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The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
1 10022 SG $153.14 $153.14 07-01-2012
2 10030 SG $75.83 $75.83 01-01-2014
3 10060 SG $44.29 $44.29 07-01-2012
4 10061 SG $49.78 $49.78 07-01-2012
5 10080 SG $49.78 $49.78 07-01-2012
6 10081 SG $123.08 $123.08 07-01-2012
7 10120 SG $49.78 $49.78 07-01-2012
8 10121 SG $428.42 $428.42 07-01-2012
9 10140 SG $84.82 $84.82 07-01-2012
10 10180 SG $448.06 $448.06 07-01-2012
11 11042 SG $128.96 $128.96 07-01-2012
12 11043 SG $128.96 $128.96 07-01-2012
13 11044 SG $332.16 $332.16 07-01-2012
14 11100 SG $28.07 $28.07 07-01-2012
15 11102 SG $62.58 $62.58 01-01-2019
16 11106 SG $94.93 $94.93 01-01-2019
17 11307 SG $28.07 $28.07 07-01-2012
18 11310 SG $28.07 $28.07 07-01-2012
19 11311 SG $28.07 $28.07 07-01-2012
20 11312 SG $28.07 $28.07 07-01-2012
21 11313 SG $28.07 $28.07 07-01-2012
22 11400 SG $63.17 $63.17 07-01-2012
23 11401 SG $69.02 $69.02 07-01-2012
24 11402 SG $75.22 $75.22 07-01-2012
25 11403 SG $80.75 $80.75 07-01-2012
26 11404 SG $355.97 $355.97 07-01-2012
27 11406 SG $428.42 $428.42 07-01-2012
28 11420 SG $58.61 $58.61 07-01-2012
29 11421 SG $69.68 $69.68 07-01-2012
30 11422 SG $76.51 $76.51 07-01-2012
31 11423 SG $85.63 $85.63 07-01-2012
32 11424 SG $428.42 $428.42 07-01-2012
33 11426 SG $472.74 $472.74 07-01-2012
34 11440 SG $68.37 $68.37 07-01-2012
35 11441 SG $76.84 $76.84 07-01-2012
36 11442 SG $84.33 $84.33 07-01-2012
37 11443 SG $94.42 $94.42 07-01-2012
38 11444 SG $290.35 $290.35 07-01-2012
39 11446 SG $472.74 $472.74 07-01-2012
40 11450 SG $472.74 $472.74 07-01-2012
41 11451 SG $472.74 $472.74 07-01-2012
42 11462 SG $472.74 $472.74 07-01-2012
43 11463 SG $472.74 $472.74 07-01-2012
44 11470 SG $472.74 $472.74 07-01-2012
45 11471 SG $472.74 $472.74 07-01-2012
46 11600 SG $87.58 $87.58 07-01-2012
47 11601 SG $99.96 $99.96 07-01-2012
48 11602 SG $108.75 $108.75 07-01-2012
49 11603 SG $115.91 $115.91 07-01-2012
50 11604 SG $345.17 $345.17 07-01-2012
51 11606 SG $428.42 $428.42 07-01-2012
52 11620 SG $88.56 $88.56 07-01-2012
53 11621 SG $100.93 $100.93 07-01-2012
54 11622 SG $111.68 $111.68 07-01-2012
55 11623 SG $121.44 $121.44 07-01-2012
56 11624 SG $428.42 $428.42 07-01-2012
57 11626 SG $472.74 $472.74 07-01-2012
58 11640 SG $93.12 $93.12 07-01-2012
59 11641 SG $108.43 $108.43 07-01-2012
60 11642 SG $121.12 $121.12 07-01-2012
61 11643 SG $131.55 $131.55 07-01-2012
62 11644 SG $428.42 $428.42 07-01-2012
63 11646 SG $472.74 $472.74 07-01-2012
64 11750 SG $83.35 $83.35 07-01-2012
65 11755 SG $58.61 $58.61 07-01-2012
66 11760 SG $74.50 $74.50 07-01-2012
67 11762 SG $107.12 $107.12 07-01-2012
68 11770 SG $513.77 $513.77 07-01-2012
69 11771 SG $513.77 $513.77 07-01-2012
70 11772 SG $513.77 $513.77 07-01-2012
71 11921 SG $74.50 $74.50 07-01-2012
72 11950 SG $32.89 $32.89 07-01-2012
73 11951 SG $39.07 $39.07 07-01-2012
74 11952 SG $45.28 $45.28 07-01-2012
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
DMA Provider Reimbursement/ Updated 03/2018 1 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
75 11954 SG $45.28 $45.28 07-01-2012
76 11960 SG $464.76 $464.76 07-01-2012
77 11970 SG $707.34 $707.34 07-01-2012
78 11971 SG $400.29 $400.29 07-01-2012
79 11976 SG $56.01 $56.01 07-01-2012
80 12005 SG $69.83 $69.83 07-01-2012
81 12006 SG $69.83 $69.83 07-01-2012
82 12007 SG $69.83 $69.83 07-01-2012
83 12015 SG $45.28 $45.28 07-01-2012
84 12016 SG $69.83 $69.83 07-01-2012
85 12017 SG $69.83 $69.83 07-01-2012
86 12018 SG $69.83 $69.83 07-01-2012
87 12020 SG $98.55 $98.55 07-01-2012
88 12021 SG $98.55 $98.55 07-01-2012
89 12031 SG $74.50 $74.50 07-01-2012
90 12032 SG $74.50 $74.50 07-01-2012
91 12034 SG $77.13 $77.13 07-01-2012
92 12035 SG $77.13 $77.13 07-01-2012
93 12036 SG $77.13 $77.13 07-01-2012
94 12037 SG $225.91 $225.91 07-01-2012
95 12041 SG $74.50 $74.50 07-01-2012
96 12042 SG $74.50 $74.50 07-01-2012
97 12044 SG $77.13 $77.13 07-01-2012
98 12045 SG $77.13 $77.13 07-01-2012
99 12046 SG $77.13 $77.13 07-01-2012
100 12047 SG $225.91 $225.91 07-01-2012
101 12051 SG $74.50 $74.50 07-01-2012
102 12052 SG $74.50 $74.50 07-01-2012
103 12053 SG $74.50 $74.50 07-01-2012
104 12054 SG $77.13 $77.13 07-01-2012
105 12055 SG $77.13 $77.13 07-01-2012
106 12056 SG $77.13 $77.13 07-01-2012
107 12057 SG $225.91 $225.91 07-01-2012
108 13100 SG $247.32 $247.32 07-01-2012
109 13101 SG $247.32 $247.32 07-01-2012
110 13120 SG $77.13 $77.13 07-01-2012
111 13121 SG $98.55 $98.55 07-01-2012
112 13131 SG $98.55 $98.55 07-01-2012
113 13132 SG $98.55 $98.55 07-01-2012
114 13151 SG $247.32 $247.32 07-01-2012
115 13152 SG $247.32 $247.32 07-01-2012
116 13160 SG $464.76 $464.76 07-01-2012
117 14000 SG $419.09 $419.09 07-01-2012
118 14001 SG $460.12 $460.12 07-01-2012
119 14020 SG $460.12 $460.12 07-01-2012
120 14021 SG $460.12 $460.12 07-01-2012
121 14040 SG $419.09 $419.09 07-01-2012
122 14041 SG $460.12 $460.12 07-01-2012
123 14060 SG $460.12 $460.12 07-01-2012
124 14061 SG $460.12 $460.12 07-01-2012
125 14301 SG $822.22 $822.22 07-01-2012
126 14350 SG $505.79 $505.79 07-01-2012
127 15002 SG $247.32 $247.32 07-01-2012
128 15004 SG $247.32 $247.32 07-01-2012
129 15040 SG $77.13 $77.13 07-01-2012
130 15050 SG $247.32 $247.32 07-01-2012
131 15100 SG $464.76 $464.76 07-01-2012
132 15110 SG $326.01 $326.01 07-01-2012
133 15115 SG $326.01 $326.01 07-01-2012
134 15120 SG $464.76 $464.76 07-01-2012
135 15130 SG $419.09 $419.09 07-01-2012
136 15135 SG $419.09 $419.09 07-01-2012
137 15150 SG $326.01 $326.01 07-01-2012
138 15155 SG $326.01 $326.01 07-01-2012
139 15200 SG $460.12 $460.12 07-01-2012
140 15220 SG $419.09 $419.09 07-01-2012
141 15240 SG $460.12 $460.12 07-01-2012
142 15260 SG $419.09 $419.09 07-01-2012
143 15271 SG $113.12 $113.12 01-01-2013
144 15273 SG $176.96 $176.96 01-01-2013
145 15275 SG $113.12 $113.12 01-01-2013
146 15277 SG $176.96 $176.96 01-01-2013
147 15570 SG $505.79 $505.79 07-01-2012
148 15572 SG $505.79 $505.79 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 2 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
149 15574 SG $505.79 $505.79 07-01-2012
150 15576 SG $505.79 $505.79 07-01-2012
151 15600 SG $505.79 $505.79 07-01-2012
152 15610 SG $505.79 $505.79 07-01-2012
153 15620 SG $582.73 $582.73 07-01-2012
154 15630 SG $505.79 $505.79 07-01-2012
155 15650 SG $638.51 $638.51 07-01-2012
156 15730 SG $1,193.59 $1,193.59 01-01-2018
157 15731 SG $505.79 $505.79 07-01-2012
158 15732 SG $505.79 $505.79 07-01-2012
159 15733 SG $1,193.59 $1,193.59 01-01-2018
160 15734 SG $505.79 $505.79 07-01-2012
161 15736 SG $505.79 $505.79 07-01-2012
162 15738 SG $505.79 $505.79 07-01-2012
163 15740 SG $419.09 $419.09 07-01-2012
164 15750 SG $464.76 $464.76 07-01-2012
165 15760 SG $464.76 $464.76 07-01-2012
166 15770 SG $505.79 $505.79 07-01-2012
167 15780 SG $370.53 $370.53 07-01-2012
168 15781 SG $152.33 $152.33 07-01-2012
169 15782 SG $152.33 $152.33 07-01-2012
170 15783 SG $94.16 $94.16 07-01-2012
171 15789 SG $51.66 $51.66 07-01-2012
172 15819 SG $74.50 $74.50 07-01-2012
173 15820 SG $505.79 $505.79 07-01-2012
174 15821 SG $505.79 $505.79 07-01-2012
175 15822 SG $505.79 $505.79 07-01-2012
176 15823 SG $638.51 $638.51 07-01-2012
177 15830 SG $513.77 $513.77 07-01-2012
178 15832 SG $513.77 $513.77 07-01-2012
179 15833 SG $513.77 $513.77 07-01-2012
180 15834 SG $513.77 $513.77 07-01-2012
181 15835 SG $394.06 $394.06 07-01-2012
182 15836 SG $469.44 $469.44 07-01-2012
183 15837 SG $569.83 $569.83 07-01-2012
184 15838 SG $569.83 $569.83 07-01-2012
185 15839 SG $469.44 $469.44 07-01-2012
186 15840 SG $582.73 $582.73 07-01-2012
187 15841 SG $582.73 $582.73 07-01-2012
188 15842 SG $715.18 $715.18 07-01-2012
189 15845 SG $582.73 $582.73 07-01-2012
190 15850 SG $94.16 $94.16 07-01-2012
191 15851 SG $49.16 $49.16 07-01-2012
192 15920 SG $199.35 $199.35 07-01-2012
193 15922 SG $582.73 $582.73 07-01-2012
194 15931 SG $513.77 $513.77 07-01-2012
195 15933 SG $513.77 $513.77 07-01-2012
196 15934 SG $505.79 $505.79 07-01-2012
197 15935 SG $582.73 $582.73 07-01-2012
198 15936 SG $537.06 $537.06 07-01-2012
199 15937 SG $582.73 $582.73 07-01-2012
200 15940 SG $513.77 $513.77 07-01-2012
201 15941 SG $513.77 $513.77 07-01-2012
202 15944 SG $505.79 $505.79 07-01-2012
203 15945 SG $582.73 $582.73 07-01-2012
204 15946 SG $582.73 $582.73 07-01-2012
205 15950 SG $513.77 $513.77 07-01-2012
206 15951 SG $590.71 $590.71 07-01-2012
207 15952 SG $460.12 $460.12 07-01-2012
208 15953 SG $537.06 $537.06 07-01-2012
209 15956 SG $460.12 $460.12 07-01-2012
210 15958 SG $537.06 $537.06 07-01-2012
211 16025 SG $66.57 $66.57 07-01-2012
212 16030 SG $87.54 $87.54 07-01-2012
213 16035 SG $94.16 $94.16 07-01-2012
214 17004 SG $77.17 $77.17 07-01-2012
215 17106 SG $94.16 $94.16 07-01-2012
216 17107 SG $94.16 $94.16 07-01-2012
217 17108 SG $94.16 $94.16 07-01-2012
218 17264 SG $51.66 $51.66 07-01-2012
219 17266 SG $94.16 $94.16 07-01-2012
220 17270 SG $51.66 $51.66 07-01-2012
221 17271 SG $51.66 $51.66 07-01-2012
222 17273 SG $88.24 $88.24 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 3 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
223 17274 SG $94.16 $94.16 07-01-2012
224 17276 SG $94.16 $94.16 07-01-2012
225 17281 SG $75.54 $75.54 07-01-2012
226 17282 SG $86.29 $86.29 07-01-2012
227 17283 SG $94.16 $94.16 07-01-2012
228 17284 SG $94.16 $94.16 07-01-2012
229 17286 SG $94.16 $94.16 07-01-2012
230 17311 SG $128.55 $128.55 07-01-2012
231 17313 SG $128.55 $128.55 07-01-2012
232 19000 SG $63.49 $63.49 07-01-2012
233 19020 SG $448.06 $448.06 07-01-2012
234 19081 SG $333.45 $333.45 01-01-2014
235 19083 SG $333.45 $333.45 01-01-2014
236 19085 SG $333.45 $333.45 01-01-2014
237 19100 SG $192.17 $192.17 07-01-2012
238 19101 SG $468.60 $468.60 07-01-2012
239 19110 SG $468.60 $468.60 07-01-2012
240 19112 SG $509.64 $509.64 07-01-2012
241 19120 SG $509.64 $509.64 07-01-2012
242 19125 SG $509.64 $509.64 07-01-2012
243 19296 SG $1,359.12 $1,359.12 07-01-2012
244 19298 SG $1,359.12 $1,359.12 07-01-2012
245 19300 SG $586.57 $586.57 07-01-2012
246 19301 SG $509.64 $509.64 07-01-2012
247 19302 SG $990.28 $990.28 07-01-2012
248 19303 SG $684.54 $684.54 07-01-2012
249 19304 SG $684.54 $684.54 07-01-2012
250 19316 SG $684.54 $684.54 07-01-2012
251 19318 SG $756.26 $756.26 07-01-2012
252 19324 SG $756.26 $756.26 07-01-2012
253 19325 SG $1,359.12 $1,359.12 07-01-2012
254 19328 SG $494.11 $494.11 07-01-2012
255 19330 SG $494.11 $494.11 07-01-2012
256 19340 SG $638.28 $638.28 07-01-2012
257 19342 SG $827.60 $827.60 07-01-2012
258 19350 SG $586.57 $586.57 07-01-2012
259 19355 SG $684.54 $684.54 07-01-2012
260 19357 SG $960.32 $960.32 07-01-2012
261 19366 SG $740.31 $740.31 07-01-2012
262 19370 SG $684.54 $684.54 07-01-2012
263 19371 SG $684.54 $684.54 07-01-2012
264 19380 SG $812.04 $812.04 07-01-2012
265 20005 SG $474.15 $474.15 07-01-2012
266 20103 SG $340.98 $340.98 07-01-2012
267 20150 SG $1,521.36 $1,521.36 07-01-2012
268 20200 SG $428.42 $428.42 07-01-2012
269 20205 SG $469.44 $469.44 07-01-2012
270 20206 SG $216.83 $216.83 07-01-2012
271 20220 SG $238.11 $238.11 07-01-2012
272 20225 SG $345.17 $345.17 07-01-2012
273 20240 SG $472.74 $472.74 07-01-2012
274 20245 SG $513.77 $513.77 07-01-2012
275 20250 SG $515.19 $515.19 07-01-2012
276 20251 SG $515.19 $515.19 07-01-2012
277 20500 SG $58.61 $58.61 07-01-2012
278 20520 SG $89.87 $89.87 07-01-2012
279 20525 SG $513.77 $513.77 07-01-2012
280 20526 SG $28.98 $28.98 07-01-2012
281 20527 SG $30.00 $30.00 01-01-2013
282 20550 SG $21.81 $21.81 07-01-2012
283 20551 SG $21.49 $21.49 07-01-2012
284 20552 SG $21.17 $21.17 07-01-2012
285 20553 SG $23.77 $23.77 07-01-2012
286 20600 SG $21.49 $21.49 07-01-2012
287 20604 SG $32.31 $32.31 01-01-2015
288 20605 SG $24.42 $24.42 07-01-2012
289 20606 SG $35.06 $35.06 01-01-2015
290 20610 SG $32.89 $32.89 07-01-2012
291 20611 SG $41.15 $41.15 01-01-2015
292 20612 SG $22.79 $22.79 07-01-2012
293 20615 SG $101.26 $101.26 07-01-2012
294 20650 SG $515.19 $515.19 07-01-2012
295 20662 SG $752.77 $752.77 07-01-2012
296 20663 SG $752.77 $752.77 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 4 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
297 20665 SG $22.32 $22.32 07-01-2012
298 20670 SG $355.97 $355.97 07-01-2012
299 20680 SG $513.77 $513.77 07-01-2012
300 20690 SG $544.24 $544.24 07-01-2012
301 20692 SG $585.28 $585.28 07-01-2012
302 20693 SG $515.19 $515.19 07-01-2012
303 20694 SG $401.70 $401.70 07-01-2012
304 20696 SG $841.11 $841.11 07-01-2012
305 20697 SG $971.55 $971.55 07-01-2012
306 20822 SG $931.21 $931.21 07-01-2012
307 20900 SG $585.28 $585.28 07-01-2012
308 20902 SG $662.22 $662.22 07-01-2012
309 20910 SG $505.79 $505.79 07-01-2012
310 20912 SG $505.79 $505.79 07-01-2012
311 20920 SG $537.06 $537.06 07-01-2012
312 20922 SG $460.12 $460.12 07-01-2012
313 20924 SG $662.22 $662.22 07-01-2012
314 20926 SG $443.99 $443.99 07-01-2012
315 20950 SG $49.78 $49.78 07-01-2012
316 20972 SG $1,566.80 $1,566.80 07-01-2012
317 20973 SG $1,566.80 $1,566.80 07-01-2012
318 20982 SG $1,521.36 $1,521.36 07-01-2012
319 20983 SG $1,757.78 $1,757.78 01-01-2015
320 21010 SG $498.10 $498.10 07-01-2012
321 21011 SG $159.85 $159.85 07-01-2012
322 21012 SG $281.83 $281.83 07-01-2012
323 21013 SG $222.12 $222.12 07-01-2012
324 21014 SG $281.83 $281.83 07-01-2012
325 21015 SG $471.48 $471.48 07-01-2012
326 21016 SG $803.54 $803.54 07-01-2012
327 21025 SG $638.79 $638.79 07-01-2012
328 21026 SG $638.79 $638.79 07-01-2012
329 21029 SG $638.80 $638.80 07-01-2012
330 21030 SG $220.11 $220.11 07-01-2012
331 21031 SG $180.38 $180.38 07-01-2012
332 21034 SG $679.84 $679.84 07-01-2012
333 21040 SG $498.10 $498.10 07-01-2012
334 21044 SG $638.79 $638.79 07-01-2012
335 21046 SG $638.79 $638.79 07-01-2012
336 21047 SG $638.79 $638.79 07-01-2012
337 21048 SG $1,411.38 $1,411.38 07-01-2012
338 21050 SG $679.84 $679.84 07-01-2012
339 21060 SG $638.79 $638.79 07-01-2012
340 21070 SG $679.84 $679.84 07-01-2012
341 21100 SG $638.79 $638.79 07-01-2012
342 21110 SG $263.58 $263.58 07-01-2012
343 21120 SG $850.10 $850.10 07-01-2012
344 21121 SG $850.10 $850.10 07-01-2012
345 21122 SG $850.10 $850.10 07-01-2012
346 21123 SG $850.10 $850.10 07-01-2012
347 21125 SG $850.10 $850.10 07-01-2012
348 21127 SG $1,211.36 $1,211.36 07-01-2012
349 21137 SG $848.59 $848.59 07-01-2012
350 21138 SG $1,411.38 $1,411.38 07-01-2012
351 21139 SG $1,411.38 $1,411.38 07-01-2012
352 21150 SG $1,411.38 $1,411.38 07-01-2012
353 21181 SG $850.10 $850.10 07-01-2012
354 21198 SG $1,411.38 $1,411.38 07-01-2012
355 21199 SG $1,411.38 $1,411.38 07-01-2012
356 21206 SG $812.55 $812.55 07-01-2012
357 21208 SG $990.80 $990.80 07-01-2012
358 21209 SG $812.55 $812.55 07-01-2012
359 21210 SG $990.80 $990.80 07-01-2012
360 21215 SG $990.80 $990.80 07-01-2012
361 21230 SG $990.80 $990.80 07-01-2012
362 21235 SG $850.10 $850.10 07-01-2012
363 21240 SG $756.78 $756.78 07-01-2012
364 21242 SG $812.55 $812.55 07-01-2012
365 21243 SG $812.55 $812.55 07-01-2012
366 21244 SG $990.80 $990.80 07-01-2012
367 21245 SG $990.80 $990.80 07-01-2012 X 21245 7/31/2018
368 21246 SG $990.80 $990.80 07-01-2012 X 21246 7/31/2018
369 21248 SG $990.80 $990.80 07-01-2012 X 21248 7/31/2018
370 21249 SG $990.80 $990.80 07-01-2012 X 21249 7/31/2018
DMA Provider Reimbursement/ Updated 03/2018 5 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
371 21260 SG $1,411.38 $1,411.38 07-01-2012
372 21267 SG $990.80 $990.80 07-01-2012
373 21270 SG $812.55 $812.55 07-01-2012
374 21275 SG $990.80 $990.80 07-01-2012
375 21280 SG $812.55 $812.55 07-01-2012
376 21282 SG $604.19 $604.19 07-01-2012
377 21295 SG $279.40 $279.40 07-01-2012
378 21296 SG $425.65 $425.65 07-01-2012
379 21310 SG $118.76 $118.76 07-01-2012
380 21315 SG $118.76 $118.76 07-01-2012
381 21320 SG $430.44 $430.44 07-01-2012
382 21325 SG $616.08 $616.08 07-01-2012
383 21330 SG $671.86 $671.86 07-01-2012
384 21335 SG $850.10 $850.10 07-01-2012
385 21336 SG $635.39 $635.39 07-01-2012
386 21337 SG $430.44 $430.44 07-01-2012
387 21338 SG $616.08 $616.08 07-01-2012
388 21339 SG $671.86 $671.86 07-01-2012
389 21340 SG $756.78 $756.78 07-01-2012
390 21345 SG $850.10 $850.10 07-01-2012
391 21355 SG $679.84 $679.84 07-01-2012
392 21356 SG $539.14 $539.14 07-01-2012
393 21360 SG $848.59 $848.59 07-01-2012
394 21390 SG $1,411.38 $1,411.38 07-01-2012
395 21400 SG $351.85 $351.85 07-01-2012
396 21401 SG $471.48 $471.48 07-01-2012
397 21406 SG $1,411.38 $1,411.38 07-01-2012
398 21407 SG $1,411.38 $1,411.38 07-01-2012
399 21421 SG $616.08 $616.08 07-01-2012
400 21440 SG $279.69 $279.69 07-01-2012
401 21445 SG $616.08 $616.08 07-01-2012
402 21450 SG $118.76 $118.76 07-01-2012
403 21451 SG $363.49 $363.49 07-01-2012
404 21452 SG $430.44 $430.44 07-01-2012
405 21453 SG $679.84 $679.84 07-01-2012
406 21454 SG $671.86 $671.86 07-01-2012
407 21461 SG $756.78 $756.78 07-01-2012
408 21462 SG $812.55 $812.55 07-01-2012
409 21465 SG $756.78 $756.78 07-01-2012
410 21480 SG $118.76 $118.76 07-01-2012
411 21485 SG $430.44 $430.44 07-01-2012
412 21490 SG $679.84 $679.84 07-01-2012
413 21497 SG $430.44 $430.44 07-01-2012
414 21501 SG $448.06 $448.06 07-01-2012
415 21502 SG $474.15 $474.15 07-01-2012
416 21550 SG $307.39 $307.39 07-01-2012
417 21552 SG $803.54 $803.54 07-01-2012
418 21554 SG $803.54 $803.54 07-01-2012
419 21555 SG $472.74 $472.74 07-01-2012
420 21556 SG $472.74 $472.74 07-01-2012
421 21557 SG $747.14 $747.14 07-01-2012
422 21558 SG $803.54 $803.54 07-01-2012
423 21600 SG $544.24 $544.24 07-01-2012
424 21610 SG $544.24 $544.24 07-01-2012
425 21685 SG $263.58 $263.58 07-01-2012
426 21700 SG $474.15 $474.15 07-01-2012
427 21720 SG $515.19 $515.19 07-01-2012
428 21725 SG $69.16 $69.16 07-01-2012
429 21820 SG $82.08 $82.08 07-01-2012
430 21920 SG $125.69 $125.69 07-01-2012
431 21925 SG $472.74 $472.74 07-01-2012
432 21930 SG $472.74 $472.74 07-01-2012
433 21931 SG $803.54 $803.54 07-01-2012
434 21932 SG $601.15 $601.15 07-01-2012
435 21933 SG $803.54 $803.54 07-01-2012
436 21935 SG $513.77 $513.77 07-01-2012
437 21936 SG $803.54 $803.54 07-01-2012
438 22102 SG $1,655.41 $1,655.41 07-01-2012
439 22310 SG $82.08 $82.08 07-01-2012
440 22315 SG $82.08 $82.08 07-01-2012
441 22505 SG $416.61 $416.61 07-01-2012
442 22510 SG $1,215.52 $1,215.52 01-01-2015
443 22511 SG $1,215.52 $1,215.52 01-01-2015
444 22513 SG $2,953.52 $2,953.52 01-01-2015
DMA Provider Reimbursement/ Updated 03/2018 6 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
445 22514 SG $2,953.52 $2,953.52 01-01-2015
446 22551 SG $6,686.59 $6,686.59 01-01-2015
447 22900 SG $590.71 $590.71 07-01-2012
448 22901 SG $803.54 $803.54 07-01-2012
449 22902 SG $601.15 $601.15 07-01-2012
450 22903 SG $803.54 $803.54 07-01-2012
451 22904 SG $601.15 $601.15 07-01-2012
452 22905 SG $803.54 $803.54 07-01-2012
453 23000 SG $428.42 $428.42 07-01-2012
454 23020 SG $666.30 $666.30 07-01-2012
455 23030 SG $375.60 $375.60 07-01-2012
456 23031 SG $489.09 $489.09 07-01-2012
457 23035 SG $515.19 $515.19 07-01-2012
458 23040 SG $585.28 $585.28 07-01-2012
459 23044 SG $662.22 $662.22 07-01-2012
460 23065 SG $88.56 $88.56 07-01-2012
461 23066 SG $472.74 $472.74 07-01-2012
462 23071 SG $803.54 $803.54 07-01-2012
463 23073 SG $803.54 $803.54 07-01-2012
464 23075 SG $428.42 $428.42 07-01-2012
465 23076 SG $472.74 $472.74 07-01-2012
466 23077 SG $513.77 $513.77 07-01-2012
467 23078 SG $803.54 $803.54 07-01-2012
468 23100 SG $474.15 $474.15 07-01-2012
469 23101 SG $896.24 $896.24 07-01-2012
470 23105 SG $662.22 $662.22 07-01-2012
471 23106 SG $662.22 $662.22 07-01-2012
472 23107 SG $662.22 $662.22 07-01-2012
473 23120 SG $718.00 $718.00 07-01-2012
474 23125 SG $718.00 $718.00 07-01-2012
475 23130 SG $840.06 $840.06 07-01-2012
476 23140 SG $592.13 $592.13 07-01-2012
477 23145 SG $718.00 $718.00 07-01-2012
478 23146 SG $718.00 $718.00 07-01-2012
479 23150 SG $662.22 $662.22 07-01-2012
480 23155 SG $718.00 $718.00 07-01-2012
481 23156 SG $718.00 $718.00 07-01-2012
482 23170 SG $544.24 $544.24 07-01-2012
483 23172 SG $544.24 $544.24 07-01-2012
484 23174 SG $544.24 $544.24 07-01-2012
485 23180 SG $662.22 $662.22 07-01-2012
486 23182 SG $662.22 $662.22 07-01-2012
487 23184 SG $662.22 $662.22 07-01-2012
488 23190 SG $662.22 $662.22 07-01-2012
489 23195 SG $718.00 $718.00 07-01-2012
490 23330 SG $290.35 $290.35 07-01-2012
491 23333 SG $304.40 $304.40 01-01-2014
492 23334 SG $824.76 $824.76 01-01-2014
493 23395 SG $840.06 $840.06 07-01-2012
494 23397 SG $1,340.72 $1,340.72 07-01-2012
495 23400 SG $896.24 $896.24 07-01-2012
496 23405 SG $544.24 $544.24 07-01-2012
497 23406 SG $544.24 $544.24 07-01-2012
498 23410 SG $840.06 $840.06 07-01-2012
499 23412 SG $1,018.30 $1,018.30 07-01-2012
500 23415 SG $840.06 $840.06 07-01-2012
501 23420 SG $1,018.30 $1,018.30 07-01-2012
502 23430 SG $784.27 $784.27 07-01-2012
503 23440 SG $784.27 $784.27 07-01-2012
504 23450 SG $1,162.48 $1,162.48 07-01-2012
505 23455 SG $1,340.72 $1,340.72 07-01-2012
506 23460 SG $1,162.48 $1,162.48 07-01-2012
507 23462 SG $1,018.30 $1,018.30 07-01-2012
508 23465 SG $1,162.48 $1,162.48 07-01-2012
509 23466 SG $1,018.30 $1,018.30 07-01-2012
510 23480 SG $784.27 $784.27 07-01-2012
511 23485 SG $1,340.72 $1,340.72 07-01-2012
512 23490 SG $707.34 $707.34 07-01-2012
513 23491 SG $1,029.75 $1,029.75 07-01-2012
514 23500 SG $82.08 $82.08 07-01-2012
515 23505 SG $82.08 $82.08 07-01-2012
516 23515 SG $851.02 $851.02 07-01-2012
517 23520 SG $82.08 $82.08 07-01-2012
518 23525 SG $82.08 $82.08 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 7 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
519 23530 SG $690.73 $690.73 07-01-2012
520 23532 SG $635.39 $635.39 07-01-2012
521 23540 SG $82.08 $82.08 07-01-2012
522 23545 SG $82.08 $82.08 07-01-2012
523 23550 SG $690.73 $690.73 07-01-2012
524 23552 SG $767.67 $767.67 07-01-2012
525 23570 SG $82.08 $82.08 07-01-2012
526 23575 SG $82.08 $82.08 07-01-2012
527 23585 SG $851.02 $851.02 07-01-2012
528 23600 SG $62.58 $62.58 07-01-2012
529 23605 SG $82.08 $82.08 07-01-2012
530 23615 SG $927.95 $927.95 07-01-2012
531 23616 SG $927.95 $927.95 07-01-2012
532 23620 SG $62.58 $62.58 07-01-2012
533 23625 SG $82.08 $82.08 07-01-2012
534 23630 SG $983.74 $983.74 07-01-2012
535 23650 SG $82.08 $82.08 07-01-2012
536 23655 SG $344.16 $344.16 07-01-2012
537 23660 SG $690.73 $690.73 07-01-2012
538 23665 SG $82.08 $82.08 07-01-2012
539 23670 SG $851.02 $851.02 07-01-2012
540 23675 SG $82.08 $82.08 07-01-2012
541 23680 SG $690.73 $690.73 07-01-2012
542 23700 SG $344.16 $344.16 07-01-2012
543 23800 SG $1,106.69 $1,106.69 07-01-2012
544 23802 SG $1,018.30 $1,018.30 07-01-2012
545 23921 SG $340.40 $340.40 07-01-2012
546 23930 SG $375.60 $375.60 07-01-2012
547 23931 SG $448.06 $448.06 07-01-2012
548 23935 SG $474.15 $474.15 07-01-2012
549 24000 SG $662.22 $662.22 07-01-2012
550 24006 SG $662.22 $662.22 07-01-2012
551 24065 SG $119.82 $119.82 07-01-2012
552 24066 SG $428.42 $428.42 07-01-2012
553 24071 SG $803.54 $803.54 07-01-2012
554 24073 SG $803.54 $803.54 07-01-2012
555 24075 SG $428.42 $428.42 07-01-2012
556 24076 SG $472.74 $472.74 07-01-2012
557 24077 SG $513.77 $513.77 07-01-2012
558 24079 SG $803.54 $803.54 07-01-2012
559 24100 SG $401.70 $401.70 07-01-2012
560 24101 SG $662.22 $662.22 07-01-2012
561 24102 SG $662.22 $662.22 07-01-2012
562 24105 SG $515.19 $515.19 07-01-2012
563 24110 SG $474.15 $474.15 07-01-2012
564 24115 SG $585.28 $585.28 07-01-2012
565 24116 SG $585.28 $585.28 07-01-2012
566 24120 SG $515.19 $515.19 07-01-2012
567 24125 SG $585.28 $585.28 07-01-2012
568 24126 SG $585.28 $585.28 07-01-2012
569 24130 SG $585.28 $585.28 07-01-2012
570 24134 SG $544.24 $544.24 07-01-2012
571 24136 SG $544.24 $544.24 07-01-2012
572 24138 SG $544.24 $544.24 07-01-2012
573 24140 SG $585.28 $585.28 07-01-2012
574 24145 SG $585.28 $585.28 07-01-2012
575 24147 SG $544.24 $544.24 07-01-2012
576 24149 SG $1,033.13 $1,033.13 07-01-2012
577 24152 SG $1,521.36 $1,521.36 07-01-2012
578 24155 SG $707.34 $707.34 07-01-2012
579 24160 SG $544.24 $544.24 07-01-2012
580 24164 SG $585.28 $585.28 07-01-2012
581 24200 SG $100.28 $100.28 07-01-2012
582 24201 SG $428.42 $428.42 07-01-2012
583 24300 SG $522.60 $522.60 07-01-2012
584 24301 SG $662.22 $662.22 07-01-2012
585 24305 SG $662.22 $662.22 07-01-2012
586 24310 SG $515.19 $515.19 07-01-2012
587 24320 SG $707.34 $707.34 07-01-2012
588 24330 SG $1,029.75 $1,029.75 07-01-2012
589 24331 SG $707.34 $707.34 07-01-2012
590 24332 SG $752.77 $752.77 07-01-2012
591 24340 SG $707.34 $707.34 07-01-2012
592 24341 SG $707.33 $707.33 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 8 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
593 24342 SG $707.34 $707.34 07-01-2012
594 24343 SG $1,033.13 $1,033.13 07-01-2012
595 24344 SG $2,811.06 $2,811.06 07-01-2012
596 24345 SG $544.24 $544.24 07-01-2012
597 24346 SG $1,521.36 $1,521.36 07-01-2012
598 24360 SG $777.40 $777.40 07-01-2012
599 24361 SG $1,541.01 $1,541.01 07-01-2012
600 24362 SG $909.98 $909.98 07-01-2012
601 24363 SG $1,719.25 $1,719.25 07-01-2012
602 24365 SG $777.40 $777.40 07-01-2012
603 24366 SG $1,541.01 $1,541.01 07-01-2012
604 24370 SG $6,324.00 $6,324.00 01-01-2013
605 24371 SG $6,324.00 $6,324.00 01-01-2013
606 24400 SG $662.22 $662.22 07-01-2012
607 24410 SG $662.22 $662.22 07-01-2012
608 24420 SG $707.34 $707.34 07-01-2012
609 24430 SG $1,029.75 $1,029.75 07-01-2012
610 24435 SG $1,106.69 $1,106.69 07-01-2012
611 24470 SG $707.34 $707.34 07-01-2012
612 24495 SG $544.24 $544.24 07-01-2012
613 24498 SG $1,029.75 $1,029.75 07-01-2012
614 24500 SG $82.08 $82.08 07-01-2012
615 24505 SG $82.08 $82.08 07-01-2012
616 24515 SG $927.95 $927.95 07-01-2012
617 24516 SG $927.95 $927.95 07-01-2012
618 24530 SG $82.08 $82.08 07-01-2012
619 24535 SG $82.08 $82.08 07-01-2012
620 24538 SG $517.43 $517.43 07-01-2012
621 24545 SG $927.95 $927.95 07-01-2012
622 24546 SG $983.74 $983.74 07-01-2012
623 24560 SG $82.08 $82.08 07-01-2012
624 24565 SG $82.08 $82.08 07-01-2012
625 24566 SG $517.43 $517.43 07-01-2012
626 24575 SG $851.02 $851.02 07-01-2012
627 24576 SG $82.08 $82.08 07-01-2012
628 24577 SG $82.08 $82.08 07-01-2012
629 24579 SG $851.02 $851.02 07-01-2012
630 24582 SG $517.42 $517.42 07-01-2012
631 24586 SG $927.95 $927.95 07-01-2012
632 24587 SG $983.74 $983.74 07-01-2012
633 24600 SG $82.08 $82.08 07-01-2012
634 24605 SG $416.61 $416.61 07-01-2012
635 24615 SG $851.02 $851.02 07-01-2012
636 24620 SG $82.08 $82.08 07-01-2012
637 24635 SG $851.02 $851.02 07-01-2012
638 24640 SG $55.03 $55.03 07-01-2012
639 24650 SG $62.58 $62.58 07-01-2012
640 24655 SG $82.08 $82.08 07-01-2012
641 24665 SG $767.67 $767.67 07-01-2012
642 24666 SG $927.95 $927.95 07-01-2012
643 24670 SG $82.08 $82.08 07-01-2012
644 24675 SG $82.08 $82.08 07-01-2012
645 24685 SG $690.73 $690.73 07-01-2012
646 24800 SG $784.27 $784.27 07-01-2012
647 24802 SG $840.06 $840.06 07-01-2012
648 24925 SG $515.19 $515.19 07-01-2012
649 25000 SG $515.19 $515.19 07-01-2012
650 25001 SG $752.77 $752.77 07-01-2012
651 25020 SG $515.19 $515.19 07-01-2012
652 25023 SG $585.28 $585.28 07-01-2012
653 25024 SG $585.28 $585.28 07-01-2012
654 25025 SG $585.28 $585.28 07-01-2012
655 25028 SG $401.70 $401.70 07-01-2012
656 25031 SG $474.15 $474.15 07-01-2012
657 25035 SG $474.15 $474.15 07-01-2012
658 25040 SG $718.00 $718.00 07-01-2012
659 25065 SG $123.08 $123.08 07-01-2012
660 25066 SG $472.74 $472.74 07-01-2012
661 25071 SG $803.54 $803.54 07-01-2012
662 25073 SG $803.54 $803.54 07-01-2012
663 25075 SG $428.42 $428.42 07-01-2012
664 25076 SG $513.77 $513.77 07-01-2012
665 25077 SG $513.77 $513.77 07-01-2012
666 25078 SG $803.54 $803.54 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 9 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
667 25085 SG $515.19 $515.19 07-01-2012
668 25100 SG $474.15 $474.15 07-01-2012
669 25101 SG $585.28 $585.28 07-01-2012
670 25105 SG $662.22 $662.22 07-01-2012
671 25107 SG $585.28 $585.28 07-01-2012
672 25109 SG $752.77 $752.77 07-01-2012
673 25110 SG $515.19 $515.19 07-01-2012
674 25111 SG $472.66 $472.66 07-01-2012
675 25112 SG $549.60 $549.60 07-01-2012
676 25115 SG $592.13 $592.13 07-01-2012
677 25116 SG $592.13 $592.13 07-01-2012
678 25118 SG $544.24 $544.24 07-01-2012
679 25119 SG $585.28 $585.28 07-01-2012
680 25120 SG $585.28 $585.28 07-01-2012
681 25125 SG $585.28 $585.28 07-01-2012
682 25126 SG $585.28 $585.28 07-01-2012
683 25130 SG $585.28 $585.28 07-01-2012
684 25135 SG $585.28 $585.28 07-01-2012
685 25136 SG $585.28 $585.28 07-01-2012
686 25145 SG $544.24 $544.24 07-01-2012
687 25150 SG $544.24 $544.24 07-01-2012
688 25151 SG $544.24 $544.24 07-01-2012
689 25210 SG $559.80 $559.80 07-01-2012
690 25215 SG $636.74 $636.74 07-01-2012
691 25230 SG $662.22 $662.22 07-01-2012
692 25240 SG $662.22 $662.22 07-01-2012
693 25248 SG $474.15 $474.15 07-01-2012
694 25250 SG $471.79 $471.79 07-01-2012
695 25251 SG $471.79 $471.79 07-01-2012
696 25259 SG $62.58 $62.58 07-01-2012
697 25260 SG $662.22 $662.22 07-01-2012
698 25263 SG $544.24 $544.24 07-01-2012
699 25265 SG $585.28 $585.28 07-01-2012
700 25270 SG $662.22 $662.22 07-01-2012
701 25272 SG $585.28 $585.28 07-01-2012
702 25274 SG $662.22 $662.22 07-01-2012
703 25275 SG $662.22 $662.22 07-01-2012
704 25280 SG $662.22 $662.22 07-01-2012
705 25290 SG $585.28 $585.28 07-01-2012
706 25295 SG $515.19 $515.19 07-01-2012
707 25300 SG $585.28 $585.28 07-01-2012
708 25301 SG $585.28 $585.28 07-01-2012
709 25310 SG $707.34 $707.34 07-01-2012
710 25312 SG $784.27 $784.27 07-01-2012
711 25315 SG $707.34 $707.34 07-01-2012
712 25316 SG $1,029.75 $1,029.75 07-01-2012
713 25320 SG $707.34 $707.34 07-01-2012
714 25332 SG $777.40 $777.40 07-01-2012
715 25335 SG $707.34 $707.34 07-01-2012
716 25350 SG $1,029.75 $1,029.75 07-01-2012
717 25355 SG $707.34 $707.34 07-01-2012
718 25360 SG $585.28 $585.28 07-01-2012
719 25365 SG $585.28 $585.28 07-01-2012
720 25370 SG $707.34 $707.34 07-01-2012
721 25375 SG $784.27 $784.27 07-01-2012
722 25390 SG $585.28 $585.28 07-01-2012
723 25391 SG $784.27 $784.27 07-01-2012
724 25392 SG $585.28 $585.28 07-01-2012
725 25393 SG $784.27 $784.27 07-01-2012
726 25394 SG $582.70 $582.70 07-01-2012
727 25400 SG $1,029.75 $1,029.75 07-01-2012
728 25405 SG $1,106.69 $1,106.69 07-01-2012
729 25415 SG $1,029.75 $1,029.75 07-01-2012
730 25420 SG $1,106.69 $1,106.69 07-01-2012
731 25425 SG $707.34 $707.34 07-01-2012
732 25426 SG $784.27 $784.27 07-01-2012
733 25430 SG $931.21 $931.21 07-01-2012
734 25431 SG $931.21 $931.21 07-01-2012
735 25440 SG $1,106.69 $1,106.69 07-01-2012
736 25441 SG $1,541.01 $1,541.01 07-01-2012
737 25442 SG $1,541.01 $1,541.01 07-01-2012
738 25443 SG $909.97 $909.97 07-01-2012
739 25444 SG $909.97 $909.97 07-01-2012
740 25445 SG $909.97 $909.97 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 10 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
741 25446 SG $1,719.25 $1,719.25 07-01-2012
742 25447 SG $777.40 $777.40 07-01-2012
743 25449 SG $777.40 $777.40 07-01-2012
744 25450 SG $707.34 $707.34 07-01-2012
745 25455 SG $707.34 $707.34 07-01-2012
746 25490 SG $707.34 $707.34 07-01-2012
747 25491 SG $707.34 $707.34 07-01-2012
748 25492 SG $707.34 $707.34 07-01-2012
749 25500 SG $62.58 $62.58 07-01-2012
750 25505 SG $82.08 $82.08 07-01-2012
751 25515 SG $690.73 $690.73 07-01-2012
752 25520 SG $82.08 $82.08 07-01-2012
753 25525 SG $767.67 $767.67 07-01-2012
754 25526 SG $823.45 $823.45 07-01-2012
755 25530 SG $62.58 $62.58 07-01-2012
756 25535 SG $82.08 $82.08 07-01-2012
757 25545 SG $690.73 $690.73 07-01-2012
758 25560 SG $62.58 $62.58 07-01-2012
759 25565 SG $82.08 $82.08 07-01-2012
760 25574 SG $851.02 $851.02 07-01-2012
761 25575 SG $851.02 $851.02 07-01-2012
762 25600 SG $62.58 $62.58 07-01-2012
763 25605 SG $82.08 $82.08 07-01-2012
764 25606 SG $558.46 $558.46 07-01-2012
765 25607 SG $983.74 $983.74 07-01-2012
766 25608 SG $983.74 $983.74 07-01-2012
767 25609 SG $983.74 $983.74 07-01-2012
768 25622 SG $62.58 $62.58 07-01-2012
769 25624 SG $82.08 $82.08 07-01-2012
770 25628 SG $690.73 $690.73 07-01-2012
771 25630 SG $62.58 $62.58 07-01-2012
772 25635 SG $82.08 $82.08 07-01-2012
773 25645 SG $690.73 $690.73 07-01-2012
774 25650 SG $62.58 $62.58 07-01-2012
775 25651 SG $925.86 $925.86 07-01-2012
776 25652 SG $1,454.97 $1,454.97 07-01-2012
777 25660 SG $82.08 $82.08 07-01-2012
778 25670 SG $558.46 $558.46 07-01-2012
779 25671 SG $444.98 $444.98 07-01-2012
780 25675 SG $82.08 $82.08 07-01-2012
781 25676 SG $517.43 $517.43 07-01-2012
782 25680 SG $82.08 $82.08 07-01-2012
783 25685 SG $558.46 $558.46 07-01-2012
784 25690 SG $82.08 $82.08 07-01-2012
785 25695 SG $517.43 $517.43 07-01-2012
786 25800 SG $1,106.69 $1,106.69 07-01-2012
787 25805 SG $840.06 $840.06 07-01-2012
788 25810 SG $1,162.48 $1,162.48 07-01-2012
789 25820 SG $549.60 $549.60 07-01-2012
790 25825 SG $1,162.48 $1,162.48 07-01-2012
791 25830 SG $1,162.48 $1,162.48 07-01-2012
792 25907 SG $515.19 $515.19 07-01-2012
793 25922 SG $515.19 $515.19 07-01-2012
794 25929 SG $460.12 $460.12 07-01-2012
795 26010 SG $49.78 $49.78 07-01-2012
796 26011 SG $315.79 $315.79 07-01-2012
797 26020 SG $431.62 $431.62 07-01-2012
798 26025 SG $359.18 $359.18 07-01-2012
799 26030 SG $431.62 $431.62 07-01-2012
800 26034 SG $431.62 $431.62 07-01-2012
801 26035 SG $582.70 $582.70 07-01-2012
802 26037 SG $427.72 $427.72 07-01-2012
803 26040 SG $636.74 $636.74 07-01-2012
804 26045 SG $559.80 $559.80 07-01-2012
805 26055 SG $431.62 $431.62 07-01-2012
806 26060 SG $431.62 $431.62 07-01-2012
807 26070 SG $431.62 $431.62 07-01-2012
808 26075 SG $549.60 $549.60 07-01-2012
809 26080 SG $549.60 $549.60 07-01-2012
810 26100 SG $431.62 $431.62 07-01-2012
811 26105 SG $359.18 $359.18 07-01-2012
812 26110 SG $359.18 $359.18 07-01-2012
813 26111 SG $803.54 $803.54 07-01-2012
814 26113 SG $803.54 $803.54 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 11 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
815 26115 SG $472.74 $472.74 07-01-2012
816 26116 SG $472.74 $472.74 07-01-2012
817 26117 SG $513.77 $513.77 07-01-2012
818 26118 SG $803.54 $803.54 07-01-2012
819 26121 SG $636.74 $636.74 07-01-2012
820 26123 SG $636.74 $636.74 07-01-2012
821 26130 SG $472.66 $472.66 07-01-2012
822 26135 SG $636.74 $636.74 07-01-2012
823 26140 SG $431.62 $431.62 07-01-2012
824 26145 SG $472.66 $472.66 07-01-2012
825 26160 SG $472.66 $472.66 07-01-2012
826 26170 SG $472.66 $472.66 07-01-2012
827 26180 SG $472.66 $472.66 07-01-2012
828 26185 SG $549.60 $549.60 07-01-2012
829 26200 SG $431.62 $431.62 07-01-2012
830 26205 SG $559.80 $559.80 07-01-2012
831 26210 SG $431.62 $431.62 07-01-2012
832 26215 SG $472.66 $472.66 07-01-2012
833 26230 SG $782.32 $782.32 07-01-2012
834 26235 SG $472.66 $472.66 07-01-2012
835 26236 SG $472.66 $472.66 07-01-2012
836 26250 SG $472.66 $472.66 07-01-2012
837 26260 SG $472.66 $472.66 07-01-2012
838 26262 SG $431.62 $431.62 07-01-2012
839 26320 SG $428.42 $428.42 07-01-2012
840 26340 SG $62.58 $62.58 07-01-2012
841 26341 SG $179.41 $179.41 01-01-2013
842 26350 SG $446.31 $446.31 07-01-2012
843 26352 SG $636.74 $636.74 07-01-2012
844 26356 SG $636.74 $636.74 07-01-2012
845 26357 SG $636.74 $636.74 07-01-2012
846 26358 SG $636.74 $636.74 07-01-2012
847 26370 SG $636.74 $636.74 07-01-2012
848 26372 SG $636.74 $636.74 07-01-2012
849 26373 SG $559.80 $559.80 07-01-2012
850 26390 SG $636.74 $636.74 07-01-2012
851 26392 SG $559.80 $559.80 07-01-2012
852 26410 SG $472.66 $472.66 07-01-2012
853 26412 SG $559.80 $559.80 07-01-2012
854 26415 SG $636.74 $636.74 07-01-2012
855 26416 SG $559.80 $559.80 07-01-2012
856 26418 SG $549.60 $549.60 07-01-2012
857 26420 SG $636.74 $636.74 07-01-2012
858 26426 SG $559.80 $559.80 07-01-2012
859 26428 SG $559.80 $559.80 07-01-2012
860 26432 SG $472.66 $472.66 07-01-2012
861 26433 SG $472.66 $472.66 07-01-2012
862 26434 SG $559.80 $559.80 07-01-2012
863 26437 SG $472.66 $472.66 07-01-2012
864 26440 SG $472.66 $472.66 07-01-2012
865 26442 SG $559.80 $559.80 07-01-2012
866 26445 SG $472.66 $472.66 07-01-2012
867 26449 SG $559.80 $559.80 07-01-2012
868 26450 SG $472.66 $472.66 07-01-2012
869 26455 SG $472.66 $472.66 07-01-2012
870 26460 SG $472.66 $472.66 07-01-2012
871 26471 SG $431.62 $431.62 07-01-2012
872 26474 SG $431.62 $431.62 07-01-2012
873 26476 SG $359.18 $359.18 07-01-2012
874 26477 SG $359.18 $359.18 07-01-2012
875 26478 SG $359.18 $359.18 07-01-2012
876 26479 SG $359.18 $359.18 07-01-2012
877 26480 SG $559.80 $559.80 07-01-2012
878 26483 SG $559.80 $559.80 07-01-2012
879 26485 SG $518.76 $518.76 07-01-2012
880 26489 SG $559.80 $559.80 07-01-2012
881 26490 SG $559.80 $559.80 07-01-2012
882 26492 SG $559.80 $559.80 07-01-2012
883 26494 SG $559.80 $559.80 07-01-2012
884 26496 SG $559.80 $559.80 07-01-2012
885 26497 SG $559.80 $559.80 07-01-2012
886 26498 SG $636.74 $636.74 07-01-2012
887 26499 SG $559.80 $559.80 07-01-2012
888 26500 SG $549.60 $549.60 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 12 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
889 26502 SG $636.74 $636.74 07-01-2012
890 26508 SG $472.66 $472.66 07-01-2012
891 26510 SG $559.80 $559.80 07-01-2012
892 26516 SG $446.31 $446.31 07-01-2012
893 26517 SG $559.80 $559.80 07-01-2012
894 26518 SG $559.80 $559.80 07-01-2012
895 26520 SG $472.66 $472.66 07-01-2012
896 26525 SG $472.66 $472.66 07-01-2012
897 26530 SG $644.68 $644.68 07-01-2012
898 26531 SG $1,088.22 $1,088.22 07-01-2012
899 26535 SG $777.40 $777.40 07-01-2012
900 26536 SG $909.97 $909.97 07-01-2012
901 26540 SG $549.60 $549.60 07-01-2012
902 26541 SG $870.75 $870.75 07-01-2012
903 26542 SG $549.60 $549.60 07-01-2012
904 26545 SG $636.74 $636.74 07-01-2012
905 26546 SG $636.74 $636.74 07-01-2012
906 26548 SG $636.74 $636.74 07-01-2012
907 26550 SG $518.76 $518.76 07-01-2012
908 26555 SG $559.80 $559.80 07-01-2012
909 26560 SG $431.62 $431.62 07-01-2012
910 26561 SG $559.80 $559.80 07-01-2012
911 26562 SG $636.74 $636.74 07-01-2012
912 26565 SG $692.52 $692.52 07-01-2012
913 26567 SG $692.52 $692.52 07-01-2012
914 26568 SG $559.80 $559.80 07-01-2012
915 26580 SG $605.38 $605.38 07-01-2012
916 26587 SG $605.38 $605.38 07-01-2012
917 26590 SG $605.38 $605.38 07-01-2012
918 26591 SG $559.80 $559.80 07-01-2012
919 26593 SG $472.66 $472.66 07-01-2012
920 26596 SG $431.62 $431.62 07-01-2012
921 26600 SG $62.58 $62.58 07-01-2012
922 26605 SG $82.08 $82.08 07-01-2012
923 26607 SG $82.08 $82.08 07-01-2012
924 26608 SG $635.39 $635.39 07-01-2012
925 26615 SG $767.67 $767.67 07-01-2012
926 26641 SG $62.58 $62.58 07-01-2012
927 26645 SG $82.08 $82.08 07-01-2012
928 26650 SG $517.43 $517.43 07-01-2012
929 26665 SG $767.67 $767.67 07-01-2012
930 26670 SG $62.58 $62.58 07-01-2012
931 26675 SG $82.08 $82.08 07-01-2012
932 26676 SG $517.43 $517.43 07-01-2012
933 26685 SG $558.46 $558.46 07-01-2012
934 26686 SG $851.02 $851.02 07-01-2012
935 26700 SG $62.58 $62.58 07-01-2012
936 26705 SG $82.08 $82.08 07-01-2012
937 26706 SG $82.08 $82.08 07-01-2012
938 26715 SG $635.39 $635.39 07-01-2012
939 26720 SG $62.58 $62.58 07-01-2012
940 26725 SG $62.58 $62.58 07-01-2012
941 26727 SG $869.42 $869.42 07-01-2012
942 26735 SG $635.39 $635.39 07-01-2012
943 26740 SG $62.58 $62.58 07-01-2012
944 26742 SG $82.08 $82.08 07-01-2012
945 26746 SG $691.18 $691.18 07-01-2012
946 26750 SG $62.58 $62.58 07-01-2012
947 26755 SG $62.58 $62.58 07-01-2012
948 26756 SG $517.43 $517.43 07-01-2012
949 26765 SG $635.39 $635.39 07-01-2012
950 26770 SG $62.58 $62.58 07-01-2012
951 26775 SG $159.87 $159.87 07-01-2012
952 26776 SG $517.43 $517.43 07-01-2012
953 26785 SG $517.43 $517.43 07-01-2012
954 26820 SG $692.52 $692.52 07-01-2012
955 26841 SG $636.74 $636.74 07-01-2012
956 26842 SG $636.74 $636.74 07-01-2012
957 26843 SG $559.80 $559.80 07-01-2012
958 26844 SG $559.80 $559.80 07-01-2012
959 26850 SG $636.74 $636.74 07-01-2012
960 26852 SG $636.74 $636.74 07-01-2012
961 26860 SG $559.80 $559.80 07-01-2012
962 26862 SG $636.74 $636.74 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 13 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
963 26910 SG $559.80 $559.80 07-01-2012
964 26951 SG $431.62 $431.62 07-01-2012
965 26952 SG $549.60 $549.60 07-01-2012
966 26990 SG $401.70 $401.70 07-01-2012
967 26991 SG $401.70 $401.70 07-01-2012
968 27000 SG $474.15 $474.15 07-01-2012
969 27001 SG $585.28 $585.28 07-01-2012
970 27003 SG $585.28 $585.28 07-01-2012
971 27033 SG $707.34 $707.34 07-01-2012
972 27035 SG $784.27 $784.27 07-01-2012
973 27040 SG $290.35 $290.35 07-01-2012
974 27041 SG $345.17 $345.17 07-01-2012
975 27043 SG $803.54 $803.54 07-01-2012
976 27045 SG $803.54 $803.54 07-01-2012
977 27047 SG $472.74 $472.74 07-01-2012
978 27048 SG $513.77 $513.77 07-01-2012
979 27049 SG $513.77 $513.77 07-01-2012
980 27050 SG $515.19 $515.19 07-01-2012
981 27052 SG $515.19 $515.19 07-01-2012
982 27059 SG $803.54 $803.54 07-01-2012
983 27060 SG $647.91 $647.91 07-01-2012
984 27062 SG $647.91 $647.91 07-01-2012
985 27065 SG $647.91 $647.91 07-01-2012
986 27066 SG $718.00 $718.00 07-01-2012
987 27067 SG $718.00 $718.00 07-01-2012
988 27080 SG $544.24 $544.24 07-01-2012
989 27086 SG $290.35 $290.35 07-01-2012
990 27087 SG $515.19 $515.19 07-01-2012
991 27097 SG $585.28 $585.28 07-01-2012
992 27098 SG $585.28 $585.28 07-01-2012
993 27100 SG $784.27 $784.27 07-01-2012
994 27105 SG $784.27 $784.27 07-01-2012
995 27110 SG $784.27 $784.27 07-01-2012
996 27111 SG $784.27 $784.27 07-01-2012
997 27197 SG $124.27 $124.27 01-01-2017
998 27198 SG $124.27 $124.27 01-01-2017
999 27200 SG $62.58 $62.58 07-01-2012
1000 27202 SG $649.70 $649.70 07-01-2012
1001 27220 SG $62.58 $62.58 07-01-2012
1002 27230 SG $82.08 $82.08 07-01-2012
1003 27238 SG $82.08 $82.08 07-01-2012
1004 27246 SG $82.08 $82.08 07-01-2012
1005 27250 SG $82.08 $82.08 07-01-2012
1006 27252 SG $416.61 $416.61 07-01-2012
1007 27256 SG $62.58 $62.58 07-01-2012
1008 27257 SG $457.64 $457.64 07-01-2012
1009 27265 SG $82.08 $82.08 07-01-2012
1010 27266 SG $416.61 $416.61 07-01-2012
1011 27275 SG $416.61 $416.61 07-01-2012
1012 27279 SG $6,686.59 $6,686.59 01-01-2015
1013 27301 SG $489.09 $489.09 07-01-2012
1014 27305 SG $474.15 $474.15 07-01-2012
1015 27306 SG $515.19 $515.19 07-01-2012
1016 27307 SG $515.19 $515.19 07-01-2012
1017 27310 SG $662.22 $662.22 07-01-2012
1018 27323 SG $290.35 $290.35 07-01-2012
1019 27324 SG $400.29 $400.29 07-01-2012
1020 27325 SG $445.68 $445.68 07-01-2012
1021 27326 SG $445.68 $445.68 07-01-2012
1022 27327 SG $472.74 $472.74 07-01-2012
1023 27328 SG $513.77 $513.77 07-01-2012
1024 27329 SG $590.71 $590.71 07-01-2012
1025 27330 SG $662.22 $662.22 07-01-2012
1026 27331 SG $662.22 $662.22 07-01-2012
1027 27332 SG $662.22 $662.22 07-01-2012
1028 27333 SG $662.22 $662.22 07-01-2012
1029 27334 SG $662.22 $662.22 07-01-2012
1030 27335 SG $662.22 $662.22 07-01-2012
1031 27337 SG $803.54 $803.54 07-01-2012
1032 27339 SG $803.54 $803.54 07-01-2012
1033 27340 SG $515.19 $515.19 07-01-2012
1034 27345 SG $592.13 $592.13 07-01-2012
1035 27347 SG $592.13 $592.13 07-01-2012
1036 27350 SG $662.22 $662.22 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 14 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1037 27355 SG $585.28 $585.28 07-01-2012
1038 27356 SG $662.22 $662.22 07-01-2012
1039 27357 SG $718.00 $718.00 07-01-2012
1040 27360 SG $718.00 $718.00 07-01-2012
1041 27364 SG $803.54 $803.54 07-01-2012
1042 27372 SG $824.74 $824.74 07-01-2012
1043 27380 SG $401.70 $401.70 07-01-2012
1044 27381 SG $515.19 $515.19 07-01-2012
1045 27385 SG $515.19 $515.19 07-01-2012
1046 27386 SG $515.19 $515.19 07-01-2012
1047 27390 SG $401.70 $401.70 07-01-2012
1048 27391 SG $474.15 $474.15 07-01-2012
1049 27392 SG $515.19 $515.19 07-01-2012
1050 27393 SG $544.24 $544.24 07-01-2012
1051 27394 SG $585.28 $585.28 07-01-2012
1052 27395 SG $707.34 $707.34 07-01-2012
1053 27396 SG $585.28 $585.28 07-01-2012
1054 27397 SG $707.34 $707.34 07-01-2012
1055 27400 SG $707.34 $707.34 07-01-2012
1056 27403 SG $662.22 $662.22 07-01-2012
1057 27405 SG $784.27 $784.27 07-01-2012
1058 27407 SG $1,106.69 $1,106.69 07-01-2012
1059 27409 SG $784.27 $784.27 07-01-2012
1060 27416 SG $745.70 $745.70 07-01-2012
1061 27418 SG $707.34 $707.34 07-01-2012
1062 27420 SG $707.34 $707.34 07-01-2012
1063 27422 SG $1,018.30 $1,018.30 07-01-2012
1064 27424 SG $707.34 $707.34 07-01-2012
1065 27425 SG $896.24 $896.24 07-01-2012
1066 27427 SG $707.34 $707.34 07-01-2012
1067 27428 SG $1,106.69 $1,106.69 07-01-2012
1068 27429 SG $1,106.69 $1,106.69 07-01-2012
1069 27430 SG $784.27 $784.27 07-01-2012
1070 27435 SG $784.27 $784.27 07-01-2012
1071 27437 SG $721.61 $721.61 07-01-2012
1072 27438 SG $909.97 $909.97 07-01-2012
1073 27440 SG $1,270.75 $1,270.75 07-01-2012
1074 27441 SG $777.40 $777.40 07-01-2012
1075 27442 SG $777.40 $777.40 07-01-2012
1076 27443 SG $777.40 $777.40 07-01-2012
1077 27446 SG $9,721.41 $9,721.41 07-01-2012
1078 27496 SG $647.91 $647.91 07-01-2012
1079 27497 SG $515.19 $515.19 07-01-2012
1080 27498 SG $515.19 $515.19 07-01-2012
1081 27499 SG $515.19 $515.19 07-01-2012
1082 27500 SG $82.08 $82.08 07-01-2012
1083 27501 SG $82.08 $82.08 07-01-2012
1084 27502 SG $82.08 $82.08 07-01-2012
1085 27503 SG $82.08 $82.08 07-01-2012
1086 27508 SG $82.08 $82.08 07-01-2012
1087 27509 SG $558.46 $558.46 07-01-2012
1088 27510 SG $82.08 $82.08 07-01-2012
1089 27516 SG $82.08 $82.08 07-01-2012
1090 27517 SG $82.08 $82.08 07-01-2012
1091 27520 SG $82.08 $82.08 07-01-2012
1092 27524 SG $574.64 $574.64 07-01-2012
1093 27530 SG $82.08 $82.08 07-01-2012
1094 27532 SG $82.08 $82.08 07-01-2012
1095 27538 SG $82.08 $82.08 07-01-2012
1096 27550 SG $82.08 $82.08 07-01-2012
1097 27552 SG $344.16 $344.16 07-01-2012
1098 27560 SG $82.08 $82.08 07-01-2012
1099 27562 SG $344.16 $344.16 07-01-2012
1100 27566 SG $649.70 $649.70 07-01-2012
1101 27570 SG $344.16 $344.16 07-01-2012
1102 27594 SG $515.19 $515.19 07-01-2012
1103 27600 SG $515.19 $515.19 07-01-2012
1104 27601 SG $515.19 $515.19 07-01-2012
1105 27602 SG $515.19 $515.19 07-01-2012
1106 27603 SG $448.06 $448.06 07-01-2012
1107 27604 SG $474.15 $474.15 07-01-2012
1108 27605 SG $397.80 $397.80 07-01-2012
1109 27606 SG $401.70 $401.70 07-01-2012
1110 27607 SG $474.15 $474.15 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 15 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1111 27610 SG $544.24 $544.24 07-01-2012
1112 27612 SG $585.28 $585.28 07-01-2012
1113 27613 SG $116.24 $116.24 07-01-2012
1114 27614 SG $472.74 $472.74 07-01-2012
1115 27615 SG $585.28 $585.28 07-01-2012
1116 27616 SG $803.54 $803.54 07-01-2012
1117 27618 SG $428.42 $428.42 07-01-2012
1118 27619 SG $513.77 $513.77 07-01-2012
1119 27620 SG $662.22 $662.22 07-01-2012
1120 27625 SG $662.22 $662.22 07-01-2012
1121 27626 SG $662.22 $662.22 07-01-2012
1122 27630 SG $515.19 $515.19 07-01-2012
1123 27632 SG $803.54 $803.54 07-01-2012
1124 27634 SG $803.54 $803.54 07-01-2012
1125 27635 SG $585.28 $585.28 07-01-2012
1126 27637 SG $585.28 $585.28 07-01-2012
1127 27638 SG $585.28 $585.28 07-01-2012
1128 27640 SG $666.30 $666.30 07-01-2012
1129 27641 SG $544.24 $544.24 07-01-2012
1130 27647 SG $707.33 $707.33 07-01-2012
1131 27650 SG $707.34 $707.34 07-01-2012
1132 27652 SG $1,029.75 $1,029.75 07-01-2012
1133 27654 SG $707.34 $707.34 07-01-2012
1134 27656 SG $474.15 $474.15 07-01-2012
1135 27658 SG $401.70 $401.70 07-01-2012
1136 27659 SG $474.15 $474.15 07-01-2012
1137 27664 SG $474.15 $474.15 07-01-2012
1138 27665 SG $544.24 $544.24 07-01-2012
1139 27675 SG $474.15 $474.15 07-01-2012
1140 27676 SG $585.28 $585.28 07-01-2012
1141 27680 SG $585.28 $585.28 07-01-2012
1142 27681 SG $544.24 $544.24 07-01-2012
1143 27685 SG $585.28 $585.28 07-01-2012
1144 27686 SG $585.28 $585.28 07-01-2012
1145 27687 SG $585.28 $585.28 07-01-2012
1146 27690 SG $784.27 $784.27 07-01-2012
1147 27691 SG $784.27 $784.27 07-01-2012
1148 27695 SG $544.24 $544.24 07-01-2012
1149 27696 SG $544.24 $544.24 07-01-2012
1150 27698 SG $544.24 $544.24 07-01-2012
1151 27700 SG $777.40 $777.40 07-01-2012
1152 27704 SG $474.15 $474.15 07-01-2012
1153 27705 SG $666.30 $666.30 07-01-2012
1154 27707 SG $474.15 $474.15 07-01-2012
1155 27709 SG $544.24 $544.24 07-01-2012
1156 27730 SG $544.24 $544.24 07-01-2012
1157 27732 SG $544.24 $544.24 07-01-2012
1158 27734 SG $544.24 $544.24 07-01-2012
1159 27740 SG $544.24 $544.24 07-01-2012
1160 27742 SG $666.30 $666.30 07-01-2012
1161 27745 SG $1,029.75 $1,029.75 07-01-2012
1162 27750 SG $82.08 $82.08 07-01-2012
1163 27752 SG $82.08 $82.08 07-01-2012
1164 27756 SG $558.46 $558.46 07-01-2012
1165 27758 SG $767.67 $767.67 07-01-2012
1166 27759 SG $927.95 $927.95 07-01-2012
1167 27760 SG $82.08 $82.08 07-01-2012
1168 27762 SG $82.08 $82.08 07-01-2012
1169 27766 SG $690.73 $690.73 07-01-2012
1170 27780 SG $82.08 $82.08 07-01-2012
1171 27781 SG $82.08 $82.08 07-01-2012
1172 27784 SG $690.73 $690.73 07-01-2012
1173 27786 SG $82.08 $82.08 07-01-2012
1174 27788 SG $82.08 $82.08 07-01-2012
1175 27792 SG $690.73 $690.73 07-01-2012
1176 27808 SG $82.08 $82.08 07-01-2012
1177 27810 SG $82.08 $82.08 07-01-2012
1178 27814 SG $690.73 $690.73 07-01-2012
1179 27816 SG $82.08 $82.08 07-01-2012
1180 27818 SG $82.08 $82.08 07-01-2012
1181 27822 SG $690.73 $690.73 07-01-2012
1182 27823 SG $851.02 $851.02 07-01-2012
1183 27824 SG $82.08 $82.08 07-01-2012
1184 27825 SG $82.08 $82.08 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 16 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1185 27826 SG $690.73 $690.73 07-01-2012
1186 27827 SG $851.02 $851.02 07-01-2012
1187 27828 SG $927.95 $927.95 07-01-2012
1188 27829 SG $649.70 $649.70 07-01-2012
1189 27830 SG $82.08 $82.08 07-01-2012
1190 27831 SG $82.08 $82.08 07-01-2012
1191 27832 SG $649.70 $649.70 07-01-2012
1192 27840 SG $82.08 $82.08 07-01-2012
1193 27842 SG $344.16 $344.16 07-01-2012
1194 27846 SG $690.73 $690.73 07-01-2012
1195 27848 SG $690.73 $690.73 07-01-2012
1196 27860 SG $344.16 $344.16 07-01-2012
1197 27870 SG $1,106.69 $1,106.69 07-01-2012
1198 27871 SG $1,106.69 $1,106.69 07-01-2012
1199 27884 SG $515.19 $515.19 07-01-2012
1200 27889 SG $585.28 $585.28 07-01-2012
1201 27892 SG $515.19 $515.19 07-01-2012
1202 27893 SG $515.19 $515.19 07-01-2012
1203 27894 SG $515.19 $515.19 07-01-2012
1204 28002 SG $515.19 $515.19 07-01-2012
1205 28003 SG $515.19 $515.19 07-01-2012
1206 28005 SG $511.29 $511.29 07-01-2012
1207 28008 SG $511.29 $511.29 07-01-2012
1208 28010 SG $85.31 $85.31 07-01-2012
1209 28011 SG $511.29 $511.29 07-01-2012
1210 28020 SG $470.25 $470.25 07-01-2012
1211 28022 SG $470.25 $470.25 07-01-2012
1212 28024 SG $470.25 $470.25 07-01-2012
1213 28035 SG $563.66 $563.66 07-01-2012
1214 28039 SG $217.15 $217.15 07-01-2012
1215 28041 SG $803.54 $803.54 07-01-2012
1216 28043 SG $472.74 $472.74 07-01-2012
1217 28045 SG $511.29 $511.29 07-01-2012
1218 28046 SG $511.29 $511.29 07-01-2012
1219 28047 SG $803.54 $803.54 07-01-2012
1220 28050 SG $470.25 $470.25 07-01-2012
1221 28052 SG $470.25 $470.25 07-01-2012
1222 28054 SG $470.25 $470.25 07-01-2012
1223 28055 SG $563.66 $563.66 07-01-2012
1224 28060 SG $470.25 $470.25 07-01-2012
1225 28062 SG $511.29 $511.29 07-01-2012
1226 28070 SG $511.29 $511.29 07-01-2012
1227 28072 SG $511.29 $511.29 07-01-2012
1228 28080 SG $511.29 $511.29 07-01-2012
1229 28086 SG $470.25 $470.25 07-01-2012
1230 28088 SG $470.25 $470.25 07-01-2012
1231 28090 SG $511.29 $511.29 07-01-2012
1232 28092 SG $511.29 $511.29 07-01-2012
1233 28100 SG $470.25 $470.25 07-01-2012
1234 28102 SG $718.69 $718.69 07-01-2012
1235 28103 SG $718.69 $718.69 07-01-2012
1236 28104 SG $470.25 $470.25 07-01-2012
1237 28106 SG $718.69 $718.69 07-01-2012
1238 28107 SG $718.69 $718.69 07-01-2012
1239 28108 SG $470.25 $470.25 07-01-2012
1240 28110 SG $511.29 $511.29 07-01-2012
1241 28111 SG $511.29 $511.29 07-01-2012
1242 28112 SG $511.29 $511.29 07-01-2012
1243 28113 SG $511.29 $511.29 07-01-2012
1244 28114 SG $511.29 $511.29 07-01-2012
1245 28116 SG $511.29 $511.29 07-01-2012
1246 28118 SG $588.23 $588.23 07-01-2012
1247 28119 SG $588.23 $588.23 07-01-2012
1248 28120 SG $822.25 $822.25 07-01-2012
1249 28122 SG $511.29 $511.29 07-01-2012
1250 28124 SG $191.45 $191.45 07-01-2012
1251 28126 SG $511.29 $511.29 07-01-2012
1252 28130 SG $511.29 $511.29 07-01-2012
1253 28140 SG $511.29 $511.29 07-01-2012
1254 28150 SG $511.29 $511.29 07-01-2012
1255 28153 SG $511.29 $511.29 07-01-2012
1256 28160 SG $511.29 $511.29 07-01-2012
1257 28171 SG $511.29 $511.29 07-01-2012
1258 28173 SG $511.29 $511.29 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 17 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1259 28175 SG $511.29 $511.29 07-01-2012
1260 28190 SG $120.47 $120.47 07-01-2012
1261 28192 SG $428.42 $428.42 07-01-2012
1262 28193 SG $345.17 $345.17 07-01-2012
1263 28200 SG $511.29 $511.29 07-01-2012
1264 28202 SG $511.29 $511.29 07-01-2012
1265 28208 SG $511.29 $511.29 07-01-2012
1266 28210 SG $718.69 $718.69 07-01-2012
1267 28220 SG $180.38 $180.38 07-01-2012
1268 28222 SG $397.80 $397.80 07-01-2012
1269 28225 SG $397.80 $397.80 07-01-2012
1270 28226 SG $397.80 $397.80 07-01-2012
1271 28230 SG $178.11 $178.11 07-01-2012
1272 28232 SG $170.28 $170.28 07-01-2012
1273 28234 SG $470.25 $470.25 07-01-2012
1274 28238 SG $718.69 $718.69 07-01-2012
1275 28240 SG $470.25 $470.25 07-01-2012
1276 28250 SG $511.29 $511.29 07-01-2012
1277 28260 SG $511.29 $511.29 07-01-2012
1278 28261 SG $511.29 $511.29 07-01-2012
1279 28262 SG $588.23 $588.23 07-01-2012
1280 28264 SG $605.20 $605.20 07-01-2012
1281 28270 SG $511.29 $511.29 07-01-2012
1282 28272 SG $163.13 $163.13 07-01-2012
1283 28280 SG $470.25 $470.25 07-01-2012
1284 28285 SG $511.29 $511.29 07-01-2012
1285 28286 SG $588.23 $588.23 07-01-2012
1286 28288 SG $511.29 $511.29 07-01-2012
1287 28289 SG $511.29 $511.29 07-01-2012
1288 28291 SG $3,049.02 $3,049.02 01-01-2017
1289 28292 SG $546.24 $546.24 07-01-2012
1290 28295 SG $1,402.60 $1,402.60 01-01-2017
1291 28296 SG $587.27 $587.27 07-01-2012
1292 28297 SG $587.27 $587.27 07-01-2012
1293 28298 SG $587.27 $587.27 07-01-2012
1294 28299 SG $720.00 $720.00 07-01-2012
1295 28300 SG $677.65 $677.65 07-01-2012
1296 28302 SG $470.25 $470.25 07-01-2012
1297 28304 SG $677.65 $677.65 07-01-2012
1298 28305 SG $718.69 $718.69 07-01-2012
1299 28306 SG $588.23 $588.23 07-01-2012
1300 28307 SG $588.23 $588.23 07-01-2012
1301 28308 SG $470.25 $470.25 07-01-2012
1302 28309 SG $795.62 $795.62 07-01-2012
1303 28310 SG $511.29 $511.29 07-01-2012
1304 28312 SG $511.29 $511.29 07-01-2012
1305 28313 SG $470.25 $470.25 07-01-2012
1306 28315 SG $588.23 $588.23 07-01-2012
1307 28320 SG $795.62 $795.62 07-01-2012
1308 28322 SG $795.62 $795.62 07-01-2012
1309 28340 SG $588.23 $588.23 07-01-2012
1310 28341 SG $588.23 $588.23 07-01-2012
1311 28344 SG $588.23 $588.23 07-01-2012
1312 28345 SG $588.23 $588.23 07-01-2012
1313 28400 SG $82.08 $82.08 07-01-2012
1314 28405 SG $82.08 $82.08 07-01-2012
1315 28406 SG $517.43 $517.43 07-01-2012
1316 28415 SG $851.02 $851.02 07-01-2012
1317 28420 SG $767.67 $767.67 07-01-2012
1318 28430 SG $62.58 $62.58 07-01-2012
1319 28435 SG $82.08 $82.08 07-01-2012
1320 28436 SG $517.43 $517.43 07-01-2012
1321 28445 SG $690.73 $690.73 07-01-2012
1322 28450 SG $62.58 $62.58 07-01-2012
1323 28455 SG $62.58 $62.58 07-01-2012
1324 28456 SG $517.43 $517.43 07-01-2012
1325 28465 SG $690.73 $690.73 07-01-2012
1326 28470 SG $62.58 $62.58 07-01-2012
1327 28475 SG $62.58 $62.58 07-01-2012
1328 28476 SG $517.43 $517.43 07-01-2012
1329 28485 SG $767.67 $767.67 07-01-2012
1330 28490 SG $62.58 $62.58 07-01-2012
1331 28495 SG $62.58 $62.58 07-01-2012
1332 28496 SG $517.43 $517.43 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 18 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1333 28505 SG $558.46 $558.46 07-01-2012
1334 28510 SG $52.42 $52.42 07-01-2012
1335 28515 SG $62.58 $62.58 07-01-2012
1336 28525 SG $558.46 $558.46 07-01-2012
1337 28530 SG $49.81 $49.81 07-01-2012
1338 28531 SG $558.46 $558.46 07-01-2012
1339 28540 SG $62.58 $62.58 07-01-2012
1340 28545 SG $444.98 $444.98 07-01-2012
1341 28546 SG $517.43 $517.43 07-01-2012
1342 28555 SG $649.70 $649.70 07-01-2012
1343 28570 SG $62.58 $62.58 07-01-2012
1344 28575 SG $82.08 $82.08 07-01-2012
1345 28576 SG $558.46 $558.46 07-01-2012
1346 28585 SG $558.46 $558.46 07-01-2012
1347 28600 SG $62.58 $62.58 07-01-2012
1348 28605 SG $82.08 $82.08 07-01-2012
1349 28606 SG $517.43 $517.43 07-01-2012
1350 28615 SG $690.73 $690.73 07-01-2012
1351 28630 SG $55.67 $55.67 07-01-2012
1352 28635 SG $344.16 $344.16 07-01-2012
1353 28636 SG $558.46 $558.46 07-01-2012
1354 28645 SG $558.46 $558.46 07-01-2012
1355 28660 SG $41.68 $41.68 07-01-2012
1356 28665 SG $344.16 $344.16 07-01-2012
1357 28666 SG $558.46 $558.46 07-01-2012
1358 28675 SG $558.46 $558.46 07-01-2012
1359 28705 SG $795.62 $795.62 07-01-2012
1360 28715 SG $1,106.69 $1,106.69 07-01-2012
1361 28725 SG $795.62 $795.62 07-01-2012
1362 28730 SG $795.62 $795.62 07-01-2012
1363 28735 SG $795.62 $795.62 07-01-2012
1364 28737 SG $851.40 $851.40 07-01-2012
1365 28740 SG $795.62 $795.62 07-01-2012
1366 28750 SG $795.62 $795.62 07-01-2012
1367 28755 SG $588.23 $588.23 07-01-2012
1368 28760 SG $795.62 $795.62 07-01-2012
1369 28810 SG $470.25 $470.25 07-01-2012
1370 28820 SG $470.25 $470.25 07-01-2012
1371 28825 SG $470.25 $470.25 07-01-2012
1372 29000 SG $38.69 $38.69 07-01-2012
1373 29010 SG $81.09 $81.09 07-01-2012
1374 29015 SG $81.09 $81.09 07-01-2012
1375 29035 SG $81.09 $81.09 07-01-2012
1376 29040 SG $38.69 $38.69 07-01-2012
1377 29044 SG $81.09 $81.09 07-01-2012
1378 29046 SG $81.09 $81.09 07-01-2012
1379 29049 SG $38.69 $38.69 07-01-2012
1380 29055 SG $81.09 $81.09 07-01-2012
1381 29058 SG $38.69 $38.69 07-01-2012
1382 29065 SG $42.33 $42.33 07-01-2012
1383 29075 SG $40.70 $40.70 07-01-2012
1384 29085 SG $38.69 $38.69 07-01-2012
1385 29086 SG $33.21 $33.21 07-01-2012
1386 29105 SG $37.77 $37.77 07-01-2012
1387 29200 SG $21.49 $21.49 07-01-2012
1388 29305 SG $81.09 $81.09 07-01-2012
1389 29325 SG $81.09 $81.09 07-01-2012
1390 29345 SG $56.01 $56.01 07-01-2012
1391 29355 SG $54.05 $54.05 07-01-2012
1392 29358 SG $66.42 $66.42 07-01-2012
1393 29365 SG $52.74 $52.74 07-01-2012
1394 29405 SG $39.41 $39.41 07-01-2012
1395 29425 SG $40.05 $40.05 07-01-2012
1396 29435 SG $50.14 $50.14 07-01-2012
1397 29440 SG $21.81 $21.81 07-01-2012
1398 29445 SG $54.70 $54.70 07-01-2012
1399 29450 SG $38.69 $38.69 07-01-2012
1400 29505 SG $36.79 $36.79 07-01-2012
1401 29515 SG $29.63 $29.63 07-01-2012
1402 29540 SG $15.63 $15.63 07-01-2012
1403 29580 SG $22.14 $22.14 07-01-2012
1404 29581 SG $36.20 $36.20 07-01-2012
1405 29582 SG $24.26 $24.26 01-01-2013
1406 29583 SG $24.26 $24.26 01-01-2013
DMA Provider Reimbursement/ Updated 03/2018 19 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1407 29584 SG $24.26 $24.26 01-01-2013
1408 29700 SG $29.96 $29.96 07-01-2012
1409 29705 SG $25.73 $25.73 07-01-2012
1410 29710 SG $46.56 $46.56 07-01-2012
1411 29720 SG $37.77 $37.77 07-01-2012
1412 29730 SG $25.08 $25.08 07-01-2012
1413 29740 SG $35.49 $35.49 07-01-2012
1414 29750 SG $34.52 $34.52 07-01-2012
1415 29800 SG $581.64 $581.64 07-01-2012
1416 29804 SG $581.64 $581.64 07-01-2012
1417 29805 SG $581.64 $581.64 07-01-2012
1418 29806 SG $731.42 $731.42 07-01-2012
1419 29807 SG $731.42 $731.42 07-01-2012
1420 29819 SG $731.42 $731.42 07-01-2012
1421 29820 SG $731.42 $731.42 07-01-2012
1422 29821 SG $731.42 $731.42 07-01-2012
1423 29822 SG $581.64 $581.64 07-01-2012
1424 29823 SG $731.42 $731.42 07-01-2012
1425 29824 SG $714.36 $714.36 07-01-2012
1426 29825 SG $731.42 $731.42 07-01-2012
1427 29827 SG $864.13 $864.13 07-01-2012
1428 29828 SG $1,889.62 $1,889.62 07-01-2013
1429 29830 SG $581.64 $581.64 07-01-2012
1430 29834 SG $581.64 $581.64 07-01-2012
1431 29835 SG $581.64 $581.64 07-01-2012
1432 29836 SG $581.64 $581.64 07-01-2012
1433 29837 SG $581.64 $581.64 07-01-2012
1434 29838 SG $581.64 $581.64 07-01-2012
1435 29840 SG $581.64 $581.64 07-01-2012
1436 29843 SG $581.64 $581.64 07-01-2012
1437 29844 SG $581.64 $581.64 07-01-2012
1438 29845 SG $581.64 $581.64 07-01-2012
1439 29846 SG $581.64 $581.64 07-01-2012
1440 29847 SG $731.42 $731.42 07-01-2012
1441 29848 SG $1,113.16 $1,113.16 07-01-2012
1442 29850 SG $658.58 $658.58 07-01-2012
1443 29851 SG $808.35 $808.35 07-01-2012
1444 29855 SG $808.35 $808.35 07-01-2012
1445 29856 SG $808.35 $808.35 07-01-2012
1446 29860 SG $808.35 $808.35 07-01-2012
1447 29861 SG $808.35 $808.35 07-01-2012
1448 29862 SG $1,262.94 $1,262.94 07-01-2012
1449 29863 SG $808.35 $808.35 07-01-2012
1450 29866 SG $804.54 $804.54 07-01-2012
1451 29870 SG $581.64 $581.64 07-01-2012
1452 29871 SG $581.64 $581.64 07-01-2012
1453 29873 SG $581.64 $581.64 07-01-2012
1454 29874 SG $581.64 $581.64 07-01-2012
1455 29875 SG $658.58 $658.58 07-01-2012
1456 29876 SG $658.58 $658.58 07-01-2012
1457 29877 SG $658.58 $658.58 07-01-2012
1458 29879 SG $581.64 $581.64 07-01-2012
1459 29880 SG $658.58 $658.58 07-01-2012
1460 29881 SG $658.58 $658.58 07-01-2012
1461 29882 SG $581.64 $581.64 07-01-2012
1462 29883 SG $581.64 $581.64 07-01-2012
1463 29884 SG $581.64 $581.64 07-01-2012
1464 29885 SG $731.42 $731.42 07-01-2012
1465 29886 SG $581.64 $581.64 07-01-2012
1466 29887 SG $581.64 $581.64 07-01-2012
1467 29888 SG $731.42 $731.42 07-01-2012
1468 29889 SG $731.42 $731.42 07-01-2012
1469 29891 SG $731.42 $731.42 07-01-2012
1470 29892 SG $731.42 $731.42 07-01-2012
1471 29893 SG $989.31 $989.31 07-01-2012
1472 29894 SG $581.64 $581.64 07-01-2012
1473 29895 SG $581.64 $581.64 07-01-2012
1474 29897 SG $581.64 $581.64 07-01-2012
1475 29898 SG $581.64 $581.64 07-01-2012
1476 29899 SG $731.42 $731.42 07-01-2012
1477 29900 SG $581.64 $581.64 07-01-2012
1478 29901 SG $581.64 $581.64 07-01-2012
1479 29902 SG $581.64 $581.64 07-01-2012
1480 29914 SG $1,745.39 $1,745.39 01-01-2013
DMA Provider Reimbursement/ Updated 03/2018 20 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1481 29915 SG $1,745.39 $1,745.39 01-01-2013
1482 29916 SG $1,745.39 $1,745.39 07-01-2012
1483 30000 SG $88.48 $88.48 07-01-2012
1484 30020 SG $88.49 $88.49 07-01-2012
1485 30100 SG $74.24 $74.24 07-01-2012
1486 30110 SG $116.24 $116.24 07-01-2012
1487 30115 SG $430.44 $430.44 07-01-2012
1488 30117 SG $471.48 $471.48 07-01-2012
1489 30118 SG $539.14 $539.14 07-01-2012
1490 30120 SG $357.98 $357.98 07-01-2012
1491 30124 SG $263.59 $263.59 07-01-2012
1492 30125 SG $638.79 $638.79 07-01-2012
1493 30130 SG $471.48 $471.48 07-01-2012
1494 30140 SG $498.10 $498.10 07-01-2012
1495 30150 SG $679.84 $679.84 07-01-2012
1496 30160 SG $756.78 $756.78 07-01-2012
1497 30200 SG $59.26 $59.26 07-01-2012
1498 30210 SG $75.22 $75.22 07-01-2012
1499 30220 SG $363.49 $363.49 07-01-2012
1500 30310 SG $357.98 $357.98 07-01-2012
1501 30320 SG $430.44 $430.44 07-01-2012
1502 30400 SG $756.78 $756.78 07-01-2012
1503 30410 SG $812.55 $812.55 07-01-2012
1504 30420 SG $812.55 $812.55 07-01-2012
1505 30430 SG $539.14 $539.14 07-01-2012
1506 30435 SG $812.55 $812.55 07-01-2012
1507 30450 SG $990.80 $990.80 07-01-2012
1508 30460 SG $990.80 $990.80 07-01-2012
1509 30462 SG $1,211.36 $1,211.36 07-01-2012
1510 30465 SG $1,211.36 $1,211.36 07-01-2012
1511 30520 SG $616.08 $616.08 07-01-2012
1512 30540 SG $812.55 $812.55 07-01-2012
1513 30545 SG $812.56 $812.56 07-01-2012
1514 30560 SG $118.76 $118.76 07-01-2012
1515 30580 SG $756.78 $756.78 07-01-2012
1516 30600 SG $756.78 $756.78 07-01-2012
1517 30620 SG $990.80 $990.80 07-01-2012
1518 30630 SG $850.10 $850.10 07-01-2012
1519 30801 SG $279.40 $279.40 07-01-2012
1520 30802 SG $279.40 $279.40 07-01-2012
1521 30903 SG $56.43 $56.43 07-01-2012
1522 30905 SG $56.43 $56.43 07-01-2012
1523 30906 SG $56.43 $56.43 07-01-2012
1524 30915 SG $514.61 $514.61 07-01-2012
1525 30920 SG $555.64 $555.64 07-01-2012
1526 30930 SG $548.42 $548.42 07-01-2012
1527 31000 SG $88.48 $88.48 07-01-2012
1528 31002 SG $263.58 $263.58 07-01-2012
1529 31020 SG $498.10 $498.10 07-01-2012
1530 31030 SG $679.84 $679.84 07-01-2012
1531 31032 SG $756.78 $756.78 07-01-2012
1532 31040 SG $848.59 $848.59 07-01-2012
1533 31050 SG $638.79 $638.79 07-01-2012
1534 31051 SG $756.78 $756.78 07-01-2012
1535 31070 SG $498.10 $498.10 07-01-2012
1536 31075 SG $756.78 $756.78 07-01-2012
1537 31080 SG $756.78 $756.78 07-01-2012
1538 31081 SG $756.78 $756.78 07-01-2012
1539 31084 SG $756.78 $756.78 07-01-2012
1540 31085 SG $756.78 $756.78 07-01-2012
1541 31086 SG $756.78 $756.78 07-01-2012
1542 31087 SG $756.78 $756.78 07-01-2012
1543 31090 SG $812.55 $812.55 07-01-2012
1544 31200 SG $638.79 $638.79 07-01-2012
1545 31201 SG $812.55 $812.55 07-01-2012
1546 31205 SG $679.84 $679.84 07-01-2012
1547 31231 SG $57.04 $57.04 07-01-2012
1548 31233 SG $69.65 $69.65 07-01-2012
1549 31235 SG $364.06 $364.06 07-01-2012
1550 31237 SG $436.52 $436.52 07-01-2012
1551 31238 SG $364.06 $364.06 07-01-2012
1552 31239 SG $604.95 $604.95 07-01-2012
1553 31240 SG $436.52 $436.52 07-01-2012
1554 31253 SG $1,494.62 $1,494.62 01-01-2018
DMA Provider Reimbursement/ Updated 03/2018 21 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1555 31254 SG $528.01 $528.01 07-01-2012
1556 31255 SG $660.74 $660.74 07-01-2012
1557 31256 SG $528.01 $528.01 07-01-2012
1558 31257 SG $1,494.62 $1,494.62 01-01-2018
1559 31259 SG $1,494.62 $1,494.62 01-01-2018
1560 31267 SG $528.01 $528.01 07-01-2012
1561 31276 SG $528.01 $528.01 07-01-2012
1562 31287 SG $528.01 $528.01 07-01-2012
1563 31288 SG $528.01 $528.01 07-01-2012
1564 31295 SG $1,494.62 $1,494.62 02-01-2018
1565 31296 SG $1,494.62 $1,494.62 02-01-2018
1566 31297 SG $1,494.62 $1,494.62 02-01-2018
1567 31298 SG $1,494.62 $1,494.62 01-01-2018
1568 31300 SG $671.86 $671.86 07-01-2012
1569 31320 SG $638.79 $638.79 07-01-2012
1570 31400 SG $638.80 $638.80 07-01-2012
1571 31420 SG $638.80 $638.80 07-01-2012
1572 31500 SG $87.03 $87.03 07-01-2012
1573 31502 SG $47.29 $47.29 07-01-2012
1574 31505 SG $29.11 $29.11 07-01-2012
1575 31510 SG $436.52 $436.52 07-01-2012
1576 31511 SG $69.65 $69.65 07-01-2012
1577 31512 SG $436.52 $436.52 07-01-2012
1578 31513 SG $69.65 $69.65 07-01-2012
1579 31515 SG $364.06 $364.06 07-01-2012
1580 31520 SG $57.04 $57.04 07-01-2012
1581 31525 SG $364.06 $364.06 07-01-2012
1582 31526 SG $486.98 $486.98 07-01-2012
1583 31527 SG $414.53 $414.53 07-01-2012
1584 31528 SG $436.52 $436.52 07-01-2012
1585 31529 SG $436.52 $436.52 07-01-2012
1586 31530 SG $486.98 $486.98 07-01-2012
1587 31531 SG $528.01 $528.01 07-01-2012
1588 31535 SG $486.98 $486.98 07-01-2012
1589 31536 SG $528.01 $528.01 07-01-2012
1590 31540 SG $528.01 $528.01 07-01-2012
1591 31541 SG $604.95 $604.95 07-01-2012
1592 31545 SG $604.95 $604.95 07-01-2012
1593 31546 SG $604.95 $604.95 07-01-2012
1594 31551 SG $1,739.72 $1,739.72 01-01-2017
1595 31552 SG $1,739.72 $1,739.72 01-01-2017
1596 31553 SG $1,739.72 $1,739.72 01-01-2017
1597 31554 SG $1,739.72 $1,739.72 01-01-2017
1598 31560 SG $660.74 $660.74 07-01-2012
1599 31561 SG $660.74 $660.74 07-01-2012
1600 31570 SG $436.52 $436.52 07-01-2012
1601 31571 SG $486.98 $486.98 07-01-2012
1602 31572 SG $1,286.22 $1,286.22 01-01-2017
1603 31573 SG $655.03 $655.03 01-01-2017
1604 31574 SG $655.03 $655.03 01-01-2017
1605 31575 SG $57.04 $57.04 07-01-2012
1606 31576 SG $486.98 $486.98 07-01-2012
1607 31577 SG $186.93 $186.93 07-01-2012
1608 31578 SG $486.98 $486.98 07-01-2012
1609 31579 SG $108.10 $108.10 07-01-2012
1610 31580 SG $812.55 $812.55 07-01-2012
1611 31590 SG $812.55 $812.55 07-01-2012
1612 31591 SG $1,739.72 $1,739.72 01-01-2017
1613 31592 SG $1,739.72 $1,739.72 01-01-2017
1614 31595 SG $638.79 $638.79 07-01-2012
1615 31603 SG $279.40 $279.40 07-01-2012
1616 31605 SG $263.58 $263.58 07-01-2012
1617 31611 SG $539.14 $539.14 07-01-2012
1618 31612 SG $425.65 $425.65 07-01-2012
1619 31613 SG $498.10 $498.10 07-01-2012
1620 31614 SG $638.79 $638.79 07-01-2012
1621 31615 SG $301.61 $301.61 07-01-2012
1622 31622 SG $301.61 $301.61 07-01-2012
1623 31623 SG $374.07 $374.07 07-01-2012
1624 31624 SG $374.07 $374.07 07-01-2012
1625 31625 SG $374.07 $374.07 07-01-2012
1626 31628 SG $374.07 $374.07 07-01-2012
1627 31629 SG $374.07 $374.07 07-01-2012
1628 31630 SG $498.89 $498.89 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 22 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1629 31631 SG $498.89 $498.89 07-01-2012
1630 31635 SG $374.07 $374.07 07-01-2012
1631 31636 SG $498.89 $498.89 07-01-2012
1632 31638 SG $498.89 $498.89 07-01-2012
1633 31640 SG $498.89 $498.89 07-01-2012
1634 31641 SG $498.89 $498.89 07-01-2012
1635 31643 SG $374.07 $374.07 07-01-2012
1636 31645 SG $301.61 $301.61 07-01-2012
1637 31646 SG $301.61 $301.61 07-01-2012
1638 31652 SG $1,058.17 $1,058.17 01-01-2016
1639 31653 SG $1,058.17 $1,058.17 01-01-2016
1640 31717 SG $186.93 $186.93 07-01-2012
1641 31730 SG $186.93 $186.93 07-01-2012
1642 31750 SG $812.55 $812.55 07-01-2012
1643 31755 SG $638.79 $638.79 07-01-2012
1644 31820 SG $357.98 $357.98 07-01-2012
1645 31825 SG $498.10 $498.10 07-01-2012
1646 31830 SG $498.10 $498.10 07-01-2012
1647 32400 SG $296.11 $296.11 07-01-2012
1648 32405 SG $296.11 $296.11 07-01-2012
1649 32552 SG $48.59 $48.59 07-01-2012
1650 32554 SG $185.50 $185.50 01-01-2013
1651 32555 SG $185.50 $185.50 01-01-2013
1652 32556 SG $185.50 $185.50 01-01-2013
1653 32557 SG $185.50 $185.50 01-01-2013
1654 32960 SG $184.12 $184.12 07-01-2012
1655 33010 SG $188.87 $188.87 07-01-2012
1656 33011 SG $188.87 $188.87 07-01-2012
1657 33206 SG $5,997.78 $5,997.78 07-01-2012
1658 33207 SG $5,997.78 $5,997.78 07-01-2012
1659 33208 SG $6,947.50 $6,947.50 07-01-2012
1660 33210 SG $3,205.85 $3,205.85 07-01-2012
1661 33211 SG $3,205.85 $3,205.85 07-01-2012
1662 33212 SG $4,714.35 $4,714.35 07-01-2012
1663 33213 SG $5,137.88 $5,137.88 07-01-2012
1664 33214 SG $6,947.50 $6,947.50 07-01-2012
1665 33215 SG $848.73 $848.73 07-01-2012
1666 33216 SG $3,205.85 $3,205.85 07-01-2012
1667 33217 SG $3,205.85 $3,205.85 07-01-2012
1668 33218 SG $848.73 $848.73 07-01-2012
1669 33220 SG $848.73 $848.73 07-01-2012
1670 33221 SG $5,478.14 $5,478.14 01-01-2013
1671 33222 SG $419.09 $419.09 07-01-2012
1672 33223 SG $419.09 $419.09 07-01-2012
1673 33224 SG $13,278.20 $13,278.20 07-01-2012
1674 33226 SG $848.73 $848.73 07-01-2012
1675 33227 SG $4,627.44 $4,627.44 01-01-2013
1676 33228 SG $5,478.14 $5,478.14 01-01-2013
1677 33229 SG $5,478.14 $5,478.14 01-01-2013
1678 33230 SG $16,787.11 $16,787.11 01-01-2013
1679 33231 SG $16,787.11 $16,787.11 01-01-2013
1680 33233 SG $498.13 $498.13 07-01-2012
1681 33234 SG $848.73 $848.73 07-01-2012
1682 33235 SG $848.73 $848.73 07-01-2012
1683 33241 SG $848.73 $848.73 07-01-2012
1684 33262 SG $16,787.11 $16,787.11 01-01-2013
1685 33263 SG $16,787.11 $16,787.11 01-01-2013
1686 33264 SG $16,787.11 $16,787.11 01-01-2013
1687 33270 SG $23,197.82 $23,197.82 01-01-2015
1688 33271 SG $4,817.58 $4,817.58 01-01-2015
1689 33273 SG $1,096.45 $1,096.45 01-01-2015
1690 33282 SG $3,483.32 $3,483.32 07-01-2012
1691 33284 SG $307.39 $307.39 07-01-2012
1692 33285 SG $5,399.93 $5,399.93 01-01-2019
1693 35188 SG $746.96 $746.96 07-01-2012
1694 35207 SG $746.96 $746.96 07-01-2012
1695 35761 SG $1,051.04 $1,051.04 07-01-2012
1696 35875 SG $1,201.53 $1,201.53 07-01-2012
1697 35876 SG $1,201.53 $1,201.53 07-01-2012
1698 36002 SG $84.20 $84.20 07-01-2012
1699 36260 SG $582.48 $582.48 07-01-2012
1700 36261 SG $498.13 $498.13 07-01-2012
1701 36262 SG $425.68 $425.68 07-01-2012
1702 36430 SG $31.58 $31.58 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 23 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1703 36440 SG $120.23 $120.23 07-01-2012
1704 36450 SG $120.23 $120.23 07-01-2012
1705 36465 SG $690.68 $690.68 01-01-2018
1706 36466 SG $690.68 $690.68 01-01-2018
1707 36470 SG $28.07 $28.07 07-01-2012
1708 36471 SG $28.07 $28.07 07-01-2012
1709 36473 SG $1,088.73 $1,088.73 01-01-2017
1710 36475 SG $1,235.55 $1,235.55 07-01-2012
1711 36478 SG $1,087.15 $1,087.15 07-01-2012
1712 36511 SG $407.22 $407.22 07-01-2012
1713 36512 SG $407.22 $407.22 07-01-2012
1714 36513 SG $407.22 $407.22 07-01-2012
1715 36514 SG $407.22 $407.22 07-01-2012
1716 36515 SG $1,083.15 $1,083.15 07-01-2012
1717 36516 SG $1,083.15 $1,083.15 07-01-2012
1718 36522 SG $1,083.15 $1,083.15 07-01-2012
1719 36555 SG $310.03 $310.03 07-01-2012
1720 36556 SG $310.03 $310.03 07-01-2012
1721 36557 SG $499.26 $499.26 07-01-2012
1722 36558 SG $499.26 $499.26 07-01-2012
1723 36560 SG $582.48 $582.48 07-01-2012
1724 36561 SG $582.48 $582.48 07-01-2012
1725 36563 SG $582.48 $582.48 07-01-2012
1726 36565 SG $582.48 $582.48 07-01-2012
1727 36566 SG $3,245.33 $3,245.33 07-01-2012
1728 36568 SG $310.03 $310.03 07-01-2012
1729 36569 SG $310.03 $310.03 07-01-2012
1730 36570 SG $540.29 $540.29 07-01-2012
1731 36571 SG $540.29 $540.29 07-01-2012
1732 36572 SG $270.54 $270.54 01-01-2019
1733 36573 SG $477.21 $477.21 01-01-2019
1734 36575 SG $336.06 $336.06 07-01-2012
1735 36576 SG $382.48 $382.48 07-01-2012
1736 36578 SG $499.26 $499.26 07-01-2012
1737 36580 SG $310.03 $310.03 07-01-2012
1738 36581 SG $499.26 $499.26 07-01-2012
1739 36582 SG $582.48 $582.48 07-01-2012
1740 36583 SG $582.48 $582.48 07-01-2012
1741 36584 SG $310.03 $310.03 07-01-2012
1742 36585 SG $540.29 $540.29 07-01-2012
1743 36589 SG $263.61 $263.61 07-01-2012
1744 36590 SG $310.03 $310.03 07-01-2012
1745 36595 SG $853.22 $853.22 07-01-2012
1746 36596 SG $386.11 $386.11 07-01-2012
1747 36597 SG $386.11 $386.11 07-01-2012
1748 36598 SG $79.12 $79.12 07-01-2012
1749 36640 SG $469.00 $469.00 07-01-2012
1750 36800 SG $589.75 $589.75 07-01-2012
1751 36810 SG $589.75 $589.75 07-01-2012
1752 36815 SG $589.75 $589.75 07-01-2012
1753 36818 SG $670.02 $670.02 07-01-2012
1754 36819 SG $670.02 $670.02 07-01-2012
1755 36820 SG $670.01 $670.01 07-01-2012
1756 36821 SG $670.01 $670.01 07-01-2012
1757 36825 SG $746.95 $746.95 07-01-2012
1758 36830 SG $746.95 $746.95 07-01-2012
1759 36831 SG $1,201.53 $1,201.53 07-01-2012
1760 36832 SG $746.95 $746.95 07-01-2012
1761 36833 SG $746.95 $746.95 07-01-2012
1762 36835 SG $666.69 $666.69 07-01-2012
1763 36860 SG $103.64 $103.64 07-01-2012
1764 36861 SG $589.75 $589.75 07-01-2012
1765 36901 SG $315.52 $315.52 01-01-2017
1766 36902 SG $2,544.84 $2,544.84 01-01-2017
1767 36903 SG $4,822.09 $4,822.09 01-01-2017
1768 36904 SG $2,544.84 $2,544.84 01-01-2017
1769 36905 SG $4,822.09 $4,822.09 01-01-2017
1770 36906 SG $7,549.32 $7,549.32 01-01-2017
1771 37184 SG $1,372.08 $1,372.08 07-01-2012
1772 37187 SG $1,372.08 $1,372.08 07-01-2012
1773 37188 SG $1,372.08 $1,372.08 07-01-2012
1774 37197 SG $1,002.20 $1,002.20 01-01-2013
1775 37200 SG $1,021.94 $1,021.94 07-01-2012
1776 37211 SG $353.59 $353.59 01-01-2013
DMA Provider Reimbursement/ Updated 03/2018 24 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1777 37212 SG $353.59 $353.59 01-01-2013
1778 37220 SG $1,809.64 $1,809.64 01-01-2013
1779 37221 SG $3,894.00 $3,894.00 01-01-2013
1780 37236 SG $4,331.34 $4,331.34 01-01-2014
1781 37238 SG $4,331.34 $4,331.34 01-01-2014
1782 37246 SG $2,544.84 $2,544.84 01-01-2017
1783 37248 SG $2,544.84 $2,544.84 01-01-2017
1784 37500 SG $704.03 $704.03 07-01-2012
1785 37607 SG $555.64 $555.64 07-01-2012
1786 37609 SG $428.42 $428.42 07-01-2012
1787 37650 SG $514.61 $514.61 07-01-2012
1788 37700 SG $514.60 $514.60 07-01-2012
1789 37718 SG $555.64 $555.64 07-01-2012
1790 37722 SG $704.03 $704.03 07-01-2012
1791 37735 SG $704.03 $704.03 07-01-2012
1792 37760 SG $555.64 $555.64 07-01-2012
1793 37761 SG $912.91 $912.91 07-01-2012
1794 37765 SG $914.59 $914.59 07-01-2012
1795 37766 SG $914.59 $914.59 07-01-2012
1796 37780 SG $555.64 $555.64 07-01-2012
1797 37785 SG $555.64 $555.64 07-01-2012
1798 38206 SG $407.22 $407.22 07-01-2012
1799 38220 SG $104.19 $104.19 07-01-2012
1800 38221 SG $109.40 $109.40 07-01-2012
1801 38222 SG $100.42 $100.42 01-01-2018
1802 38230 SG $1,083.15 $1,083.15 07-01-2012
1803 38232 SG $1,299.40 $1,299.40 01-01-2013
1804 38241 SG $1,083.15 $1,083.15 07-01-2012
1805 38242 SG $407.22 $407.22 07-01-2012
1806 38243 SG $427.62 $427.62 01-01-2013
1807 38300 SG $315.79 $315.79 07-01-2012
1808 38305 SG $448.06 $448.06 07-01-2012
1809 38308 SG $489.11 $489.11 07-01-2012
1810 38500 SG $489.11 $489.11 07-01-2012
1811 38505 SG $216.83 $216.83 07-01-2012
1812 38510 SG $489.11 $489.11 07-01-2012
1813 38520 SG $489.11 $489.11 07-01-2012
1814 38525 SG $489.11 $489.11 07-01-2012
1815 38530 SG $489.11 $489.11 07-01-2012
1816 38542 SG $678.15 $678.15 07-01-2012
1817 38550 SG $530.14 $530.14 07-01-2012
1818 38555 SG $607.07 $607.07 07-01-2012
1819 38570 SG $1,261.40 $1,261.40 07-01-2012
1820 38571 SG $1,474.92 $1,474.92 07-01-2012
1821 38572 SG $1,261.40 $1,261.40 07-01-2012
1822 38573 SG $2,847.43 $2,847.43 01-01-2018
1823 38700 SG $812.56 $812.56 07-01-2012
1824 38740 SG $678.15 $678.15 07-01-2012
1825 38745 SG $796.12 $796.12 07-01-2012
1826 38760 SG $489.11 $489.11 07-01-2012
1827 40500 SG $430.44 $430.44 07-01-2012
1828 40510 SG $498.10 $498.10 07-01-2012
1829 40520 SG $430.44 $430.44 07-01-2012
1830 40525 SG $498.10 $498.10 07-01-2012
1831 40527 SG $498.10 $498.10 07-01-2012
1832 40530 SG $498.10 $498.10 07-01-2012
1833 40650 SG $363.49 $363.49 07-01-2012
1834 40652 SG $363.49 $363.49 07-01-2012
1835 40654 SG $363.49 $363.49 07-01-2012
1836 40700 SG $990.80 $990.80 07-01-2012
1837 40701 SG $990.80 $990.80 07-01-2012
1838 40702 SG $1,411.38 $1,411.38 07-01-2012
1839 40720 SG $990.80 $990.80 07-01-2012
1840 40761 SG $679.84 $679.84 07-01-2012
1841 40800 SG $49.78 $49.78 07-01-2012
1842 40801 SG $351.85 $351.85 07-01-2012
1843 40805 SG $156.61 $156.61 07-01-2012
1844 40806 SG $69.35 $69.35 07-01-2012 X 40806 7/31/2018
1845 40808 SG $88.48 $88.48 07-01-2012
1846 40810 SG $107.12 $107.12 07-01-2012
1847 40812 SG $134.48 $134.48 07-01-2012
1848 40814 SG $430.44 $430.44 07-01-2012
1849 40816 SG $498.10 $498.10 07-01-2012
1850 40818 SG $118.76 $118.76 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 25 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1851 40819 SG $279.40 $279.40 07-01-2012 X 40819 7/31/2018
1852 40820 SG $150.43 $150.43 07-01-2012
1853 40830 SG $88.48 $88.48 07-01-2012
1854 40831 SG $279.40 $279.40 07-01-2012
1855 40840 SG $498.10 $498.10 07-01-2012
1856 40842 SG $539.14 $539.14 07-01-2012
1857 40843 SG $539.14 $539.14 07-01-2012
1858 40844 SG $812.55 $812.55 07-01-2012
1859 40845 SG $812.55 $812.55 07-01-2012
1860 41000 SG $79.45 $79.45 07-01-2012
1861 41005 SG $118.76 $118.76 07-01-2012
1862 41006 SG $425.65 $425.65 07-01-2012
1863 41007 SG $357.98 $357.98 07-01-2012
1864 41008 SG $357.98 $357.98 07-01-2012
1865 41009 SG $118.76 $118.76 07-01-2012
1866 41010 SG $279.40 $279.40 07-01-2012
1867 41015 SG $118.76 $118.76 07-01-2012
1868 41016 SG $279.40 $279.40 07-01-2012
1869 41017 SG $279.40 $279.40 07-01-2012
1870 41018 SG $279.40 $279.40 07-01-2012
1871 41100 SG $83.03 $83.03 07-01-2012
1872 41105 SG $81.08 $81.08 07-01-2012
1873 41108 SG $74.89 $74.89 07-01-2012
1874 41110 SG $108.10 $108.10 07-01-2012
1875 41112 SG $430.44 $430.44 07-01-2012
1876 41113 SG $430.44 $430.44 07-01-2012
1877 41114 SG $498.10 $498.10 07-01-2012
1878 41115 SG $121.77 $121.77 07-01-2012
1879 41116 SG $357.98 $357.98 07-01-2012
1880 41120 SG $671.86 $671.86 07-01-2012
1881 41251 SG $118.76 $118.76 07-01-2012
1882 41252 SG $351.85 $351.85 07-01-2012
1883 41500 SG $425.65 $425.65 07-01-2012
1884 41510 SG $357.98 $357.98 07-01-2012
1885 41520 SG $351.85 $351.85 07-01-2012
1886 41805 SG $119.18 $119.18 07-01-2012
1887 41806 SG $153.35 $153.35 07-01-2012
1888 41820 SG $263.58 $263.58 07-01-2012
1889 41821 SG $263.58 $263.58 07-01-2012
1890 41822 SG $141.64 $141.64 07-01-2012
1891 41823 SG $195.69 $195.69 07-01-2012
1892 41825 SG $110.04 $110.04 07-01-2012
1893 41826 SG $122.43 $122.43 07-01-2012
1894 41827 SG $498.10 $498.10 07-01-2012
1895 41830 SG $178.11 $178.11 07-01-2012
1896 41850 SG $577.93 $577.93 07-01-2012
1897 41870 SG $848.59 $848.59 07-01-2012
1898 41872 SG $180.06 $180.06 07-01-2012
1899 41874 SG $170.94 $170.94 07-01-2012
1900 42000 SG $118.76 $118.76 07-01-2012
1901 42100 SG $70.98 $70.98 07-01-2012
1902 42104 SG $99.64 $99.64 07-01-2012
1903 42106 SG $125.03 $125.03 07-01-2012
1904 42107 SG $498.10 $498.10 07-01-2012
1905 42120 SG $756.78 $756.78 07-01-2012
1906 42140 SG $351.85 $351.85 07-01-2012
1907 42145 SG $671.86 $671.86 07-01-2012
1908 42160 SG $130.57 $130.57 07-01-2012
1909 42180 SG $118.76 $118.76 07-01-2012
1910 42182 SG $638.79 $638.79 07-01-2012
1911 42200 SG $812.55 $812.55 07-01-2012
1912 42205 SG $812.55 $812.55 07-01-2012
1913 42210 SG $812.55 $812.55 07-01-2012
1914 42215 SG $990.80 $990.80 07-01-2012
1915 42220 SG $812.55 $812.55 07-01-2012
1916 42225 SG $757.10 $757.10 07-01-2012
1917 42226 SG $812.56 $812.56 07-01-2012
1918 42235 SG $604.19 $604.19 07-01-2012
1919 42260 SG $616.08 $616.08 07-01-2012
1920 42281 SG $577.93 $577.93 07-01-2012 X 42281 7/31/2018
1921 42300 SG $357.98 $357.98 07-01-2012
1922 42305 SG $430.44 $430.44 07-01-2012
1923 42310 SG $118.76 $118.76 07-01-2012
1924 42320 SG $118.76 $118.76 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 26 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1925 42335 SG $173.86 $173.86 07-01-2012
1926 42340 SG $430.44 $430.44 07-01-2012
1927 42400 SG $59.26 $59.26 07-01-2012
1928 42405 SG $430.44 $430.44 07-01-2012
1929 42408 SG $471.48 $471.48 07-01-2012
1930 42409 SG $471.48 $471.48 07-01-2012
1931 42410 SG $679.84 $679.84 07-01-2012
1932 42415 SG $990.80 $990.80 07-01-2012
1933 42420 SG $990.80 $990.80 07-01-2012
1934 42425 SG $990.80 $990.80 07-01-2012
1935 42440 SG $679.84 $679.84 07-01-2012
1936 42450 SG $498.10 $498.10 07-01-2012
1937 42500 SG $539.14 $539.14 07-01-2012
1938 42505 SG $756.78 $756.78 07-01-2012
1939 42507 SG $679.84 $679.84 07-01-2012
1940 42509 SG $756.78 $756.78 07-01-2012
1941 42510 SG $756.78 $756.78 07-01-2012
1942 42600 SG $357.98 $357.98 07-01-2012
1943 42650 SG $38.74 $38.74 07-01-2012
1944 42660 SG $45.58 $45.58 07-01-2012
1945 42665 SG $850.10 $850.10 07-01-2012
1946 42700 SG $118.76 $118.76 07-01-2012
1947 42720 SG $357.98 $357.98 07-01-2012
1948 42725 SG $638.79 $638.79 07-01-2012
1949 42800 SG $75.86 $75.86 07-01-2012
1950 42804 SG $357.98 $357.98 07-01-2012
1951 42806 SG $498.10 $498.10 07-01-2012
1952 42808 SG $430.44 $430.44 07-01-2012
1953 42810 SG $539.14 $539.14 07-01-2012
1954 42815 SG $812.55 $812.55 07-01-2012
1955 42820 SG $523.91 $523.91 07-01-2012
1956 42821 SG $656.63 $656.63 07-01-2012
1957 42825 SG $600.85 $600.85 07-01-2012
1958 42826 SG $600.85 $600.85 07-01-2012
1959 42830 SG $600.85 $600.85 07-01-2012
1960 42831 SG $600.85 $600.85 07-01-2012
1961 42835 SG $600.85 $600.85 07-01-2012
1962 42836 SG $600.85 $600.85 07-01-2012
1963 42860 SG $523.91 $523.91 07-01-2012
1964 42870 SG $523.91 $523.91 07-01-2012
1965 42890 SG $990.80 $990.80 07-01-2012
1966 42892 SG $990.80 $990.80 07-01-2012
1967 42900 SG $279.40 $279.40 07-01-2012
1968 42950 SG $498.10 $498.10 07-01-2012
1969 42955 SG $498.10 $498.10 07-01-2012
1970 42960 SG $56.43 $56.43 07-01-2012
1971 42962 SG $638.79 $638.79 07-01-2012
1972 42970 SG $39.82 $39.82 07-01-2012
1973 42972 SG $471.48 $471.48 07-01-2012
1974 43030 SG $577.93 $577.93 07-01-2012
1975 43180 SG $909.11 $909.11 01-01-2015
1976 43191 SG $318.43 $318.43 01-01-2014
1977 43192 SG $481.15 $481.15 01-01-2014
1978 43193 SG $481.15 $481.15 01-01-2014
1979 43194 SG $481.15 $481.15 01-01-2014
1980 43195 SG $481.15 $481.15 01-01-2014
1981 43196 SG $481.15 $481.15 01-01-2014
1982 43197 SG $318.43 $318.43 01-01-2014
1983 43198 SG $318.43 $318.43 01-01-2014
1984 43200 SG $288.74 $288.74 07-01-2012
1985 43201 SG $288.74 $288.74 07-01-2012
1986 43202 SG $288.74 $288.74 07-01-2012
1987 43204 SG $288.74 $288.74 07-01-2012
1988 43205 SG $288.74 $288.74 07-01-2012
1989 43210 SG $1,595.99 $1,595.99 01-01-2016
1990 43211 SG $318.43 $318.43 01-01-2014
1991 43212 SG $1,126.28 $1,126.28 01-01-2014
1992 43213 SG $481.15 $481.15 01-01-2014
1993 43214 SG $481.15 $481.15 01-01-2014
1994 43215 SG $288.74 $288.74 07-01-2012
1995 43216 SG $288.74 $288.74 07-01-2012
1996 43217 SG $288.74 $288.74 07-01-2012
1997 43220 SG $288.74 $288.74 07-01-2012
1998 43226 SG $288.74 $288.74 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 27 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
1999 43227 SG $361.19 $361.19 07-01-2012
2000 43229 SG $935.04 $935.04 01-01-2014
2001 43231 SG $361.20 $361.20 07-01-2012
2002 43232 SG $361.20 $361.20 07-01-2012
2003 43233 SG $481.15 $481.15 01-01-2014
2004 43235 SG $288.74 $288.74 07-01-2012
2005 43236 SG $361.19 $361.19 07-01-2012
2006 43237 SG $361.19 $361.19 07-01-2012
2007 43238 SG $361.19 $361.19 07-01-2012
2008 43239 SG $361.19 $361.19 07-01-2012
2009 43240 SG $361.20 $361.20 07-01-2012
2010 43241 SG $361.19 $361.19 07-01-2012
2011 43242 SG $361.20 $361.20 07-01-2012
2012 43243 SG $361.19 $361.19 07-01-2012
2013 43244 SG $361.19 $361.19 07-01-2012
2014 43245 SG $361.19 $361.19 07-01-2012
2015 43246 SG $361.19 $361.19 07-01-2012
2016 43247 SG $361.19 $361.19 07-01-2012
2017 43248 SG $361.19 $361.19 07-01-2012
2018 43249 SG $361.19 $361.19 07-01-2012
2019 43250 SG $361.19 $361.19 07-01-2012
2020 43251 SG $361.19 $361.19 07-01-2012
2021 43253 SG $481.15 $481.15 01-01-2014
2022 43254 SG $318.43 $318.43 01-01-2014
2023 43255 SG $361.19 $361.19 07-01-2012
2024 43259 SG $402.23 $402.23 07-01-2012
2025 43260 SG $471.33 $471.33 07-01-2012
2026 43261 SG $471.33 $471.33 07-01-2012
2027 43262 SG $471.33 $471.33 07-01-2012
2028 43263 SG $471.33 $471.33 07-01-2012
2029 43264 SG $471.33 $471.33 07-01-2012
2030 43265 SG $471.33 $471.33 07-01-2012
2031 43266 SG $1,126.28 $1,126.28 01-01-2014
2032 43270 SG $481.15 $481.15 01-01-2014
2033 43274 SG $918.39 $918.39 01-01-2014
2034 43275 SG $918.39 $918.39 01-01-2014
2035 43276 SG $918.39 $918.39 01-01-2014
2036 43277 SG $918.39 $918.39 01-01-2014
2037 43278 SG $918.39 $918.39 01-01-2014
2038 43450 SG $265.21 $265.21 07-01-2012
2039 43453 SG $265.21 $265.21 07-01-2012
2040 43653 SG $1,261.40 $1,261.40 07-01-2012
2041 43755 SG $29.91 $29.91 07-01-2012
2042 43756 SG $51.40 $51.40 07-01-2012
2043 43757 SG $51.40 $51.40 07-01-2012
2044 43760 SG $121.60 $121.60 07-01-2012
2045 43761 SG $288.75 $288.75 07-01-2012
2046 43762 SG $100.98 $100.98 01-01-2019
2047 43763 SG $100.98 $100.98 01-01-2019
2048 43870 SG $288.74 $288.74 07-01-2012
2049 44100 SG $288.74 $288.74 07-01-2012
2050 44312 SG $392.30 $392.30 07-01-2012
2051 44340 SG $505.79 $505.79 07-01-2012
2052 44360 SG $370.27 $370.27 07-01-2012
2053 44361 SG $370.27 $370.27 07-01-2012
2054 44363 SG $370.27 $370.27 07-01-2012
2055 44364 SG $370.27 $370.27 07-01-2012
2056 44365 SG $370.27 $370.27 07-01-2012
2057 44366 SG $370.27 $370.27 07-01-2012
2058 44369 SG $370.27 $370.27 07-01-2012
2059 44370 SG $1,079.55 $1,079.55 07-01-2012
2060 44372 SG $370.27 $370.27 07-01-2012
2061 44373 SG $370.27 $370.27 07-01-2012
2062 44376 SG $370.27 $370.27 07-01-2012
2063 44377 SG $370.27 $370.27 07-01-2012
2064 44378 SG $370.27 $370.27 07-01-2012
2065 44379 SG $1,079.55 $1,079.55 07-01-2012
2066 44380 SG $297.82 $297.82 07-01-2012
2067 44381 SG $398.18 $398.18 01-01-2015
2068 44382 SG $297.82 $297.82 07-01-2012
2069 44384 SG $398.18 $398.18 01-01-2015
2070 44385 SG $291.80 $291.80 07-01-2012
2071 44386 SG $291.80 $291.80 07-01-2012
2072 44388 SG $291.80 $291.80 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 28 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2073 44389 SG $291.80 $291.80 07-01-2012
2074 44390 SG $291.80 $291.80 07-01-2012
2075 44391 SG $291.80 $291.80 07-01-2012
2076 44392 SG $291.80 $291.80 07-01-2012
2077 44394 SG $291.80 $291.80 07-01-2012
2078 44401 SG $368.96 $368.96 01-01-2015
2079 44402 SG $368.96 $368.96 01-01-2015
2080 44403 SG $368.96 $368.96 01-01-2015
2081 44404 SG $368.96 $368.96 01-01-2015
2082 44405 SG $368.96 $368.96 01-01-2015
2083 44406 SG $368.96 $368.96 01-01-2015
2084 44407 SG $368.96 $368.96 01-01-2015
2085 44408 SG $368.96 $368.96 01-01-2015
2086 45000 SG $296.66 $296.66 07-01-2012
2087 45005 SG $382.52 $382.52 07-01-2012
2088 45020 SG $382.52 $382.52 07-01-2012
2089 45100 SG $414.77 $414.77 07-01-2012
2090 45108 SG $487.22 $487.22 07-01-2012
2091 45150 SG $487.22 $487.22 07-01-2012
2092 45160 SG $487.22 $487.22 07-01-2012
2093 45171 SG $484.91 $484.91 07-01-2012
2094 45172 SG $823.54 $823.54 07-01-2012
2095 45190 SG $1,059.77 $1,059.77 07-01-2012
2096 45300 SG $56.65 $56.65 07-01-2012
2097 45303 SG $308.03 $308.03 07-01-2012
2098 45305 SG $290.51 $290.51 07-01-2012
2099 45307 SG $403.43 $403.43 07-01-2012
2100 45308 SG $290.51 $290.51 07-01-2012
2101 45309 SG $290.51 $290.51 07-01-2012
2102 45315 SG $290.51 $290.51 07-01-2012
2103 45317 SG $290.51 $290.51 07-01-2012
2104 45320 SG $403.43 $403.43 07-01-2012
2105 45321 SG $403.43 $403.43 07-01-2012
2106 45327 SG $434.54 $434.54 07-01-2012
2107 45330 SG $78.15 $78.15 07-01-2012
2108 45331 SG $236.96 $236.96 07-01-2012
2109 45332 SG $236.96 $236.96 07-01-2012
2110 45333 SG $290.51 $290.51 07-01-2012
2111 45334 SG $290.51 $290.51 07-01-2012
2112 45335 SG $236.96 $236.96 07-01-2012
2113 45337 SG $236.96 $236.96 07-01-2012
2114 45338 SG $290.51 $290.51 07-01-2012
2115 45340 SG $290.51 $290.51 07-01-2012
2116 45341 SG $290.51 $290.51 07-01-2012
2117 45342 SG $290.51 $290.51 07-01-2012
2118 45346 SG $386.51 $386.51 01-01-2015
2119 45347 SG $386.51 $386.51 01-01-2015
2120 45349 SG $386.51 $386.51 01-01-2015
2121 45350 SG $386.51 $386.51 01-01-2015
2122 45378 SG $364.26 $364.26 07-01-2012
2123 45379 SG $364.26 $364.26 07-01-2012
2124 45380 SG $364.26 $364.26 07-01-2012
2125 45381 SG $364.26 $364.26 07-01-2012
2126 45382 SG $364.26 $364.26 07-01-2012
2127 45384 SG $364.26 $364.26 07-01-2012
2128 45385 SG $364.26 $364.26 07-01-2012
2129 45386 SG $364.26 $364.26 07-01-2012
2130 45388 SG $368.96 $368.96 01-01-2015
2131 45389 SG $368.96 $368.96 01-01-2015
2132 45390 SG $368.96 $368.96 01-01-2015
2133 45391 SG $364.26 $364.26 07-01-2012
2134 45392 SG $364.26 $364.26 07-01-2012
2135 45393 SG $368.96 $368.96 01-01-2015
2136 45398 SG $368.96 $368.96 01-01-2015
2137 45500 SG $487.22 $487.22 07-01-2012
2138 45505 SG $552.83 $552.83 07-01-2012
2139 45560 SG $552.83 $552.83 07-01-2012
2140 45900 SG $242.50 $242.50 07-01-2012
2141 45905 SG $414.77 $414.77 07-01-2012
2142 45910 SG $414.77 $414.77 07-01-2012
2143 45915 SG $296.66 $296.66 07-01-2012
2144 45990 SG $401.34 $401.34 07-01-2012
2145 46020 SG $528.25 $528.25 07-01-2012
2146 46030 SG $242.50 $242.50 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 29 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2147 46040 SG $528.25 $528.25 07-01-2012
2148 46045 SG $487.22 $487.22 07-01-2012
2149 46050 SG $296.66 $296.66 07-01-2012
2150 46060 SG $487.22 $487.22 07-01-2012
2151 46070 SG $386.25 $386.25 07-01-2012
2152 46080 SG $528.25 $528.25 07-01-2012
2153 46083 SG $71.06 $71.06 07-01-2012
2154 46200 SG $487.22 $487.22 07-01-2012
2155 46220 SG $414.77 $414.77 07-01-2012
2156 46221 SG $103.87 $103.87 07-01-2012
2157 46230 SG $414.77 $414.77 07-01-2012
2158 46250 SG $528.25 $528.25 07-01-2012
2159 46255 SG $528.25 $528.25 07-01-2012
2160 46257 SG $528.25 $528.25 07-01-2012
2161 46258 SG $528.25 $528.25 07-01-2012
2162 46260 SG $528.25 $528.25 07-01-2012
2163 46261 SG $605.19 $605.19 07-01-2012
2164 46262 SG $605.19 $605.19 07-01-2012
2165 46270 SG $528.25 $528.25 07-01-2012
2166 46275 SG $528.25 $528.25 07-01-2012
2167 46280 SG $605.19 $605.19 07-01-2012
2168 46285 SG $414.77 $414.77 07-01-2012
2169 46288 SG $605.19 $605.19 07-01-2012
2170 46320 SG $73.91 $73.91 07-01-2012
2171 46500 SG $93.12 $93.12 07-01-2012
2172 46505 SG $169.66 $169.66 07-01-2012
2173 46604 SG $308.03 $308.03 07-01-2012
2174 46606 SG $124.71 $124.71 07-01-2012
2175 46607 SG $386.51 $386.51 01-01-2015
2176 46608 SG $290.51 $290.51 07-01-2012
2177 46610 SG $403.43 $403.43 07-01-2012
2178 46611 SG $290.51 $290.51 07-01-2012
2179 46612 SG $403.43 $403.43 07-01-2012
2180 46614 SG $69.35 $69.35 07-01-2012
2181 46615 SG $475.87 $475.87 07-01-2012
2182 46700 SG $528.25 $528.25 07-01-2012
2183 46706 SG $480.38 $480.38 07-01-2012
2184 46707 SG $1,105.66 $1,105.66 07-01-2012
2185 46750 SG $593.86 $593.86 07-01-2012
2186 46753 SG $528.25 $528.25 07-01-2012
2187 46754 SG $487.22 $487.22 07-01-2012
2188 46760 SG $552.83 $552.83 07-01-2012
2189 46761 SG $593.86 $593.86 07-01-2012
2190 46762 SG $904.82 $904.82 07-01-2012
2191 46900 SG $94.16 $94.16 07-01-2012
2192 46910 SG $110.38 $110.38 07-01-2012
2193 46916 SG $51.66 $51.66 07-01-2012
2194 46917 SG $389.62 $389.62 07-01-2012
2195 46922 SG $389.62 $389.62 07-01-2012
2196 46924 SG $389.62 $389.62 07-01-2012
2197 46930 SG $114.11 $114.11 07-01-2012
2198 46940 SG $78.79 $78.79 07-01-2012
2199 46942 SG $75.54 $75.54 07-01-2012
2200 46945 SG $131.21 $131.21 07-01-2012
2201 46946 SG $310.07 $310.07 07-01-2012
2202 46947 SG $904.82 $904.82 07-01-2012
2203 47000 SG $296.11 $296.11 07-01-2012
2204 47382 SG $1,521.82 $1,521.82 07-01-2012
2205 47383 SG $1,913.29 $1,913.29 01-01-2015
2206 47533 SG $1,156.54 $1,156.54 01-01-2016
2207 47534 SG $1,156.54 $1,156.54 01-01-2016
2208 47535 SG $1,156.54 $1,156.54 01-01-2016
2209 47536 SG $1,156.54 $1,156.54 01-01-2016
2210 47537 SG $256.49 $256.49 01-01-2016
2211 47538 SG $2,187.72 $2,187.72 01-01-2016
2212 47539 SG $2,187.72 $2,187.72 01-01-2016
2213 47540 SG $2,187.72 $2,187.72 01-01-2016
2214 47541 SG $1,156.54 $1,156.54 01-01-2016
2215 47552 SG $539.79 $539.79 07-01-2012
2216 47553 SG $580.83 $580.83 07-01-2012
2217 47554 SG $580.83 $580.83 07-01-2012
2218 47555 SG $580.83 $580.83 07-01-2012
2219 47556 SG $1,052.63 $1,052.63 07-01-2012
2220 47562 SG $1,611.50 $1,611.50 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 30 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2221 47563 SG $1,611.50 $1,611.50 07-01-2012
2222 48102 SG $296.11 $296.11 07-01-2012
2223 49082 SG $185.50 $185.50 01-01-2013
2224 49083 SG $185.50 $185.50 01-01-2013
2225 49084 SG $185.50 $185.50 01-01-2013
2226 49180 SG $296.11 $296.11 07-01-2012
2227 49250 SG $631.29 $631.29 07-01-2012
2228 49320 SG $631.34 $631.34 07-01-2012
2229 49321 SG $708.28 $708.28 07-01-2012
2230 49322 SG $708.28 $708.28 07-01-2012
2231 49402 SG $513.31 $513.31 07-01-2012
2232 49407 SG $359.89 $359.89 01-01-2014
2233 49418 SG $1,016.18 $1,016.18 01-01-2013
2234 49419 SG $476.27 $476.27 07-01-2012
2235 49421 SG $485.23 $485.23 07-01-2012
2236 49422 SG $425.68 $425.68 07-01-2012
2237 49423 SG $543.44 $543.44 07-01-2012
2238 49426 SG $513.31 $513.31 07-01-2012
2239 49429 SG $848.73 $848.73 07-01-2012
2240 49495 SG $675.39 $675.39 07-01-2012
2241 49496 SG $675.38 $675.38 07-01-2012
2242 49500 SG $675.39 $675.39 07-01-2012
2243 49501 SG $1,129.96 $1,129.96 07-01-2012
2244 49505 SG $675.39 $675.39 07-01-2012
2245 49507 SG $1,129.96 $1,129.96 07-01-2012
2246 49520 SG $909.41 $909.41 07-01-2012
2247 49521 SG $1,129.96 $1,129.96 07-01-2012
2248 49525 SG $675.39 $675.39 07-01-2012
2249 49540 SG $557.40 $557.40 07-01-2012
2250 49550 SG $731.16 $731.16 07-01-2012
2251 49553 SG $1,129.96 $1,129.96 07-01-2012
2252 49555 SG $731.16 $731.16 07-01-2012
2253 49557 SG $1,129.96 $1,129.96 07-01-2012
2254 49560 SG $675.39 $675.39 07-01-2012
2255 49561 SG $1,129.96 $1,129.96 07-01-2012
2256 49565 SG $675.39 $675.39 07-01-2012
2257 49566 SG $1,129.96 $1,129.96 07-01-2012
2258 49570 SG $675.39 $675.39 07-01-2012
2259 49572 SG $1,129.96 $1,129.96 07-01-2012
2260 49580 SG $675.39 $675.39 07-01-2012
2261 49582 SG $1,129.96 $1,129.96 07-01-2012
2262 49585 SG $675.39 $675.39 07-01-2012
2263 49587 SG $1,129.96 $1,129.96 07-01-2012
2264 49590 SG $598.44 $598.44 07-01-2012
2265 49650 SG $806.80 $806.80 07-01-2012
2266 49651 SG $1,040.83 $1,040.83 07-01-2012
2267 49652 SG $598.78 $598.78 07-01-2012
2268 49653 SG $748.17 $748.17 07-01-2012
2269 49654 SG $688.19 $688.19 07-01-2012
2270 49655 SG $828.38 $828.38 07-01-2012
2271 49656 SG $690.67 $690.67 07-01-2012
2272 49657 SG $997.64 $997.64 07-01-2012
2273 50200 SG $296.11 $296.11 07-01-2012
2274 50382 SG $876.86 $876.86 07-01-2012
2275 50384 SG $635.02 $635.02 07-01-2012
2276 50387 SG $543.44 $543.44 07-01-2012
2277 50389 SG $211.43 $211.43 07-01-2012
2278 50390 SG $296.11 $296.11 07-01-2012
2279 50391 SG $36.65 $36.65 07-01-2012
2280 50395 SG $372.26 $372.26 07-01-2012
2281 50396 SG $102.08 $102.08 07-01-2012
2282 50432 SG $800.25 $800.25 01-01-2016
2283 50433 SG $800.25 $800.25 01-01-2016
2284 50434 SG $278.62 $278.62 01-01-2016
2285 50435 SG $278.62 $278.62 01-01-2016
2286 50436 SG $665.52 $665.52 01-01-2019
2287 50437 SG $1,159.44 $1,159.44 01-01-2019
2288 50551 SG $266.36 $266.36 07-01-2012
2289 50553 SG $432.73 $432.73 07-01-2012
2290 50555 SG $266.36 $266.36 07-01-2012
2291 50557 SG $432.73 $432.73 07-01-2012
2292 50561 SG $432.73 $432.73 07-01-2012
2293 50562 SG $211.43 $211.43 07-01-2012
2294 50570 SG $211.42 $211.42 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 31 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2295 50572 SG $211.42 $211.42 07-01-2012
2296 50574 SG $211.42 $211.42 07-01-2012
2297 50575 SG $1,276.88 $1,276.88 07-01-2012
2298 50576 SG $635.02 $635.02 07-01-2012
2299 50580 SG $635.02 $635.02 07-01-2012
2300 50590 SG $1,469.86 $1,469.86 07-01-2012
2301 50592 SG $318.71 $318.71 07-01-2012
2302 50686 SG $36.65 $36.65 07-01-2012
2303 50688 SG $349.36 $349.36 07-01-2012
2304 50693 SG $1,191.80 $1,191.80 01-01-2016
2305 50694 SG $1,191.80 $1,191.80 01-01-2016
2306 50695 SG $1,191.80 $1,191.80 01-01-2016
2307 50947 SG $1,261.40 $1,261.40 07-01-2012
2308 50948 SG $1,261.40 $1,261.40 07-01-2012
2309 50951 SG $266.36 $266.36 07-01-2012
2310 50953 SG $266.36 $266.36 07-01-2012
2311 50955 SG $432.73 $432.73 07-01-2012
2312 50957 SG $432.73 $432.73 07-01-2012
2313 50961 SG $432.73 $432.73 07-01-2012
2314 50970 SG $266.36 $266.36 07-01-2012
2315 50972 SG $266.36 $266.36 07-01-2012
2316 50974 SG $372.26 $372.26 07-01-2012
2317 50976 SG $372.26 $372.26 07-01-2012
2318 50980 SG $432.73 $432.73 07-01-2012
2319 51020 SG $623.15 $623.15 07-01-2012
2320 51030 SG $623.15 $623.15 07-01-2012
2321 51040 SG $623.15 $623.15 07-01-2012
2322 51045 SG $308.84 $308.84 07-01-2012
2323 51050 SG $623.14 $623.14 07-01-2012
2324 51065 SG $623.14 $623.14 07-01-2012
2325 51080 SG $375.60 $375.60 07-01-2012
2326 51500 SG $675.39 $675.39 07-01-2012
2327 51520 SG $623.14 $623.14 07-01-2012
2328 51700 SG $50.46 $50.46 07-01-2012
2329 51703 SG $36.65 $36.65 07-01-2012
2330 51705 SG $70.00 $70.00 07-01-2012
2331 51710 SG $349.36 $349.36 07-01-2012
2332 51715 SG $590.55 $590.55 07-01-2012
2333 51720 SG $54.70 $54.70 07-01-2012
2334 51725 SG $107.84 $107.84 07-01-2012
2335 51726 SG $161.28 $161.28 07-01-2012
2336 51727 SG $103.80 $103.80 07-01-2012
2337 51728 SG $103.80 $103.80 07-01-2012
2338 51729 SG $103.80 $103.80 07-01-2012
2339 51784 SG $36.65 $36.65 07-01-2012
2340 51785 SG $60.66 $60.66 07-01-2012
2341 51880 SG $432.73 $432.73 07-01-2012
2342 52000 SG $266.36 $266.36 07-01-2012
2343 52001 SG $414.74 $414.74 07-01-2012
2344 52005 SG $444.71 $444.71 07-01-2012
2345 52007 SG $505.17 $505.17 07-01-2012
2346 52010 SG $308.84 $308.84 07-01-2012
2347 52204 SG $444.71 $444.71 07-01-2012
2348 52214 SG $505.17 $505.17 07-01-2012
2349 52224 SG $505.17 $505.17 07-01-2012
2350 52234 SG $505.17 $505.17 07-01-2012
2351 52235 SG $546.20 $546.20 07-01-2012
2352 52240 SG $546.20 $546.20 07-01-2012
2353 52250 SG $623.15 $623.15 07-01-2012
2354 52260 SG $444.71 $444.71 07-01-2012
2355 52265 SG $211.42 $211.42 07-01-2012
2356 52270 SG $444.71 $444.71 07-01-2012
2357 52275 SG $505.17 $505.17 07-01-2012
2358 52276 SG $546.20 $546.20 07-01-2012
2359 52277 SG $505.17 $505.17 07-01-2012
2360 52281 SG $444.71 $444.71 07-01-2012
2361 52282 SG $1,177.73 $1,177.73 07-01-2012
2362 52283 SG $505.17 $505.17 07-01-2012
2363 52285 SG $444.71 $444.71 07-01-2012
2364 52287 SG $508.08 $508.08 01-01-2013
2365 52290 SG $444.71 $444.71 07-01-2012
2366 52300 SG $505.17 $505.17 07-01-2012
2367 52301 SG $546.20 $546.20 07-01-2012
2368 52305 SG $505.17 $505.17 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 32 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2369 52310 SG $414.74 $414.74 07-01-2012
2370 52315 SG $505.17 $505.17 07-01-2012
2371 52317 SG $432.73 $432.73 07-01-2012
2372 52318 SG $505.17 $505.17 07-01-2012
2373 52320 SG $678.92 $678.92 07-01-2012
2374 52325 SG $623.15 $623.15 07-01-2012
2375 52327 SG $505.17 $505.17 07-01-2012
2376 52330 SG $505.17 $505.17 07-01-2012
2377 52332 SG $505.17 $505.17 07-01-2012
2378 52334 SG $546.20 $546.20 07-01-2012
2379 52341 SG $546.21 $546.21 07-01-2012
2380 52342 SG $546.21 $546.21 07-01-2012
2381 52343 SG $546.21 $546.21 07-01-2012
2382 52344 SG $546.21 $546.21 07-01-2012
2383 52345 SG $546.21 $546.21 07-01-2012
2384 52346 SG $546.21 $546.21 07-01-2012
2385 52351 SG $546.20 $546.20 07-01-2012
2386 52352 SG $623.15 $623.15 07-01-2012
2387 52353 SG $723.15 $723.15 07-01-2012
2388 52354 SG $623.15 $623.15 07-01-2012
2389 52355 SG $623.14 $623.14 07-01-2012
2390 52356 SG $1,569.35 $1,569.35 01-01-2014
2391 52400 SG $546.20 $546.20 07-01-2012
2392 52450 SG $546.20 $546.20 07-01-2012
2393 52500 SG $546.20 $546.20 07-01-2012
2394 52601 SG $723.15 $723.15 07-01-2012
2395 52630 SG $605.18 $605.18 07-01-2012
2396 52640 SG $505.17 $505.17 07-01-2012
2397 52647 SG $1,258.50 $1,258.50 07-01-2012
2398 52648 SG $1,258.50 $1,258.50 07-01-2012
2399 52700 SG $505.17 $505.17 07-01-2012
2400 53000 SG $382.95 $382.95 07-01-2012
2401 53010 SG $382.95 $382.95 07-01-2012
2402 53020 SG $382.95 $382.95 07-01-2012
2403 53025 SG $677.80 $677.80 07-01-2012
2404 53040 SG $455.40 $455.40 07-01-2012
2405 53060 SG $68.05 $68.05 07-01-2012
2406 53080 SG $496.44 $496.44 07-01-2012
2407 53085 SG $677.79 $677.79 07-01-2012
2408 53200 SG $382.95 $382.95 07-01-2012
2409 53210 SG $723.28 $723.28 07-01-2012
2410 53215 SG $629.15 $629.15 07-01-2012
2411 53220 SG $549.53 $549.53 07-01-2012
2412 53230 SG $549.53 $549.53 07-01-2012
2413 53235 SG $496.43 $496.43 07-01-2012
2414 53240 SG $549.53 $549.53 07-01-2012
2415 53250 SG $455.40 $455.40 07-01-2012
2416 53260 SG $455.40 $455.40 07-01-2012
2417 53265 SG $455.40 $455.40 07-01-2012
2418 53270 SG $455.41 $455.41 07-01-2012
2419 53275 SG $455.40 $455.40 07-01-2012
2420 53400 SG $590.56 $590.56 07-01-2012
2421 53405 SG $549.53 $549.53 07-01-2012
2422 53410 SG $549.53 $549.53 07-01-2012
2423 53420 SG $590.56 $590.56 07-01-2012
2424 53425 SG $549.53 $549.53 07-01-2012
2425 53430 SG $549.53 $549.53 07-01-2012
2426 53431 SG $549.52 $549.52 07-01-2012
2427 53440 SG $2,992.51 $2,992.51 07-01-2012
2428 53442 SG $477.07 $477.07 07-01-2012
2429 53444 SG $2,992.51 $2,992.51 07-01-2012
2430 53445 SG $5,664.22 $5,664.22 07-01-2012
2431 53446 SG $477.07 $477.07 07-01-2012
2432 53447 SG $5,664.22 $5,664.22 07-01-2012
2433 53449 SG $477.07 $477.07 07-01-2012
2434 53450 SG $477.07 $477.07 07-01-2012
2435 53460 SG $382.95 $382.95 07-01-2012
2436 53502 SG $455.40 $455.40 07-01-2012
2437 53505 SG $549.53 $549.53 07-01-2012
2438 53510 SG $455.40 $455.40 07-01-2012
2439 53515 SG $549.53 $549.53 07-01-2012
2440 53520 SG $549.53 $549.53 07-01-2012
2441 53600 SG $37.11 $37.11 07-01-2012
2442 53605 SG $444.71 $444.71 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 33 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2443 53620 SG $60.23 $60.23 07-01-2012
2444 53621 SG $63.17 $63.17 07-01-2012
2445 53660 SG $36.65 $36.65 07-01-2012
2446 53665 SG $382.95 $382.95 07-01-2012
2447 53850 SG $1,599.91 $1,599.91 07-01-2012
2448 53852 SG $1,599.91 $1,599.91 07-01-2012
2449 53855 SG $69.38 $69.38 07-01-2012
2450 54000 SG $455.41 $455.41 07-01-2012
2451 54001 SG $455.40 $455.40 07-01-2012
2452 54015 SG $566.02 $566.02 07-01-2012
2453 54055 SG $57.62 $57.62 07-01-2012
2454 54057 SG $389.62 $389.62 07-01-2012
2455 54060 SG $389.62 $389.62 07-01-2012
2456 54065 SG $389.62 $389.62 07-01-2012
2457 54100 SG $355.97 $355.97 07-01-2012
2458 54105 SG $400.29 $400.29 07-01-2012
2459 54110 SG $586.19 $586.19 07-01-2012
2460 54111 SG $586.19 $586.19 07-01-2012
2461 54112 SG $586.19 $586.19 07-01-2012
2462 54115 SG $375.60 $375.60 07-01-2012
2463 54120 SG $586.19 $586.19 07-01-2012
2464 54150 SG $411.05 $411.05 07-01-2012
2465 54160 SG $483.49 $483.49 07-01-2012
2466 54161 SG $483.49 $483.49 07-01-2012
2467 54162 SG $483.49 $483.49 07-01-2012
2468 54163 SG $483.49 $483.49 07-01-2012
2469 54164 SG $483.49 $483.49 07-01-2012
2470 54200 SG $62.19 $62.19 07-01-2012
2471 54205 SG $704.15 $704.15 07-01-2012
2472 54220 SG $102.08 $102.08 07-01-2012
2473 54240 SG $26.37 $26.37 07-01-2012
2474 54300 SG $627.22 $627.22 07-01-2012
2475 54304 SG $627.22 $627.22 07-01-2012
2476 54308 SG $627.22 $627.22 07-01-2012
2477 54312 SG $627.22 $627.22 07-01-2012
2478 54316 SG $627.22 $627.22 07-01-2012
2479 54318 SG $627.22 $627.22 07-01-2012
2480 54322 SG $627.22 $627.22 07-01-2012
2481 54324 SG $627.22 $627.22 07-01-2012
2482 54326 SG $627.22 $627.22 07-01-2012
2483 54328 SG $627.22 $627.22 07-01-2012
2484 54340 SG $627.22 $627.22 07-01-2012
2485 54344 SG $627.22 $627.22 07-01-2012
2486 54348 SG $627.22 $627.22 07-01-2012
2487 54352 SG $627.22 $627.22 07-01-2012
2488 54360 SG $627.22 $627.22 07-01-2012
2489 54380 SG $627.22 $627.22 07-01-2012
2490 54385 SG $627.22 $627.22 07-01-2012
2491 54400 SG $3,033.54 $3,033.54 07-01-2012 X 54400 7/31/2018
2492 54406 SG $627.22 $627.22 07-01-2012
2493 54415 SG $627.22 $627.22 07-01-2012
2494 54420 SG $704.15 $704.15 07-01-2012
2495 54435 SG $704.15 $704.15 07-01-2012
2496 54437 SG $800.25 $800.25 01-01-2016
2497 54440 SG $704.15 $704.15 07-01-2012
2498 54450 SG $161.28 $161.28 07-01-2012
2499 54500 SG $333.63 $333.63 07-01-2012
2500 54505 SG $411.05 $411.05 07-01-2012
2501 54512 SG $483.49 $483.49 07-01-2012
2502 54520 SG $524.53 $524.53 07-01-2012
2503 54522 SG $524.53 $524.53 07-01-2012
2504 54530 SG $675.39 $675.39 07-01-2012
2505 54550 SG $675.39 $675.39 07-01-2012
2506 54560 SG $790.14 $790.14 07-01-2012
2507 54600 SG $601.47 $601.47 07-01-2012
2508 54620 SG $524.53 $524.53 07-01-2012
2509 54640 SG $675.39 $675.39 07-01-2012
2510 54660 SG $483.49 $483.49 07-01-2012 X 54660 7/31/2018
2511 54670 SG $524.53 $524.53 07-01-2012
2512 54680 SG $524.53 $524.53 07-01-2012
2513 54690 SG $1,261.40 $1,261.40 07-01-2012
2514 54692 SG $2,465.65 $2,465.65 07-01-2012
2515 54700 SG $483.49 $483.49 07-01-2012
2516 54800 SG $119.82 $119.82 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 34 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2517 54830 SG $524.53 $524.53 07-01-2012
2518 54840 SG $601.47 $601.47 07-01-2012
2519 54860 SG $524.53 $524.53 07-01-2012
2520 54861 SG $601.47 $601.47 07-01-2012
2521 54865 SG $411.05 $411.05 07-01-2012
2522 54900 SG $601.47 $601.47 07-01-2012 X 54900 7/31/2018
2523 54901 SG $601.47 $601.47 07-01-2012 X 54901 7/31/2018
2524 55000 SG $63.82 $63.82 07-01-2012
2525 55040 SG $598.44 $598.44 07-01-2012
2526 55041 SG $731.16 $731.16 07-01-2012
2527 55060 SG $601.47 $601.47 07-01-2012
2528 55100 SG $315.79 $315.79 07-01-2012
2529 55110 SG $483.49 $483.49 07-01-2012
2530 55120 SG $483.49 $483.49 07-01-2012
2531 55150 SG $411.05 $411.05 07-01-2012
2532 55175 SG $411.05 $411.05 07-01-2012
2533 55180 SG $483.49 $483.49 07-01-2012
2534 55200 SG $483.49 $483.49 07-01-2012
2535 55250 SG $483.49 $483.49 07-01-2012
2536 55400 SG $411.05 $411.05 07-01-2012
2537 55450 SG $202.85 $202.85 07-01-2012
2538 55500 SG $524.53 $524.53 07-01-2012
2539 55520 SG $601.47 $601.47 07-01-2012
2540 55530 SG $601.47 $601.47 07-01-2012
2541 55535 SG $675.39 $675.39 07-01-2012
2542 55540 SG $731.16 $731.16 07-01-2012
2543 55550 SG $1,261.40 $1,261.40 07-01-2012
2544 55600 SG $790.14 $790.14 07-01-2012
2545 55680 SG $411.05 $411.05 07-01-2012
2546 55700 SG $319.36 $319.36 07-01-2012
2547 55705 SG $319.36 $319.36 07-01-2012
2548 55706 SG $331.99 $331.99 07-01-2012
2549 55720 SG $432.73 $432.73 07-01-2012
2550 55725 SG $505.17 $505.17 07-01-2012
2551 55860 SG $684.55 $684.55 07-01-2012
2552 55873 SG $5,317.04 $5,317.04 07-01-2012
2553 55874 SG $1,485.28 $1,485.28 01-01-2018
2554 55875 SG $1,177.73 $1,177.73 07-01-2012
2555 55876 SG $67.39 $67.39 07-01-2012
2556 56405 SG $40.70 $40.70 07-01-2012
2557 56420 SG $47.84 $47.84 07-01-2012
2558 56440 SG $454.26 $454.26 07-01-2012
2559 56441 SG $381.81 $381.81 07-01-2012
2560 56442 SG $381.81 $381.81 07-01-2012
2561 56501 SG $55.68 $55.68 07-01-2012
2562 56515 SG $503.10 $503.10 07-01-2012
2563 56605 SG $32.57 $32.57 07-01-2012
2564 56620 SG $628.01 $628.01 07-01-2012
2565 56625 SG $806.26 $806.26 07-01-2012
2566 56700 SG $381.81 $381.81 07-01-2012
2567 56740 SG $495.29 $495.29 07-01-2012
2568 56800 SG $495.29 $495.29 07-01-2012
2569 56805 SG $673.18 $673.18 07-01-2012
2570 56810 SG $628.01 $628.01 07-01-2012
2571 56820 SG $40.70 $40.70 07-01-2012
2572 56821 SG $47.84 $47.84 07-01-2012
2573 57000 SG $381.81 $381.81 07-01-2012
2574 57010 SG $454.26 $454.26 07-01-2012
2575 57020 SG $316.23 $316.23 07-01-2012
2576 57022 SG $409.12 $409.12 07-01-2012
2577 57023 SG $375.60 $375.60 07-01-2012
2578 57061 SG $51.77 $51.77 07-01-2012
2579 57065 SG $381.81 $381.81 07-01-2012
2580 57100 SG $33.21 $33.21 07-01-2012
2581 57105 SG $454.26 $454.26 07-01-2012
2582 57130 SG $454.26 $454.26 07-01-2012
2583 57135 SG $454.26 $454.26 07-01-2012
2584 57155 SG $316.23 $316.23 07-01-2012
2585 57156 SG $105.30 $105.30 01-01-2013
2586 57160 SG $33.54 $33.54 07-01-2012
2587 57170 SG $4.64 $4.64 07-01-2012
2588 57180 SG $126.13 $126.13 07-01-2012
2589 57200 SG $381.81 $381.81 07-01-2012
2590 57210 SG $454.26 $454.26 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 35 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2591 57220 SG $704.90 $704.90 07-01-2012
2592 57230 SG $613.88 $613.88 07-01-2012
2593 57240 SG $746.60 $746.60 07-01-2012
2594 57250 SG $746.60 $746.60 07-01-2012
2595 57260 SG $746.60 $746.60 07-01-2012
2596 57265 SG $1,015.86 $1,015.86 07-01-2012
2597 57268 SG $613.88 $613.88 07-01-2012
2598 57287 SG $1,147.56 $1,147.56 07-01-2012
2599 57288 SG $837.63 $837.63 07-01-2012
2600 57289 SG $746.60 $746.60 07-01-2012
2601 57291 SG $746.60 $746.60 07-01-2012
2602 57300 SG $613.88 $613.88 07-01-2012
2603 57320 SG $1,147.56 $1,147.56 07-01-2012
2604 57400 SG $454.26 $454.26 07-01-2012
2605 57410 SG $454.26 $454.26 07-01-2012
2606 57415 SG $454.26 $454.26 07-01-2012
2607 57420 SG $42.00 $42.00 07-01-2012
2608 57421 SG $56.01 $56.01 07-01-2012
2609 57426 SG $688.70 $688.70 07-01-2012
2610 57452 SG $40.05 $40.05 07-01-2012
2611 57454 SG $49.49 $49.49 07-01-2012
2612 57455 SG $52.42 $52.42 07-01-2012
2613 57456 SG $50.46 $50.46 07-01-2012
2614 57460 SG $164.75 $164.75 07-01-2012
2615 57461 SG $173.86 $173.86 07-01-2012
2616 57500 SG $74.24 $74.24 07-01-2012
2617 57505 SG $45.26 $45.26 07-01-2012
2618 57510 SG $46.56 $46.56 07-01-2012
2619 57511 SG $47.84 $47.84 07-01-2012
2620 57513 SG $454.26 $454.26 07-01-2012
2621 57520 SG $454.26 $454.26 07-01-2012
2622 57522 SG $454.26 $454.26 07-01-2012
2623 57530 SG $613.88 $613.88 07-01-2012
2624 57550 SG $613.88 $613.88 07-01-2012
2625 57556 SG $837.62 $837.62 07-01-2012
2626 57558 SG $495.29 $495.29 07-01-2012
2627 57700 SG $381.81 $381.81 07-01-2012
2628 57720 SG $495.29 $495.29 07-01-2012
2629 57800 SG $24.09 $24.09 07-01-2012
2630 58100 SG $40.05 $40.05 07-01-2012
2631 58120 SG $454.26 $454.26 07-01-2012
2632 58145 SG $746.60 $746.60 07-01-2012
2633 58301 SG $38.42 $38.42 07-01-2012
2634 58346 SG $454.26 $454.26 07-01-2012
2635 58353 SG $924.85 $924.85 07-01-2012
2636 58545 SG $1,162.86 $1,162.86 07-01-2012
2637 58546 SG $1,261.39 $1,261.39 07-01-2012
2638 58550 SG $1,474.92 $1,474.92 07-01-2012
2639 58552 SG $1,611.50 $1,611.50 07-01-2012
2640 58555 SG $405.13 $405.13 07-01-2012
2641 58558 SG $518.63 $518.63 07-01-2012
2642 58559 SG $477.58 $477.58 07-01-2012
2643 58560 SG $629.64 $629.64 07-01-2012
2644 58561 SG $629.64 $629.64 07-01-2012
2645 58562 SG $518.63 $518.63 07-01-2012
2646 58563 SG $1,161.16 $1,161.16 07-01-2012
2647 58565 SG $1,236.43 $1,236.43 07-01-2012 x 58565 12/31/2018
2648 58600 SG $1,147.56 $1,147.56 07-01-2012
2649 58615 SG $673.18 $673.18 07-01-2012
2650 58660 SG $862.60 $862.60 07-01-2012
2651 58661 SG $862.60 $862.60 07-01-2012
2652 58662 SG $862.60 $862.60 07-01-2012
2653 58670 SG $729.87 $729.87 07-01-2012
2654 58671 SG $729.87 $729.87 07-01-2012
2655 58672 SG $862.60 $862.60 07-01-2012 X 58672 7/31/2018
2656 58673 SG $862.60 $862.60 07-01-2012 X 58673 7/31/2018
2657 58800 SG $495.29 $495.29 07-01-2012
2658 58820 SG $613.88 $613.88 07-01-2012
2659 58900 SG $495.29 $495.29 07-01-2012
2660 59000 SG $62.19 $62.19 07-01-2012
2661 59001 SG $215.13 $215.13 07-01-2012
2662 59012 SG $97.63 $97.63 07-01-2012
2663 59020 SG $22.79 $22.79 07-01-2012
2664 59025 SG $11.72 $11.72 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 36 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2665 59150 SG $1,611.50 $1,611.50 07-01-2012
2666 59151 SG $1,611.50 $1,611.50 07-01-2012
2667 59160 SG $495.29 $495.29 07-01-2012
2668 59200 SG $34.52 $34.52 07-01-2012
2669 59300 SG $70.98 $70.98 07-01-2012
2670 59320 SG $381.81 $381.81 07-01-2012
2671 59812 SG $628.01 $628.01 07-01-2012
2672 59820 SG $628.01 $628.01 07-01-2012
2673 59821 SG $628.01 $628.01 07-01-2012
2674 59840 SG $628.01 $628.01 07-01-2012
2675 59841 SG $628.01 $628.01 07-01-2012
2676 59866 SG $97.63 $97.63 07-01-2012 X 59866 7/31/2018
2677 59870 SG $628.01 $628.01 07-01-2012
2678 59871 SG $628.01 $628.01 07-01-2012
2679 60000 SG $279.40 $279.40 07-01-2012
2680 60100 SG $44.29 $44.29 07-01-2012
2681 60200 SG $678.15 $678.15 07-01-2012
2682 60220 SG $573.55 $573.55 07-01-2012
2683 60225 SG $689.40 $689.40 07-01-2012
2684 60280 SG $796.12 $796.12 07-01-2012
2685 60281 SG $796.12 $796.12 07-01-2012
2686 61000 SG $301.77 $301.77 07-01-2012
2687 61001 SG $301.77 $301.77 07-01-2012
2688 61020 SG $193.31 $193.31 07-01-2012
2689 61026 SG $193.31 $193.31 07-01-2012
2690 61050 SG $193.31 $193.31 07-01-2012
2691 61055 SG $193.31 $193.31 07-01-2012
2692 61070 SG $146.52 $146.52 07-01-2012
2693 61215 SG $647.98 $647.98 07-01-2012
2694 61330 SG $1,411.38 $1,411.38 07-01-2012
2695 61790 SG $486.72 $486.72 07-01-2012
2696 61791 SG $353.83 $353.83 07-01-2012
2697 61880 SG $795.40 $795.40 07-01-2012
2698 61885 SG $8,971.02 $8,971.02 07-01-2012
2699 61886 SG $13,324.30 $13,324.30 07-01-2012
2700 61888 SG $518.03 $518.03 07-01-2012
2701 62194 SG $288.94 $288.94 07-01-2012
2702 62225 SG $349.36 $349.36 07-01-2012
2703 62230 SG $606.94 $606.94 07-01-2012
2704 62252 SG $42.33 $42.33 07-01-2012
2705 62263 SG $341.70 $341.70 07-01-2012
2706 62264 SG $341.70 $341.70 07-01-2012
2707 62267 SG $133.63 $133.63 07-01-2012
2708 62268 SG $193.31 $193.31 07-01-2012
2709 62269 SG $296.11 $296.11 07-01-2012
2710 62270 SG $125.36 $125.36 07-01-2012
2711 62272 SG $125.36 $125.36 07-01-2012
2712 62273 SG $249.75 $249.75 07-01-2012
2713 62280 SG $275.93 $275.93 07-01-2012
2714 62281 SG $275.93 $275.93 07-01-2012
2715 62282 SG $275.93 $275.93 07-01-2012
2716 62287 SG $1,152.90 $1,152.90 07-01-2012
2717 62292 SG $301.77 $301.77 07-01-2012
2718 62294 SG $193.31 $193.31 07-01-2012
2719 62320 SG $233.92 $233.92 01-01-2017
2720 62321 SG $233.92 $233.92 01-01-2017
2721 62322 SG $233.92 $233.92 01-01-2017
2722 62323 SG $233.92 $233.92 01-01-2017
2723 62324 SG $294.68 $294.68 01-01-2017
2724 62325 SG $294.68 $294.68 01-01-2017
2725 62326 SG $294.68 $294.68 01-01-2017
2726 62327 SG $294.68 $294.68 01-01-2017
2727 62350 SG $606.94 $606.94 07-01-2012
2728 62355 SG $414.15 $414.15 07-01-2012
2729 62360 SG $606.94 $606.94 07-01-2012
2730 62361 SG $8,683.07 $8,683.07 07-01-2012
2731 62362 SG $8,683.07 $8,683.07 07-01-2012
2732 62365 SG $580.35 $580.35 07-01-2012
2733 62367 SG $16.93 $16.93 07-01-2012
2734 62368 SG $20.51 $20.51 07-01-2012
2735 62369 SG $84.01 $84.01 07-01-2012
2736 62370 SG $81.56 $81.56 07-01-2012
2737 62380 SG $3,049.02 $3,049.02 01-01-2017
2738 63600 SG $445.68 $445.68 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 37 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2739 63610 SG $373.22 $373.22 07-01-2012
2740 63615 SG $638.90 $638.90 07-01-2012
2741 63650 SG $2,487.15 $2,487.15 07-01-2012
2742 63655 SG $3,889.59 $3,889.59 07-01-2012
2743 63661 SG $674.71 $674.71 07-01-2012
2744 63662 SG $674.71 $674.71 07-01-2012
2745 63663 SG $674.71 $674.71 07-01-2012
2746 63664 SG $674.71 $674.71 07-01-2012
2747 63685 SG $11,735.11 $11,735.11 07-01-2012
2748 63688 SG $518.03 $518.03 07-01-2012
2749 63744 SG $647.98 $647.98 07-01-2012
2750 63746 SG $336.06 $336.06 07-01-2012
2751 64400 SG $54.05 $54.05 07-01-2012
2752 64405 SG $42.65 $42.65 07-01-2012
2753 64408 SG $49.16 $49.16 07-01-2012
2754 64410 SG $275.93 $275.93 07-01-2012
2755 64413 SG $51.45 $51.45 07-01-2012
2756 64415 SG $125.36 $125.36 07-01-2012
2757 64416 SG $249.68 $249.68 07-01-2012
2758 64417 SG $125.36 $125.36 07-01-2012
2759 64418 SG $73.59 $73.59 07-01-2012
2760 64420 SG $125.36 $125.36 07-01-2012
2761 64421 SG $249.75 $249.75 07-01-2012
2762 64425 SG $47.86 $47.86 07-01-2012
2763 64430 SG $151.55 $151.55 07-01-2012
2764 64435 SG $73.59 $73.59 07-01-2012
2765 64445 SG $70.00 $70.00 07-01-2012
2766 64446 SG $512.77 $512.77 07-01-2012
2767 64447 SG $144.99 $144.99 07-01-2012
2768 64450 SG $43.09 $43.09 07-01-2012
2769 64455 SG $32.66 $32.66 07-01-2012
2770 64479 SG $275.93 $275.93 07-01-2012
2771 64483 SG $275.93 $275.93 07-01-2012
2772 64490 SG $234.30 $234.30 07-01-2012
2773 64493 SG $234.30 $234.30 07-01-2012
2774 64505 SG $38.42 $38.42 07-01-2012
2775 64508 SG $82.15 $82.15 07-01-2012
2776 64510 SG $275.93 $275.93 07-01-2012
2777 64517 SG $151.55 $151.55 07-01-2012
2778 64520 SG $275.93 $275.93 07-01-2012
2779 64530 SG $275.93 $275.93 07-01-2012
2780 64555 SG $2,941.63 $2,941.63 07-01-2012
2781 64561 SG $2,528.18 $2,528.18 07-01-2012
2782 64568 SG $19,530.45 $19,530.45 01-01-2013
2783 64569 SG $2,846.23 $2,846.23 01-01-2013
2784 64570 SG $1,116.26 $1,116.26 01-01-2013
2785 64575 SG $3,236.51 $3,236.51 07-01-2012
2786 64581 SG $3,349.99 $3,349.99 07-01-2012
2787 64585 SG $412.36 $412.36 07-01-2012
2788 64590 SG $8,971.02 $8,971.02 07-01-2012
2789 64595 SG $518.03 $518.03 07-01-2012
2790 64600 SG $341.70 $341.70 07-01-2012
2791 64605 SG $341.70 $341.70 07-01-2012
2792 64610 SG $341.70 $341.70 07-01-2012
2793 64611 SG $55.91 $55.91 01-01-2013
2794 64612 SG $66.09 $66.09 07-01-2012
2795 64615 SG $48.54 $48.54 01-01-2013
2796 64616 SG $46.82 $46.82 01-01-2014
2797 64617 SG $100.71 $100.71 01-01-2014
2798 64620 SG $275.93 $275.93 07-01-2012
2799 64630 SG $288.06 $288.06 07-01-2012
2800 64632 SG $57.60 $57.60 07-01-2012
2801 64633 SG $254.49 $254.49 01-01-2013
2802 64635 SG $385.35 $385.35 01-01-2013
2803 64640 SG $107.45 $107.45 07-01-2012
2804 64642 SG $61.29 $61.29 01-01-2014
2805 64644 SG $72.68 $72.68 01-01-2014
2806 64646 SG $65.29 $65.29 01-01-2014
2807 64647 SG $74.84 $74.84 01-01-2014
2808 64680 SG $378.86 $378.86 07-01-2012
2809 64681 SG $414.15 $414.15 07-01-2012
2810 64702 SG $373.22 $373.22 07-01-2012
2811 64704 SG $373.22 $373.22 07-01-2012
2812 64708 SG $445.68 $445.68 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 38 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2813 64712 SG $445.68 $445.68 07-01-2012
2814 64713 SG $445.68 $445.68 07-01-2012
2815 64714 SG $445.68 $445.68 07-01-2012
2816 64716 SG $486.72 $486.72 07-01-2012
2817 64718 SG $445.68 $445.68 07-01-2012
2818 64719 SG $445.68 $445.68 07-01-2012
2819 64721 SG $445.68 $445.68 07-01-2012
2820 64722 SG $373.22 $373.22 07-01-2012
2821 64726 SG $373.22 $373.22 07-01-2012
2822 64732 SG $445.68 $445.68 07-01-2012
2823 64734 SG $445.68 $445.68 07-01-2012
2824 64736 SG $445.68 $445.68 07-01-2012
2825 64738 SG $445.68 $445.68 07-01-2012
2826 64740 SG $445.68 $445.68 07-01-2012
2827 64742 SG $445.68 $445.68 07-01-2012
2828 64744 SG $445.68 $445.68 07-01-2012
2829 64746 SG $445.68 $445.68 07-01-2012
2830 64763 SG $638.90 $638.90 07-01-2012
2831 64766 SG $1,177.55 $1,177.55 07-01-2012
2832 64771 SG $445.68 $445.68 07-01-2012
2833 64772 SG $445.68 $445.68 07-01-2012
2834 64774 SG $445.68 $445.68 07-01-2012
2835 64776 SG $486.72 $486.72 07-01-2012
2836 64782 SG $486.72 $486.72 07-01-2012
2837 64784 SG $486.72 $486.72 07-01-2012
2838 64786 SG $621.38 $621.38 07-01-2012
2839 64788 SG $486.72 $486.72 07-01-2012
2840 64790 SG $486.72 $486.72 07-01-2012
2841 64792 SG $621.38 $621.38 07-01-2012
2842 64795 SG $445.68 $445.68 07-01-2012
2843 64802 SG $445.68 $445.68 07-01-2012
2844 64820 SG $638.90 $638.90 07-01-2012
2845 64821 SG $636.74 $636.74 07-01-2012
2846 64822 SG $931.21 $931.21 07-01-2012
2847 64823 SG $931.21 $931.21 07-01-2012
2848 64831 SG $698.32 $698.32 07-01-2012
2849 64834 SG $580.35 $580.35 07-01-2012
2850 64835 SG $621.38 $621.38 07-01-2012
2851 64836 SG $621.38 $621.38 07-01-2012
2852 64840 SG $580.35 $580.35 07-01-2012
2853 64856 SG $580.35 $580.35 07-01-2012
2854 64857 SG $580.35 $580.35 07-01-2012
2855 64858 SG $580.35 $580.35 07-01-2012
2856 64861 SG $621.38 $621.38 07-01-2012
2857 64862 SG $621.38 $621.38 07-01-2012
2858 64864 SG $621.38 $621.38 07-01-2012
2859 64865 SG $698.32 $698.32 07-01-2012
2860 64885 SG $580.35 $580.35 07-01-2012
2861 64886 SG $580.35 $580.35 07-01-2012
2862 64890 SG $580.35 $580.35 07-01-2012
2863 64891 SG $580.35 $580.35 07-01-2012
2864 64892 SG $580.35 $580.35 07-01-2012
2865 64893 SG $580.35 $580.35 07-01-2012
2866 64895 SG $621.38 $621.38 07-01-2012
2867 64896 SG $621.38 $621.38 07-01-2012
2868 64897 SG $621.38 $621.38 07-01-2012
2869 64898 SG $621.38 $621.38 07-01-2012
2870 64905 SG $580.35 $580.35 07-01-2012
2871 64907 SG $507.89 $507.89 07-01-2012
2872 65091 SG $660.79 $660.79 07-01-2012
2873 65093 SG $660.79 $660.79 07-01-2012 X 65093 7/31/2018
2874 65101 SG $660.79 $660.79 07-01-2012
2875 65103 SG $660.79 $660.79 07-01-2012 X 65103 7/31/2018
2876 65105 SG $737.72 $737.72 07-01-2012 X 65105 7/31/2018
2877 65110 SG $793.52 $793.52 07-01-2012
2878 65112 SG $971.75 $971.75 07-01-2012
2879 65114 SG $971.75 $971.75 07-01-2012
2880 65130 SG $542.07 $542.07 07-01-2012 X 65130 7/31/2018
2881 65135 SG $501.03 $501.03 07-01-2012 X 65135 7/31/2018
2882 65140 SG $660.79 $660.79 07-01-2012 X 65140 7/31/2018
2883 65150 SG $501.03 $501.03 07-01-2012 X 65150 7/31/2018
2884 65155 SG $660.79 $660.79 07-01-2012 X 65155 7/31/2018
2885 65175 SG $379.24 $379.24 07-01-2012 X 65175 7/31/2018
2886 65235 SG $429.05 $429.05 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 39 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2887 65260 SG $488.34 $488.34 07-01-2012
2888 65265 SG $650.31 $650.31 07-01-2012
2889 65270 SG $451.69 $451.69 07-01-2012
2890 65272 SG $491.02 $491.02 07-01-2012
2891 65275 SG $609.00 $609.00 07-01-2012
2892 65280 SG $565.28 $565.28 07-01-2012
2893 65285 SG $733.15 $733.15 07-01-2012
2894 65286 SG $181.09 $181.09 07-01-2012
2895 65290 SG $540.49 $540.49 07-01-2012
2896 65400 SG $356.60 $356.60 07-01-2012
2897 65410 SG $429.05 $429.05 07-01-2012
2898 65420 SG $429.05 $429.05 07-01-2012
2899 65426 SG $664.77 $664.77 07-01-2012
2900 65435 SG $30.28 $30.28 07-01-2012
2901 65436 SG $572.34 $572.34 07-01-2012
2902 65450 SG $77.12 $77.12 07-01-2012
2903 65600 SG $153.68 $153.68 07-01-2012
2904 65710 SG $969.68 $969.68 07-01-2012
2905 65730 SG $969.68 $969.68 07-01-2012
2906 65750 SG $969.68 $969.68 07-01-2012
2907 65755 SG $969.68 $969.68 07-01-2012
2908 65756 SG $1,458.61 $1,458.61 01-01-2015
2909 65770 SG $1,388.32 $1,388.32 07-01-2012
2910 65772 SG $547.02 $547.02 07-01-2012
2911 65775 SG $547.02 $547.02 07-01-2012
2912 65800 SG $356.60 $356.60 07-01-2012
2913 65810 SG $532.05 $532.05 07-01-2012
2914 65815 SG $491.02 $491.02 07-01-2012
2915 65820 SG $258.78 $258.78 07-01-2012
2916 65850 SG $609.00 $609.00 07-01-2012
2917 65855 SG $126.99 $126.99 07-01-2012
2918 65860 SG $118.84 $118.84 07-01-2012
2919 65865 SG $356.60 $356.60 07-01-2012
2920 65870 SG $609.00 $609.00 07-01-2012
2921 65875 SG $609.00 $609.00 07-01-2012
2922 65880 SG $547.02 $547.02 07-01-2012
2923 65900 SG $602.81 $602.81 07-01-2012
2924 65920 SG $843.03 $843.03 07-01-2012
2925 65930 SG $664.77 $664.77 07-01-2012
2926 66020 SG $356.60 $356.60 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 40 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
2927 66030 SG $258.78 $258.78 07-01-2012
2928 66130 SG $843.03 $843.03 07-01-2012
2929 66150 SG $609.00 $609.00 07-01-2012
2930 66155 SG $609.00 $609.00 07-01-2012
2931 66160 SG $491.02 $491.02 07-01-2012
2932 66170 SG $609.00 $609.00 07-01-2012
2933 66172 SG $609.00 $609.00 07-01-2012
2934 66179 SG $1,458.61 $1,458.61 01-01-2015
2935 66180 SG $811.08 $811.08 07-01-2012
2936 66184 SG $818.69 $818.69 01-01-2015
2937 66185 SG $637.32 $637.32 07-01-2012
2938 66220 SG $656.22 $656.22 07-01-2012
2939 66225 SG $755.30 $755.30 07-01-2012
2940 66250 SG $429.05 $429.05 07-01-2012
2941 66500 SG $258.78 $258.78 07-01-2012
2942 66505 SG $258.78 $258.78 07-01-2012
2943 66600 SG $532.05 $532.05 07-01-2012
2944 66605 SG $532.05 $532.05 07-01-2012
2945 66625 SG $284.40 $284.40 07-01-2012
2946 66630 SG $532.05 $532.05 07-01-2012
2947 66635 SG $532.05 $532.05 07-01-2012
2948 66680 SG $532.05 $532.05 07-01-2012
2949 66682 SG $491.02 $491.02 07-01-2012
2950 66700 SG $429.05 $429.05 07-01-2012
2951 66710 SG $429.05 $429.05 07-01-2012
2952 66711 SG $429.05 $429.05 07-01-2012
2953 66720 SG $429.05 $429.05 07-01-2012
2954 66740 SG $491.02 $491.02 07-01-2012
2955 66761 SG $172.89 $172.89 07-01-2012
2956 66762 SG $175.18 $175.18 07-01-2012
2957 66770 SG $184.04 $184.04 07-01-2012
2958 66820 SG $181.09 $181.09 07-01-2012
2959 66821 SG $246.37 $246.37 07-01-2012
2960 66825 SG $609.00 $609.00 07-01-2012
2961 66830 SG $284.40 $284.40 07-01-2012
2962 66840 SG $535.92 $535.92 07-01-2012
2963 66850 SG $891.94 $891.94 07-01-2012
2964 66852 SG $657.91 $657.91 07-01-2012
2965 66920 SG $657.91 $657.91 07-01-2012
2966 66930 SG $713.69 $713.69 07-01-2012
2967 66940 SG $591.70 $591.70 07-01-2012
2968 66982 SG $835.01 $835.01 07-01-2012
2969 66983 SG $835.01 $835.01 07-01-2012
2970 66984 SG $835.01 $835.01 07-01-2012
2971 66985 SG $740.76 $740.76 07-01-2012
2972 66986 SG $740.76 $740.76 07-01-2012
2973 67005 SG $650.31 $650.31 07-01-2012
2974 67010 SG $650.31 $650.31 07-01-2012
2975 67015 SG $459.88 $459.88 07-01-2012
2976 67025 SG $459.88 $459.88 07-01-2012
2977 67027 SG $733.15 $733.15 07-01-2012
2978 67028 SG $77.13 $77.13 07-01-2012
2979 67030 SG $374.86 $374.86 07-01-2012
2980 67031 SG $246.37 $246.37 07-01-2012
2981 67036 SG $733.15 $733.15 07-01-2012
2982 67039 SG $967.17 $967.17 07-01-2012
2983 67040 SG $967.17 $967.17 07-01-2012
2984 67041 SG $1,347.28 $1,347.28 07-01-2012
2985 67042 SG $1,347.28 $1,347.28 07-01-2012
2986 67043 SG $1,347.28 $1,347.28 07-01-2012
2987 67101 SG $286.86 $286.86 07-01-2012
2988 67105 SG $184.04 $184.04 07-01-2012
2989 67107 SG $788.94 $788.94 07-01-2012
2990 67108 SG $967.17 $967.17 07-01-2012
2991 67110 SG $311.92 $311.92 07-01-2012
2992 67113 SG $1,347.28 $1,347.28 07-01-2012
2993 67115 SG $447.31 $447.31 07-01-2012
2994 67120 SG $447.31 $447.31 07-01-2012
2995 67121 SG $532.34 $532.34 07-01-2012
2996 67141 SG $191.59 $191.59 07-01-2012
2997 67145 SG $180.06 $180.06 07-01-2012
2998 67208 SG $191.78 $191.78 07-01-2012
2999 67210 SG $184.04 $184.04 07-01-2012
3000 67218 SG $621.07 $621.07 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 41 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
3001 67220 SG $146.27 $146.27 07-01-2012
3002 67221 SG $117.86 $117.86 07-01-2012
3003 67227 SG $459.88 $459.88 07-01-2012
3004 67228 SG $184.04 $184.04 07-01-2012
3005 67250 SG $492.72 $492.72 07-01-2012
3006 67255 SG $573.37 $573.37 07-01-2012
3007 67311 SG $540.49 $540.49 07-01-2012
3008 67312 SG $617.43 $617.43 07-01-2012
3009 67314 SG $617.43 $617.43 07-01-2012
3010 67316 SG $617.43 $617.43 07-01-2012
3011 67318 SG $617.43 $617.43 07-01-2012
3012 67343 SG $851.45 $851.45 07-01-2012
3013 67345 SG $77.49 $77.49 07-01-2012
3014 67346 SG $335.13 $335.13 07-01-2012
3015 67400 SG $542.07 $542.07 07-01-2012
3016 67405 SG $619.01 $619.01 07-01-2012
3017 67412 SG $674.79 $674.79 07-01-2012
3018 67413 SG $674.79 $674.79 07-01-2012
3019 67414 SG $1,335.17 $1,335.17 07-01-2012
3020 67415 SG $379.24 $379.24 07-01-2012
3021 67420 SG $793.52 $793.52 07-01-2012
3022 67430 SG $793.52 $793.52 07-01-2012
3023 67440 SG $793.52 $793.52 07-01-2012
3024 67445 SG $793.52 $793.52 07-01-2012
3025 67450 SG $793.52 $793.52 07-01-2012
3026 67500 SG $77.12 $77.12 07-01-2012
3027 67505 SG $102.71 $102.71 07-01-2012
3028 67515 SG $22.14 $22.14 07-01-2012
3029 67570 SG $737.72 $737.72 07-01-2012
3030 67700 SG $102.71 $102.71 07-01-2012
3031 67710 SG $147.81 $147.81 07-01-2012
3032 67715 SG $379.24 $379.24 07-01-2012
3033 67800 SG $48.84 $48.84 07-01-2012
3034 67801 SG $59.26 $59.26 07-01-2012
3035 67805 SG $76.51 $76.51 07-01-2012
3036 67808 SG $451.69 $451.69 07-01-2012
3037 67810 SG $102.71 $102.71 07-01-2012
3038 67825 SG $51.13 $51.13 07-01-2012
3039 67830 SG $350.42 $350.42 07-01-2012
3040 67835 SG $451.69 $451.69 07-01-2012
3041 67840 SG $152.70 $152.70 07-01-2012
3042 67850 SG $108.43 $108.43 07-01-2012
3043 67875 SG $257.83 $257.83 07-01-2012
3044 67880 SG $470.09 $470.09 07-01-2012
3045 67882 SG $492.72 $492.72 07-01-2012
3046 67901 SG $625.45 $625.45 07-01-2012
3047 67902 SG $625.45 $625.45 07-01-2012
3048 67903 SG $569.66 $569.66 07-01-2012
3049 67904 SG $569.66 $569.66 07-01-2012
3050 67906 SG $625.45 $625.45 07-01-2012
3051 67908 SG $569.66 $569.66 07-01-2012
3052 67909 SG $569.66 $569.66 07-01-2012
3053 67911 SG $492.72 $492.72 07-01-2012
3054 67912 SG $492.72 $492.72 07-01-2012
3055 67914 SG $492.72 $492.72 07-01-2012
3056 67915 SG $167.69 $167.69 07-01-2012
3057 67916 SG $569.66 $569.66 07-01-2012
3058 67917 SG $569.66 $569.66 07-01-2012
3059 67921 SG $492.72 $492.72 07-01-2012
3060 67922 SG $164.10 $164.10 07-01-2012
3061 67923 SG $569.66 $569.66 07-01-2012
3062 67924 SG $569.66 $569.66 07-01-2012
3063 67930 SG $164.10 $164.10 07-01-2012
3064 67935 SG $451.69 $451.69 07-01-2012
3065 67938 SG $77.13 $77.13 07-01-2012
3066 67950 SG $451.69 $451.69 07-01-2012
3067 67961 SG $492.72 $492.72 07-01-2012
3068 67966 SG $492.72 $492.72 07-01-2012
3069 67971 SG $542.07 $542.07 07-01-2012
3070 67973 SG $542.07 $542.07 07-01-2012
3071 67974 SG $542.07 $542.07 07-01-2012
3072 67975 SG $492.72 $492.72 07-01-2012
3073 68020 SG $42.97 $42.97 07-01-2012
3074 68040 SG $21.49 $21.49 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 42 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
3075 68100 SG $91.49 $91.49 07-01-2012
3076 68110 SG $116.88 $116.88 07-01-2012
3077 68115 SG $451.69 $451.69 07-01-2012
3078 68130 SG $429.05 $429.05 07-01-2012
3079 68135 SG $55.35 $55.35 07-01-2012
3080 68320 SG $569.66 $569.66 07-01-2012
3081 68325 SG $619.01 $619.01 07-01-2012
3082 68326 SG $619.01 $619.01 07-01-2012
3083 68328 SG $619.01 $619.01 07-01-2012
3084 68330 SG $609.00 $609.00 07-01-2012
3085 68335 SG $619.01 $619.01 07-01-2012
3086 68340 SG $569.66 $569.66 07-01-2012
3087 68360 SG $491.02 $491.02 07-01-2012
3088 68362 SG $491.02 $491.02 07-01-2012
3089 68400 SG $102.71 $102.71 07-01-2012
3090 68420 SG $175.50 $175.50 07-01-2012
3091 68440 SG $54.38 $54.38 07-01-2012
3092 68500 SG $542.07 $542.07 07-01-2012
3093 68505 SG $542.07 $542.07 07-01-2012
3094 68510 SG $379.24 $379.24 07-01-2012
3095 68520 SG $542.07 $542.07 07-01-2012
3096 68525 SG $379.24 $379.24 07-01-2012
3097 68530 SG $224.34 $224.34 07-01-2012
3098 68540 SG $542.07 $542.07 07-01-2012
3099 68550 SG $542.07 $542.07 07-01-2012
3100 68700 SG $501.03 $501.03 07-01-2012
3101 68705 SG $102.71 $102.71 07-01-2012
3102 68720 SG $619.01 $619.01 07-01-2012
3103 68745 SG $619.01 $619.01 07-01-2012
3104 68750 SG $619.01 $619.01 07-01-2012
3105 68760 SG $77.12 $77.12 07-01-2012
3106 68761 SG $66.75 $66.75 07-01-2012
3107 68770 SG $569.66 $569.66 07-01-2012
3108 68810 SG $103.82 $103.82 07-01-2012
3109 68811 SG $451.69 $451.69 07-01-2012
3110 68815 SG $451.69 $451.69 07-01-2012
3111 68816 SG $666.16 $666.16 07-01-2013
3112 68840 SG $50.46 $50.46 07-01-2012
3113 69000 SG $49.78 $49.78 07-01-2012
3114 69005 SG $96.38 $96.38 07-01-2012
3115 69020 SG $49.78 $49.78 07-01-2012
3116 69100 SG $57.96 $57.96 07-01-2012
3117 69105 SG $81.08 $81.08 07-01-2012
3118 69110 SG $355.97 $355.97 07-01-2012
3119 69120 SG $498.10 $498.10 07-01-2012
3120 69140 SG $498.10 $498.10 07-01-2012
3121 69145 SG $428.42 $428.42 07-01-2012
3122 69150 SG $363.49 $363.49 07-01-2012
3123 69205 SG $400.29 $400.29 07-01-2012
3124 69222 SG $127.31 $127.31 07-01-2012
3125 69310 SG $679.84 $679.84 07-01-2012
3126 69320 SG $990.80 $990.80 07-01-2012
3127 69420 SG $88.49 $88.49 07-01-2012
3128 69421 SG $471.48 $471.48 07-01-2012
3129 69424 SG $73.59 $73.59 07-01-2012
3130 69433 SG $104.52 $104.52 07-01-2012
3131 69436 SG $471.48 $471.48 07-01-2012
3132 69440 SG $539.14 $539.14 07-01-2012
3133 69450 SG $566.34 $566.34 07-01-2012
3134 69501 SG $990.80 $990.80 07-01-2012
3135 69502 SG $850.10 $850.10 07-01-2012
3136 69505 SG $990.80 $990.80 07-01-2012
3137 69511 SG $990.80 $990.80 07-01-2012
3138 69530 SG $990.80 $990.80 07-01-2012
3139 69540 SG $124.37 $124.37 07-01-2012
3140 69550 SG $812.55 $812.55 07-01-2012
3141 69552 SG $990.80 $990.80 07-01-2012
3142 69601 SG $990.80 $990.80 07-01-2012
3143 69602 SG $990.80 $990.80 07-01-2012
3144 69603 SG $990.80 $990.80 07-01-2012
3145 69604 SG $990.80 $990.80 07-01-2012
3146 69605 SG $990.80 $990.80 07-01-2012
3147 69610 SG $170.62 $170.62 07-01-2012
3148 69620 SG $498.10 $498.10 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 43 of 44
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice
Clinical Coverage Policies on the Medicaid Web site.
EFFECTIVE CODE END
PCODE MODIFIER FACILITY NON-FACILITY DATE X ENDED DATED
Ambulatory Surgical Center Fee Schedule
Pricing Specialty 068
Taxonomy 261QA1903X
3149 69631 SG $812.55 $812.55 07-01-2012
3150 69632 SG $812.55 $812.55 07-01-2012
3151 69633 SG $812.55 $812.55 07-01-2012
3152 69635 SG $990.80 $990.80 07-01-2012
3153 69636 SG $990.80 $990.80 07-01-2012
3154 69637 SG $990.80 $990.80 07-01-2012
3155 69641 SG $990.80 $990.80 07-01-2012
3156 69642 SG $990.80 $990.80 07-01-2012
3157 69643 SG $990.80 $990.80 07-01-2012
3158 69644 SG $990.80 $990.80 07-01-2012
3159 69645 SG $990.80 $990.80 07-01-2012
3160 69646 SG $990.80 $990.80 07-01-2012
3161 69650 SG $850.10 $850.10 07-01-2012
3162 69660 SG $812.55 $812.55 07-01-2012
3163 69661 SG $812.55 $812.55 07-01-2012
3164 69662 SG $812.55 $812.55 07-01-2012
3165 69666 SG $756.78 $756.78 07-01-2012
3166 69667 SG $756.78 $756.78 07-01-2012
3167 69670 SG $679.84 $679.84 07-01-2012
3168 69676 SG $679.84 $679.84 07-01-2012
3169 69700 SG $679.84 $679.84 07-01-2012
3170 69711 SG $566.34 $566.34 07-01-2012 X 69711 7/31/2018
3171 69714 SG $6,324.00 $6,324.00 02-01-2013
3172 69715 SG $6,324.00 $6,324.00 02-01-2013
3173 69717 SG $6,324.00 $6,324.00 02-01-2013
3174 69718 SG $6,324.00 $6,324.00 02-01-2013
3175 69720 SG $812.55 $812.55 07-01-2012
3176 69740 SG $812.55 $812.55 07-01-2012
3177 69745 SG $812.55 $812.55 07-01-2012
3178 69801 SG $812.55 $812.55 07-01-2012
3179 69805 SG $990.80 $990.80 07-01-2012
3180 69806 SG $990.80 $990.80 07-01-2012
3181 69820 SG $812.55 $812.55 07-01-2012
3182 69840 SG $812.55 $812.55 07-01-2012
3183 69905 SG $990.80 $990.80 07-01-2012
3184 69910 SG $990.80 $990.80 07-01-2012
3185 69915 SG $990.80 $990.80 07-01-2012
3186 69930 SG $979.75 $979.75 07-01-2012
3187 71010 SG $13.67 $13.67 07-01-2012
3188 71020 SG $18.24 $18.24 07-01-2012
3189 72083 SG $101.98 $101.98 01-01-2016
3190 72084 SG $101.98 $101.98 01-01-2016
3191 74176 SG $118.65 $118.65 01-01-2013
3192 74177 SG $217.07 $217.07 01-01-2013
3193 74178 SG $217.07 $217.07 01-01-2013
3194 76881 SG $44.67 $44.67 01-01-2013
3195 76978 SG $88.03 $88.03 01-01-2019
3196 77046 SG $100.61 $100.61 01-01-2019
3197 77047 SG $100.61 $100.61 01-01-2019
3198 77306 SG $52.86 $52.86 01-01-2015
3199 77307 SG $52.86 $52.86 01-01-2015
3200 77316 SG $52.86 $52.86 01-01-2015
3201 77317 SG $125.88 $125.88 01-01-2015
3202 77318 SG $146.94 $146.94 01-01-2015
3203 77338 SG $97.15 $97.15 07-01-2012
DMA Provider Reimbursement/ Updated 03/2018 44 of 44
