1

94728 $61.64 1

94729 $85.50 1

94750 $126.87 1

94760 $5.34 1

94761 $8.10 1

94762 $38.49 1

94770 $11.73 1

94780 $98.10 1

94781 $36.00 1

95004 $10.29 120

95012 $30.75 1

95017 $12.41 1

95018 $29.42 1

95024 $12.51 40

95027 $7.53 1

95028 $21.36 10

95044 $9.21 20

95052 $10.86 10

95056 $69.42 5

95060 $55.05 2

95065 $39.59 2

95070 $47.33 1

95071 $54.51 1

95076 $180.06 1

95079 $127.97 1

95115 $14.18 1

95117 $16.38 1

95144 $19.61 5

95145 $34.52 25

95146 $61.04 25

95147 $54.96 25

3/1/2015 148 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

95148 $82.04 25

95149 $109.65 25

95165 $20.16 25

95170 $15.18 25

95180 $207.60 5

95250 $246.00 1

95251 $67.50 1

95782 $1,427.82 1

95783 $1,946.16 1

95800 $280.22 1

95801 $143.30 1

95803 $220.44 1

95805 $654.69 1

95806 $261.68 1

95807 $730.80 1

95808 $938.69 1

95810 $969.32 1

95811 $1,018.13 1

95812 $652.50 1

95813 $781.44 1

95816 $559.32 1

95819 $638.13 1

95822 $577.37 1

95824 $0.00 1

95827 $1,224.60 1

95829 $2,938.20 1

95830 $386.15 1

95831 $48.71 1

95832 $48.51 1

95833 $58.53 1

95834 $79.50 1

95851 $28.83 3

95852 $25.61 1

95857 $84.21 1

95860 $191.99 1

95861 $269.49 1

95863 $333.59 1

95864 $378.69 1

95865 $225.98 1

95866 $207.90 1

95867 $145.49 1

95868 $206.72 1

95869 $127.56 1

95870 $137.69 1

95872 $309.68 1

3/1/2015 149 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

95873 $116.70 1

95874 $112.28 1

95875 $188.81 1

95885 $91.32 1

95886 $142.05 1

95887 $127.38 1

95905 $112.25 1

95907 $151.59 1

95908 $194.64 1

95909 $230.52 1

95910 $306.50 1

95911 $364.43 1

95912 $406.71 1

95913 $460.68 1

95921 $136.47 1

95922 $156.26 1

95923 $298.32 1

95924 $238.43 1

95925 $245.69 1

95926 $224.88 1

95927 $238.14 1

95928 $404.15 1

95929 $401.76 1

95930 $200.51 1

95933 $131.45 1

95937 $129.69 20

95938 $532.25 1

95939 $786.12 1

95940 $52.25 1

95950 $512.42 1

95951 $0.00 1

95953 $653.87 1

95954 $716.76 1

95955 $333.14 1

95956 $2,605.22 1

95957 $494.34 1

95958 $908.87 1

95961 $453.35 1

95962 $397.91 1

95965 $0.00 1

95966 $0.00 1

95967 $0.00 1

95970 $105.15 1

95971 $90.44 1

95972 $87.47 1

3/1/2015 150 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

95973 $63.66 1

95974 $331.56 1

95975 $177.33 1

95978 $396.68 1

95979 $172.46 1

95980 $76.95 1

95981 $50.34 1

95982 $85.13 1

95990 $141.42 1

95991 $188.97 1

95992 $66.18 1

96000 $150.66 1

96001 $160.97 1

96002 $34.70 1

96003 $29.60 1

96004 $186.75 1

96020 $0.00 1

96101 $122.96 4

96102 $99.18 1

96103 $42.81 1

96105 $161.61 1

96111 $199.65 1

96116 $145.41 3

96118 $150.57 3

96119 $125.81 3

96120 $74.85 1

96125 $182.87 1

96127 $8.66

96150 $33.63 1

96151 $32.00 1

96152 $30.02 1

96153 $7.40 1

96154 $29.48 1

96360 $90.32 1

96361 $23.97 1

96365 $109.41 1

96366 $29.36 1

96367 $47.01 4

96368 $32.13 1

96369 $303.48 1

96370 $23.84 1

96371 $140.13 1

96372 $39.32 1

96373 $30.48 1

96374 $89.21 1

3/1/2015 151 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

96375 $35.01 1

96401 $117.14 1

96402 $50.33 1

96405 $126.95 1

96406 $184.68 1

96409 $173.63 1

96411 $96.90 2

96413 $212.04 1

96415 $43.70 7

96416 $219.89 1

96417 $98.00 1

96420 $163.23 1

96422 $267.45 1

96423 $124.20 8

96425 $284.21 1

96440 $1,354.70 1

96446 $322.35 1

96450 $285.33 1

96521 $216.57 1

96522 $179.01 1

96523 $38.97 1

96542 $186.80 1

96567 $209.73 1

96570 $95.25 1

96571 $42.02 1

96900 $32.40 1

96904 $98.15 1

96910 $111.41 1

96912 $142.89 1

96913 $201.26 1

96920 $241.02 1

96921 $266.57 1

96922 $368.94 1

97001 $116.10 1

97002 $64.95 1

97003 $131.93 1

97004 $81.53 1

97012 $24.83 1

97016 $29.91 1

97018 $17.40 1

97022 $36.56 1

97024 $10.22 1

97026 $9.66 1

97028 $11.84 1

97032 $29.79 1

3/1/2015 152 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

97033 $50.78 1

97034 $28.20 1

97035 $19.92 1

97036 $52.22 1

97110 $50.28 1

97112 $51.57 1

97113 $66.50 1

97116 $43.92 1

97124 $41.60 1

97140 $46.08 1

97150 $26.97 1

97530 $53.79 1

97532 $41.09 1

97533 $44.96 1

97535 $53.78 1

97537 $46.61 1

97542 $47.15 1

97545 $0.00 1

97546 $0.00 1

97597 $119.42 1

97598 $39.93 1

97605 $70.37 1

97606 $83.73 1

97610 $191.49

97750 $51.39 1

97755 $55.53 1

97760 $59.12 1

97761 $51.39 1

97762 $74.54 1

97802 $54.02 5

97803 $46.05 5

97804 $24.83 6

98925 $48.60 1

98926 $70.67 1

98927 $92.18 1

98928 $113.13 1

98929 $135.20 1

98940 $43.28 1

98941 $63.12 1

98942 $82.43 1

99170 $249.99 1

99175 $26.88 1

99183 $180.17 1

99184 $373.16

99195 $158.54 1

3/1/2015 153 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

99201 $68.64 1

99202 $117.08 1

99203 $171.71 1

99204 $260.49 1

99205 $327.62 1

99211 $31.02 1

99212 $68.64 1

99213 $113.34 2

99214 $168.65 2

99215 $228.42 1

99217 $114.50 1

99218 $159.12 1

99219 $214.01 1

99220 $293.84 1

99221 $162.44 1

99222 $217.31 1

99223 $321.35 1

99224 $61.94 1

99225 $114.32 1

99226 $165.99 1

99231 $61.38 1

99232 $113.76 1

99233 $164.34 1

99234 $212.40 1

99235 $266.73 1

99236 $344.00 1

99238 $115.05 1

99239 $168.74 1

99281 $32.97

99282 $65.24

99283 $98.93

99284 $188.66

99285 $280.19

99291 $436.68 1

99292 $194.49 4

99304 $143.93 1

99305 $205.02 1

99306 $261.14 1

99307 $69.30 1

99308 $106.95 1

99309 $142.23 1

99310 $212.21 1

99315 $113.76 1

99316 $164.51 1

99318 $150.08 1

3/1/2015 154 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

99324 $86.21 1

99325 $126.08 1

99326 $217.64 1

99327 $290.51 1

99328 $340.50 1

99334 $93.84 1

99335 $148.40 1

99336 $210.36 1

99337 $300.81 1

99341 $85.65 1

99342 $125.34 1

99343 $203.81 1

99344 $285.48 1

99345 $345.84 1

99347 $86.78 1

99348 $131.54 1

99349 $200.63 1

99350 $277.55 1

99354 $156.80 1

99355 $152.37 1

99356 $144.36 1

99357 $142.34 1

99406 $22.44 1

99407 $42.84 1

99455 $0.00 1

99456 $0.00 1

99460 $155.63 1

99461 $140.31 1

99462 $64.76 1

99463 $188.81 1

99464 $116.90 1

99465 $236.31 1

99466 $388.34 1

99467 $195.18 1

99468 $1,440.17 1

99469 $624.03 1

99471 $1,387.95 1

99472 $644.28 1

99475 $909.69 1

99476 $547.95 1

99477 $568.55 1

99478 $222.96 1

99479 $195.39 1

99480 $187.82 1

99490 $67.14

3/1/2015 155 of 156

Ryan White Part A

Outpatient Medical Billing Rates

CPT Code FeeAllowable 

Units

99495 $257.52 1

99496 $361.14 1

3/1/2015 156 of 156