License for Use of Current Procedural Terminology, Fourth Edition (CPT)

NOTE: CPT codes and descriptions only are copyright 1999-2012, American Medical Association. All Rights Reserved (or such other date of publication of CPT). Applicable FARS/DFARS apply.

You, your employees and agents are authorized to use CPT internally within your organization for the sole use by yourself, employees and agents. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. You should contact CPT Intellectual Property Services, American Medical Association, 515 N. State Street, Chicago, Illinois 60610 or at telephone number 312-464-5022 or at facsimile number 312-464-5131, should you wish to make additional uses of CPT.

Applicable FARS/DFARS Restrictions Apply to Government Use. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)(June 1995), as applicable for U.S. Departmentof Defense procurements and the limited rights restrictions of FAR 52.227-14(June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14(June 1987) and FAR 52.227-19(June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

Disclaimer of Warranties and Liabilities CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is the Health Care Financing Administration and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement. 7/15/2013

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

00100 $42.90

00102 $42.90

00103 $42.90

00104 $42.90

00120 $42.90

00124 $42.90

00126 $42.90

00140 $42.90

00142 $42.90

00144 $42.90

00145 $42.90

00147 $42.90

00148 $42.90

00160 $42.90

00162 $42.90

00164 $42.90

00170 $42.90

00172 $42.90

00174 $42.90

00176 $42.90

00190 $42.90

00192 $42.90

00210 $42.90

00211 $42.90

00212 $42.90

00214 $42.90

00215 $42.90

00216 $42.90

00218 $42.90

00220 $42.90

00222 $42.90

00300 $42.90

00320 $42.90

00322 $42.90

00326 $42.90

00350 $42.90

00352 $42.90

00400 $42.90

00402 $42.90

00404 $42.90

00406 $42.90

00410 $42.90

00450 $42.90

00452 $42.90

00454 $42.90

00470 $42.90

00472 $42.90

00474 $42.90

00500 $42.90

00520 $42.90

00522 $42.90

00524 $42.90

00528 $42.90

00529 $42.90

1

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

00530 $42.90

00532 $42.90

00534 $42.90

00537 $42.90

00539 $42.90

00540 $42.90

00541 $42.90

00542 $42.90

00546 $42.90

00548 $42.90

00550 $42.90

00560 $42.90

00561 $42.90

00562 $42.90

00563 $42.90

00566 $42.90

00567 $42.90

00580 $42.90

00600 $42.90

00604 $42.90

00620 $42.90

00622 $42.90

00625 $42.90

00626 $42.90

00630 $42.90

00632 $42.90

00634 $42.90

00635 $42.90

00640 $42.90

00670 $42.90

00700 $42.90

00702 $42.90

00730 $42.90

00740 $42.90

00750 $42.90

00752 $42.90

00754 $42.90

00756 $42.90

00770 $42.90

00790 $42.90

00792 $42.90

00794 $42.90

00796 $42.90

00797 $42.90

00800 $42.90

00802 $42.90

00810 $42.90

00820 $42.90

00830 $42.90

00832 $42.90

00834 $42.90

00836 $42.90

00840 $42.90

00842 $42.90

2

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

00844 $42.90

00846 $42.90

00848 $42.90

00851 $42.90

00860 $42.90

00862 $42.90

00864 $42.90

00865 $42.90

00866 $42.90

00868 $42.90

00870 $42.90

00872 $42.90

00873 $42.90

00880 $42.90

00882 $42.90

00902 $42.90

00904 $42.90

00906 $42.90

00908 $42.90

00910 $42.90

00912 $42.90

00914 $42.90

00916 $42.90

00918 $42.90

00920 $42.90

00921 $42.90

00922 $42.90

00924 $42.90

00926 $42.90

00928 $42.90

00930 $42.90

00932 $42.90

00934 $42.90

00936 $42.90

00938 $42.90

00940 $42.90

00942 $42.90

00944 $42.90

00948 $42.90

00950 $42.90

00952 $42.90

01112 $42.90

01120 $42.90

01130 $42.90

01140 $42.90

01150 $42.90

01160 $42.90

01170 $42.90

01173 $42.90

01180 $42.90

01190 $42.90

01200 $42.90

01202 $42.90

01210 $42.90

3

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

01212 $42.90

01214 $42.90

01215 $42.90

01220 $42.90

01230 $42.90

01232 $42.90

01234 $42.90

01250 $42.90

01260 $42.90

01270 $42.90

01272 $42.90

01274 $42.90

01320 $42.90

01340 $42.90

01360 $42.90

01380 $42.90

01382 $42.90

01390 $42.90

01392 $42.90

01400 $42.90

01402 $42.90

01404 $42.90

01420 $42.90

01430 $42.90

01432 $42.90

01440 $42.90

01442 $42.90

01444 $42.90

01462 $42.90

01464 $42.90

01470 $42.90

01472 $42.90

01474 $42.90

01480 $42.90

01482 $42.90

01484 $42.90

01486 $42.90

01490 $42.90

01500 $42.90

01502 $42.90

01520 $42.90

01522 $42.90

01610 $42.90

01620 $42.90

01622 $42.90

01630 $42.90

01634 $42.90

01636 $42.90

01638 $42.90

01650 $42.90

01652 $42.90

01654 $42.90

01656 $42.90

01670 $42.90

4

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

01680 $42.90

01682 $42.90

01710 $42.90

01712 $42.90

01714 $42.90

01716 $42.90

01730 $42.90

01732 $42.90

01740 $42.90

01742 $42.90

01744 $42.90

01756 $42.90

01758 $42.90

01760 $42.90

01770 $42.90

01772 $42.90

01780 $42.90

01782 $42.90

01810 $42.90

01820 $42.90

01829 $42.90

01830 $42.90

01832 $42.90

01840 $42.90

01842 $42.90

01844 $42.90

01850 $42.90

01852 $42.90

01860 $42.90

01916 $42.90

01920 $42.90

01922 $42.90

01924 $42.90

01925 $42.90

01926 $42.90

01930 $42.90

01931 $42.90

01932 $42.90

01933 $42.90

01935 $42.90

01936 $42.90

01951 $42.90

01952 $42.90

01953 By Report

01958 $42.90

01960 $42.90

01961 $42.90

01962 $42.90

01963 $42.90

01967 $42.90

01968 $42.90

01969 $42.90

01990 $42.90*

01991 $42.90

5

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

01992 $42.90

01996 $42.89

10021 $237.41

10022 $220.68

10040 $165.20

10060 $187.54

10061 $334.94

10080 $280.82

10081 $434.62

10120 $240.40

10121 $442.88

10140 $261.01

10160 $208.44

10180 $391.91

11000 $88.25

11001 $35.42

11004 $985.84

11005 $1,321.50

11006 $1,199.82

11008 $464.10

11010 $781.41

11011 $851.30

11012 $1,130.14

11042 $186.15

11043 $373.91

11044 $520.10

11045 $67.99

11046 $121.03

11047 $205.02

11055 $74.38

11056 $91.94

11057 $104.72

11100 $163.49

11101 $52.98

11300 $151.35

11301 $188.50

11302 $222.15

11303 $245.88

11305 $155.59

11306 $191.28

11307 $227.27

11308 $244.47

11310 $177.65

11311 $178.44

11312 $254.14

11313 $295.54

11400 $193.76

11401 $236.05

11402 $262.55

11403 $305.21

11404 $346.20

11406 $502.57

11420 $194.85

11421 $251.34

6

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

11422 $280.05

11423 $324.43

11424 $374.19

11426 $539.23

11440 $213.17

11441 $267.45

11442 $299.43

11443 $359.58

11444 $453.92

11446 $632.24

11450 $599.98

11451 $769.17

11462 $585.62

11463 $768.10

11470 $656.84

11471 $820.98

11600 $304.43

11601 $363.27

11602 $394.83

11603 $452.38

11604 $503.77

11606 $725.49

11620 $308.46

11621 $365.85

11622 $408.97

11623 $482.58

11624 $544.07

11626 $659.17

11640 $317.65

11641 $378.72

11642 $433.73

11643 $515.44

11644 $636.43

11646 $836.90

11720 $51.60

11721 $72.92

11730 $160.10

11732 $58.24

11740 $77.45

11750 $363.21

11752 $522.72

11755 $216.26

11760 $365.20

11762 $459.59

11765 $261.47

11770 $442.67

11771 $915.31

11772 $1,113.58

11900 $88.73

11901 $113.05

11920 $273.95*

11921 $317.35*

11960 $1,518.82#

11970 $1,003.05

7

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

11971 $741.18

11976 $235.80

11980 $170.49

11981 $219.11

11982 $249.82

11983 $356.75

12001 $143.91

12002 $176.10

12004 $208.28

12005 $271.01

12006 $327.47

12007 $375.44

12011 $176.17

12013 $193.74

12014 $228.63

12015 $279.81

12016 $350.85

12017 $267.82

12018 $345.05

12020 $449.47

12021 $276.04

12031 $376.56

12032 $480.78

12034 $497.86

12035 $615.47

12036 $676.97

12037 $749.96

12041 $383.76

12042 $461.55

12044 $571.15

12045 $640.60

12046 $840.47

12047 $925.55

12051 $411.42

12052 $470.58

12053 $551.50

12054 $589.77

12055 $754.49

12056 $876.86

12057 $895.99

13100 $530.57

13101 $629.43

13102 $195.01

13120 $557.45

13121 $681.41

13122 $215.10

13131 $616.13

13132 $763.64

13133 $290.41

13150 $596.95

13151 $677.71

13152 $768.95

13153 $315.38

13160 $1,344.88

8

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

14000 $1,000.74

14001 $1,291.28

14020 $1,122.01

14021 $1,410.78

14040 $1,238.20

14041 $1,531.07

14060 $1,266.31

14061 $1,643.01

14301 $1,751.20

14302 $371.01

14350 $1,194.02

15002 $560.01

15003 $122.19

15004 $652.34

15005 $203.42

15040 $405.31

15050 $913.80

15100 $1,390.25

15101 $296.59

15110 $1,418.39

15111 $191.21

15115 $1,424.13

15116 $253.50

15120 $1,384.69

15121 $331.63

15130 $1,088.67

15131 $150.76

15135 $1,435.00

15136 $156.49

15150 $1,134.16

15151 $199.13

15152 $259.24

15155 $1,273.51

15156 $268.50

15157 $315.02

15200 $1,340.48

15201 $235.73

15220 $1,242.33

15221 $217.97

15240 $1,512.36

15241 $296.62

15260 $1,647.89

15261 $348.05

15271 $217.40

15272 $41.57

15273 $442.81

15274 $100.80

15275 $247.60

15276 $56.94

15277 $488.47

15278 $121.84

15570 $1,475.90#

15572 $1,423.68#

15574 $1,484.23*

9

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

15576 $1,318.52#

15600 $504.37

15610 $556.06

15620 $698.57

15630 $734.39

15650 $808.10

15731 $1,856.43

15732 $2,123.49

15734 $2,457.53

15736 $2,164.96

15738 $2,312.83

15740 $1,651.96

15750 $1,514.77

15756 $3,928.35

15757 $3,897.86

15758 $3,889.17

15760 $1,393.82

15770 $1,115.14

15777 $339.16#

15780 $1,466.83*

15781 $883.66*

15783 $775.13

15786 $392.76*

15787 $77.93*

15823 $1,008.65*

15830 $1,941.36#

15832 $1,541.99*

15839 $1,419.01*

15840 $1,702.43

15841 $2,721.05

15842 $4,463.42

15845 $1,700.57

15850 $138.64

15851 $158.06

15852 $79.70

15920 $1,001.15

15922 $1,289.02

15931 $1,129.64

15933 $1,399.05

15934 $1,532.27

15935 $1,827.01

15936 $1,483.98

15937 $1,722.99

15940 $1,153.69

15941 $1,497.28

15944 $1,489.37

15945 $1,634.84

15946 $2,719.40

15950 $962.40

15951 $1,324.70

15952 $1,500.74

15953 $1,645.54

15956 $1,914.51

15958 $1,946.33

10

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

16000 $113.18

16020 $129.19

16025 $239.52

16030 $296.82

16035 $342.02

16036 $138.09

17000 $128.39

17003 $10.75

17004 $274.07

17106 $544.79

17107 $707.96

17108 $1,037.87

17110 $172.90

17111 $207.09

17250 $124.23

17260 $151.39#

17261 $228.07#

17262 $279.14#

17263 $305.64#

17264 $328.10#

17266 $373.24#

17270 $240.19#

17271 $261.13#

17272 $298.08#

17273 $333.41#

17274 $395.73#

17276 $461.08#

17280 $223.77#

17281 $285.14#

17282 $327.95#

17283 $395.08#

17284 $451.74#

17286 $589.16#

17311 $1,039.02

17312 $615.23

17313 $946.41

17314 $570.44

17315 $125.90

17340 $85.86

17360 $209.52

19000 $174.60

19001 $44.57

19020 $748.22

19030 $255.39

19100 $238.59

19101 $544.79

19102 $340.58

19103 $858.14

19105 $2,912.46

19110 $777.91

19112 $733.59

19120 $797.47

19125 $886.84

19126 $271.27

11

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

19260 $2,006.67

19271 $2,679.17

19272 $2,968.80

19290 $247.36

19291 $107.50

19295 $134.27

19296 $6,128.63

19297 $158.61

19298 $1,747.20

19300 $832.79*

19301 $1,079.11*

19302 $1,487.28*

19303 $1,673.05*

19304 $942.64*

19305 $1,869.24*

19306 $1,981.14*

19307 $1,975.90*

19316 $1,274.06*

19318 $1,838.45#

19325 $1,065.25*

19328 $815.45#

19330 $1,045.19#

19340 $1,664.68#

19342 $1,528.12*

19350 $1,333.51#

19355 $1,138.54#

19357 $2,469.92#

19361 $2,634.48#

19364 $4,625.00#

19366 $2,327.13#

19367 $2,992.92#

19368 $3,695.25#

19369 $3,427.63#

19370 $1,131.91#

19371 $1,297.26#

19380 $1,277.64#

20005 $504.24

20100 $1,015.17

20101 $715.72

20102 $777.56

20103 $929.22

20150 $1,662.28

20200 $323.31

20205 $455.54

20206 $355.69

20220 $261.90

20225 $801.04

20240 $370.02

20245 $1,032.28

20250 $631.69

20251 $683.22

20500 $173.39

20501 $179.99

20520 $324.26

12

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

20525 $759.02

20526 $123.36

20527 $124.34

20550 $95.40

20551 $98.28

20552 $90.01

20553 $104.68

20555 $567.36

20600 $78.05

20605 $109.19

20610 $98.32

20612 $97.78

20615 $387.82

20650 $333.74

20660 $399.76

20661 $799.86

20662 $715.18

20663 $760.09

20664 $1,377.97

20665 $170.82

20670 $590.07

20680 $995.49

20690 $978.81

20692 $1,852.54

20693 $746.35

20694 $679.81

20696 $1,947.91

20697 $3,088.89

20802 $4,020.43

20808 $6,128.51

20816 $3,354.50

20900 $661.95

20902 $508.03

20910 $739.44

20920 $660.47

20922 $990.23

20924 $827.97

20926 $720.80

20930 $300.00

20931 $182.85

20936 $243.75

20937 $277.68

20938 $302.86

20950 $393.97

20955 $4,224.98

20956 $4,394.73

20957 $3,877.68

20969 $4,727.29

20970 $4,590.96

20974 $119.90

20975 $290.47

20979 $85.70*

20982 $5,223.37

20985 $246.80

13

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

21010 $1,275.14

21011 $553.23

21012 $552.74

21013 $837.22

21014 $858.01

21015 $1,169.68

21016 $1,715.13

21025 $1,446.08

21026 $992.72

21029 $1,259.69

21030 $832.72

21031 $623.13

21032 $635.69

21034 $2,191.66

21040 $837.20

21044 $1,479.80

21045 $2,057.75

21046 $1,826.07

21047 $2,190.92

21048 $1,875.66

21049 $2,064.84

21050 $1,428.61

21060 $1,351.32

21070 $1,063.16

21073 $619.69

21076 $1,639.80

21077 $4,113.89

21082 $2,707.30*

21083 $2,541.62*

21084 $2,943.09*

21085 $1,303.07*

21086 $3,061.74*

21087 $3,035.91*

21100 $957.25

21110 $1,269.96

21116 $234.92

21120 $990.71*

21121 $1,250.93*

21122 $1,159.48*

21123 $1,453.50*

21125 $5,235.46*

21127 $5,941.44*

21141 $2,251.09

21142 $2,316.22

21143 $2,438.52

21145 $2,564.27*

21146 $2,687.53*

21147 $2,942.96*

21150 $2,641.91*

21151 $3,144.26*

21154 $3,381.04*

21155 $3,694.89*

21159 $4,382.04*

21160 $4,545.16*

14

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

21172 $3,140.57*

21175 $3,871.46#

21179 $2,375.87*

21180 $2,612.92*

21181 $1,124.58*

21182 $3,553.23*

21183 $3,947.76*

21184 $3,730.37*

21188 $2,646.02*

21193 $2,069.07*

21194 $2,317.73*

21195 $2,243.26*

21196 $2,459.73*

21198 $1,926.64*

21199 $1,716.84

21206 $2,051.28*

21208 $3,002.38

21209 $1,342.49

21210 $3,563.21

21215 $6,224.06

21230 $1,228.24

21235 $1,186.87

21240 $1,843.35

21242 $1,683.55

21243 $2,792.99

21244 $1,764.29

21245 $1,837.31

21246 $1,392.63

21247 $2,645.30*

21248 $1,801.47

21249 $2,477.75

21255 $2,218.09*

21256 $2,053.96*

21260 $2,086.21

21261 $3,623.00

21263 $3,223.86

21267 $2,716.03

21268 $2,975.83

21270 $1,590.43

21275 $1,392.72

21280 $960.34

21282 $629.49

21310 $205.62

21315 $445.10

21320 $410.54

21325 $751.28

21330 $919.25

21335 $1,201.28

21336 $1,052.71

21337 $652.06

21338 $1,203.40

21339 $1,370.74

21340 $1,370.35

21343 $1,989.73

15

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

21344 $2,499.50

21345 $1,365.65

21346 $1,509.77

21347 $1,827.79

21348 $1,983.00

21355 $703.98

21356 $810.06

21360 $886.22

21365 $1,864.64

21366 $2,130.75

21385 $1,145.93

21386 $1,156.40

21387 $1,216.93

21390 $1,339.17

21395 $1,655.07

21400 $308.43

21401 $743.53

21406 $931.10

21407 $1,086.41

21408 $1,479.34

21421 $1,273.90

21422 $1,102.55

21423 $1,364.09

21431 $1,197.93

21432 $1,173.17

21433 $2,920.83

21435 $2,304.00

21436 $3,025.64

21440 $910.12

21445 $1,223.28

21450 $965.01

21451 $1,207.63

21452 $868.50

21453 $1,450.99

21454 $901.60

21461 $3,329.04

21462 $3,523.42

21465 $1,553.56

21470 $2,012.22

21480 $154.05

21485 $1,106.42

21490 $1,533.58

21495 $1,158.32

21497 $1,167.04

21501 $729.19

21502 $835.49

21510 $733.53

21550 $415.90

21552 $737.66

21554 $1,213.68

21555 $668.45

21556 $884.74

21557 $1,602.15

21558 $2,246.70

16

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

21600 $922.45

21610 $1,819.18

21615 $1,073.93

21616 $1,388.21

21620 $845.85

21630 $2,042.45

21632 $2,036.25

21685 $1,686.49

21700 $627.76

21705 $941.90

21720 $827.10

21725 $813.77

21740 $2,005.30

21750 $1,156.73

21800 $181.41

21805 $430.81

21810 $853.26

21820 $227.90

21825 $903.21

21920 $413.74

21925 $720.83

21930 $763.01

21931 $777.13

21932 $1,092.54

21933 $1,220.72

21935 $1,711.90

21936 $2,350.33

22010 $1,536.98

22015 $1,473.60

22100 $1,467.84

22101 $1,393.13

22102 $1,313.45

22103 $232.83

22110 $1,716.48

22112 $1,702.82

22114 $1,642.72

22116 $230.30

22206 $3,926.06

22207 $3,928.06

22208 $969.62

22210 $2,885.29

22212 $2,411.87

22214 $2,420.25

22216 $602.52

22220 $2,639.61

22222 $2,419.14

22224 $2,604.51

22226 $602.21

22305 $309.98

22310 $498.66

22315 $1,412.59

22318 $2,624.36

22319 $2,919.82

22325 $2,333.47

17

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

22326 $2,406.27

22327 $2,415.86

22328 $463.61

22505 $205.68

22520 $3,446.41

22521 $3,439.60

22522 $388.02

22523 $11,385.49

22524 $11,310.62

22525 $6,991.19

22526 $3,601.52

22527 $2,968.89

22532 $2,900.86

22533 $2,745.63

22534 $599.33

22548 $3,136.09#

22551 $2,785.46

22552 $650.28

22554 $2,052.56#

22556 $2,724.02#

22558 $2,542.89#

22585 $550.97#

22586 $2,588.06

22590 $2,542.54#

22595 $2,422.83#

22600 $2,080.28#

22610 $2,045.17#

22612 $2,609.54#

22614 $644.79#

22630 $2,512.43#

22632 $525.26#

22633 $3,015.12

22634 $817.98

22800 $2,218.18#

22802 $3,459.08#

22804 $3,991.59#

22808 $2,993.26#

22810 $3,348.67#

22812 $3,673.80#

22818 $3,657.47

22819 $4,396.12

22830 $1,322.51#

22840 $1,256.80#

22841 $450.00#

22842 $1,259.27#

22843 $1,343.68#

22844 $1,630.63#

22845 $1,205.90#

22846 $1,251.59#

22847 $1,409.06#

22848 $595.32#

22849 $2,126.06#

22850 $1,174.76

22851 $672.73#

18

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

22852 $1,125.64#

22855 $1,815.77#

22856 $2,704.35#

22857 $2,446.01#

22861 $3,642.56#

22862 $3,194.75#

22864 $3,247.52

22865 $3,466.89#

22900 $930.44

22901 $1,099.72

22902 $698.27

22903 $720.72

22904 $1,751.34

22905 $2,219.05

23000 $923.50

23020 $1,128.90

23030 $698.55

23031 $661.76

23035 $1,113.06

23040 $1,177.53

23044 $929.18

23065 $353.06

23066 $865.35

23071 $689.87

23073 $1,141.40

23075 $747.44

23076 $883.39

23077 $1,890.98

23078 $2,387.47

23100 $811.59

23101 $724.48

23105 $1,043.07

23106 $804.67

23107 $1,081.79

23120 $952.82

23125 $1,158.54

23130 $990.68

23140 $868.40

23145 $1,134.99

23146 $1,010.74

23150 $1,081.13

23155 $1,297.29

23156 $1,106.82

23170 $911.29

23172 $921.60

23174 $1,236.81

23180 $1,093.30

23182 $1,079.02

23184 $1,201.50

23190 $928.65

23195 $1,236.00

23200 $2,505.38

23210 $2,949.48

23220 $3,244.18

19

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

23330 $424.79

23331 $963.45

23332 $1,450.11

23350 $201.33

23395 $2,120.99

23397 $1,880.52

23400 $1,595.06

23405 $1,027.97

23406 $1,269.70

23410 $1,349.19

23412 $1,401.58

23415 $1,136.72

23420 $1,592.69

23430 $1,227.66

23440 $1,242.62

23450 $1,560.73

23455 $1,654.34

23460 $1,793.77

23462 $1,761.39

23465 $1,842.78

23466 $1,846.20

23470 $1,993.56

23472 $2,424.78

23473 $2,706.21

23474 $2,926.03

23480 $1,346.11

23485 $1,579.46

23490 $1,414.46

23491 $1,667.43

23500 $351.24

23505 $567.01

23515 $1,180.56

23520 $367.56

23525 $601.94

23530 $932.19

23532 $1,016.53

23540 $361.15

23545 $557.12

23550 $931.64

23552 $1,075.26

23570 $371.31

23575 $640.72

23585 $1,621.78

23600 $520.43

23605 $747.41

23615 $1,454.50

23616 $2,053.28

23620 $430.08

23625 $611.36

23630 $1,282.89

23650 $511.04

23655 $648.19

23660 $953.02

23665 $684.05

20

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

23670 $1,443.58

23675 $885.08

23680 $1,528.19

23700 $319.46

23800 $1,686.29

23802 $2,111.42

23900 $2,291.84

23920 $1,854.05

23921 $764.79

23930 $562.27

23931 $446.29

23935 $825.25

24000 $775.24

24006 $1,167.02

24065 $409.82

24066 $987.11

24071 $667.56

24073 $1,138.59

24075 $781.88

24076 $890.16

24077 $1,720.10

24079 $2,198.48

24100 $676.24

24101 $812.28

24102 $1,006.35

24105 $562.21

24110 $955.78

24115 $1,206.23

24116 $1,414.68

24120 $862.07

24125 $1,010.47

24126 $1,058.16

24130 $824.36

24134 $1,221.86

24136 $1,028.78

24138 $1,095.61

24140 $1,148.74

24145 $964.30

24147 $1,009.93

24149 $1,922.93

24150 $2,573.20

24152 $2,230.04

24155 $1,400.54

24160 $988.34

24164 $809.40

24200 $325.68

24201 $883.92

24220 $252.92

24300 $660.57

24301 $1,224.43

24305 $942.36

24310 $777.27

24320 $1,279.11

24330 $1,173.34

21

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

24331 $1,288.15

24332 $996.20

24340 $1,003.27

24341 $1,218.08

24342 $1,276.56

24343 $1,150.35

24344 $1,797.99

24345 $1,145.09

24346 $1,799.90

24357 $715.12

24358 $851.55

24359 $1,079.87

24360 $1,474.58

24361 $1,653.01

24362 $1,743.60

24363 $2,413.05

24365 $1,043.33

24366 $1,113.66

24370 $2,560.36

24371 $2,955.83

24400 $1,347.62

24410 $1,772.01

24420 $1,626.38

24430 $1,743.40

24435 $1,767.90

24470 $967.03

24495 $1,047.77

24498 $1,425.22

24500 $570.36

24505 $804.22

24515 $1,438.22

24516 $1,414.45

24530 $605.99

24535 $992.56

24538 $1,213.15

24545 $1,528.38

24546 $1,713.30

24560 $513.23

24565 $853.70

24566 $1,165.66

24575 $1,198.84

24576 $541.03

24577 $879.44

24579 $1,370.15

24582 $1,312.84

24586 $1,784.40

24587 $1,789.17

24600 $597.34

24605 $760.98

24615 $1,167.92

24620 $904.45

24635 $1,097.43

24640 $226.31

24650 $415.68

22

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

24655 $704.21

24665 $1,061.15

24666 $1,199.24

24670 $463.71

24675 $733.45

24685 $1,066.06

24800 $1,357.17

24802 $1,645.22

24900 $1,202.72

24920 $1,107.86

24925 $919.85

24930 $1,268.48

24931 $1,329.34

24935 $1,750.89

24940 $1,190.27

25000 $538.15

25001 $552.79

25020 $921.83

25023 $1,802.90

25024 $1,288.17

25025 $2,019.82

25028 $839.51

25031 $564.75

25035 $951.28

25040 $918.02

25065 $405.38

25066 $578.41

25071 $699.21

25073 $869.20

25075 $760.20

25076 $841.56

25077 $1,457.64

25078 $1,933.08

25085 $731.13

25100 $557.65

25101 $653.97

25105 $783.48

25107 $998.46

25109 $874.40

25110 $549.01

25111 $513.77

25112 $625.57

25115 $1,237.34

25116 $975.71

25118 $615.12

25119 $804.61

25120 $808.12

25125 $967.87

25126 $970.96

25130 $723.79

25135 $905.49

25136 $799.12

25145 $838.63

25150 $919.99

23

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

25151 $952.75

25170 $2,443.61

25210 $792.49

25215 $1,004.84

25230 $698.90

25240 $694.69

25246 $254.32

25248 $671.56

25250 $860.55

25251 $1,175.66

25259 $661.04

25260 $1,025.36

25263 $1,022.11

25265 $1,221.52

25270 $795.83

25272 $902.59

25274 $1,090.19

25275 $1,100.63

25280 $919.73

25290 $707.23

25295 $849.21

25300 $1,121.23

25301 $1,050.19

25310 $1,007.68

25312 $1,176.48

25315 $1,261.03

25316 $1,486.75

25320 $1,608.37

25332 $1,384.47

25335 $1,526.94

25337 $1,451.01

25350 $1,100.80

25355 $1,252.93

25360 $1,068.40

25365 $1,499.97

25370 $1,649.04

25375 $1,529.57

25390 $1,260.64

25391 $1,635.83

25392 $1,665.74

25393 $1,860.91

25394 $1,282.75

25400 $1,317.73

25405 $1,705.72

25415 $1,587.85

25420 $1,922.48

25425 $1,580.25

25426 $1,849.46

25430 $1,171.80

25431 $1,291.00

25440 $1,260.07

25441 $1,524.22

25442 $1,302.12

25443 $1,276.44

24

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

25444 $1,320.60

25445 $1,179.19

25446 $1,927.70

25447 $1,351.46

25449 $1,708.67

25450 $1,002.40

25455 $1,010.15

25490 $1,154.23

25491 $1,209.20

25492 $1,323.18

25500 $434.17

25505 $809.10

25515 $1,092.64

25520 $912.50

25525 $1,278.33

25526 $1,563.06

25530 $414.99

25535 $787.44

25545 $1,013.30

25560 $443.95

25565 $841.91

25574 $1,098.79

25575 $1,474.06

25600 $519.16

25605 $886.61

25606 $1,074.65

25607 $1,197.97

25608 $1,346.19

25609 $1,714.97

25622 $484.91

25624 $759.87

25628 $1,174.77

25630 $487.88

25635 $724.82

25645 $925.94

25650 $513.53

25651 $783.43

25652 $1,012.54

25660 $666.45

25670 $985.78

25671 $859.27

25675 $715.49

25676 $1,027.21

25680 $784.58

25685 $1,202.66

25690 $776.45

25695 $1,032.65

25800 $1,198.49

25805 $1,382.57

25810 $1,421.22

25820 $998.55

25825 $1,231.09

25830 $1,537.22

25900 $1,160.66

25

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

25905 $1,146.08

25907 $998.01

25909 $1,118.59

25915 $1,744.07

25920 $1,133.38

25922 $962.36

25924 $1,112.68

25927 $1,305.48

25929 $971.19

25931 $1,179.73

26010 $412.09

26011 $603.87

26020 $700.86

26025 $684.00

26030 $799.78

26034 $873.53

26035 $1,398.38

26037 $930.84

26040 $498.63

26045 $757.46

26055 $864.09

26060 $426.11

26070 $502.35

26075 $529.76

26080 $628.11

26100 $538.30

26105 $542.54

26110 $517.13

26111 $680.05

26113 $891.78

26115 $791.73

26116 $855.93

26117 $1,225.72

26118 $1,740.30

26121 $970.56

26123 $1,356.71

26125 $458.13

26130 $739.98

26135 $895.25

26140 $818.16

26145 $830.39

26160 $891.00

26170 $655.77

26180 $716.70

26185 $887.05

26200 $729.73

26205 $980.44

26210 $713.77

26215 $918.79

26230 $812.73

26235 $800.03

26236 $714.03

26250 $1,758.75

26260 $1,316.09

26

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

26262 $1,032.45

26320 $558.56

26340 $528.17

26341 $155.79

26350 $1,114.86

26352 $1,287.78

26356 $1,726.32

26358 $1,452.88

26370 $1,192.70

26372 $1,400.47

26373 $1,340.94

26390 $1,325.82

26392 $1,534.65

26410 $881.58

26412 $1,085.59

26415 $1,274.59

26416 $1,220.80

26418 $899.16

26420 $1,116.53

26426 $812.98

26428 $1,176.76

26432 $778.51

26433 $831.12

26434 $1,019.57

26437 $978.44

26440 $962.78

26442 $1,524.18

26445 $894.23

26449 $1,126.41

26450 $631.08

26455 $637.01

26460 $617.39

26471 $966.64

26474 $926.19

26476 $912.35

26477 $909.15

26478 $977.91

26479 $969.07

26480 $1,181.35

26483 $1,329.88

26485 $1,271.76

26489 $1,484.10

26490 $1,256.82

26492 $1,404.76

26494 $1,269.95

26496 $1,365.63

26497 $1,371.81

26498 $1,836.46

26499 $1,312.12

26500 $983.94

26502 $1,123.99

26508 $1,008.13

26510 $936.85

26516 $1,109.10

27

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

26517 $1,303.37

26518 $1,330.62

26520 $1,014.53

26525 $1,016.79

26530 $871.21

26531 $1,013.92

26535 $682.77

26536 $1,118.31

26540 $1,038.27

26541 $1,271.17

26545 $1,113.52

26546 $1,581.42

26548 $1,209.84

26550 $2,676.00

26551 $4,896.28

26553 $4,683.97

26554 $5,489.62

26555 $2,207.47

26556 $4,996.40

26560 $928.51

26561 $1,509.14

26562 $2,097.65

26565 $1,073.55

26567 $1,074.90

26580 $2,445.25

26587 $1,708.40

26590 $2,103.33

26591 $679.90

26593 $937.73

26596 $1,221.58

26600 $467.11

26605 $512.29

26607 $737.36

26608 $768.93

26615 $933.43

26641 $594.85

26645 $682.97

26650 $766.19

26665 $1,022.17

26670 $536.34

26675 $726.27

26676 $806.53

26685 $937.35

26686 $1,014.99

26700 $528.57

26705 $663.43

26715 $930.38

26720 $315.25

26725 $540.62

26727 $755.18

26735 $967.96

26740 $363.02

26742 $590.22

26746 $1,208.15

28

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

26750 $294.98

26755 $505.10

26756 $671.44

26765 $809.27

26770 $449.91

26775 $616.29

26776 $710.96

26785 $884.61

26820 $1,249.67

26841 $1,150.93

26842 $1,247.10

26843 $1,169.94

26844 $1,293.18

26850 $1,092.64

26852 $1,260.09

26860 $879.96

26861 $173.12

26862 $1,145.93

26863 $393.94

26910 $1,135.94

26951 $1,024.78

26952 $1,017.21

26990 $1,017.49

26991 $1,130.46

26992 $1,578.72

27000 $694.68

27001 $885.90

27003 $970.52

27005 $1,191.27

27006 $1,209.45

27025 $1,512.62

27027 $1,437.14#

27030 $1,498.76

27033 $1,603.30

27035 $1,695.92

27036 $1,660.99

27040 $536.97

27041 $1,134.11

27043 $777.61

27045 $1,231.93

27047 $752.96

27048 $1,005.89

27049 $2,259.27

27050 $649.28

27052 $942.69

27054 $1,121.50

27057 $1,615.22#

27059 $3,014.00

27060 $755.37

27062 $741.81

27065 $840.26

27066 $1,331.03

27067 $1,698.90

27070 $1,388.90

29

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

27071 $1,500.97

27075 $3,486.38

27076 $4,227.86

27077 $4,721.47

27078 $3,437.34

27080 $840.48

27086 $405.33

27087 $1,034.78

27090 $1,364.75

27091 $2,651.98

27093 $297.82

27095 $370.83

27096 $266.57

27097 $1,109.56

27098 $1,133.14

27100 $1,351.10

27105 $1,418.78

27110 $1,590.61

27111 $1,474.06

27120 $2,133.35

27122 $1,815.21

27125 $1,872.04#

27130 $2,390.50#

27132 $2,784.75#

27134 $3,195.78#

27137 $2,449.57#

27138 $2,547.94#

27140 $1,475.03

27146 $2,119.90

27147 $2,430.43

27151 $2,633.41

27156 $2,841.26

27158 $2,131.11

27161 $2,006.00

27165 $2,272.57

27170 $1,947.70

27175 $1,093.93

27176 $1,506.69

27177 $1,833.21

27178 $1,506.69

27179 $1,604.00

27181 $1,849.25

27185 $1,136.88

27187 $1,633.97

27193 $767.71

27194 $1,173.12

27200 $289.29

27202 $872.31

27215 $1,035.57

27216 $1,538.48

27217 $1,442.41

27218 $1,999.71

27220 $863.93

27222 $1,595.05

30

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

27226 $1,744.85

27227 $2,754.39

27228 $3,139.94

27230 $771.98

27232 $1,267.01

27235 $1,495.80

27236 $1,978.32

27238 $749.94

27240 $1,583.80

27244 $2,034.94

27245 $2,035.42

27246 $625.67

27248 $1,225.29

27250 $318.92

27252 $1,253.70

27253 $1,551.95

27254 $2,087.45

27256 $507.26

27257 $560.32

27258 $1,826.28

27259 $2,565.62

27265 $661.86

27266 $950.21

27267 $711.84

27268 $877.37

27269 $2,059.76

27275 $299.20

27280 $1,709.82#

27282 $1,400.03

27284 $2,685.04

27286 $2,737.06

27290 $2,687.49

27295 $2,097.29

27301 $1,076.11

27303 $1,044.96

27305 $786.80

27306 $593.30

27307 $779.57

27310 $1,198.23

27323 $433.96

27324 $641.92

27325 $906.31

27326 $834.10

27327 $730.29

27328 $1,025.03

27329 $1,713.88

27330 $671.89

27331 $774.85

27332 $1,046.21#

27333 $952.80#

27334 $1,119.68

27335 $1,253.79

27337 $690.35

27339 $1,241.98

31

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

27340 $600.18

27345 $781.59

27347 $860.73

27350 $1,066.59

27355 $984.49

27356 $1,208.88

27357 $1,332.65

27358 $466.67

27360 $1,396.24

27364 $2,588.92

27365 $3,437.93

27370 $254.74

27372 $961.86

27380 $966.72

27381 $1,306.24

27385 $934.22

27386 $1,362.87

27390 $726.78

27391 $938.60

27392 $1,163.61

27393 $830.33

27394 $1,066.06

27395 $1,439.27

27396 $1,003.60

27397 $1,500.70

27400 $1,133.81

27403 $1,048.00

27405 $1,108.15

27407 $1,296.14

27409 $1,584.85

27412 $2,733.99

27415 $2,264.69

27416 $1,613.18

27418 $1,366.90

27420 $1,197.28

27422 $1,219.46

27424 $1,223.21

27425 $725.09

27427 $1,174.78

27428 $1,828.60

27429 $2,051.13

27430 $1,215.14

27435 $1,325.25

27437 $1,079.47

27438 $1,384.65

27440 $1,307.25#

27441 $1,351.38#

27442 $1,431.09#

27443 $1,338.99#

27445 $2,072.52#

27446 $1,828.18#

27447 $2,552.03#

27448 $1,352.00

27450 $1,673.98

32

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

27454 $2,144.12

27455 $1,546.97

27457 $1,584.41

27465 $2,066.27

27466 $1,946.99

27468 $2,216.26

27470 $1,942.90

27472 $2,091.86

27475 $1,080.91

27477 $1,199.92

27479 $1,463.03

27485 $1,096.50

27486 $2,333.15#

27487 $2,924.45#

27488 $1,986.26

27495 $1,863.46

27496 $882.09

27497 $950.51

27498 $1,067.07

27499 $1,144.00

27500 $837.93

27501 $819.84

27502 $1,275.95

27503 $1,320.43

27506 $2,211.61

27507 $1,609.51

27508 $852.15

27509 $1,050.66

27510 $1,132.16

27511 $1,652.57

27513 $2,062.05

27514 $1,602.56

27516 $816.28

27517 $1,118.50

27519 $1,470.55

27520 $516.72

27524 $1,235.71

27530 $479.50

27532 $998.62

27535 $1,484.78

27536 $1,965.69

27538 $761.21

27540 $1,332.13

27550 $810.94

27552 $1,022.36

27556 $1,446.33

27557 $1,732.94

27558 $1,978.30

27560 $589.97

27562 $783.64

27566 $1,468.29

27570 $243.88

27580 $2,377.74

27590 $1,370.55

33

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

27591 $1,594.76

27592 $1,164.88

27594 $843.49

27596 $1,224.35

27598 $1,226.18

27600 $690.15

27601 $728.82

27602 $837.41

27603 $862.61

27604 $775.90

27605 $548.61

27606 $475.24

27607 $1,005.14

27610 $1,073.46

27612 $932.36

27613 $408.28

27614 $939.82

27615 $1,703.13

27616 $2,093.75

27618 $710.03

27619 $793.32

27620 $747.20

27625 $964.72

27626 $1,034.69

27630 $895.61

27632 $687.98

27634 $1,134.28

27635 $968.82

27637 $1,244.00

27638 $1,278.40

27640 $1,385.20

27641 $1,105.18

27645 $2,949.48

27646 $2,554.12

27647 $1,818.67

27648 $254.26

27650 $1,101.60

27652 $1,151.23

27654 $1,181.78

27656 $999.79

27658 $625.42

27659 $814.11

27664 $599.25

27665 $686.40

27675 $823.21

27676 $1,027.58

27680 $715.48

27681 $889.59

27685 $1,074.12

27686 $913.14

27687 $760.04

27690 $1,055.48

27691 $1,244.26

27692 $180.36

34

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

27695 $798.01

27696 $943.59

27698 $1,075.40

27700 $1,006.41#

27702 $1,615.04#

27703 $1,879.20#

27704 $961.70

27705 $1,254.68

27707 $656.35

27709 $1,938.68

27712 $1,818.96

27715 $1,754.02

27720 $1,445.61

27722 $1,460.03

27724 $2,103.89

27725 $2,007.04

27726 $1,613.51

27727 $1,704.52

27730 $954.87

27732 $724.65

27734 $1,038.47

27740 $1,026.85

27742 $1,130.76

27745 $1,245.04

27750 $553.80

27752 $870.55

27756 $943.93

27758 $1,466.38

27759 $1,647.09

27760 $536.29

27762 $773.01

27766 $997.02

27767 $449.82

27768 $710.91

27769 $1,204.70

27780 $489.81

27781 $673.78

27784 $1,174.13

27786 $507.67

27788 $682.95

27792 $1,074.63

27808 $533.82

27810 $762.44

27814 $1,270.53

27816 $510.56

27818 $788.99

27822 $1,380.28

27823 $1,569.90

27824 $502.94

27825 $884.13

27826 $1,372.77

27827 $1,781.31

27828 $2,136.08

27829 $1,120.51

35

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

27830 $609.00

27831 $645.62

27832 $1,235.91

27840 $614.36

27842 $811.56

27846 $1,207.19

27848 $1,337.05

27860 $294.82

27870 $1,721.96

27871 $1,132.44

27880 $1,558.60

27881 $1,481.42

27882 $1,031.35

27884 $972.61

27886 $1,111.60

27888 $1,136.58

27889 $1,104.81

27892 $912.07

27893 $996.22

27894 $1,442.41

28001 $447.41

28002 $739.67

28003 $1,210.23

28005 $988.67

28008 $706.56

28010 $386.73

28011 $542.14

28020 $876.81

28022 $799.33

28024 $750.95

28035 $856.72

28039 $849.97

28041 $784.02

28043 $654.97

28045 $818.13

28046 $1,253.73

28047 $1,754.84

28050 $697.29

28052 $716.34

28054 $610.83

28055 $645.99

28060 $848.63

28062 $966.84

28070 $868.60

28072 $824.03

28080 $854.55

28086 $882.92

28088 $779.43

28090 $767.19

28092 $690.23

28100 $992.69

28102 $960.40

28103 $674.97

28104 $848.30

36

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

28106 $777.51

28107 $850.52

28108 $716.30

28110 $752.00

28111 $824.98

28112 $801.98

28113 $971.30

28114 $1,759.94

28116 $1,271.21

28118 $972.38

28119 $863.40

28120 $1,112.09

28122 $990.42

28124 $781.32

28126 $642.97

28130 $1,188.42

28140 $993.09

28150 $699.38

28153 $674.24

28160 $682.31

28171 $1,489.69

28173 $1,342.56

28175 $842.59

28190 $411.95

28192 $774.34

28193 $881.90

28200 $790.08

28202 $984.98

28208 $761.92

28210 $955.16

28220 $734.43

28222 $843.43

28225 $668.47

28226 $953.23

28230 $704.85

28232 $632.79

28234 $663.81

28238 $1,104.00

28240 $713.92

28250 $945.48

28260 $1,117.81

28261 $1,615.98

28262 $2,377.50

28264 $1,589.98

28270 $805.30

28272 $642.73

28280 $852.87

28285 $874.13

28286 $743.03

28288 $985.58

28289 $1,213.33

28290 $958.08

28292 $1,302.98

28293 $1,716.65

37

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

28294 $1,234.33

28296 $1,177.99

28297 $1,348.25

28298 $1,188.94

28299 $1,489.58

28300 $1,097.44

28302 $1,170.46

28304 $1,335.83

28305 $1,119.10

28306 $1,001.89

28307 $1,131.64

28308 $915.89

28309 $1,505.64

28310 $890.21

28312 $828.39

28313 $853.00

28315 $788.66

28320 $1,031.29

28322 $1,287.74

28340 $964.91

28341 $1,125.09

28344 $700.79

28345 $865.58

28360 $1,784.96

28400 $402.72

28405 $625.19

28406 $860.16

28415 $1,845.65

28420 $2,059.53

28430 $379.33

28435 $575.33

28436 $723.73

28445 $1,771.71

28446 $2,016.56

28450 $348.32

28455 $430.03

28456 $508.03

28465 $1,013.80

28470 $354.47

28475 $418.04

28476 $559.31

28485 $879.34

28490 $233.21

28495 $287.84

28496 $705.43

28505 $1,095.02

28510 $199.60

28515 $261.47

28525 $924.93

28530 $185.58

28531 $557.56

28540 $317.95

28545 $470.10

28546 $895.95

38

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

28555 $1,436.56

28570 $265.97

28575 $582.67

28576 $639.93

28585 $1,452.61

28600 $304.76

28605 $520.09

28606 $651.02

28615 $1,303.80

28630 $257.55

28635 $284.30

28636 $484.97

28645 $1,083.99

28660 $190.59

28665 $257.81

28666 $319.22

28675 $938.55

28705 $2,159.55

28715 $1,552.59

28725 $1,292.13

28730 $1,225.60

28735 $1,319.45

28737 $1,173.67

28740 $1,388.67

28750 $1,339.71

28755 $826.45

28760 $1,290.44

28800 $932.49

28805 $1,269.58

28810 $736.17

28820 $934.87

28825 $886.33

29000 $441.86

29010 $379.32

29015 $463.74

29020 $335.69

29025 $464.19

29035 $351.63

29040 $366.09

29044 $452.37

29046 $422.75

29049 $157.55

29055 $352.12

29058 $198.29

29065 $153.70

29075 $138.24

29085 $152.15

29086 $124.94

29105 $141.62

29125 $102.99

29126 $123.35

29130 $67.29

29131 $84.34

29200 $87.79

39

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

29240 $95.17

29260 $84.41

29280 $82.38

29305 $391.66

29325 $433.99

29345 $219.88

29355 $229.70

29358 $255.51

29365 $197.68

29405 $131.72

29425 $127.11

29435 $192.41

29440 $73.73

29445 $226.37

29450 $243.09

29505 $132.93

29515 $116.66

29520 $79.62

29530 $85.76

29540 $60.14

29550 $50.13

29580 $85.48

29581 $95.10

29582 $109.01

29583 $68.31

29584 $109.01

29700 $104.94

29705 $108.27

29710 $199.10

29715 $131.86

29720 $132.07

29730 $106.34

29740 $152.92

29750 $174.28

29805 $769.78

29806 $1,748.85

29807 $1,703.92

29819 $959.97

29820 $884.86

29821 $965.19

29822 $941.33

29823 $1,028.37

29824 $1,109.63

29825 $959.49

29826 $295.84

29827 $1,774.43

29828 $1,523.24

29830 $741.21

29834 $802.46

29835 $828.04

29836 $942.82

29837 $866.40

29838 $966.87

29840 $735.66

40

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

29843 $787.83

29844 $813.55

29845 $947.84

29846 $851.30

29847 $888.04

29848 $830.06

29850 $1,019.15

29851 $1,532.95

29855 $1,290.45

29856 $1,640.14

29860 $1,092.13

29861 $1,195.68

29862 $1,343.55

29863 $1,344.33

29866 $1,723.77

29867 $2,106.05

29868 $2,769.08

29870 $930.55

29871 $840.04

29873 $850.64

29874 $882.08

29875 $810.27

29876 $1,076.94

29877 $1,021.16

29879 $1,089.25

29880 $922.85#

29881 $887.18#

29882 $1,150.10

29883 $1,382.87

29884 $1,017.90

29885 $1,232.68

29886 $1,040.39

29887 $1,228.06

29888 $1,633.42

29889 $2,011.71

29891 $1,127.60

29892 $1,039.87

29893 $1,000.24

29894 $861.19

29895 $804.97

29897 $853.07

29898 $948.56

29899 $1,742.22

29900 $747.87

29901 $866.21

29902 $956.85

29904 $1,044.39

29905 $1,129.05

29906 $1,159.21

29907 $1,438.29

29914 $1,668.75

29915 $1,703.13

29916 $1,704.57

30000 $366.85

41

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

30020 $372.47

30100 $226.30

30110 $369.59

30115 $701.87

30117 $1,369.26

30118 $1,265.45

30120 $843.45

30124 $469.03

30125 $1,002.35

30130 $612.97

30140 $707.55

30150 $1,264.39

30160 $1,282.66

30200 $182.71

30210 $240.93

30220 $481.90

30300 $365.51

30310 $335.26

30320 $735.65

30400 $1,648.76*

30410 $1,947.24*

30420 $2,259.14*

30430 $1,416.66*

30435 $1,826.16*

30450 $2,484.24*

30460 $1,335.11

30462 $2,384.64

30465 $1,622.23

30520 $1,024.53

30540 $1,129.02

30545 $1,422.69

30560 $425.04

30580 $1,044.57

30600 $935.57

30620 $1,018.44

30630 $1,029.77

30801 $361.22#

30802 $463.23#

30901 $156.73

30903 $330.03

30905 $411.27

30906 $454.97

30915 $956.60

30920 $1,389.28

30930 $202.55

31000 $288.70

31002 $325.68

31020 $765.45

31030 $1,103.54

31032 $938.96

31040 $1,254.86

31050 $791.91

31051 $1,056.29

31070 $714.42

42

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

31075 $1,287.35

31080 $1,699.55

31081 $2,347.50

31084 $1,909.44

31085 $2,496.16

31086 $1,853.80

31087 $1,795.49

31090 $1,670.07

31200 $919.55

31201 $1,219.46

31205 $1,483.69

31225 $3,125.64

31230 $3,483.35

31231 $326.84

31233 $425.10

31235 $484.50

31237 $523.68

31238 $539.10

31239 $1,149.52

31240 $273.68

31254 $466.26

31255 $684.97

31256 $337.29

31267 $542.55

31276 $864.79

31287 $396.49

31288 $459.64

31290 $1,956.87

31291 $2,070.04

31292 $1,691.24

31293 $1,839.32

31294 $2,109.09

31295 $3,182.01

31296 $3,239.56

31297 $3,185.81

31300 $2,081.58

31320 $1,058.94

31360 $3,479.80

31365 $4,331.99

31367 $3,680.23

31368 $4,078.95

31370 $3,442.24

31375 $3,266.63

31380 $3,219.44

31382 $3,537.88

31390 $4,802.45

31395 $5,039.94

31400 $1,636.72

31420 $1,391.85

31500 $194.15

31502 $60.63

31505 $133.06

31510 $342.60

31511 $349.70

43

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

31512 $338.63

31513 $224.86

31515 $335.85

31520 $268.59

31525 $410.91

31526 $269.26

31527 $335.46

31528 $247.56

31529 $277.43

31530 $338.97

31531 $364.20

31535 $325.19

31536 $362.18

31540 $416.29

31541 $454.54

31545 $625.48

31546 $951.36

31560 $540.16

31561 $591.00

31570 $559.09

31571 $428.88

31575 $185.21

31576 $361.16

31577 $397.94

31578 $457.39

31579 $345.13

31580 $2,010.76

31582 $3,123.29

31584 $2,511.36

31587 $1,690.22

31588 $1,897.11

31590 $1,432.45

31595 $1,253.79

31600 $678.31

31601 $444.45

31603 $383.62

31605 $317.19

31610 $1,188.27

31611 $886.42

31612 $137.68

31613 $741.52

31614 $1,245.63

31615 $299.49

31620 $439.84

31622 $507.13

31623 $537.32

31624 $508.61

31625 $549.08

31626 $728.26

31627 $2,015.28

31628 $620.01

31629 $964.63

31630 $351.19

31631 $399.58

44

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

31632 $121.60

31633 $150.13

31634 $2,971.25

31635 $569.91

31636 $390.05

31637 $133.46

31638 $445.13

31640 $450.11

31641 $453.73

31643 $313.21

31645 $521.64

31646 $470.10

31647 $392.77

31648 $403.42

31649 $130.45

31651 $139.21

31717 $426.78

31720 $89.46

31725 $164.56

31730 $1,865.37

31750 $2,250.85

31755 $2,808.76

31760 $2,316.96

31766 $3,016.16

31770 $2,257.47

31775 $2,325.28

31780 $2,012.12

31781 $2,561.96

31785 $1,845.67

31786 $2,443.98

31800 $1,194.76

31805 $1,372.45

31820 $715.23

31825 $994.87

31830 $727.51

32035 $1,212.65

32036 $1,305.68

32096 $1,369.63

32097 $1,369.63

32098 $1,321.74

32100 $1,375.68

32110 $2,482.58

32120 $1,470.17

32124 $1,567.66

32140 $1,674.23

32141 $2,593.11

32150 $1,695.27

32151 $1,699.74

32160 $1,332.49

32200 $1,909.05

32201 $1,387.33

32215 $1,348.61

32220 $2,683.20

32225 $1,682.13

45

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

32310 $1,547.09

32320 $2,705.79

32400 $244.78

32405 $684.45

32440 $2,654.63

32442 $5,219.24

32445 $6,007.90

32480 $2,510.69

32482 $2,684.88

32484 $2,440.76

32486 $4,004.54

32488 $4,054.59

32491 $2,488.83

32501 $418.88

32503 $3,067.38

32504 $3,476.46

32505 $1,613.81

32506 $281.22

32507 $281.22

32540 $2,929.48

32550 $1,232.55

32551 $300.84

32552 $314.76

32553 $899.41

32554 $828.91

32555 $958.57

32556 $883.72

32557 $1,411.21

32560 $388.15

32561 $158.51

32562 $142.86

32601 $525.61

32604 $819.29

32606 $788.55

32607 $541.87

32608 $667.81

32609 $457.25

32650 $1,123.53

32651 $1,854.64

32652 $2,818.45

32653 $1,789.80

32654 $2,000.42

32655 $1,619.53

32656 $1,347.20

32658 $1,201.73

32659 $1,226.82

32661 $1,346.85

32662 $1,504.41

32663 $2,376.85

32664 $1,431.92

32665 $2,075.97

32666 $1,498.81

32667 $281.22

32668 $281.81

46

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

32669 $2,280.13

32670 $2,726.86

32671 $3,023.73

32672 $2,583.64

32673 $2,041.61

32674 $369.71

32701 $375.45

32800 $1,590.53

32810 $1,519.71

32815 $4,767.80

32820 $2,359.66

32851 $5,591.35#

32852 $6,114.49#

32853 $7,828.07#

32854 $8,324.71#

32900 $2,352.07

32905 $2,263.76

32906 $2,801.32

32940 $2,090.18

32960 $245.79

32997 $629.21

32998 $4,442.53

33010 $202.29

33011 $203.96

33015 $854.19

33020 $1,482.39

33025 $1,355.68

33030 $3,411.37

33031 $4,231.71

33050 $1,693.15

33120 $3,590.17

33130 $2,354.13

33140 $2,693.68

33141 $227.21

33202 $1,313.16

33203 $1,363.24

33206 $759.95

33207 $808.31

33208 $874.58

33210 $301.40

33211 $307.68

33212 $551.54

33213 $576.09

33214 $803.59

33215 $505.54

33216 $620.83

33217 $617.38

33218 $649.82

33220 $655.50

33221 $601.11

33222 $568.71

33223 $686.26

33224 $852.24

33225 $770.25

47

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

33226 $819.43

33227 $573.89

33228 $599.09

33229 $623.81

33230 $651.13

33231 $675.85

33233 $388.43

33234 $809.97

33235 $1,055.18

33236 $1,329.50

33237 $1,422.21

33238 $1,584.03

33240 $625.92

33241 $366.75

33243 $2,314.67

33244 $1,421.46

33249 $1,512.61

33250 $2,506.87

33251 $2,771.77

33254 $2,326.33

33255 $2,802.27

33256 $3,330.86

33257 $988.49

33258 $1,115.01

33259 $1,436.54

33261 $2,778.29

33262 $627.07

33263 $652.28

33264 $677.00

33265 $2,313.06

33266 $3,162.83

33282 $527.69

33284 $375.39

33300 $4,190.66

33305 $7,035.87

33310 $1,992.66

33315 $3,282.05

33320 $1,796.10

33321 $2,034.11

33322 $2,372.61

33330 $2,572.04

33332 $2,379.87

33335 $3,216.27

33361 $2,287.78

33362 $2,503.48

33363 $2,592.19

33364 $2,752.93

33365 $3,012.66

33367 $1,061.77

33368 $1,286.48

33369 $1,698.56

33400 $3,906.69

33401 $2,424.84

33403 $2,535.83

48

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

33404 $3,000.90

33405 $3,876.33

33406 $4,934.52

33410 $4,355.65

33411 $5,764.62

33412 $5,461.98

33413 $5,554.25

33414 $3,685.86

33415 $3,504.04

33416 $3,478.75

33417 $2,838.04

33420 $2,497.13

33422 $2,871.90

33425 $4,693.03

33426 $4,085.86

33427 $4,193.91

33430 $4,780.64

33460 $4,161.32

33463 $5,301.39

33464 $4,195.34

33465 $4,733.91

33468 $4,204.62

33470 $2,200.03

33471 $2,323.29

33472 $2,228.33

33474 $3,709.99

33475 $4,016.51

33476 $2,596.03

33478 $2,683.05

33496 $2,858.61

33500 $2,690.13

33501 $1,918.55

33502 $2,174.66

33503 $2,237.80

33504 $2,498.72

33505 $3,545.55

33506 $3,509.41

33507 $2,938.62

33508 $27.71

33510 $3,315.16

33511 $3,640.93

33512 $4,140.49

33513 $4,260.27

33514 $4,497.25

33516 $4,675.87

33517 $323.34

33518 $710.61

33519 $939.64

33521 $1,128.67

33522 $1,267.16

33523 $1,440.36

33530 $907.20

33533 $3,188.24

33534 $3,769.39

49

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

33535 $4,204.39

33536 $4,508.31

33542 $4,511.35

33545 $5,301.09

33548 $5,085.87

33572 $398.14

33600 $2,921.89

33602 $2,817.69

33606 $3,002.86

33608 $3,062.69

33610 $3,117.57

33611 $3,344.97

33612 $3,400.27

33615 $3,399.34

33617 $3,684.67

33619 $4,638.48

33620 $2,525.92

33621 $1,492.16

33622 $5,872.00

33641 $2,802.20

33645 $2,965.92

33647 $3,114.07

33660 $3,009.55

33665 $3,281.27

33670 $3,391.74

33675 $3,380.56

33676 $3,608.85

33677 $3,612.21

33681 $3,131.94

33684 $3,240.05

33688 $3,236.51

33690 $2,031.68

33692 $3,498.82

33694 $3,473.68

33697 $3,522.57

33702 $2,642.31

33710 $3,637.74

33720 $2,630.91

33722 $2,781.40

33724 $2,621.03

33726 $3,621.26

33730 $3,432.25

33732 $2,815.73

33735 $2,183.76

33736 $2,396.21

33737 $2,266.72

33750 $2,331.19

33755 $2,283.86

33762 $2,262.30

33764 $2,217.92

33766 $2,328.43

33767 $2,431.08

33768 $748.79

33770 $3,763.71

50

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

33771 $3,907.33

33774 $3,075.14

33775 $3,277.75

33776 $3,461.51

33777 $3,359.43

33778 $4,033.11

33779 $4,168.11

33780 $4,240.59

33781 $4,150.97

33782 $5,517.71

33783 $5,963.84

33786 $3,907.65

33788 $2,746.63

33800 $1,576.23

33802 $1,938.06

33803 $1,964.59

33813 $2,162.82

33814 $2,600.82

33820 $1,651.35

33822 $1,794.48

33824 $1,999.37

33840 $2,110.48

33845 $2,272.06

33851 $2,169.65

33852 $2,385.93

33853 $3,131.92

33860 $5,517.22

33863 $5,411.32

33864 $5,528.47

33870 $4,318.10

33875 $4,717.86

33877 $6,293.06

33880 $3,144.35

33881 $2,697.79

33883 $1,948.86

33884 $718.08

33886 $1,689.27

33889 $1,390.57

33891 $1,716.73

33910 $4,518.90

33915 $2,354.84

33916 $7,199.08

33917 $2,474.91

33920 $3,098.34

33922 $2,371.01

33924 $490.00

33925 $2,931.96

33926 $4,148.98

33944 $625.48#

33945 $8,318.38#

33960 $1,721.13

33961 $968.24

33967 $440.83

33968 $57.73

51

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

33970 $608.04

33973 $883.60

33974 $1,525.15

33975 $2,270.93

33976 $2,758.74

33977 $1,937.27

33978 $2,309.30

33979 $3,362.80

33980 $3,068.02

33981 $1,446.35

33982 $3,532.27

33983 $3,982.14

33990 $743.79*

33991 $1,083.89*

33992 $355.73

33993 $312.33

34001 $1,689.86

34051 $1,697.05

34101 $1,050.24

34151 $2,458.93

34201 $1,812.99

34203 $1,678.69

34401 $2,515.77

34421 $1,274.94

34451 $2,824.18

34471 $1,892.12

34490 $1,074.02

34502 $2,650.78

34800 $1,971.45

34802 $2,181.27

34803 $2,256.05

34804 $2,181.32

34805 $2,084.83

34806 $179.66

34808 $362.66

34812 $592.62

34813 $418.44

34820 $860.93

34825 $1,215.72

34826 $360.64

34830 $3,123.79

34831 $3,359.91

34832 $3,359.91

34833 $1,068.45

34834 $481.60

34900 $1,561.55

35001 $1,980.95

35002 $1,992.09

35011 $1,745.22

35013 $2,183.20

35021 $2,153.55

35022 $2,466.50

35081 $3,081.43

35082 $3,844.82

52

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

35091 $3,161.27

35092 $4,585.66

35102 $3,333.52

35103 $3,952.73

35111 $2,332.59

35112 $3,186.51

35121 $2,886.79

35122 $3,678.64

35131 $2,435.10

35132 $2,886.97

35141 $1,948.74

35142 $2,328.33

35151 $2,189.74

35152 $2,473.97

35188 $1,611.98

35189 $2,684.87

35190 $1,314.94

35201 $1,636.39

35206 $1,347.50

35207 $1,250.52

35211 $2,360.15

35216 $3,499.08

35221 $2,500.74

35226 $1,457.91

35231 $2,076.80

35236 $1,715.57

35241 $2,465.29

35246 $2,529.09

35251 $2,953.94

35256 $1,785.01

35261 $1,817.20

35266 $1,499.39

35271 $2,371.76

35276 $2,494.50

35281 $2,831.89

35286 $1,630.14

35301 $1,839.41

35302 $1,982.73

35303 $2,189.09

35304 $2,259.53

35305 $2,170.91

35306 $793.82

35311 $2,676.46

35321 $1,558.79

35331 $2,561.24

35341 $2,418.74

35351 $2,256.38

35355 $1,825.61

35361 $2,696.04

35371 $1,440.40

35372 $1,725.35

35390 $281.19

35400 $263.10

35458 $859.96

53

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

35460 $550.48

35471 $3,896.80

35472 $2,932.23

35475 $2,398.30

35476 $2,205.03

35500 $565.69

35501 $2,655.36

35506 $2,348.79

35509 $2,505.86

35510 $2,179.40

35511 $2,208.18

35512 $2,137.06

35515 $2,351.84

35516 $2,162.28

35521 $2,423.11

35522 $2,173.70

35523 $2,243.93

35525 $2,007.90

35526 $2,991.03

35531 $3,561.85

35535 $3,186.79

35536 $3,461.15

35537 $3,698.32

35538 $4,142.15

35539 $3,890.17

35540 $4,512.54

35556 $2,472.74

35558 $2,174.91

35563 $2,341.89

35565 $2,320.34

35566 $2,953.86

35570 $2,529.33

35571 $2,343.84

35572 $606.64

35600 $443.46

35601 $2,485.75

35606 $2,071.19

35612 $1,846.77

35616 $1,936.67

35621 $1,937.42

35623 $2,324.57

35626 $2,733.53

35631 $3,254.50

35632 $3,025.14

35633 $3,350.00

35634 $2,960.17

35636 $2,825.21

35637 $3,048.45

35638 $3,103.22

35646 $3,025.22

35647 $2,742.61

35650 $1,872.33

35654 $2,407.47

35656 $1,907.45

54

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

35661 $1,911.04

35663 $2,218.70

35665 $2,070.94

35666 $2,235.05

35671 $1,972.77

35682 $625.19

35683 $727.98

35685 $353.39

35686 $292.35

35691 $1,670.76

35693 $1,470.86

35694 $1,745.26

35695 $1,812.45

35697 $261.96

35700 $270.81

35701 $972.01

35721 $785.22

35741 $883.85

35761 $661.05

35800 $1,226.68

35820 $3,450.34

35840 $2,025.76

35860 $1,464.84

35875 $1,042.22

35876 $1,665.07

35879 $1,631.59

35881 $1,800.71

35883 $2,132.71

35884 $2,198.19

35901 $863.37

35903 $983.24

35905 $2,977.29

35907 $3,375.97

36000 $40.27

36002 $265.62

36005 $490.55

36010 $777.67

36011 $1,295.57

36012 $1,331.92#

36013 $1,237.42#

36014 $1,250.75#

36015 $1,350.44#

36100 $803.40

36120 $674.66

36140 $683.62

36147 $1,306.22

36148 $404.80

36160 $796.10

36200 $981.23

36215 $1,700.67

36216 $1,895.97

36217 $3,218.22

36218 $304.74

36221 $1,705.61

55

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

36222 $2,120.20

36223 $2,318.79

36224 $2,519.16

36225 $2,302.70

36226 $2,566.05

36227 $388.65

36228 $1,758.88

36245 $1,538.99

36246 $1,398.87

36247 $2,447.60

36248 $241.11

36251 $2,224.48

36252 $2,450.87

36253 $3,382.25

36254 $3,517.26

36260 $1,074.42

36261 $664.54

36262 $504.65

36400 $48.10

36405 $42.91

36406 $31.18

36410 $27.35

36415 $3.00

36415 26 $3.00

36415 TC $3.00

36420 $91.11

36425 $69.22

36430 $48.62

36440 $98.89

36450 $192.02

36455 $203.97

36460 $618.56

36470 $241.28

36471 $281.06#

36475 $2,653.49

36476 $619.04

36478 $2,102.67

36479 $628.93

36481 $3,201.40

36500 $312.58

36510 $154.12

36511 $164.76

36512 $161.98

36513 $167.31

36514 $804.97

36515 $3,168.25

36516 $3,078.63

36522 $2,077.89

36555 $420.77

36556 $381.66

36557 $1,213.48

36558 $1,233.05

36560 $2,142.06

36561 $1,858.54

56

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

36563 $2,101.67

36565 $1,578.52

36566 $8,394.97

36568 $457.94

36569 $388.05

36570 $1,842.09

36571 $2,022.01

36575 $260.00

36576 $618.28

36578 $825.61

36580 $335.45

36581 $1,189.73

36582 $1,724.52

36583 $2,139.90

36584 $314.61

36585 $1,873.69

36589 $276.77

36590 $480.38

36591 $33.31

36592 $38.57

36593 $44.32

36595 $888.46

36596 $208.44

36597 $201.88

36598 $171.47

36600 $50.64

36620 $91.80

36625 $183.57

36640 $220.22

36660 $125.30

36680 $103.51

36800 $275.91

36810 $370.31

36815 $255.99

36818 $1,161.12

36819 $1,278.47

36820 $1,398.08

36821 $1,197.79

36822 $645.92

36823 $2,269.87

36825 $1,377.74

36830 $1,140.25

36831 $787.47

36832 $1,005.42

36833 $1,137.25

36835 $728.74

36838 $2,008.77

36860 $335.26

36861 $268.91

36870 $2,828.37

37140 $3,883.67

37145 $3,606.51

37160 $3,699.48

37180 $3,558.66

57

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

37181 $3,883.37

37182 $1,480.91

37183 $8,813.83

37184 $3,517.77

37185 $1,128.68

37186 $2,156.28

37187 $3,256.47

37188 $2,716.07

37191 $4,011.04

37192 $2,687.23

37193 $2,571.44

37195 $498.39

37197 $2,340.04

37200 $392.67

37202 $557.04

37204 $1,573.46

37205 $6,549.85

37206 $3,860.37

37207 $745.87

37208 $359.72

37210 $5,513.21

37211 $701.81

37212 $619.49

37213 $433.89

37214 $251.65

37215 $1,850.86

37216 $1,777.75

37220 $4,944.71

37221 $7,205.38

37222 $1,413.65

37223 $3,998.90

37224 $5,943.37

37225 $16,843.50

37226 $13,868.56

37227 $22,730.38

37228 $8,445.36

37229 $16,623.73

37230 $12,725.04

37231 $20,202.22

37232 $1,898.19

37233 $2,296.54

37234 $6,026.32

37235 $6,180.79

37250 $185.70

37251 $139.53

37500 $1,115.58

37565 $1,292.95

37600 $1,215.81

37605 $1,390.23

37606 $966.52

37607 $649.06

37609 $508.35

37615 $866.41

37616 $1,861.45

58

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

37617 $2,293.55

37618 $657.66

37619 $2,889.67

37650 $804.32

37660 $1,976.32

37700 $427.79

37718 $752.94

37722 $829.81

37735 $1,101.47

37760 $1,051.38

37761 $941.61

37765 $1,088.61

37766 $1,301.24

37780 $432.91

37785 $587.94

37788 $2,348.03#

37790 $823.89*

38100 $1,932.64

38101 $1,946.97

38102 $441.98

38115 $2,140.09

38120 $1,756.19

38200 $242.19

38205 $140.59

38206 $142.44

38207 $78.57

38208 $49.86

38209 $21.22

38210 $139.19

38211 $126.23

38212 $82.89

38213 $21.22

38214 $71.76

38215 $82.89

38220 $251.03

38221 $261.04

38230 $346.41#

38232 $346.41#

38240 $286.97#

38241 $285.90#

38242 $200.51#

38243 $202.81*

38300 $450.33

38305 $768.19

38308 $750.64

38380 $965.02

38381 $1,349.55

38500 $537.87

38505 $201.29

38510 $857.66

38520 $774.78

38525 $721.64

38530 $913.99

38542 $871.32

59

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

38550 $837.67

38555 $1,588.17

38564 $1,170.46

38570 $902.36

38571 $1,351.07

38572 $1,624.02

38700 $1,369.65

38720 $2,282.72

38724 $2,478.74

38740 $1,148.94

38745 $1,457.74

38746 $369.71

38747 $449.70

38760 $1,405.56

38765 $2,163.29

38770 $1,360.42

38780 $1,733.47

38790 $138.86

38792 $66.54

38794 $498.34

38900 $231.72

39000 $835.74

39010 $1,336.00

39200 $1,481.22

39220 $1,933.26

39400 $852.72

39501 $1,425.91

39503 $10,329.32

39540 $1,456.28

39541 $1,579.36

39545 $1,504.91

39560 $1,326.26

39561 $2,086.44

40490 $207.98

40500 $819.11

40510 $785.94

40520 $796.60

40525 $927.28*

40527 $1,050.05* #

40530 $880.93

40650 $714.21

40652 $795.64

40654 $923.47

40700 $1,655.92

40701 $1,836.65

40702 $1,624.10

40720 $1,724.26

40761 $1,822.39

40800 $336.40

40801 $508.46

40804 $345.78

40805 $632.98

40806 $176.59

40808 $297.34

60

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

40810 $331.75

40812 $465.27

40814 $626.13

40816 $657.05

40818 $566.89

40819 $500.16

40820 $423.71

40830 $427.79

40831 $546.10

40840 $1,331.81

40842 $1,327.50

40843 $1,794.85

40844 $2,212.22

40845 $2,444.69

41000 $262.18

41005 $367.99

41006 $587.84

41007 $578.13

41008 $612.30

41009 $650.39

41010 $327.62

41015 $725.75

41016 $705.69

41017 $718.61

41018 $838.46

41019 $803.53

41100 $273.70

41105 $278.02

41108 $239.39

41110 $344.95

41112 $542.96

41113 $594.53

41114 $1,066.25

41115 $403.31

41116 $536.05

41120 $1,725.76

41130 $2,161.10

41135 $3,615.10

41140 $3,649.30

41145 $4,626.39

41150 $3,666.15

41153 $3,996.42

41155 $5,046.28

41250 $432.54

41251 $478.35

41252 $517.38

41500 $745.74

41510 $707.53

41512 $1,040.09

41520 $565.82

41530 $5,035.15

41800 $432.15

41805 $390.69

41806 $573.06

61

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

41822 $467.96

41823 $690.79

41825 $339.53

41826 $504.80

41827 $713.31

41828 $498.86

41830 $633.63

41872 $610.69

41874 $601.26

42000 $321.47

42100 $245.15

42104 $350.17

42106 $440.78

42120 $1,654.37

42140 $412.08

42145 $1,192.53

42160 $377.01

42180 $404.76

42182 $535.61

42200 $1,444.64

42205 $1,513.91

42210 $1,713.88

42215 $1,197.20

42220 $884.01

42225 $1,455.02

42226 $1,484.14

42235 $1,215.27

42260 $1,399.98

42300 $344.06

42305 $726.50

42310 $269.37

42320 $412.26

42330 $382.45

42335 $614.56

42340 $769.08

42400 $171.11

42405 $493.58

42408 $749.43

42409 $547.87

42410 $1,057.23

42415 $1,806.85

42420 $2,031.38

42425 $1,429.02

42426 $2,315.77

42440 $700.00

42450 $749.30

42500 $715.59

42505 $925.40

42507 $859.92

42508 $1,200.01

42509 $1,360.18

42550 $212.23

42600 $793.86

42650 $137.06

62

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

42660 $199.30

42665 $514.74

42700 $311.02

42720 $766.76

42725 $1,379.03

42800 $261.17

42802 $373.29

42804 $316.88

42806 $357.32

42808 $376.06

42809 $285.75

42810 $637.42

42815 $939.36

42820 $492.40

42821 $511.32

42825 $441.97

42826 $424.54

42830 $349.10

42831 $375.47

42835 $323.05

42836 $406.56

42842 $1,660.89

42844 $2,290.08

42845 $3,752.85

42860 $315.76

42870 $950.74

42890 $2,374.42

42892 $3,158.54

42894 $3,994.99

42900 $578.87

42950 $1,305.88

42955 $1,243.50

42960 $287.46

42961 $714.07

42962 $878.08

42970 $691.99

42971 $776.03

42972 $870.70

43020 $900.81

43030 $882.66

43045 $2,197.70

43100 $1,068.84

43101 $1,700.77

43107 $4,298.34

43108 $7,894.73

43112 $4,542.20

43113 $7,373.87

43116 $9,024.76

43117 $4,170.82

43118 $6,433.00

43121 $4,863.43

43122 $4,314.49

43123 $7,644.78

43124 $6,486.32

63

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

43130 $1,337.24

43135 $2,520.56

43200 $342.00

43201 $494.94

43202 $455.35

43204 $383.81

43205 $382.83

43206 By Report

43215 $263.60

43216 $366.07

43217 $612.47

43219 $289.65

43220 $216.95

43226 $240.14

43227 $363.23

43228 $380.46

43231 $324.50

43232 $445.53

43235 $477.96

43236 $610.79

43237 $399.86

43238 $498.18

43239 $553.36

43240 $678.38

43241 $266.16

43242 $724.01

43243 $457.03

43244 $504.20

43245 $321.07

43246 $430.18

43247 $342.29

43248 $321.40

43249 $296.52

43250 $323.01

43251 $372.94

43252 By Report

43255 $482.39

43256 $434.10

43257 $553.48

43258 $456.17

43259 $519.19

43260 $592.05

43261 $622.22

43262 $731.12

43263 $722.67

43264 $877.02

43265 $984.47

43267 $726.34

43268 $740.22

43269 $809.93

43271 $730.65

43272 $732.08

43273 $216.44

43279 $2,168.77

64

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

43280 $1,812.02

43281 $2,594.36

43282 $2,919.08

43283 $267.41

43300 $1,047.37

43305 $1,872.11

43310 $2,518.73

43312 $2,721.10

43313 $5,143.79

43314 $5,028.75

43320 $2,333.76*

43325 $2,249.98

43327 $1,363.04

43328 $1,946.21

43330 $2,231.45

43331 $2,270.54

43332 $1,949.88

43333 $2,121.93

43334 $2,116.53

43335 $2,262.46

43336 $2,555.47

43337 $2,750.54

43338 $198.41

43340 $2,303.65

43341 $2,491.52

43350 $2,015.37

43351 $2,220.85

43352 $1,801.22

43360 $3,831.68

43361 $4,305.43

43400 $2,644.28

43401 $2,627.82

43405 $2,447.26

43410 $1,811.44

43415 $4,353.82

43420 $1,745.08

43425 $2,432.39

43450 $249.59

43453 $462.94

43456 $932.96

43458 $619.66

43460 $383.86

43500 $1,312.91

43501 $2,254.24

43502 $2,550.49

43510 $1,544.98

43520 $1,148.85

43605 $1,397.43

43610 $1,640.92

43611 $2,043.31

43620 $3,292.19

43621 $3,804.47

43622 $3,856.13

43631 $2,430.57

65

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

43632 $3,408.06

43633 $3,224.24

43634 $3,563.58

43635 $189.77

43640 $1,971.82

43641 $2,006.43

43644 $2,903.13#

43645 $3,097.71#

43651 $1,087.54

43652 $1,272.61

43653 $950.38

43752 $71.21

43753 $36.90

43754 $148.20

43755 $228.28

43756 $339.41

43757 $479.48

43760 $762.79

43761 $198.78

43770 $1,865.35#

43771 $2,122.89#

43772 $1,592.51#

43773 $2,120.98#

43774 $1,604.68#

43775 $2,120.35*

43800 $1,555.16

43810 $1,699.76

43820 $2,244.15

43825 $2,163.92

43830 $1,163.88

43831 $983.11

43832 $1,750.98

43840 $2,275.20

43845 $3,290.85#

43846 $2,723.33#

43847 $3,014.12#

43848 $3,230.68#

43850 $2,725.66

43855 $2,828.19

43860 $2,740.29

43865 $2,861.48

43870 $1,190.38

43880 $2,673.80

43886 $595.05#

43887 $537.66#

43888 $757.54#

44005 $1,834.98

44010 $1,454.65

44015 $240.68

44020 $1,631.07

44021 $1,635.44

44025 $1,659.12

44050 $1,565.84

44055 $2,512.91

66

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

44100 $194.15

44110 $1,424.15

44111 $1,654.35

44120 $2,053.22

44121 $409.07

44125 $1,986.16

44126 $4,131.81

44127 $4,780.85

44128 $410.44

44130 $2,205.19

44139 $205.15

44140 $2,251.33

44141 $3,058.75

44143 $2,794.01

44144 $2,977.40

44145 $2,799.32

44146 $3,567.60

44147 $3,275.29

44150 $3,138.29

44155 $3,510.13

44157 $3,637.79

44158 $3,735.20

44160 $2,086.00

44180 $1,539.77

44186 $1,087.47

44187 $1,862.32

44188 $2,057.53

44202 $2,328.11

44203 $409.00

44204 $2,599.65

44205 $2,262.78

44206 $2,959.55

44207 $3,096.82

44208 $3,372.25

44210 $3,034.05

44211 $3,761.52

44212 $3,498.60

44213 $321.80

44227 $2,814.52

44300 $1,409.73

44310 $1,759.45

44312 $991.23

44314 $1,697.69

44316 $2,363.47

44320 $2,019.24

44322 $1,648.59

44340 $1,039.76

44345 $1,768.90

44346 $1,992.86

44360 $267.78

44361 $294.68

44363 $352.56

44364 $376.48

44365 $335.26

67

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

44366 $443.65

44369 $453.74

44370 $489.55

44372 $439.87

44373 $351.90

44376 $518.60

44377 $549.20

44378 $705.27

44379 $749.90

44380 $114.97

44382 $137.77

44383 $279.79

44385 $420.09

44386 $566.75

44388 $570.98

44389 $644.21

44390 $762.08

44391 $815.89

44392 $718.03

44393 $830.21

44394 $812.04

44397 $471.71

44500 $42.76

44602 $2,375.70

44603 $2,727.14

44604 $1,777.75

44605 $2,190.25

44615 $1,807.23

44620 $1,460.27

44625 $1,722.72

44626 $2,706.44

44640 $2,364.65

44650 $2,448.79

44660 $2,269.33

44661 $2,625.34

44680 $1,792.73

44700 $1,730.99

44701 $284.86

44705 By Report*

44720 $443.83#

44721 $647.86#

44800 $1,274.75

44820 $1,405.53

44850 $1,257.71

44900 $1,294.60

44901 $1,349.52

44950 $1,073.38

44955 $141.77

44960 $1,460.91

44970 $1,000.28

45000 $708.24

45005 $430.88

45020 $951.09

45100 $497.88

68

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

45108 $608.77

45110 $3,128.51

45111 $1,833.91

45112 $3,211.14

45113 $3,345.39

45114 $3,041.94

45116 $2,699.22

45119 $3,319.84

45120 $2,650.84

45121 $2,905.60

45123 $1,906.14

45126 $4,813.10

45130 $1,858.73

45135 $2,287.74

45136 $3,112.47

45150 $663.09

45160 $1,703.04

45171 $995.94

45172 $1,360.51

45190 $1,154.13

45300 $195.65

45303 $1,471.32

45305 $312.44

45307 $370.07

45308 $336.33

45309 $345.75

45315 $368.19

45317 $393.60

45320 $388.26

45321 $183.00

45327 $215.40

45330 $220.40

45331 $264.99

45332 $470.16

45333 $476.38

45334 $279.89

45335 $440.92

45337 $243.70

45338 $517.54

45339 $560.86

45340 $776.71

45341 $267.97

45342 $408.87

45345 $298.45

45355 $350.72

45378 $638.43

45379 $820.37

45380 $761.87

45381 $763.21

45382 $991.19

45383 $927.86

45384 $762.00

45385 $862.53

45386 $1,079.96

69

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

45387 $590.90

45391 $507.08

45392 $649.10

45395 $3,361.44

45397 $3,666.66

45400 $1,957.01

45402 $2,603.60

45500 $885.98

45505 $986.05

45520 $245.30

45540 $1,800.81

45541 $1,567.06

45550 $2,484.24

45560 $1,180.98

45562 $1,875.66

45563 $2,743.75

45800 $2,019.29

45805 $2,433.00

45820 $1,916.82

45825 $2,488.67

45900 $339.73

45905 $280.76

45910 $326.99

45915 $531.91

45990 $180.99

46020 $450.34

46030 $225.07

46040 $858.86

46045 $715.66

46050 $319.24

46060 $787.39

46070 $364.42

46080 $402.70

46083 $281.69

46200 $708.01

46220 $329.16

46221 $433.58

46230 $442.14

46250 $740.34

46255 $814.44

46257 $696.98

46258 $766.52

46260 $787.95

46261 $876.58

46262 $923.56

46270 $812.16

46275 $868.76

46280 $779.60

46285 $866.20

46288 $911.66

46320 $294.81

46500 $378.26

46505 $468.72

46600 $139.85

70

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

46604 $957.78

46606 $355.48

46608 $366.34

46610 $358.29

46611 $278.00

46612 $434.02

46614 $204.43

46615 $234.38

46700 $1,097.19

46705 $872.14

46706 $282.80

46707 $771.82

46710 $1,834.45

46712 $3,549.67

46715 $845.50

46716 $1,897.47

46730 $3,127.28

46735 $3,522.00

46740 $3,351.08

46742 $4,046.61

46744 $5,755.86

46746 $6,129.84

46748 $6,729.35

46750 $1,287.16

46751 $1,009.91

46753 $986.30

46754 $487.17

46760 $1,859.27

46761 $1,575.83

46762 $1,569.77

46900 $385.22

46910 $405.07

46916 $367.11

46917 $705.26

46922 $424.50

46924 $839.21

46930 $326.54

46940 $373.35

46942 $350.94

46945 $488.16

46946 $500.48

46947 $636.17

47000 $561.02

47001 $174.48

47010 $2,007.99

47011 $320.31

47015 $1,935.07

47100 $1,403.16

47120 $3,890.89

47122 $5,740.23

47125 $5,151.92

47130 $5,525.82

47135 $8,201.30#

47136 $7,017.64#

71

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

47140 $5,961.58

47141 $6,827.07

47142 $7,862.66

47146 $554.93#

47147 $647.74#

47300 $1,889.05

47350 $2,289.92

47360 $3,136.34

47361 $5,085.01

47362 $2,415.52

47370 $2,075.89

47371 $2,097.72

47380 $2,411.69

47381 $2,475.47

47382 $7,567.80

47400 $3,603.44

47420 $2,247.09

47425 $2,280.07

47460 $2,114.14

47480 $1,454.61

47490 $555.24

47500 $170.30

47505 $65.64

47510 $804.05

47511 $1,002.06

47525 $746.51

47530 $2,113.11

47550 $279.23

47552 $545.34

47553 $550.40

47554 $835.81

47555 $652.82

47556 $741.42#

47560 $451.72

47561 $494.25

47562 $1,095.62#

47563 $1,190.94#

47564 $1,857.15#

47570 $1,291.95

47600 $1,784.05#

47605 $1,878.23#

47610 $2,098.44#

47620 $2,304.95#

47630 $938.57

47700 $1,749.63

47701 $2,896.43

47711 $2,593.14

47712 $3,344.30

47715 $2,217.99

47720 $1,919.96

47721 $2,258.68

47740 $2,187.87#

47741 $2,463.75#

47760 $3,772.57

72

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

47765 $5,092.19

47780 $4,141.58

47785 $5,436.02

47800 $2,641.83

47802 $2,546.59

47900 $2,296.25

48000 $3,119.41

48001 $3,869.47

48020 $1,963.42

48100 $1,480.43

48102 $838.77

48105 $4,787.24

48120 $1,855.22

48140 $2,612.39

48145 $2,730.53

48146 $3,115.24

48148 $2,082.97

48150 $5,195.81

48152 $4,828.97

48153 $5,179.42

48154 $4,850.23

48155 $3,029.04

48400 $189.05

48500 $1,915.21

48510 $1,802.91

48511 $1,410.78

48520 $1,828.96

48540 $2,190.79

48545 $2,247.12

48547 $3,000.09

48548 $2,783.68

48552 $397.26#

48554 $4,240.65#

48556 $2,115.46#

49000 $1,287.64

49002 $1,753.72

49010 $1,576.10

49020 $2,666.60

49021 $1,326.81

49040 $1,680.62

49041 $1,390.68

49060 $1,845.29

49061 $1,354.96

49062 $1,237.49

49082 $276.15

49083 $493.46

49084 $178.62

49180 $261.31

49203 $2,003.09

49204 $2,561.82

49205 $2,940.86

49215 $3,708.92

49220 $1,587.97

49250 $971.61

73

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

49255 $1,321.88

49320 $546.61

49321 $578.37

49322 $622.38

49323 $1,079.32

49324 $657.85

49325 $702.81

49326 $319.75

49327 $219.30

49400 $224.96

49402 $1,431.34

49411 $844.85

49412 $138.02

49418 $2,182.29

49419 $734.89

49421 $390.57

49422 $640.29

49423 $827.14

49424 $224.97

49425 $1,257.11

49426 $1,052.98

49427 $78.62

49428 $719.09

49429 $741.85

49435 $203.44

49436 $310.02

49440 $1,607.39

49441 $1,806.75

49442 $1,440.82

49446 $1,516.08

49450 $1,006.06

49451 $1,102.92

49452 $1,365.48

49460 $1,099.62

49465 $252.28

49491 $1,319.12

49492 $1,557.92

49495 $655.70

49496 $953.40

49500 $621.46

49501 $1,004.39

49505 $863.59

49507 $972.67

49520 $1,050.98

49521 $1,192.45

49525 $951.51

49540 $1,124.83

49550 $957.39

49553 $1,049.14

49555 $992.41

49557 $1,203.53

49560 $1,229.39

49561 $1,554.03

49565 $1,279.96

74

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

49566 $1,569.91

49568 $451.13

49570 $688.92

49572 $855.80

49580 $546.54

49582 $798.35

49585 $735.57

49587 $787.40

49590 $951.52

49600 $1,214.14

49605 $8,285.95

49606 $1,892.18

49610 $1,045.40

49611 $899.21

49650 $708.86

49651 $923.63

49652 $1,190.53

49653 $1,485.47

49654 $1,353.85

49655 $1,652.72

49656 $1,470.31

49657 $2,118.47

49900 $1,355.33

49904 $2,415.49

49905 $599.16

50010 $1,235.84

50020 $1,797.65

50021 $1,406.71

50040 $1,574.96

50045 $1,584.69

50060 $1,942.96

50065 $2,062.53

50070 $2,022.07

50075 $2,489.18

50080 $1,479.83

50081 $2,178.40

50100 $1,700.14

50120 $1,614.98

50125 $1,768.98

50130 $1,758.65

50135 $1,912.41

50200 $899.03

50205 $1,256.21

50220 $1,772.02

50225 $2,041.37

50230 $2,186.66

50234 $2,218.78

50236 $2,499.01

50240 $2,255.26

50250 $2,076.01

50280 $1,623.85

50290 $1,526.66

50300 $1,227.60

50320 $2,403.21

75

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

50327 $365.87#

50328 $319.88#

50329 $299.66#

50340 $1,569.04

50360 $4,282.85

50365 $4,759.72

50370 $1,998.18

50380 $3,316.34

50382 $1,816.99

50384 $1,465.41

50385 $1,735.06

50386 $1,130.71

50387 $838.08

50389 $454.48

50390 $169.71

50391 $204.28

50392 $310.04

50393 $377.50

50394 $159.42

50395 $310.15

50396 $193.88

50398 $749.63

50400 $1,974.81

50405 $2,382.50

50500 $2,114.47

50520 $1,764.23

50525 $2,450.73

50526 $2,480.40

50540 $1,956.51

50541 $1,567.75

50542 $1,988.04

50543 $2,540.17

50544 $2,132.34

50545 $2,292.84

50546 $2,045.50

50547 $2,687.68

50548 $2,305.32

50551 $596.33

50553 $640.66

50555 $685.00

50557 $696.61

50561 $791.44

50562 $995.24

50570 $845.53

50572 $915.70

50574 $974.33

50575 $1,231.49

50576 $971.24

50580 $1,047.08

50590 $1,176.74

50592 $4,647.29

50593 $6,852.69

50600 $1,599.37

50605 $1,647.18

76

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

50610 $1,610.02

50620 $1,538.91

50630 $1,519.69

50650 $1,763.59

50660 $1,949.70

50684 $164.20

50686 $237.28

50688 $133.74

50690 $158.03

50700 $1,573.56

50715 $2,027.35

50722 $1,783.00

50725 $1,878.29

50727 $848.85

50728 $1,181.55

50740 $2,039.39

50750 $1,966.80

50760 $1,913.86

50770 $1,966.80

50780 $1,880.76

50782 $2,000.71

50783 $1,922.02

50785 $2,062.97

50800 $1,574.07

50810 $2,202.33

50815 $2,081.46

50820 $2,245.01

50825 $2,831.36

50830 $3,082.00

50840 $2,093.19

50845 $2,128.52

50860 $1,607.38

50900 $1,442.81

50920 $1,497.16

50930 $1,947.28

50940 $1,507.92

50945 $1,660.82

50947 $2,367.07

50948 $2,179.54

50951 $622.16

50953 $661.07

50955 $707.09

50957 $713.13

50961 $641.00

50970 $637.08

50972 $616.14

50974 $814.01

50976 $802.58

50980 $611.90

51020 $787.29

51030 $790.64

51040 $482.05

51045 $818.49

51050 $795.59

77

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

51060 $981.12

51065 $977.29

51080 $685.93

51100 $100.77

51101 $196.57

51102 $367.25

51500 $1,076.26

51520 $1,003.21

51525 $1,460.81

51530 $1,335.24

51535 $1,322.27

51550 $1,640.60

51555 $2,164.04

51565 $2,208.61

51570 $2,524.85

51575 $3,113.27

51580 $3,239.53

51585 $3,610.68

51590 $3,305.66

51595 $3,748.62

51596 $4,026.40

51597 $3,918.24

51600 $275.45

51605 $64.63

51610 $168.33

51700 $132.38

51701 $86.31

51702 $109.28

51703 $207.82

51705 $144.07

51710 $154.65

51715 $470.60

51720 $177.78

51725 $294.42

51725 26 $132.88

51725 TC $161.54

51726 $407.15

51726 26 $148.84

51726 TC $258.31

51727 $487.99

51727 TC $300.30

51728 $486.33

51728 TC $303.17

51729 $532.71

51729 TC $310.83

51736 $24.47

51736 26 $14.60

51736 TC $9.87

51741 $24.95

51741 26 $14.60

51741 TC $10.34

51784 $301.03

51784 26 $133.75

51784 TC $167.29

78

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

51785 $392.42

51785 26 $138.05

51785 TC $254.37

51792 $323.19

51792 26 $96.57

51792 TC $226.62

51797 $174.25

51797 26 $69.65

51797 TC $104.61

51798 $27.57

51800 $1,776.30

51820 $1,842.18

51840 $1,122.96

51841 $1,336.94

51845 $995.35

51860 $1,258.37

51865 $1,521.63

51880 $789.35

51900 $1,409.44

51920 $1,381.90

51925 $1,768.64

51940 $2,810.99

51960 $2,370.35

51980 $1,208.01

51990 $1,292.29

51992 $1,457.73

52000 $323.81

52001 $609.39

52005 $413.91

52007 $680.94

52010 $568.98

52204 $566.14

52214 $998.82

52224 $1,049.85

52234 $420.94

52235 $494.55

52240 $673.50

52250 $414.88

52260 $360.22

52265 $570.34

52270 $556.85

52275 $754.18

52276 $454.97

52277 $559.41

52281 $428.99

52282 $577.80

52283 $448.47

52285 $451.69

52287 $491.07

52290 $418.73

52300 $487.94

52301 $501.46

52305 $478.14

52310 $387.57

79

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

52315 $664.61

52317 $1,250.06

52318 $814.88

52320 $423.07

52325 $551.56

52327 $453.32

52330 $779.19

52332 $770.73

52334 $439.88

52341 $493.95

52342 $537.38

52343 $598.32

52344 $649.40

52345 $692.83

52346 $783.56

52351 $528.44

52352 $620.50

52353 $685.17

52354 $728.89

52355 $816.17

52400 $814.22

52402 $460.22#

52450 $789.58#

52500 $820.43

52601 $1,437.92

52630 $671.52

52640 $523.58

52647 $2,725.28

52648 $2,813.65

52649 $1,384.34

52700 $742.87

53000 $247.58

53010 $488.34

53020 $165.54

53025 $124.50

53040 $660.52

53060 $303.84

53080 $705.44

53085 $1,107.27

53200 $261.65

53210 $1,317.52

53215 $1,578.40

53220 $765.50

53230 $1,028.80

53235 $1,069.72

53240 $714.10

53250 $687.84

53260 $335.24

53265 $360.15

53270 $347.50

53275 $444.67

53400 $1,362.89

53405 $1,483.61

53410 $1,666.74

80

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

53415 $1,926.55

53420 $1,429.84

53425 $1,594.74

53430 $1,648.54

53431 $1,966.98

53440 $1,277.69

53442 $1,322.32

53444 $1,347.26

53445 $1,272.21

53446 $1,084.58#

53447 $1,370.48

53448 $2,181.50#

53449 $1,033.32

53450 $685.66

53460 $770.70

53500 $1,271.55

53502 $820.00

53505 $819.52

53510 $1,067.22

53515 $1,350.24

53520 $938.34

53600 $136.81

53601 $130.02

53605 $111.19

53620 $189.79

53621 $176.19

53660 $111.56

53661 $109.84

53665 $66.89

53850 $3,133.27

53852 $2,908.76

53855 $1,146.66

53860 $2,331.74

54000 $235.51

54001 $298.16

54015 $522.12

54050 $211.13

54055 $190.63

54056 $227.04

54057 $214.26

54060 $286.60

54065 $355.24

54100 $314.83

54105 $428.88

54110 $1,056.87

54115 $750.52

54120 $1,069.08

54125 $1,380.68

54130 $2,033.36

54135 $2,583.27

54150 $250.41

54160 $351.94

54161 $331.97

54162 $418.27

81

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

54163 $362.77

54164 $319.82

54200 $170.45

54205 $896.33

54220 $326.95

54230 $157.81#

54235 $146.94

54240 $163.04#

54240 26 $112.50

54240 TC $50.54#

54300 $1,085.21

54304 $1,271.42

54308 $1,212.33

54312 $1,387.86

54316 $1,697.30

54318 $1,193.48

54322 $1,326.14

54324 $1,647.83

54326 $1,607.65

54328 $1,596.40

54332 $1,725.28

54336 $2,096.92

54340 $961.10

54344 $1,611.30

54348 $1,710.26

54352 $2,417.45

54360 $1,222.73*

54380 $1,520.76

54385 $1,657.43

54390 $2,189.20

54420 $1,194.17

54430 $1,082.19

54435 $698.88

54450 $116.10

54500 $126.13

54505 $353.16

54512 $911.62

54520 $547.80

54522 $1,018.46

54530 $851.32

54535 $1,262.02

54550 $830.68

54560 $1,163.73

54600 $762.82

54620 $506.90

54640 $805.56

54650 $1,204.22

54660 $597.81

54670 $680.17

54680 $1,336.40

54690 $1,228.47

54692 $1,367.67

54700 $359.33

54800 $218.19

82

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

54830 $625.34

54840 $539.28

54860 $704.40

54861 $955.17

54865 $600.90

54900 $1,347.13

54901 $1,782.03

55000 $189.34

55040 $567.93

55041 $859.50

55060 $638.81

55100 $347.86

55110 $651.21

55120 $601.89

55150 $827.10

55175 $609.29

55180 $1,165.08

55200 $693.27

55250 $602.02

55300 $320.63

55450 $579.34

55500 $663.62

55520 $750.03

55530 $592.06

55535 $724.19

55540 $896.21

55550 $721.51

55600 $708.92

55605 $877.31

55650 $1,217.70

55680 $580.66

55700 $350.15

55705 $450.23

55706 $622.55

55720 $762.66

55725 $1,000.29

55801 $1,860.55

55810 $2,247.11

55812 $2,748.51

55815 $3,014.13

55821 $1,485.96

55831 $1,609.33

55840 $2,281.30

55842 $2,445.06

55845 $2,796.69

55866 $2,962.76

55873 $10,148.16

55875 $1,292.92

55876 $219.68

55920 $763.55

56405 $182.10

56420 $199.67

56440 $309.40

56441 $238.73

83

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

56442 $80.10#

56501 $214.28

56515 $372.24

56605 $136.27

56606 $62.33

56620 $852.77

56625 $1,030.26

56630 $1,521.18

56631 $1,934.25

56632 $2,250.92

56633 $1,984.20

56634 $2,105.42

56637 $2,463.85

56640 $2,414.19

56700 $315.79

56740 $506.93

56800 $408.21

56805 $1,966.62#

56810 $442.04

56820 $183.73

56821 $244.15

57000 $321.31

57010 $736.59

57020 $158.85

57022 $285.97

57023 $530.69

57061 $185.36

57065 $320.20

57100 $145.98

57105 $223.25

57106 $817.87

57107 $2,416.69

57109 $2,823.92

57110 $1,537.66

57111 $2,761.72

57112 $2,877.32

57120 $867.13

57130 $295.33

57135 $319.06

57150 $74.30

57155 $721.01

57156 $320.78

57160 $124.78

57170 $101.73

57180 $230.09

57200 $502.09

57210 $618.72

57220 $538.95

57230 $670.99

57240 $1,141.01

57250 $1,156.44

57260 $1,427.28

57265 $1,565.14

57267 $444.34

84

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

57268 $816.18

57270 $1,366.60

57280 $1,633.81

57282 $847.03

57283 $1,177.60

57284 $1,396.84

57285 $1,151.34

57287 $1,148.61

57288 $1,211.39

57289 $1,234.12

57291 $903.22#

57292 $1,399.79#

57295 $810.87#

57296 $1,630.59#

57300 $941.47

57305 $1,572.72

57307 $1,782.40

57308 $1,092.02

57310 $773.54

57320 $895.91

57330 $1,254.75

57335 $1,985.43#

57400 $227.12

57410 $182.29

57415 $269.37

57420 $192.84

57421 $259.91

57423 $1,574.22

57425 $1,664.39

57426 $1,447.21

57452 $180.74

57454 $257.95

57455 $237.90

57456 $224.06

57460 $457.23

57461 $519.51

57500 $205.31

57505 $166.84

57510 $219.77

57511 $241.43

57513 $239.04

57520 $505.71

57522 $438.75

57530 $581.24

57531 $2,981.35

57540 $1,334.23

57545 $1,408.54

57550 $690.06

57555 $1,025.01

57556 $963.80

57558 $208.03

57700 $519.69

57720 $517.79

57800 $99.37

85

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

58100 $181.92

58110 $81.19

58120 $429.42

58140 $1,571.92

58145 $926.10

58146 $1,984.51

58150 $1,712.76

58152 $2,139.66

58180 $1,642.67

58200 $2,269.15

58210 $3,038.75

58240 $4,835.95

58260 $1,416.14

58262 $1,581.14

58263 $1,699.31

58267 $1,809.78

58270 $1,511.57

58275 $1,687.48

58280 $1,808.97

58285 $2,257.59

58290 $1,971.37

58291 $2,144.69

58292 $2,262.75

58293 $2,354.10

58294 $2,096.82

58300 $116.90

58301 $157.98

58340 $186.20

58346 $747.30

58353 $1,539.69

58356 $2,869.46

58400 $744.83

58410 $1,377.60

58520 $1,366.87

58540 $1,558.74

58541 $1,478.95

58542 $1,653.86

58543 $1,680.79

58544 $1,821.94

58545 $1,535.18

58546 $1,937.94

58548 $3,121.68

58550 $1,511.21

58552 $1,681.39

58553 $1,952.05

58554 $2,261.44

58555 $492.27

58558 $648.30

58559 $590.94

58560 $667.37

58561 $945.41

58562 $675.57

58563 $2,541.22

58565 $2,878.67

86

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

58570 $1,590.98

58571 $1,774.37

58572 $1,984.69

58573 $2,278.91

58600 $620.30

58605 $559.24

58611 $134.31

58615 $414.55

58660 $1,150.61

58661 $1,105.36

58662 $1,207.83

58670 $621.26

58671 $621.26

58672 $1,264.12

58673 $1,373.88

58700 $1,321.48

58720 $1,234.79

58740 $1,498.70

58752 $1,495.17

58760 $1,387.71

58770 $1,462.24

58800 $532.82

58805 $683.77

58820 $526.35

58822 $1,250.45

58823 $1,354.24

58825 $1,188.11

58900 $710.62

58920 $1,198.52

58925 $1,262.02

58940 $878.00

58943 $1,940.81

58950 $1,857.37

58951 $2,394.53

58952 $2,701.55

58953 $3,349.50

58954 $3,632.03

58956 $2,277.29

58957 $2,610.30

58958 $2,877.49

58960 $1,596.57

59000 $201.29

59001 $301.93

59012 $341.60

59015 $256.61

59020 $112.59

59020 26 $62.54

59020 TC $50.06

59025 $77.30

59025 26 $50.21

59025 TC $27.09

59030 $188.13

59050 $85.76

59051 $71.61#

87

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

59070 $668.53

59072 $877.66

59074 $654.17

59076 $877.66

59100 $1,395.94#

59120 $1,326.78

59121 $1,328.43

59130 $1,456.91

59135 $1,437.90

59136 $1,520.74

59140 $625.59

59150 $1,285.22

59151 $1,251.24

59160 $333.66

59200 $115.94

59300 $314.33

59320 $255.21

59325 $382.17

59350 $475.34

59400 $3,485.80

59409 $1,382.67

59410 $1,758.41

59412 $173.57

59414 $154.95

59430 $303.71

59510 $3,850.38

59514 $1,553.47

59515 $2,124.71

59525 $820.74

59610 $3,650.08

59612 $1,548.44

59614 $1,922.68

59618 $3,900.90

59620 $1,603.30

59622 $2,180.40

59812 $523.27

59820 $619.40

59821 $626.15

59830 $724.19

59840 $355.85

59841 $632.38

59850 $594.19

59851 $660.27

59852 $861.52

59855 $691.18

59856 $814.03

59857 $895.66

59870 $776.91

59871 $224.04

60000 $281.98

60100 $185.28

60200 $1,107.65

60210 $1,190.44

60212 $1,699.23

88

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

60220 $1,191.55

60225 $1,566.90

60240 $1,549.36

60252 $2,229.98

60254 $2,837.84

60260 $1,849.28

60270 $2,317.67

60271 $1,787.84

60280 $742.61

60281 $995.50

60300 $186.21

60500 $1,620.39

60502 $2,162.91

60505 $2,354.62

60512 $413.21

60520 $1,743.74

60521 $1,897.16

60522 $2,313.01

60540 $1,781.19

60545 $2,046.44

60600 $2,365.67

60605 $3,141.02

60650 $2,007.67

61000 $193.68

61001 $179.09

61020 $220.22

61026 $211.55

61050 $180.25

61055 $229.28

61070 $137.57

61105 $737.87

61107 $508.99

61108 $1,453.06

61120 $1,194.25

61140 $2,025.27

61150 $2,170.86

61151 $1,591.85

61154 $2,035.75

61156 $1,994.76

61210 $594.96

61215 $803.67

61250 $1,386.88

61253 $1,278.20

61304 $2,636.85

61305 $3,222.60

61312 $3,342.07

61313 $3,186.81

61314 $2,932.76

61315 $3,320.94

61316 $142.00

61320 $3,057.98

61321 $3,416.12

61322 $3,816.15

61323 $3,834.56

89

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

61330 $2,950.70

61332 $3,052.81

61333 $3,369.89

61334 $1,968.60

61340 $2,316.31

61343 $3,532.16

61345 $3,271.86

61440 $2,955.04

61450 $3,084.98

61458 $3,225.12

61460 $3,375.35

61470 $2,807.61

61480 $2,872.96

61490 $3,037.44

61500 $2,164.36

61510 $3,508.30

61512 $4,100.03

61514 $3,060.92

61516 $2,984.01

61517 $140.84

61518 $4,436.30

61519 $4,740.32

61520 $6,077.18

61521 $5,113.22

61522 $3,508.31

61524 $3,339.94

61526 $5,862.37

61530 $4,942.21

61531 $1,955.46

61533 $2,446.59

61534 $2,636.17

61535 $1,598.14

61536 $4,140.06

61537 $3,965.23

61538 $4,286.40

61539 $3,788.17

61540 $3,501.64

61541 $3,446.89

61542 $3,356.47

61543 $3,484.43

61544 $2,782.49

61545 $5,111.25

61546 $3,701.91

61548 $2,540.05

61550 $1,617.65

61552 $1,870.52

61556 $2,731.20

61558 $2,616.59

61559 $3,188.05

61563 $3,175.97

61564 $3,525.95

61566 $3,605.80

61567 $4,111.78

61570 $2,993.82

90

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

61571 $3,188.87

61575 $4,021.35

61576 $5,829.03

61580 $4,111.26

61581 $4,517.89

61582 $4,851.22

61583 $4,657.05

61584 $4,581.29

61585 $5,176.26

61586 $3,892.25

61590 $5,120.41

61591 $5,158.42

61592 $5,108.31

61595 $3,914.99

61596 $4,178.36

61597 $4,647.81

61598 $4,530.53

61600 $3,533.18

61601 $3,848.76

61605 $3,658.64

61606 $4,833.56

61607 $4,630.74

61608 $5,233.06

61609 $1,005.70

61610 $3,029.53

61611 $657.39

61612 $2,470.49

61613 $5,257.10

61615 $3,839.11

61616 $5,380.25

61618 $2,117.89

61619 $2,408.66

61623 $934.66

61624 $1,867.53

61626 $1,471.91#

61630 $2,138.60

61635 $2,338.07

61640 $1,093.26

61641 $384.18

61642 $768.54

61680 $3,631.90

61682 $6,733.27

61684 $4,566.29

61686 $7,234.56

61690 $3,506.48

61692 $5,883.17

61697 $6,797.74

61698 $7,451.74

61700 $5,492.48

61702 $6,471.39

61703 $2,176.17

61705 $4,178.86

61708 $3,736.65

61710 $2,825.76

91

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

61711 $4,192.14

61720 $2,034.58

61735 $2,547.34

61750 $2,255.60

61751 $2,201.29

61760 $2,533.10

61770 $2,599.79

61781 $380.21

61782 $315.77

61783 $380.69

61790 $1,396.14

61796 $1,615.88

61797 $353.16

61798 $2,214.12

61799 $487.90

61800 $246.19

61850 $1,571.67

61860 $2,508.82

61863 $2,408.12

61864 $458.84

61867 $3,663.37

61868 $807.64

61870 $1,895.13

61875 $1,657.19

61880 $911.23

61885 $827.65

61886 $1,349.81

61888 $630.24

62000 $1,648.68

62005 $2,035.26

62010 $2,453.67

62100 $2,591.02

62116 $2,842.00

62117 $2,710.69

62120 $2,816.94

62121 $2,657.91

62140 $1,675.02

62141 $1,846.02

62142 $1,422.92

62143 $1,673.53

62145 $2,276.57

62146 $1,999.54

62147 $2,337.01

62148 $204.38

62160 $306.54

62161 $2,432.88

62162 $3,029.69

62163 $1,958.68

62164 $3,348.93

62165 $2,531.79

62180 $2,565.48

62190 $1,476.87

62192 $1,566.34

62194 $637.07

92

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

62200 $2,205.37

62201 $1,923.92

62220 $1,655.74

62223 $1,693.64

62225 $837.57

62230 $1,356.86

62252 $134.22

62252 26 $74.59

62252 TC $59.63

62256 $956.68

62258 $1,810.13

62263 $1,108.97

62264 $702.43

62267 $403.04

62270 $252.56

62272 $315.91

62273 $289.31

62280 $527.62

62281 $399.37

62282 $454.33

62284 $302.23

62287 $962.82

62290 $543.23

62291 $513.32

62292 $1,012.67

62294 $1,204.08

62310 $390.16

62311 $327.72

62318 $380.73

62319 $280.77

62350 $673.97*

62351 $1,423.09*

62355 $435.53

62360 $514.18*

62361 $551.21*

62362 $644.34*

62365 $483.90*

62367 $68.70

62368 $93.14

62369 $193.63

62370 $205.38

63001 $2,000.59#

63003 $2,004.20#

63005 $1,908.39#

63011 $1,790.98#

63012 $1,932.93#

63015 $2,391.63#

63016 $2,458.44#

63017 $2,022.21#

63020 $1,890.42#

63030 $1,564.44#

63035 $315.96#

63040 $2,275.47#

63042 $2,121.79#

93

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

63043 By Report#

63044 By Report#

63045 $2,058.61#

63046 $1,966.77#

63047 $1,792.35#

63048 $349.47#

63050 $2,494.90#

63051 $2,799.94#

63055 $2,629.35#

63056 $2,418.51#

63057 $528.53#

63064 $2,874.49#

63066 $333.39#

63075 $2,219.62#

63076 $408.33#

63077 $2,442.71#

63078 $321.81#

63081 $2,878.99

63082 $439.76

63085 $3,111.17

63086 $314.05

63087 $3,934.91

63088 $427.75

63090 $3,256.64

63091 $297.66

63101 $3,761.49

63102 $3,683.14

63103 $481.12

63170 $2,552.05

63172 $2,253.87#

63173 $2,766.85#

63180 $2,379.52#

63182 $2,614.14#

63185 $1,911.01#

63190 $2,073.42#

63194 $2,141.09#

63195 $2,463.47#

63196 $2,372.30#

63197 $2,743.45#

63198 $2,795.14#

63199 $3,246.60#

63200 $2,464.00#

63250 $4,767.86

63251 $4,873.12

63252 $4,872.45

63265 $2,694.41

63266 $2,775.62

63267 $2,227.38

63268 $2,330.60

63270 $3,330.60

63271 $3,322.08

63272 $3,075.02

63273 $2,989.88

63275 $2,902.85

94

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

63276 $2,880.02

63277 $2,520.28

63278 $2,545.59

63280 $3,399.18

63281 $3,363.73

63282 $3,169.81

63283 $3,044.89

63285 $4,199.30

63286 $4,137.61

63287 $4,407.07

63290 $4,482.74

63295 $536.62

63300 $2,968.63

63301 $3,443.93

63302 $3,493.42

63303 $3,713.36

63304 $3,769.34

63305 $3,705.65

63306 $3,501.88

63307 $3,862.67

63308 $526.28

63600 $1,581.12

63610 $777.53

63620 $1,783.57

63621 $405.32

63650 $744.42

63655 $1,334.49

63661 $928.79

63662 $1,293.05

63663 $1,314.88

63664 $1,328.37

63685 $605.20

63688 $612.29

63700 $2,017.63

63702 $2,275.40

63704 $2,638.96

63706 $2,938.21

63707 $1,488.63

63709 $1,794.71

63710 $1,782.83

63740 $1,527.52

63741 $1,059.72

63744 $1,097.33

63746 $956.67

64400 $195.79

64402 $196.60

64405 $160.73

64408 $167.05

64410 $206.45

64412 $220.71

64413 $204.41

64415 $197.07

64416 $142.65

64417 $212.09

95

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

64418 $227.76

64420 $185.80

64421 $252.91

64425 $225.08

64430 $222.46

64435 $219.48

64445 $221.52

64446 $143.13

64447 $197.94

64448 $128.51

64449 $148.39

64450 $127.83#

64455 $81.05

64479 $390.28

64480 $186.06

64483 $362.22

64484 $146.19

64490 $316.87

64491 $158.32

64492 $158.80

64493 $284.87

64494 $144.28

64495 $144.76

64505 $172.44

64508 $109.72

64510 $208.95

64517 $300.21

64520 $298.38

64530 $311.87

64550 $25.80

64553 $369.06

64555 $326.92

64561 $1,268.68

64565 $287.72

64566 $184.91

64568 $1,025.70

64569 $1,265.65

64570 $1,096.61

64575 $527.11

64580 $501.71

64581 $1,139.72

64585 $392.52

64590 $418.38

64595 $387.02

64600 $626.07

64605 $890.71

64610 $1,168.15

64611 $175.97

64612 $215.66#

64613 $274.70

64614 $299.67

64615 $227.40

64620 $350.36

64630 $353.04

96

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

64632 $143.12

64633 $654.21

64634 $288.71

64635 $642.70

64636 $259.65

64640 $216.62

64650 $191.02#

64653 $228.99#

64680 $505.72

64681 $590.91

64702 $816.62

64704 $531.96

64708 $813.87

64712 $940.16

64713 $1,228.54

64714 $1,082.83

64716 $883.11

64718 $961.89

64719 $648.01

64721 $692.07

64722 $597.93

64726 $463.86

64727 $307.65

64732 $699.10

64734 $649.40

64736 $682.65

64738 $792.23

64740 $765.08

64742 $834.89

64744 $783.51

64746 $718.97

64752 $819.25

64755 $1,531.90

64760 $849.66

64761 $779.09

64763 $911.28

64766 $1,004.65

64771 $959.73

64772 $942.74

64774 $692.56

64776 $644.65

64778 $265.55

64782 $756.36

64783 $367.68

64784 $1,218.63

64786 $1,787.75

64787 $413.51

64788 $656.26

64790 $1,358.59

64792 $1,901.05

64795 $319.60

64802 $924.72

64804 $1,498.27

64809 $1,279.18

97

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

64818 $1,094.01

64820 $1,236.47

64821 $1,140.03

64822 $1,140.03

64823 $1,302.97

64831 $1,122.85

64832 $566.93

64834 $1,230.31

64835 $1,340.46

64836 $1,368.69

64837 $631.94

64840 $1,567.91

64856 $1,679.70

64857 $1,748.01

64858 $1,998.90

64859 $430.58

64861 $2,183.29

64862 $2,219.58

64864 $1,476.35

64865 $1,872.93

64866 $1,943.96

64868 $1,717.26

64870 $1,813.88

64872 $197.55

64874 $301.37

64876 $311.02

64885 $1,914.69

64886 $2,205.94

64890 $1,786.30

64891 $1,955.34

64892 $1,783.79

64893 $1,855.13

64895 $2,239.70

64896 $2,392.37

64897 $2,137.90

64898 $2,344.77

64901 $1,053.53

64902 $1,144.70

64905 $1,718.12

64907 $2,131.06

64910 $1,353.74

64911 $1,695.21

65091 $1,061.66

65093 $1,046.82

65101 $1,231.03

65103 $1,287.84

65105 $1,421.93

65110 $2,036.90

65112 $2,365.96

65114 $2,484.52

65125 $732.72#

65130 $1,223.43

65135 $1,241.87

65140 $1,333.75

98

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

65150 $938.21

65155 $1,419.61

65175 $1,080.00

65205 $93.31

65210 $114.61

65220 $95.52

65222 $112.51

65235 $1,188.28

65260 $1,580.61

65265 $1,844.41

65270 $425.30

65272 $804.29

65273 $631.27

65275 $926.59

65280 $1,146.34

65285 $1,888.18

65286 $1,142.04

65290 $835.09

65400 $1,118.77

65410 $236.30

65420 $824.24

65426 $1,056.93

65430 $192.48

65435 $133.14

65436 $651.04

65450 $533.77

65600 $648.15

65710 $1,853.84

65730 $2,060.65

65750 $2,073.56

65755 $2,067.14

65756 $1,971.68

65760 $1,595.20*

65770 $2,507.08

65775 $906.61*

65778 $2,086.39

65779 $1,882.71

65780 $1,474.94*

65781 $2,209.35*

65782 $1,962.60*

65800 $199.39

65810 $776.68

65815 $1,042.20

65820 $1,225.68

65850 $1,426.11

65855 $562.67

65860 $535.16

65865 $774.81

65870 $994.67

65875 $1,050.19

65880 $1,091.14

65900 $1,588.64

65920 $1,314.54

65930 $1,079.05

99

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

66020 $297.31

66030 $265.03

66130 $1,164.42

66150 $1,434.74

66155 $1,433.59

66160 $1,623.82

66165 $1,405.37

66170 $1,998.36

66172 $2,520.47

66174 $1,610.13

66175 $1,761.57

66180 $1,965.02

66185 $1,264.73

66220 $1,240.43

66225 $1,590.55

66250 $1,228.67

66500 $574.73

66505 $629.60

66600 $1,365.95

66605 $1,748.49

66625 $715.18

66630 $958.88

66635 $947.05

66680 $876.37

66682 $1,067.44

66700 $736.83#

66710 $737.71#

66711 $1,053.85

66720 $775.15#

66740 $714.02

66761 $485.00

66762 $781.57

66770 $860.68

66820 $646.06

66821 $541.94

66825 $1,257.98

66830 $1,177.93

66840 $1,185.51

66850 $1,331.89

66852 $1,433.49

66920 $1,247.91

66930 $1,419.15

66940 $1,321.86

66982 $1,348.93

66983 $1,250.11

66984 $1,080.29

66985 $1,288.98

66986 $1,525.29

66990 $152.86

67005 $801.20

67010 $909.21

67015 $966.57

67025 $1,206.40

67027 $1,448.03

100

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

67028 $172.17

67030 $867.47

67031 $641.14

67036 $1,618.36

67039 $2,096.37

67040 $2,393.57

67041 $2,247.29

67042 $2,572.13

67043 $2,728.34

67101 $1,302.01

67105 $1,192.68

67107 $2,067.92

67108 $2,717.01

67110 $1,436.93

67112 $2,242.69

67113 $2,960.03

67115 $829.34

67120 $1,093.26

67121 $1,542.59

67141 $874.71

67145 $874.06

67210 $864.29

67218 $2,310.90

67220 $893.85

67221 $476.44

67225 $50.21

67227 $1,001.65

67228 $1,691.87

67229 $1,937.82

67250 $1,309.29

67255 $1,416.77

67311 $1,008.86

67312 $1,215.02

67314 $1,137.06

67316 $1,369.29

67318 $1,160.19

67320 $547.71

67331 $533.72

67332 $580.03

67334 $512.27

67335 $259.55

67340 $608.87

67343 $1,106.99

67345 $406.09

67346 $346.54

67400 $1,558.29

67405 $1,303.59

67412 $1,425.01

67413 $1,433.74

67414 $2,222.97

67415 $181.00

67420 $2,741.46

67430 $2,044.55

67440 $2,003.18

101

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

67445 $2,390.71

67450 $2,082.53

67500 $137.92

67505 $153.42

67515 $166.47

67550 $1,618.76

67560 $1,640.01

67570 $2,000.06

67700 $418.22

67710 $349.79

67715 $373.04

67800 $210.09

67801 $271.50

67805 $336.07

67808 $622.23

67810 $270.84

67820 $85.47

67825 $213.76

67830 $423.49

67835 $745.62

67840 $440.14

67850 $341.86

67875 $275.44

67880 $752.87

67882 $934.66

67900 $1,053.78*

67901 $1,244.50

67902 $1,231.16

67903 $984.64

67904 $1,213.23

67906 $842.88

67908 $818.74

67909 $883.84

67911 $954.61

67912 $1,402.29*

67914 $634.13

67915 $568.99

67916 $883.39

67917 $967.04*

67921 $606.69

67922 $554.29

67923 $939.03

67924 $964.45*

67930 $599.59

67935 $981.14

67938 $379.74

67950 $942.24

67961 $945.93

67966 $1,282.00

67971 $1,236.70

67973 $1,595.39

67974 $1,592.89

67975 $1,168.17

68020 $198.58

102

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

68040 $109.29

68100 $271.86

68110 $363.90

68115 $496.19

68130 $863.49

68135 $259.72

68200 $68.35

68320 $1,182.50

68325 $1,117.69

68326 $1,096.63

68328 $1,205.16

68330 $990.54

68335 $1,101.06

68340 $889.98

68360 $872.27

68362 $1,116.82

68371 $678.12*

68400 $450.57

68420 $509.56

68440 $168.22

68500 $1,672.02

68505 $1,648.66

68510 $738.02

68520 $1,146.40

68525 $463.48

68530 $692.72

68540 $1,554.84

68550 $1,908.55

68700 $1,025.28

68705 $384.71

68720 $1,275.64

68745 $1,291.20

68750 $1,330.61

68760 $327.42

68761 $241.08

68770 $1,069.77

68801 $200.72

68810 $393.51

68811 $346.50

68815 $717.94

68816 $1,152.83

68840 $211.31

68850 $97.99

69000 $301.68

69005 $351.50

69020 $372.49

69100 $159.66

69105 $223.78

69110 $734.99

69120 $668.04

69140 $1,424.14

69145 $637.46

69150 $1,737.89

69155 $2,802.48

103

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

69200 $195.43

69205 $167.95

69210 $85.21

69220 $219.56

69222 $352.16

69300 $1,191.30*

69310 $1,783.96

69320 $2,517.03

69400 $236.31

69401 $142.06

69405 $428.63

69420 $307.74

69421 $247.13

69424 $205.12

69433 $327.44

69436 $267.31

69440 $1,142.23

69450 $897.87

69501 $1,221.49

69502 $1,624.63

69505 $1,979.36

69511 $2,030.01

69530 $2,743.00

69535 $4,480.27

69540 $333.33

69550 $1,709.94

69552 $2,610.05

69554 $4,237.56

69601 $1,749.20

69602 $1,817.77

69603 $2,077.08

69604 $1,859.37

69605 $2,582.42

69610 $635.40

69620 $1,123.37

69631 $1,465.95

69632 $1,793.23

69633 $1,731.64

69635 $2,021.60

69636 $2,272.88

69637 $2,274.98

69641 $1,735.71

69642 $2,234.97

69643 $2,043.86

69644 $2,443.95

69645 $2,393.43

69646 $2,551.76

69650 $1,338.85

69660 $1,550.38

69661 $2,024.43

69662 $1,943.57

69666 $1,346.27

69667 $1,347.42

69670 $1,573.99

104

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

69676 $1,380.44

69700 $1,141.93

69711 $1,437.94

69714 $1,806.56

69715 $2,240.40

69717 $1,897.75

69718 $2,264.33

69720 $1,983.79

69725 $3,179.30

69740 $1,964.69

69745 $2,087.48

69801 $321.69

69805 $1,774.70

69806 $1,583.54

69820 $1,428.82

69840 $1,399.98

69905 $1,529.89

69910 $1,710.08

69915 $2,604.38

69930 $2,067.57*

69950 $3,027.91

69955 $3,348.91

69960 $3,266.14

69970 $3,632.11

69990 $350.86

70010 $107.14

70010 26 $107.10

70010 TC $135.38

70015 $243.19

70015 26 $103.65

70015 TC $139.53

70030 $45.04

70030 26 $14.60

70030 TC $30.44

70100 $53.37

70100 26 $15.75

70100 TC $37.62

70110 $61.91

70110 26 $21.90

70110 TC $40.01

70120 $55.29

70120 26 $15.75

70120 TC $39.53

70130 $91.41

70130 26 $29.87

70130 TC $61.54

70134 $72.75

70134 26 $28.91

70134 TC $43.84

70140 $46.87

70140 26 $17.38

70140 TC $29.48

70150 $66.41

70150 26 $22.57

105

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

70150 TC $43.84

70160 $51.74

70160 26 $15.08

70160 TC $36.66

70170 26 $26.33

70190 $56.35

70190 26 $18.73

70190 TC $37.62

70200 $68.23

70200 26 $24.39

70200 TC $43.84

70210 $47.91

70210 26 $15.08

70210 TC $32.83

70220 $60.95

70220 26 $21.90

70220 TC $39.05

70240 $46.87

70240 26 $16.90

70240 TC $29.96

70250 $58.36

70250 26 $21.70

70250 TC $36.66

70260 $74.18

70260 26 $29.87

70260 TC $44.32

70300 $23.11

70300 26 $9.89

70300 TC $13.22

70310 $58.72

70310 26 $13.93

70310 TC $44.80

70320 $82.38

70320 26 $20.36

70320 TC $62.02

70328 $49.54

70328 26 $16.23

70328 TC $33.31

70330 $74.63

70330 26 $21.70

70330 TC $52.93

70332 $112.15

70332 26 $46.78

70332 TC $65.37

70336 $542.42*

70336 26 $126.80#

70336 TC $415.62*

70350 $34.04

70350 26 $16.99

70350 TC $17.04

70355 $33.66

70355 26 $19.01

70355 TC $14.65

70360 $43.13

106

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

70360 26 $14.60

70360 TC $28.53

70370 $123.56

70370 26 $27.56

70370 TC $95.99

70371 $147.16

70371 26 $73.18

70371 TC $73.98

70373 $123.01

70373 26 $38.03

70373 TC $84.99

70380 $59.88

70380 26 $16.04

70380 TC $43.84

70390 $153.54

70390 26 $33.15

70390 TC $120.39

70450 $251.01

70450 26 $73.19

70450 TC $177.81

70460 $329.47

70460 26 $97.11

70460 TC $232.36

70470 $335.17

70470 26 $109.51

70470 TC $225.66

70480 $419.10

70480 26 $110.66

70480 TC $308.44

70481 $483.54

70481 26 $119.12

70481 TC $364.42

70482 $534.18

70482 26 $124.79

70482 TC $409.40

70486 $346.41

70486 26 $98.74

70486 TC $247.67

70487 $415.66

70487 26 $112.01

70487 TC $303.65

70488 $497.72

70488 26 $122.29

70488 TC $375.42

70490 $340.63

70490 26 $110.66

70490 TC $229.97

70491 $407.64

70491 26 $119.30

70491 TC $288.34

70492 $482.99

70492 26 $124.79

70492 TC $358.20

70496 $746.83

107

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

70496 26 $150.82

70496 TC $596.00

70498 $771.23

70498 26 $150.82

70498 TC $620.41

70540 $606.89*

70540 26 $116.15#

70540 TC $490.74*

70542 $685.45*

70542 26 $140.16

70542 TC $545.29*

70543 $844.66*

70543 26 $185.02

70543 TC $659.64*

70544 $677.84*

70544 26 $103.37

70544 TC $574.47*

70545 $667.31*

70545 26 $103.37

70545 TC $563.95*

70546 $1,024.18*

70546 26 $155.44

70546 TC $868.74*

70547 $678.80*

70547 26 $103.85

70547 TC $574.95*

70548 $716.60*

70548 26 $103.85

70548 TC $612.75*

70549 $1,025.79*

70549 26 $155.14

70549 TC $870.65*

70551 $641.95*

70551 26 $127.76#

70551 TC $514.18*

70552 $719.00*

70552 26 $154.09#

70552 TC $564.90*

70553 $847.42*

70553 26 $203.57#

70553 TC $643.85*

70554 $738.14*

70554 26 $182.81#

70554 TC $555.33*

70555 26 $222.47#

70557 26 $276.43*

70558 26 $280.12*

70559 26 $280.60*

71010 $36.62

71010 26 $15.75

71010 TC $20.87

71015 $47.73

71015 26 $18.25

71015 TC $29.48

108

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

71020 $47.45

71020 26 $18.92

71020 TC $28.53

71021 $58.95

71021 26 $23.72

71021 TC $35.23

71022 $74.56

71022 26 $27.37

71022 TC $47.19

71023 $101.75

71023 26 $32.56

71023 TC $69.20

71030 $71.69

71030 26 $26.41

71030 TC $45.27

71034 $132.02

71034 26 $39.37

71034 TC $92.64

71035 $54.81

71035 26 $15.28

71035 TC $39.53

71100 $50.80

71100 26 $19.40

71100 TC $31.40

71101 $61.82

71101 26 $23.24

71101 TC $38.57

71110 $63.73

71110 26 $23.72

71110 TC $40.01

71111 $82.88

71111 26 $28.04

71111 TC $54.84

71120 $48.97

71120 26 $17.10

71120 TC $31.88

71130 $57.98

71130 26 $19.40

71130 TC $38.57

71250 $318.24

71250 26 $87.80

71250 TC $230.45

71260 $397.27

71260 26 $107.49

71260 TC $289.78

71270 $479.42

71270 26 $118.82

71270 TC $360.59

71275 $611.19

71275 26 $165.42

71275 TC $445.76

71550 $698.50*

71550 26 $125.46#

71550 TC $573.04*

109

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

71551 $778.02*

71551 26 $149.00

71551 TC $629.02*

71552 $990.82*

71552 26 $194.33

71552 TC $796.49*

71555 $695.36*

71555 26 $155.82#

71555 TC $539.54*

72010 $122.84

72010 26 $40.25

72010 TC $82.60

72020 $36.52

72020 26 $13.26

72020 TC $23.26

72040 $55.22

72040 26 $19.99

72040 TC $35.23

72050 $75.15

72050 26 $27.48

72050 TC $47.67

72052 $96.22

72052 26 $31.80

72052 TC $64.41

72069 $59.53

72069 26 $19.99

72069 TC $39.53

72070 $52.71

72070 26 $19.40

72070 TC $33.31

72072 $57.50

72072 26 $18.92

72072 TC $38.57

72074 $68.02

72074 26 $18.92

72074 TC $49.10

72080 $56.65

72080 26 $19.99

72080 TC $36.66

72090 $80.13

72090 26 $25.76

72090 TC $54.36

72100 $55.70

72100 26 $19.99

72100 TC $35.70

72110 $76.11

72110 26 $27.48

72110 TC $48.62

72114 $98.13

72114 26 $28.93

72114 TC $69.20

72120 $65.27

72120 26 $20.47

72120 TC $44.80

110

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

72125 $325.91

72125 26 $92.12

72125 TC $233.79

72126 $396.40

72126 26 $105.19

72126 TC $291.21

72127 $471.06

72127 26 $109.51

72127 TC $361.55

72128 $318.33

72128 26 $85.97

72128 TC $232.36

72129 $397.84

72129 26 $105.19

72129 TC $292.65

72130 $473.45

72130 26 $109.51

72130 TC $363.94

72131 $317.37

72131 26 $85.97

72131 TC $231.40

72132 $396.88

72132 26 $105.19

72132 TC $291.69

72133 26 $109.03

72141 $573.58*

72141 26 $138.34#

72141 TC $435.23*

72142 $735.59*

72142 26 $166.38#

72142 TC $569.21*

72146 $574.53*

72146 26 $138.34#

72146 TC $436.19*

72147 $653.77*

72147 26 $165.90#

72147 TC $487.87*

72148 $564.07*

72148 26 $128.35#

72148 TC $435.71*

72149 $709.43*

72149 26 $154.09#

72149 TC $555.33*

72156 $851.61*

72156 26 $222.11#

72156 TC $629.50*

72157 $794.67*

72157 26 $222.11#

72157 TC $572.56*

72158 $830.31*

72158 26 $204.64#

72158 TC $625.67*

72159 $711.02*

72159 26 $154.25#

111

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

72159 TC $556.77*

72170 $44.68

72170 26 $15.67

72170 TC $29.01

72190 $66.51

72190 26 $19.32

72190 TC $47.19

72191 $605.04

72191 26 $155.93

72191 TC $449.11

72192 $267.93

72192 26 $93.46

72192 TC $174.46

72193 $411.99

72193 26 $100.20

72193 TC $311.79

72194 $460.52

72194 26 $105.19

72194 TC $355.33

72195 $634.02*

72195 26 $126.53

72195 TC $507.49*

72196 $706.72*

72196 26 $149.48#

72196 TC $557.25*

72197 $865.46*

72197 26 $194.33

72197 TC $671.13*

72198 $700.91*

72198 26 $154.66#

72198 TC $546.24*

72200 $46.00

72200 26 $15.08

72200 TC $30.92

72202 $53.57

72202 26 $16.43

72202 TC $37.14

72220 $45.04

72220 26 $15.08

72220 TC $29.96

72240 $201.27

72240 26 $78.48

72240 TC $122.79

72255 $192.84

72255 26 $79.14

72255 TC $113.70

72265 $196.55

72265 26 $71.85

72265 TC $124.70

72270 $306.67

72270 26 $114.98

72270 TC $191.69

72275 $187.06

72275 26 $69.05

112

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

72275 TC $118.00

72285 $188.90

72285 26 $105.35

72285 TC $83.55

72291 26 $121.43

72292 26 $125.07

72295 $162.10

72295 26 $75.68

72295 TC $86.42

73000 $44.85

73000 26 $14.41

73000 TC $30.44

73010 $49.46

73010 26 $16.15

73010 TC $33.31

73020 $37.00

73020 26 $13.26

73020 TC $23.74

73030 $47.74

73030 26 $16.82

73030 TC $30.92

73040 $163.17

73040 26 $47.56

73040 TC $115.61

73050 $62.01

73050 26 $18.65

73050 TC $43.36

73060 $45.04

73060 26 $15.08

73060 TC $29.96

73070 $44.18

73070 26 $13.74

73070 TC $30.44

73080 $51.74

73080 26 $15.08

73080 TC $36.66

73085 $157.61

73085 26 $49.65

73085 TC $107.95

73090 $43.41

73090 26 $14.41

73090 TC $29.01

73092 $50.11

73092 26 $14.41

73092 TC $35.70

73100 $49.27

73100 26 $15.48

73100 TC $33.79

73110 $57.96

73110 26 $15.08

73110 TC $42.88

73115 $171.30

73115 26 $48.51

73115 TC $122.79

113

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

73120 $42.93

73120 26 $14.41

73120 TC $28.53

73130 $50.31

73130 26 $15.08

73130 TC $35.23

73140 $51.44

73140 26 $11.91

73140 TC $39.53

73200 $316.05

73200 26 $86.57

73200 TC $229.49

73201 $387.10

73201 26 $100.20

73201 TC $286.91

73202 $488.27

73202 26 $105.19

73202 TC $383.08

73206 $556.01

73206 26 $155.22

73206 TC $400.78

73218 $622.38*

73218 26 $116.81

73218 TC $505.57*

73219 $692.63*

73219 26 $140.16

73219 TC $552.46*

73220 $857.10*

73220 26 $185.50#

73220 TC $671.60*

73221 $420.87*

73221 26 $118.17#

73221 TC $302.70*

73222 $651.96*

73222 26 $140.16

73222 TC $511.79*

73223 $810.21*

73223 26 $185.50

73223 TC $624.71*

73225 $710.62*

73225 26 $147.63#

73225 TC $562.99*

73500 $42.77

73500 26 $16.15

73500 TC $26.61

73510 $60.77

73510 26 $19.32

73510 TC $41.45

73520 $64.13

73520 26 $23.64

73520 TC $40.49

73525 $162.69

73525 26 $49.95

73525 TC $112.74

114

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

73530 26 $25.18

73540 $68.71

73540 26 $18.65

73540 TC $50.06

73550 $44.20

73550 26 $15.67

73550 TC $28.53

73560 $48.03

73560 26 $16.15

73560 TC $31.88

73562 $57.79

73562 26 $16.82

73562 TC $40.97

73564 $67.66

73564 26 $20.47

73564 TC $47.19

73565 $55.21

73565 26 $16.63

73565 TC $38.57

73580 $199.35

73580 26 $49.77

73580 TC $149.58

73590 $43.13

73590 26 $15.08

73590 TC $28.05

73592 $43.41

73592 26 $13.93

73592 TC $29.48

73600 $44.85

73600 26 $14.41

73600 TC $30.44

73610 $51.74

73610 26 $15.08

73610 TC $36.66

73615 $162.69

73615 26 $49.47

73615 TC $113.22

73620 $42.93

73620 26 $13.45

73620 TC $29.48

73630 $48.87

73630 26 $14.60

73630 TC $34.27

73650 $44.37

73650 26 $13.93

73650 TC $30.44

73660 $46.66

73660 26 $11.43

73660 TC $35.23

73700 $317.01

73700 26 $86.57

73700 TC $230.45

73701 $392.37

73701 26 $100.20

115

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

73701 TC $292.17

73702 $487.32

73702 26 $105.19

73702 TC $382.12

73706 $613.19

73706 26 $163.60

73706 TC $449.59

73718 $618.37*

73718 26 $116.62

73718 TC $501.74*

73719 $703.63*

73719 26 $140.16

73719 TC $563.47*

73720 $862.37*

73720 26 $185.02#

73720 TC $677.35*

73721 $420.87*

73721 26 $118.17#

73721 TC $302.70*

73722 $660.86*

73722 26 $140.94

73722 TC $519.93*

73723 $809.73*

73723 26 $185.50

73723 TC $624.23*

73725 $705.12*

73725 26 $156.01#

73725 TC $549.11*

74000 $38.06

74000 26 $15.75

74000 TC $22.31

74010 $60.08

74010 26 $20.07

74010 TC $40.01

74020 $63.25

74020 26 $23.24

74020 TC $40.01

74022 $76.19

74022 26 $27.56

74022 TC $48.62

74150 $274.77

74150 26 $102.70

74150 TC $172.07

74160 $420.82

74160 26 $109.99

74160 TC $310.83

74170 $483.45

74170 26 $120.95

74170 TC $362.51

74174 $752.92

74174 26 $189.45

74174 TC $563.47

74175 $613.97

74175 26 $163.90

116

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

74175 TC $450.07

74176 $358.59

74176 26 $150.15

74176 TC $208.44

74177 $525.21

74177 26 $156.97

74177 TC $368.25

74178 $612.75

74178 26 $173.69

74178 TC $439.06

74181 $564.52*

74181 26 $125.46#

74181 TC $439.06*

74182 $774.19*

74182 26 $149.00

74182 TC $625.19*

74183 $868.33*

74183 26 $194.33

74183 TC $674.00*

74185 $700.43*

74185 26 $154.66#

74185 TC $545.76*

74190 26 $41.61

74210 $119.55

74210 26 $30.73

74210 TC $88.82

74220 $140.26

74220 26 $39.97

74220 TC $100.30

74230 $140.67

74230 26 $45.63

74230 TC $95.04

74240 $177.08

74240 26 $60.04

74240 TC $117.05

74241 $184.92

74241 26 $59.26

74241 TC $125.66

74245 $273.52

74245 26 $78.48

74245 TC $195.04

74246 $198.14

74246 26 $59.56

74246 TC $138.58

74247 $219.19

74247 26 $59.56

74247 TC $159.63

74249 $294.10

74249 26 $78.48

74249 TC $215.61

74250 $165.34

74250 26 $40.64

74250 TC $124.70

74251 $618.72

117

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

74251 26 $59.56

74251 TC $559.16

74260 $508.51

74260 26 $43.13

74260 TC $465.38

74261 $806.93

74261 26 $207.10

74261 TC $599.83

74262 $886.98

74262 26 $214.90

74262 TC $672.08

74263 $1,148.63

74263 26 $200.94

74263 TC $947.69

74270 $240.24

74270 26 $59.56

74270 TC $180.68

74280 $336.32

74280 26 $85.30

74280 TC $251.02

74283 $325.70

74283 26 $172.77

74283 TC $152.93

74290 $106.81

74290 26 $27.56

74290 TC $79.25

74291 $102.56

74291 26 $17.58

74291 TC $84.99

74300 26 $31.32

74301 26 $18.36

74305 26 $36.61

74320 $151.39

74320 26 $46.30

74320 TC $105.08

74327 $213.62

74327 26 $62.60

74327 TC $151.02

74328 26 $61.97

74329 $246.07

74329 26 $62.44

74329 TC $193.77

74330 26 $79.36

74340 26 $47.08

74355 26 $66.59

74360 26 $49.47

74363 $441.22

74363 26 $75.92

74363 TC $375.29

74400 $171.95

74400 26 $42.46

74400 TC $129.49

74410 $170.03

74410 26 $41.98

118

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

74410 TC $128.05

74415 $208.79

74415 26 $42.46

74415 TC $166.33

74420 26 $31.32

74425 26 $30.85

74430 $64.22

74430 26 $27.08

74430 TC $37.14

74440 $127.71

74440 26 $33.15

74440 TC $94.56

74445 26 $98.79

74450 26 $28.83

74455 $128.06

74455 26 $28.24

74455 TC $99.82

74470 26 $46.60

74475 $149.47

74475 26 $46.30

74475 TC $103.17

74480 $149.47

74480 26 $46.30

74480 TC $103.17

74710 $53.61

74710 26 $27.47

74710 TC $26.13

74740 $118.50

74740 26 $32.56

74740 TC $85.94

74742 $239.54

74742 26 $53.52

74742 TC $193.77

74775 26 $54.19#

75557 $559.43*

75557 26 $202.19

75557 TC $357.24*

75559 $761.15*

75559 26 $253.19

75559 TC $507.96*

75561 $736.83*

75561 26 $223.13

75561 TC $513.71*

75563 $869.48*

75563 26 $257.21

75563 TC $612.27*

75565 $94.44*

75565 26 $21.42

75565 TC $73.03*

75571 $171.67

75571 26 $49.36

75571 TC $122.31

75572 $474.05

75572 26 $149.82

119

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

75572 TC $324.23

75573 $650.28

75573 26 $217.92

75573 TC $432.36

75574 $696.17

75574 26 $205.44

75574 TC $490.74

75600 $314.06

75600 26 $41.98

75600 TC $272.07

75605 $241.26

75605 26 $97.42

75605 TC $143.84

75625 $241.19

75625 26 $96.87

75625 TC $144.32

75630 $294.96

75630 26 $152.08

75630 TC $142.88

75635 $684.56

75635 26 $206.14

75635 TC $478.41

75658 $285.05

75658 26 $110.11

75658 TC $174.94

75705 $392.08

75705 26 $188.43

75705 TC $203.65

75710 $277.51

75710 26 $96.35

75710 TC $181.16

75716 $330.25

75716 26 $111.66

75716 TC $218.60

75726 $277.92

75726 26 $97.71

75726 TC $180.20

75731 $259.51

75731 26 $97.96

75731 TC $161.54

75733 $320.34

75733 26 $112.27

75733 TC $208.07

75736 $269.85

75736 26 $95.87

75736 TC $173.98

75741 $255.38

75741 26 $112.02

75741 TC $143.36

75743 $299.61

75743 26 $141.42

75743 TC $158.19

75746 $262.79

75746 26 $98.37

120

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

75746 TC $164.42

75756 $290.20

75756 26 $100.91

75756 TC $189.30

75774 $150.76

75774 26 $30.85

75774 TC $119.92

75791 $512.07

75791 26 $144.78

75791 TC $367.29

75801 26 $75.13

75803 26 $102.24

75805 26 $70.91

75807 $462.44

75807 26 $102.24

75807 TC $375.29

75809 $157.68

75809 26 $41.12

75809 TC $116.57

75810 26 $99.26

75820 $193.55

75820 26 $60.23

75820 TC $133.31

75822 $244.01

75822 26 $90.60

75822 TC $153.41

75825 $233.42

75825 26 $96.76

75825 TC $136.66

75827 $238.39

75827 26 $96.46

75827 TC $141.93

75831 $246.78

75831 26 $101.98

75831 TC $144.80

75833 $293.33

75833 26 $124.61

75833 TC $168.72

75840 $247.25

75840 26 $103.89

75840 TC $143.36

75842 $300.98

75842 26 $128.91

75842 TC $172.07

75860 $241.55

75860 26 $97.71

75860 TC $143.84

75870 $241.26

75870 26 $98.37

75870 TC $142.88

75872 $241.26

75872 26 $98.37

75872 TC $142.88

75880 $352.40

121

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

75880 26 $64.54

75880 TC $287.86

75885 $267.95

75885 26 $123.16

75885 TC $144.80

75887 $266.11

75887 26 $122.27

75887 TC $143.84

75889 $243.17

75889 26 $97.42

75889 TC $145.75

75891 $243.17

75891 26 $97.90

75891 TC $145.28

75893 $190.99

75893 26 $45.71

75893 TC $145.28

75894 26 $114.39

75896 26 $113.91

75898 26 $145.15

75901 $259.99

75901 26 $41.98

75901 TC $218.00

75902 $115.28

75902 26 $33.64

75902 TC $81.64

75945 26 $34.13

75946 $173.46

75946 26 $34.24

75946 TC $141.23

75952 $385.69

75952 26 $390.67

75953 $145.29

75953 26 $118.62

75954 26 $195.56

75956 26 $611.15

75957 26 $522.23

75958 26 $347.91

75959 26 $300.70

75960 $193.30

75960 26 $69.56

75960 TC $123.74

75962 $225.07

75962 26 $45.83

75962 TC $179.25

75964 $145.32

75964 26 $31.14

75964 TC $114.17

75966 $276.62

75966 26 $110.77

75966 TC $165.85

75970 26 $71.30

75978 $223.16

75978 26 $45.83

122

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

75978 TC $177.33

75980 26 $124.34

75982 $482.60

75982 26 $124.34

75982 TC $375.29

75984 $172.88

75984 26 $61.58

75984 TC $111.30

75989 $200.01

75989 26 $101.62

75989 TC $98.38

76000 $77.58

76000 26 $15.08

76000 TC $62.50

76001 26 $60.84

76010 $41.89

76010 26 $15.75

76010 TC $26.13

76080 $96.36

76080 26 $46.30

76080 TC $50.06

76098 $29.54

76098 26 $13.93

76098 TC $15.61

76100 $156.11

76100 26 $53.89

76100 TC $102.21

76101 $229.72

76101 26 $59.09

76101 TC $170.64

76102 $303.52

76102 26 $59.68

76102 TC $243.84

76120 $115.27

76120 26 $33.15

76120 TC $82.12

76125 26 $24.31

76140 $20.00

76140 26 $20.00

76140 TC $10.00

76376 $88.21*

76376 26 $17.10

76376 TC $71.11*

76377 $130.70*

76377 26 $68.20

76377 TC $62.50*

76380 $254.01

76380 26 $84.33

76380 TC $169.68

76390 $680.65*

76390 26 $122.93

76390 TC $557.73*

76506 $191.71

76506 26 $55.05

123

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

76506 TC $136.66

76510 $281.65

76510 26 $160.77

76510 TC $120.87

76511 $163.35

76511 26 $91.76

76511 TC $71.59

76512 $152.27

76512 26 $93.12

76512 TC $59.15

76513 $152.65

76513 26 $62.87

76513 TC $89.77

76514 $24.47

76514 26 $16.52

76514 TC $7.95

76516 $124.00

76516 26 $53.37

76516 TC $70.63

76519 $133.20

76519 26 $54.44

76519 TC $78.77

76529 $126.13

76529 26 $56.93

76529 TC $69.20

76536 $185.75

76536 26 $48.61

76536 TC $137.14

76604 $136.27

76604 26 $47.45

76604 TC $88.82

76645 $150.73

76645 26 $47.08

76645 TC $103.65

76700 $216.26

76700 26 $70.02

76700 TC $146.23

76705 $165.76

76705 26 $50.62

76705 TC $115.13

76770 $203.42

76770 26 $63.88

76770 TC $139.53

76775 $166.52

76775 26 $49.95

76775 TC $116.57

76776 $233.95

76776 26 $65.23

76776 TC $168.72

76800 $208.60

76800 26 $97.77

76800 TC $110.83

76801 $199.84

76801 26 $86.14

124

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

76801 TC $113.70

76802 $109.65

76802 26 $72.51

76802 TC $37.14

76805 $230.46

76805 26 $86.62

76805 TC $143.84

76810 $156.58

76810 26 $85.47

76810 TC $71.11

76811 $302.31

76811 26 $167.56

76811 TC $134.75

76812 $337.78

76812 26 $157.58

76812 TC $180.20

76813 $196.65

76813 26 $104.00

76813 TC $92.64

76814 $131.89

76814 26 $87.58

76814 TC $44.32

76815 $141.45

76815 26 $55.98

76815 TC $85.47

76816 $185.64

76816 26 $74.81

76816 TC $110.83

76817 $160.25

76817 26 $65.69

76817 TC $94.56

76818 $196.70

76818 26 $92.57

76818 TC $104.13

76819 $142.93

76819 26 $67.52

76819 TC $75.42

76820 $66.76

76820 26 $43.98

76820 TC $22.78

76821 $149.23

76821 26 $61.85

76821 TC $87.38

76825 $343.49

76825 26 $145.58

76825 TC $197.91

76826 $203.43

76826 26 $72.51

76826 TC $130.92

76827 $96.07

76827 26 $50.32

76827 TC $45.75

76828 $73.67

76828 26 $48.97

125

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

76828 TC $24.70

76830 $119.85

76830 26 $60.22

76830 TC $59.63

76831 $194.60

76831 26 $63.67

76831 TC $130.92

76856 $191.14

76856 26 $59.26

76856 TC $131.88

76857 $143.50

76857 26 $33.15

76857 TC $110.35

76870 $189.99

76870 26 $55.24

76870 TC $134.75

76872 $115.84

76872 26 $59.08

76872 TC $56.76

76873 $272.00

76873 26 $135.34

76873 TC $136.66

76881 $186.45

76881 26 $55.05

76881 TC $131.40

76882 $58.37

76882 26 $42.28

76882 TC $16.09

76885 $227.34

76885 26 $63.88

76885 TC $163.46

76886 $162.87

76886 26 $53.01

76886 TC $109.87

76930 $133.22

76930 26 $56.85

76930 TC $76.37

76932 26 $57.74

76936 $437.63

76936 26 $170.34

76936 TC $267.29

76937 $56.29

76937 26 $25.85

76937 TC $30.44

76940 26 $178.06

76941 26 $120.67

76942 $305.41

76942 26 $58.22

76942 TC $247.19

76945 26 $60.13

76946 $52.95

76946 26 $33.51

76946 TC $19.44

76948 $54.02

126

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

76948 26 $34.11

76948 TC $19.91

76950 $82.31

76950 26 $51.39

76950 TC $30.92

76965 $150.70

76965 26 $116.43

76965 TC $34.27

76970 $151.36

76970 26 $35.27

76970 TC $116.09

76975 26 $75.04

76977 $10.65

76977 26 $4.62

76977 TC $6.04

76998 26 $108.52

77001 $176.99

77001 26 $32.67

77001 TC $144.32

77002 $122.20

77002 26 $48.22

77002 TC $73.98

77003 $145.85

77003 26 $53.69

77003 TC $92.16

77011 $341.25

77011 26 $106.98

77011 TC $234.27

77012 $202.48

77012 26 $98.83

77012 TC $103.65

77013 26 $345.39

77014 $190.72

77014 26 $74.63

77014 TC $116.09

77021 $577.01*

77021 26 $129.81

77021 TC $447.20*

77022 26 $365.85

77031 $211.29

77031 26 $138.26

77031 TC $73.03

77032 $83.83

77032 26 $48.13

77032 TC $35.70

77051 $15.16

77051 26 $5.29

77051 TC $9.87

77052 $15.16

77052 26 $5.29

77052 TC $9.87

77053 $90.84

77053 26 $30.73

77053 TC $60.11

127

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

77054 $121.41

77054 26 $38.81

77054 TC $82.60

77055 $138.04

77055 26 $60.23

77055 TC $77.81

77056 $177.05

77056 26 $75.31

77056 TC $101.73

77057 $127.52

77057 26 $60.71

77057 TC $66.81

77058 $916.75*

77058 26 $140.36

77058 TC $776.39*

77059 $910.05*

77059 26 $140.36

77059 TC $769.69*

77071 $80.37

77072 $36.82

77072 26 $16.43

77072 TC $20.39

77073 $59.84

77073 26 $25.09

77073 TC $34.75

77074 $108.49

77074 26 $38.81

77074 TC $69.68

77075 $161.91

77075 26 $46.78

77075 TC $115.13

77076 $164.84

77076 26 $60.23

77076 TC $104.61

77077 $63.48

77077 26 $28.74

77077 TC $34.75

77078 $192.53

77078 26 $21.42

77078 TC $171.11

77080 $74.33

77080 26 $17.58

77080 TC $56.76

77081 $44.10

77081 26 $19.40

77081 TC $24.70

77082 $43.13

77082 26 $15.08

77082 TC $28.05

77084 $657.31*

77084 26 $138.34

77084 TC $518.97*

77261 $125.65

77262 $188.89

128

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

77263 $279.69

77280 $267.42

77280 26 $61.37

77280 TC $206.04

77285 $469.55

77285 26 $92.21

77285 TC $377.34

77290 $776.22

77290 26 $137.15

77290 TC $639.07

77295 $709.78

77295 26 $402.36

77295 TC $307.41

77300 $105.09

77300 26 $54.56

77300 TC $50.54

77301 $2,942.78

77301 26 $704.63

77301 TC $2,238.15

77305 $95.16

77305 26 $61.37

77305 TC $33.79

77310 $137.96

77310 26 $92.21

77310 TC $45.75

77315 $216.88

77315 26 $137.15

77315 TC $79.72

77321 $145.29

77321 26 $83.75

77321 TC $61.54

77326 $222.53

77326 26 $81.92

77326 TC $140.61

77327 $311.78

77327 26 $122.37

77327 TC $189.41

77328 $421.30

77328 26 $184.22

77328 TC $237.08

77331 $103.07

77331 26 $76.45

77331 TC $26.61

77332 $122.68

77332 26 $47.74

77332 TC $74.94

77333 $87.17

77333 26 $73.96

77333 TC $13.22

77334 $233.99

77334 26 $108.81

77334 TC $125.18

77336 $61.54

77338 $783.19

129

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

77338 26 $378.64

77338 TC $404.54

77370 $165.30

77372 $1,102.94

77373 $1,782.98

77401 $29.01

77402 $218.00

77403 $179.73

77404 $199.82

77406 $199.82

77407 $317.53

77408 $247.67

77409 $275.90

77411 $277.34

77412 $337.62

77413 $325.18

77414 $365.86

77416 $365.38

77417 $19.91

77418 $570.17

77421 $112.00

77421 26 $34.19

77421 TC $77.81

77422 $397.43

77423 $405.09

77424 By Report

77424 26 By Report

77425 $199.71

77427 $311.24

77431 $170.40

77432 $706.08

77435 $1,064.15

77469 $526.55

77470 $251.50

77470 26 $184.22

77470 TC $67.28

77600 $635.18

77600 26 $137.15

77600 TC $498.03

77605 $1,666.17

77605 26 $191.56

77605 TC $1,474.61

77610 $1,567.74

77610 26 $136.67

77610 TC $1,431.07

77615 $1,470.53

77615 26 $184.22

77615 TC $1,286.32

77750 $599.00

77750 26 $440.69

77750 TC $158.31

77761 $609.63

77761 26 $338.11

77761 TC $271.53

130

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

77762 $818.88

77762 26 $506.87

77762 TC $312.02

77763 $1,165.11

77763 26 $763.03

77763 TC $402.08

77776 $689.03

77776 26 $416.73

77776 TC $272.30

77777 $954.39

77777 26 $662.95

77777 TC $291.44

77778 $1,407.93

77778 26 $996.94

77778 TC $410.99

77785 $378.39

77785 26 $125.34

77785 TC $253.05

77786 $842.55

77786 26 $286.51

77786 TC $556.04

77787 $1,432.81

77787 26 $431.85

77787 TC $1,000.96

77789 $187.08

77789 26 $101.13

77789 TC $85.94

77790 $152.50

77790 26 $91.91

77790 TC $60.58

78012 $120.07

78012 26 $16.43

78012 TC $103.65

78013 $301.68

78013 26 $31.88

78013 TC $269.80

78014 $349.77

78014 26 $42.66

78014 TC $307.12

78015 $325.14

78015 26 $56.30

78015 TC $268.84

78016 $421.54

78016 26 $62.75

78016 TC $358.79

78018 $468.55

78018 26 $71.95

78018 TC $396.59

78020 $130.06

78020 26 $48.90

78020 TC $81.16

78070 $445.85

78070 26 $67.44

78070 TC $378.41

131

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

78071 $530.29*

78071 26 $101.64

78071 TC $428.65*

78072 26 $140.21

78075 $633.50

78075 26 $61.01

78075 TC $572.49

78102 $255.05

78102 26 $46.02

78102 TC $209.03

78103 $326.69

78103 26 $62.16

78103 TC $264.53

78104 $373.60

78104 26 $67.44

78104 TC $306.16

78110 $136.46

78110 26 $16.43

78110 TC $120.03

78111 $125.56

78111 26 $17.49

78111 TC $108.07

78120 $135.32

78120 26 $19.60

78120 TC $115.72

78121 $116.97

78121 26 $24.21

78121 TC $92.76

78130 $242.45

78130 26 $53.22

78130 TC $189.23

78135 $528.39

78135 26 $55.72

78135 TC $472.67

78140 $205.31

78140 26 $52.74

78140 TC $152.57

78185 $314.22

78185 26 $34.38

78185 TC $279.84

78190 $613.21

78190 26 $95.56

78190 TC $517.65

78191 $242.93

78191 26 $53.22

78191 TC $189.71

78195 $538.72

78195 26 $101.93

78195 TC $436.78

78201 $277.13

78201 26 $37.00

78201 TC $240.13

78202 $305.35

78202 26 $41.78

132

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

78202 TC $263.57

78205 $320.17*

78205 26 $59.47

78205 TC $260.70*

78206 $508.77*

78206 26 $80.59

78206 TC $428.17*

78215 $291.20

78215 26 $41.98

78215 TC $249.22

78216 $187.97

78216 26 $47.36

78216 TC $140.61

78226 $560.95

78226 26 $65.32

78226 TC $495.64

78227 $757.66

78227 26 $78.95

78227 TC $678.71

78230 $258.37

78230 26 $38.81

78230 TC $219.55

78231 $195.50

78231 26 $44.37

78231 TC $151.13

78232 $148.23

78232 26 $35.85

78232 TC $112.38

78261 $378.16

78261 26 $59.56

78261 TC $318.60

78262 $375.64

78262 26 $58.00

78262 TC $317.64

78264 $431.97

78264 26 $67.92

78264 TC $364.06

78267 $10.81

78268 $92.59

78270 $126.97

78270 26 $17.10

78270 TC $109.87

78271 $138.45

78271 26 $17.58

78271 TC $120.87

78272 $140.40

78272 26 $23.24

78272 TC $117.16

78278 $523.04

78278 26 $84.34

78278 TC $438.70

78282 26 $33.15

78290 $497.59

78290 26 $57.93

133

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

78290 TC $439.66

78300 $271.72

78300 26 $53.12

78300 TC $218.60

78305 $357.91

78305 26 $70.89

78305 TC $287.02

78306 $378.59

78306 26 $72.91

78306 TC $305.68

78315 $522.67

78315 26 $86.84

78315 TC $435.83

78320 $346.50*

78320 26 $87.23

78320 TC $259.27*

78350 $51.28

78350 26 $19.40

78350 TC $31.88

78351 $26.22

78414 26 $39.77

78428 $280.57

78428 26 $65.80

78428 TC $214.77

78445 $258.55

78445 26 $40.43

78445 TC $218.12

78451 $532.05*

78451 26 $117.75

78451 TC $414.30*

78452 $736.05*

78452 26 $138.20

78452 TC $597.85*

78453 $458.16*

78453 26 $85.49

78453 TC $372.67*

78454 $657.41*

78454 26 $114.58

78454 TC $542.83*

78456 $532.21

78456 26 $85.38

78456 TC $446.83

78457 $308.90

78457 26 $65.90

78457 TC $243.00

78458 $286.84

78458 26 $73.03

78458 TC $213.81

78459 26 $125.87

78466 $297.00*

78466 26 $60.70

78466 TC $236.30*

78468 $303.92*

78468 26 $68.58

134

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

78468 TC $235.34*

78469 $345.49*

78469 26 $79.52

78469 TC $265.97*

78472 $353.17

78472 26 $83.37

78472 TC $269.80

78473 $452.46

78473 26 $125.24

78473 TC $327.21

78481 $282.42

78481 26 $83.56

78481 TC $198.87

78483 $379.73#

78483 26 $125.72#

78483 TC $254.01#

78491 26 $127.79

78492 26 $159.01

78494 $354.38*

78494 26 $101.33

78494 TC $253.05*

78496 $72.98

78496 26 $42.54

78496 TC $30.44

78579 $322.01

78579 26 $43.42

78579 TC $278.59

78580 $357.30

78580 26 $62.63

78580 TC $294.68

78582 $570.53

78582 26 $94.03

78582 TC $476.50

78597 $356.90

78597 26 $65.40

78597 TC $291.51

78598 $527.39

78598 26 $74.33

78598 TC $453.05

78600 $273.37

78600 26 $37.55

78600 TC $235.82

78601 $322.21

78601 26 $43.33

78601 TC $278.89

78605 $295.33

78605 26 $45.63

78605 TC $249.70

78606 $493.53

78606 26 $53.87

78606 TC $439.66

78607 $531.53*

78607 26 $101.92

78607 TC $429.61*

135

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

78608 26 $126.17

78609 $133.05*

78609 26 $133.05

78610 $261.08

78610 26 $25.74

78610 TC $235.34

78630 $512.60*

78630 26 $58.11

78630 TC $454.49*

78635 $501.56

78635 26 $51.85

78635 TC $449.70

78645 $476.02

78645 26 $47.84

78645 TC $428.17

78647 $546.65

78647 26 $76.38

78647 TC $470.28

78650 $494.31

78650 26 $51.79

78650 TC $442.53

78660 $282.89

78660 26 $47.07

78660 TC $235.82

78700 $264.11

78700 26 $38.81

78700 TC $225.30

78701 $317.52

78701 26 $41.98

78701 TC $275.54

78707 $350.87

78707 26 $80.59

78707 TC $270.27

78708 $268.46

78708 26 $102.01

78708 TC $166.44

78709 $557.63

78709 26 $118.93

78709 TC $438.70

78710 $307.79*

78710 26 $53.30

78710 TC $254.48*

78725 $166.94

78725 26 $32.08

78725 TC $134.86

78730 $98.24

78730 26 $12.78

78730 TC $85.47

78740 $345.39

78740 26 $49.28

78740 TC $296.11

78800 $286.19

78800 26 $57.06

78800 TC $229.12

136

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

78801 $366.71

78801 26 $67.24

78801 TC $299.46

78802 $483.38

78802 26 $72.43

78802 TC $410.95

78803 $512.54*

78803 26 $90.59

78803 TC $421.95*

78804 $843.38

78804 26 $90.20

78804 TC $753.17

78805 $277.02

78805 26 $62.25

78805 TC $214.77

78806 $495.34

78806 26 $72.43

78806 TC $422.91

78807 $508.42*

78807 26 $89.82

78807 TC $418.60*

78808 $67.54

78811 26 $134.28

78812 $2,970.00*

78812 26 $165.19

78812 TC $2,822.75*

78813 26 $171.45

78814 26 $189.32

78815 $3,375.35*

78815 26 $209.41

78815 TC $3,190.50*

78816 26 $212.01

79005 $222.02

79005 26 $152.34

79005 TC $69.68

79101 $237.56

79101 26 $165.49

79101 TC $72.07

79200 $255.60

79200 26 $175.88

79200 TC $79.72

79300 26 $140.00

79403 $308.13

79403 26 $193.36

79403 TC $114.77

79440 $238.51

79440 26 $170.75

79440 TC $67.76

79445 $344.34

79445 26 $201.82

79445 TC $162.21

80047 $11.63

80048 $11.63

80050 $50.13

137

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

80051 $9.64

80053 $14.53

80055 $20.33

80061 $18.42

80069 $11.94

80074 $65.47

80076 $11.23

80100 $20.47

80101 $19.72

80102 $18.20

80104 $69.84

80150 $20.72

80152 $24.61

80154 $25.43

80156 $20.02

80157 $18.22

80158 $24.81

80160 $23.66

80162 $18.25

80164 $18.63

80166 $21.30

80168 $22.47

80170 $22.53

80172 $22.39

80173 $20.02

80174 $23.66

80176 $20.19

80178 $9.09

80182 $18.63

80184 $15.74

80185 $18.22

80186 $18.92

80188 $22.81

80190 $23.03

80192 $23.03

80194 $20.07

80195 $18.87

80196 $9.75

80197 $18.87

80198 $19.45

80200 $22.16

80201 $16.39

80202 $18.63

80299 $18.83

80400 $44.82

80402 $119.51

80406 $107.56

80408 $172.52

80410 $110.45

80412 $453.06

80414 $70.98

80415 $76.82

80416 $181.44

80417 $60.48

138

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

80418 $796.72

80420 $98.99

80422 $63.30

80424 $69.42

80426 $204.00

80428 $91.72

80430 $107.89

80432 $185.71

80434 $139.00

80435 $141.60

80436 $125.30

80438 $69.30

80439 $92.39

80440 $79.91

80500 $35.35

81000 $4.35

81001 $4.35

81002 $3.52

81003 $3.09

81005 $2.98

81007 $3.53

81015 $4.18

81020 $5.07

81025 $8.70

81050 $4.12

82000 $17.03

82003 $27.82

82009 $6.21

82010 $11.23

82013 $15.36

82016 $19.06

82017 $23.18

82024 $53.10

82030 $31.57

82040 $6.80

82042 $7.11

82043 $7.95

82044 $6.29

82045 $46.66

82055 $14.85

82075 $16.57

82085 $13.34

82088 $56.02

82101 $41.26

82103 $18.47

82104 $19.88

82105 $23.06

82106 $23.06

82107 $88.54

82108 $31.62

82120 $5.17

82127 $19.06

82128 $19.06

82131 $23.18

139

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

82135 $22.62

82136 $23.18

82139 $23.18

82140 $20.03

82143 $9.44

82145 $21.36

82150 $8.91

82154 $39.63

82157 $40.24

82160 $34.37

82163 $28.21

82164 $20.07

82172 $21.30

82175 $26.08

82180 $13.59

82190 $20.49

82205 $15.74

82232 $22.24

82239 $23.55

82240 $36.53

82247 $6.90

82248 $6.90

82252 $6.25

82261 $23.18

82270 $4.48

82271 $4.48

82272 $4.48

82274 $21.86

82286 $9.47

82300 $31.81

82306 $40.70

82308 $36.82

82310 $7.09

82330 $18.79

82331 $7.11

82340 $8.29

82355 $15.91

82360 $17.69

82365 $17.72

82370 $17.22

82373 $24.82

82374 $6.72

82375 $16.94

82376 $8.24

82378 $26.08

82379 $23.18

82380 $12.68

82382 $23.64

82383 $34.45

82384 $34.71

82387 $28.61

82390 $14.76

82397 $19.42

82415 $17.42

140

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

82435 $6.32

82436 $6.91

82438 $6.72

82441 $8.25

82465 $5.98

82480 $10.83

82482 $10.56

82485 $28.39

82486 $24.82

82487 $21.95

82488 $29.37

82489 $25.43

82491 $24.82

82492 $24.82

82495 $27.88

82507 $38.22

82520 $20.83

82523 $25.69

82525 $17.06

82528 $30.95

82530 $22.97

82533 $22.41

82540 $6.37

82541 $24.82

82542 $24.82

82543 $24.82

82544 $24.82

82550 $8.95

82552 $18.42

82553 $15.87

82554 $16.32

82565 $7.04

82570 $7.11

82575 $12.99

82585 $11.80

82595 $7.93

82600 $26.66

82607 $20.72

82608 $19.68

82610 $18.69

82615 $11.22

82626 $34.74

82627 $30.56

82633 $42.58

82634 $40.24

82638 $16.84

82646 $28.39

82649 $35.34

82651 $35.48

82652 $52.92

82654 $19.03

82656 $15.86

82657 $24.82

82658 $24.82

141

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

82664 $47.23

82666 $29.53

82668 $25.84

82670 $38.41

82671 $44.40

82672 $29.82

82677 $33.25

82679 $34.31

82690 $23.75

82693 $20.48

82696 $32.42

82705 $3.22

82710 $23.10

82715 $23.66

82725 $18.30

82726 $24.82

82728 $18.73

82731 $88.54

82735 $25.49

82742 $27.21

82746 $20.21

82747 $23.81

82757 $23.84

82759 $29.53

82760 $15.39

82775 $28.96

82776 $11.53

82777 $17.80

82784 $12.66

82785 $22.64

82787 $11.03

82800 $11.63

82803 $26.60

82805 $39.01

82810 $12.00

82820 $13.73

82930 $7.50

82938 $24.32

82941 $24.24

82943 $19.64

82945 $5.39

82946 $20.72

82947 $5.39

82948 $4.35

82950 $6.53

82951 $13.95

82952 $5.39

82953 $20.82

82955 $13.33

82960 $8.32

82962 $2.48

82963 $29.53

82965 $10.63

82975 $21.78

142

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

82977 $9.90

82978 $19.60

82979 $9.47

82980 $23.79

82985 $20.72

83001 $25.54

83002 $25.46

83003 $22.93

83008 $23.07

83009 $92.59

83010 $17.29

83012 $23.64

83013 $92.59

83014 $10.81

83015 $25.89

83018 $30.19

83020 $17.69

83020 26 $34.87

83020 TC $17.69

83021 $24.82

83026 $3.25

83030 $11.37

83033 $8.19

83036 $13.34

83045 $6.81

83050 $10.07

83051 $10.05

83055 $6.76

83060 $11.37

83065 $9.47

83068 $11.63

83069 $3.96

83070 $6.53

83071 $9.44

83080 $23.18

83088 $40.60

83090 $23.19

83150 $26.60

83491 $24.08

83497 $17.72

83498 $37.35

83499 $34.65

83500 $31.13

83505 $33.42

83516 $15.86

83518 $11.65

83519 $18.57

83520 $17.80

83525 $15.71

83527 $17.80

83528 $21.86

83540 $8.90

83550 $12.02

83570 $12.16

143

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

83582 $19.48

83586 $17.60

83593 $36.15

83605 $14.68

83615 $8.30

83625 $17.60

83630 $26.98

83631 $26.98

83632 $27.79

83633 $7.56

83634 $15.84

83655 $16.64

83661 $30.22

83662 $26.00

83663 $26.00

83664 $26.00

83670 $12.59

83690 $9.47

83695 $17.80

83698 $46.66

83700 $15.47

83701 $34.12

83704 $43.36

83718 $11.26

83719 $15.99

83721 $13.11

83727 $23.64

83735 $9.21

83775 $10.13

83785 $33.80

83788 $24.82

83789 $24.82

83805 $24.23

83825 $22.35

83835 $23.29

83840 $22.45

83857 $14.76

83858 $20.36

83861 $22.71

83864 $27.37

83866 $13.54

83872 $8.06

83873 $14.20

83874 $17.75

83876 $46.66

83880 $46.66

83883 $18.69

83885 $33.68

83887 $32.55

83915 $15.33

83916 $27.64

83918 $22.62

83919 $22.62

83921 $22.62

144

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

83925 $26.74

83930 $9.09

83935 $9.37

83937 $41.03

83945 $17.69

83950 $88.54

83951 $88.54

83970 $56.74

83986 $4.92

83987 $21.83

83992 $20.20

83993 $26.98

84022 $21.41

84030 $7.56

84035 $5.03

84060 $10.15

84061 $10.87

84066 $13.28

84075 $7.11

84078 $10.03

84080 $20.33

84081 $22.71

84085 $9.26

84087 $14.19

84100 $6.52

84105 $7.11

84106 $5.88

84110 $11.60

84112 $88.54

84119 $11.84

84120 $20.22

84126 $35.01

84127 $16.02

84132 $6.32

84133 $5.91

84134 $20.05

84135 $26.30

84138 $26.03

84140 $28.42

84143 $31.37

84144 $28.68

84145 $36.82

84146 $26.64

84150 $34.31

84152 $25.29

84153 $25.29

84154 $25.29

84155 $5.04

84156 $5.04

84157 $5.04

84160 $7.11

84163 $20.70

84165 $14.76

84165 26 $34.87

145

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

84165 TC $14.76

84166 $24.52

84166 26 $34.87

84166 TC $24.52

84181 $23.41

84181 26 $34.87

84181 TC $23.41

84182 $24.74

84182 26 $32.48

84182 TC $24.74

84202 $19.72

84203 $11.83

84206 $24.49

84207 $38.62

84210 $14.92

84220 $12.97

84228 $15.99

84233 $88.54

84234 $89.18

84235 $71.94

84238 $50.27

84244 $30.24

84252 $27.82

84255 $35.10

84260 $42.58

84270 $29.87

84275 $18.47

84285 $32.37

84295 $6.62

84300 $6.69

84302 $6.69

84305 $29.22

84307 $25.13

84311 $9.61

84315 $3.45

84375 $26.95

84376 $7.56

84377 $7.56

84378 $15.84

84379 $15.84

84392 $6.53

84402 $35.00

84403 $35.49

84425 $29.19

84430 $15.99

84431 $23.10

84432 $22.08

84436 $9.44

84437 $8.89

84439 $12.40

84442 $20.33

84443 $23.10

84445 $69.90

84446 $19.49

146

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

84449 $24.74

84450 $7.11

84460 $7.27

84466 $17.55

84478 $7.90

84479 $8.89

84480 $19.49

84481 $23.29

84482 $21.67

84484 $13.53

84485 $10.32

84488 $10.03

84490 $10.46

84510 $14.30

84512 $10.59

84520 $5.43

84525 $5.17

84540 $6.53

84545 $9.08

84550 $6.21

84560 $6.53

84577 $17.15

84578 $4.47

84580 $9.75

84583 $6.91

84585 $21.30

84586 $48.57

84588 $46.66

84590 $15.95

84591 $15.95

84597 $18.85

84600 $22.10

84620 $16.29

84630 $15.65

84681 $28.61

84702 $20.70

84703 $10.33

84704 $20.70

85002 $6.19

85004 $8.89

85007 $4.73

85008 $4.73

85009 $5.11

85013 $3.26

85014 $3.26

85018 $3.26

85025 $10.69

85027 $8.89

85032 $5.91

85041 $4.14

85044 $5.91

85045 $5.50

85046 $7.67

85048 $3.49

147

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

85049 $6.15

85055 $24.88

85060 $42.16

85097 $138.40

85130 $16.35

85170 $4.97

85175 $6.25

85210 $17.85

85220 $24.26

85230 $24.61

85240 $24.61

85244 $28.06

85245 $31.54

85246 $31.54

85247 $31.54

85250 $26.17

85260 $24.61

85270 $24.61

85280 $26.60

85290 $22.47

85291 $12.22

85292 $26.03

85293 $26.03

85300 $16.29

85301 $14.86

85302 $16.52

85303 $19.01

85305 $15.95

85306 $21.06

85307 $21.06

85335 $17.69

85337 $14.33

85345 $5.91

85347 $5.85

85348 $5.12

85360 $11.55

85362 $9.47

85366 $11.84

85370 $15.61

85378 $9.81

85379 $13.99

85380 $13.99

85384 $11.68

85385 $11.68

85390 $7.10

85390 26 $34.87

85390 TC $7.10

85396 $34.87

85397 $31.54

85400 $12.16

85410 $10.60

85415 $23.64

85420 $8.98

85421 $14.00

148

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

85441 $5.78

85445 $9.37

85460 $10.64

85461 $9.12

85475 $12.20

85520 $18.00

85525 $16.28

85530 $19.49

85536 $8.89

85540 $11.83

85547 $11.83

85549 $25.78

85555 $9.18

85557 $18.37

85576 $29.53

85576 26 $34.87

85576 TC $29.53

85597 $24.71

85598 $24.71

85610 $5.40

85611 $5.42

85612 $13.16

85613 $13.16

85635 $13.53

85651 $4.88

85652 $3.71

85660 $7.59

85670 $7.93

85675 $9.41

85705 $13.23

85730 $8.25

85732 $8.89

85810 $16.04

86000 $9.45

86001 $7.17

86003 $7.17

86005 $10.96

86021 $20.70

86022 $25.25

86023 $17.12

86038 $16.62

86039 $15.35

86060 $10.03

86063 $7.93

86077 $92.46

86078 $92.94

86079 $92.46

86140 $7.11

86141 $17.80

86146 $34.97

86147 $34.97

86148 $22.08

86155 $21.97

86156 $9.21

149

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

86157 $11.09

86160 $16.50

86161 $16.50

86162 $27.93

86171 $13.76

86185 $12.29

86200 $17.80

86215 $18.21

86225 $18.88

86226 $16.65

86235 $24.65

86243 $28.20

86255 $16.57

86255 26 $34.87

86255 TC $16.57

86256 $16.57

86256 26 $33.80

86256 TC $16.57

86277 $21.63

86280 $11.26

86294 $24.03

86300 $24.03

86301 $24.03

86304 $24.03

86305 $24.03

86308 $7.11

86309 $8.89

86310 $10.13

86316 $24.03

86317 $20.61

86318 $17.80

86320 $30.81

86320 26 $32.84

86320 TC $30.81

86325 $30.74

86325 26 $33.32

86325 TC $30.74

86327 $31.19

86327 26 $39.67

86327 TC $31.19

86329 $19.30

86331 $16.47

86332 $33.50

86334 $30.71

86334 26 $34.39

86334 TC $30.71

86335 $40.34

86336 $17.80

86337 $29.43

86340 $20.72

86341 $27.20

86343 $17.13

86344 $10.98

86352 $186.75

150

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

86353 $67.39

86355 $51.85

86356 $24.88

86357 $51.85

86359 $51.85

86360 $64.59

86361 $24.88

86367 $51.85

86376 $19.99

86378 $27.06

86382 $23.25

86384 $15.65

86386 $21.95

86403 $14.01

86406 $14.62

86430 $7.80

86431 $7.80

86480 $85.19

86481 $102.98

86486 $7.95

86490 $7.00

86510 $8.91

86580 $11.30

86590 $15.18

86592 $5.87

86593 $6.05

86602 $13.99

86603 $17.69

86606 $20.70

86609 $17.71

86611 $13.99

86612 $17.74

86615 $18.13

86617 $21.30

86618 $23.41

86619 $18.39

86622 $12.28

86625 $18.03

86628 $16.50

86631 $16.26

86632 $17.44

86635 $15.77

86638 $16.66

86641 $19.81

86644 $19.79

86645 $23.15

86648 $20.91

86651 $18.13

86652 $18.13

86653 $18.13

86654 $18.13

86658 $17.91

86663 $18.03

86664 $21.03

151

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

86665 $24.94

86666 $13.99

86668 $14.30

86671 $16.85

86674 $20.24

86677 $19.95

86682 $17.88

86684 $21.78

86687 $11.54

86688 $19.25

86689 $26.60

86692 $23.59

86694 $19.79

86695 $18.13

86696 $26.60

86698 $17.18

86701 $12.21

86702 $18.58

86703 $18.85

86704 $16.57

86705 $16.18

86706 $14.76

86707 $15.90

86708 $17.03

86709 $15.47

86710 $18.63

86711 $19.79

86713 $21.04

86717 $16.84

86720 $18.13

86723 $18.13

86727 $17.69

86729 $16.43

86732 $18.13

86735 $17.94

86738 $18.20

86741 $18.13

86744 $18.13

86747 $20.67

86750 $18.13

86753 $17.03

86756 $17.72

86757 $26.60

86759 $18.13

86762 $19.79

86765 $17.71

86768 $18.13

86771 $18.13

86774 $20.34

86777 $19.79

86778 $19.80

86780 $18.20

86784 $17.27

86787 $17.71

152

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

86788 $23.15

86789 $19.79

86790 $17.71

86793 $18.13

86800 $21.86

86803 $19.62

86804 $21.30

86805 $71.88

86806 $65.42

86807 $54.40

86808 $40.80

86812 $35.48

86813 $79.72

86816 $38.30

86817 $88.49

86821 $77.60

86822 $50.25

86825 $74.63

86826 $24.88

86828 $54.40

86829 $40.80

86830 $110.99

86831 $95.13

86832 $174.40

86833 $158.55

86834 $491.49

86835 $443.93

86850 $8.05

86870 $39.71

86880 $7.39

86885 $7.87

86886 $7.11

86900 $4.10

86901 $4.10

86902 $5.25

86904 $13.07

86905 $5.25

86906 $10.66

86921 $94.99

86922 $94.99

86940 $11.27

86941 $16.65

86945 $142.74

87001 $18.16

87003 $23.14

87015 $9.18

87040 $14.19

87045 $12.97

87046 $12.97

87070 $11.84

87071 $12.97

87073 $12.97

87075 $13.01

87076 $11.11

153

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

87077 $11.11

87081 $9.12

87084 $11.84

87086 $11.10

87088 $11.13

87101 $10.60

87102 $11.55

87103 $12.40

87106 $14.19

87107 $14.19

87109 $21.15

87110 $26.93

87116 $14.85

87118 $15.04

87140 $7.67

87143 $17.22

87147 $7.11

87149 $27.57

87150 $48.24

87152 $7.19

87153 $158.57

87158 $7.19

87164 $14.76

87164 26 $33.43

87164 TC $14.76

87166 $15.53

87168 $5.87

87169 $5.87

87172 $5.87

87176 $8.09

87177 $12.23

87181 $1.59

87184 $9.49

87185 $1.59

87186 $11.88

87187 $14.25

87188 $9.12

87190 $7.77

87197 $20.65

87205 $5.87

87206 $7.39

87207 $8.24

87207 26 $34.87

87207 TC $8.24

87209 $24.71

87210 $5.87

87220 $5.87

87230 $27.14

87250 $26.88

87252 $35.83

87253 $27.76

87254 $26.88

87255 $46.55

87260 $16.49

154

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

87265 $16.49

87267 $16.49

87269 $16.49

87270 $16.49

87271 $16.49

87272 $16.49

87273 $16.49

87274 $16.49

87275 $16.49

87276 $16.49

87277 $16.49

87278 $16.49

87279 $16.49

87280 $16.49

87281 $16.49

87283 $16.49

87285 $16.49

87290 $16.49

87300 $16.49

87301 $16.49

87305 $16.49

87320 $16.49

87324 $16.49

87327 $16.49

87328 $16.49

87329 $16.49

87332 $16.49

87335 $16.49

87336 $16.49

87337 $16.49

87338 $16.49

87339 $16.49

87340 $14.20

87341 $14.20

87350 $15.84

87380 $22.56

87385 $16.49

87389 By Report

87390 $24.25

87391 $24.25

87400 $16.49

87420 $16.49

87425 $16.49

87427 $16.49

87430 $16.49

87449 $16.49

87450 $13.18

87451 $13.18

87470 $27.57

87471 $48.24

87472 $58.88

87475 $27.57

87476 $48.24

87477 $58.88

155

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

87480 $27.57

87481 $48.24

87482 $57.39

87485 $27.57

87486 $48.24

87487 $58.88

87490 $27.57

87491 $48.24

87492 $48.06

87493 $48.24

87495 $27.57

87496 $48.24

87497 $58.88

87498 $48.24

87500 $48.24

87501 $70.54

87502 $116.96

87503 $28.55

87510 $27.57

87511 $48.24

87512 $57.39

87515 $27.57

87516 $48.24

87517 $58.88

87520 $27.57

87521 $48.24

87522 $58.88

87525 $27.57

87526 $48.24

87527 $57.39

87528 $27.57

87529 $48.24

87530 $58.88

87531 $27.57

87532 $48.24

87533 $57.39

87534 $27.57

87535 $48.24

87536 $116.96

87537 $27.57

87538 $48.24

87539 $58.88

87540 $27.57

87541 $48.24

87542 $57.39

87550 $27.57

87551 $48.24

87552 $58.88

87555 $27.57

87556 $48.24

87557 $58.88

87560 $27.57

87561 $48.24

87562 $58.88

156

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

87580 $27.57

87581 $48.24

87582 $57.39

87590 $27.57

87591 $48.24

87592 $58.88

87620 $27.57

87621 $48.24

87622 $57.39

87631 $176.34

87632 $293.37

87633 $572.91

87640 $48.24

87641 $48.24

87650 $27.57

87651 $48.24

87652 $57.39

87653 $48.24

87660 $27.57

87797 $27.57

87798 $48.24

87799 $58.88

87800 $55.14

87801 $96.49

87802 $16.49

87803 $16.49

87804 $16.49

87807 $16.49

87808 $16.49

87809 $16.49

87810 $16.49

87850 $16.49

87880 $16.49

87899 $16.49

87900 $179.17

87901 $353.88

87902 $353.88

87903 $671.68

87904 $35.83

87905 $16.80

87906 $176.94

87910 $353.88

87912 $353.88

88104 $117.69

88104 26 $50.88

88104 TC $66.81

88106 $126.92

88106 26 $33.80

88106 TC $93.12

88108 $119.19

88108 26 $39.46

88108 TC $79.72

88112 $176.07

88112 26 $104.00

157

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

88112 TC $72.07

88120 $895.43

88120 TC $793.25

88121 $803.40

88121 TC $715.15

88125 $36.26

88125 26 $23.05

88125 TC $13.22

88130 $20.69

88140 $10.99

88141 $52.11

88142 $27.85

88143 $27.85

88147 $15.65

88148 $20.89

88150 $14.53

88152 $14.53

88153 $14.53

88154 $14.53

88155 $8.24

88160 $98.82

88160 26 $45.41

88160 TC $53.41

88161 $94.51

88161 26 $43.98

88161 TC $50.54

88162 $149.44

88162 26 $69.24

88162 TC $80.20

88164 $14.53

88165 $14.53

88166 $14.53

88167 $14.53

88172 $90.07

88172 26 $62.98

88172 TC $27.09

88173 $237.09

88173 26 $124.83

88173 TC $112.26

88174 $29.37

88175 $36.41

88177 $49.42

88177 TC $10.82

88182 $167.45

88182 26 $63.69

88182 TC $103.76

88184 $124.70

88185 $75.90

88187 $121.60

88188 $154.44

88189 $190.88

88230 $105.56

88233 $193.44

88235 $110.41

158

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

88237 $173.62

88239 $194.15

88245 $204.62

88248 $238.04

88249 $238.04

88261 $242.93

88262 $171.33

88263 $206.58

88264 $171.33

88267 $247.11

88269 $228.63

88271 $29.44

88272 $36.80

88273 $44.17

88274 $47.85

88275 $55.20

88280 $34.50

88283 $94.30

88285 $26.11

88289 $30.35

88291 $52.61

88300 $21.76

88300 26 $7.59

88300 TC $14.17

88302 $45.70

88302 26 $11.91

88302 TC $33.79

88304 $66.59

88304 26 $19.88

88304 TC $46.71

88305 $112.77

88305 26 $66.06

88305 TC $46.71

88307 $448.15

88307 26 $145.46

88307 TC $302.70

88309 $684.44

88309 26 $256.74

88309 TC $427.69

88311 $33.00

88311 26 $21.70

88311 TC $11.30

88312 $147.44

88312 26 $47.62

88312 TC $99.82

88313 $99.51

88313 26 $21.22

88313 TC $78.29

88314 $122.25

88314 26 $40.14

88314 TC $82.12

88319 $132.53

88319 26 $48.02

88319 TC $84.51

159

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

88321 $160.93

88323 $233.67

88323 26 $151.55

88323 TC $82.12

88325 $342.06

88329 $93.14

88331 $162.94

88331 26 $109.05

88331 TC $53.89

88332 $72.34

88332 26 $53.86

88332 TC $18.48

88333 $170.24

88333 26 $110.13

88333 TC $60.11

88334 $105.79

88334 26 $67.70

88334 TC $38.10

88342 $177.98

88342 26 $75.29

88342 TC $102.69

88346 $169.93

88346 26 $75.37

88346 TC $94.56

88347 $127.82

88347 26 $70.11

88347 TC $57.71

88348 $1,047.25

88348 26 $132.90

88348 TC $914.35

88349 $628.81

88349 26 $70.67

88349 TC $558.14

88355 $291.77

88355 26 $151.28

88355 TC $140.49

88356 $445.80

88356 26 $236.00

88356 TC $209.80

88358 $133.03

88358 26 $79.15

88358 TC $53.89

88360 $199.58

88360 26 $94.50

88360 TC $105.08

88361 $242.10

88361 26 $102.57

88361 TC $139.53

88362 $478.35

88362 26 $193.91

88362 TC $284.45

88365 $273.77

88365 26 $104.57

88365 TC $169.20

160

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

88367 $387.32

88367 26 $108.54

88367 TC $278.77

88368 $352.60

88368 26 $113.06

88368 TC $239.54

88371 $30.55

88371 26 $33.91

88371 TC $30.55

88372 $31.27

88372 26 $29.13

88372 TC $31.27

88375 By Report

88380 $251.40

88380 26 $130.52#

88380 TC $120.87

88381 $237.50

88381 26 $94.14

88381 TC $143.36

88387 $59.04

88387 26 $50.61

88387 TC $8.43

88388 $54.79

88388 26 $41.57

88388 TC $13.22

88720 $6.90

88738 $6.90

88740 $6.90

88741 $6.90

89049 $413.89

89050 $6.50

89051 $7.57

89055 $5.87

89060 $9.83

89060 26 $34.39

89060 TC $9.83

89125 $5.93

89160 $5.07

89190 $6.53

89220 $24.70

89230 $3.17

89300 $9.45

89310 $11.83

89320 $16.57

89322 $21.30

89325 $14.67

89331 $26.93

90281 $30.29

90371 $134.90

90389 $8.00

90396 $118.75

90460 $39.48

90461 $20.43

90471 $39.48

161

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

90472 $20.43

90473 $39.48

90474 $20.43

90632 $71.07

90636 $100.71

90649 $142.50

90650 $145.92

90653 By Report

90654 $16.74

90655 $15.56

90656 $15.56

90657 $15.56

90658 $15.56

90660 $22.03

90661 $13.35

90662 $13.70

90664 $20.47

90666 $13.35

90668 $11.93

90680 $79.69

90707 $54.69

90714 $8.00

90715 $40.10

90716 $95.49

90732 $55.82

90733 $119.31

90734 $117.03

90736 $172.06

90740 $188.43

90746 $58.99

90747 $52.34

90748 $50.65

90785 $8.65

90791 $264.33

90792 $230.12

90832 $111.40

90833 $76.68

90834 $148.82

90836 $124.71

90837 $218.98

90838 $201.00

90845 $139.23

90847 $165.86

90849 $58.76

90853 $45.36

90863 $99.05

90867 $588.09#

90868 $261.42#

90869 $701.65

90870 $298.22

90935 $127.28

90937 $182.03

90945 $147.98

90947 $217.50

162

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

90951 $1,625.55

90954 $1,412.11

90955 $792.87

90956 $548.59

90957 $1,120.93

90958 $758.96

90959 $512.17

90960 $491.12

90961 $411.96

90962 $316.38

90963 $949.64

90964 $826.87

90965 $786.15

90966 $411.48

90967 $31.02

90968 $26.70

90969 $26.02

90970 $13.54

90989 $277.60

90997 $158.31

91010 $287.52

91010 26 $119.28

91010 TC $168.24

91013 $38.54

91013 TC $21.83

91020 $381.54

91020 26 $134.82

91020 TC $246.71

91022 $282.38

91022 26 $134.71

91022 TC $147.67

91030 $225.86

91030 26 $85.36

91030 TC $140.49

91034 $301.66

91034 26 $89.40

91034 TC $212.26

91035 $768.67

91035 26 $147.31

91035 TC $621.36

91037 $259.97

91037 26 $90.77

91037 TC $169.20

91038 $714.06

91038 26 $102.27

91038 TC $611.79

91040 $449.22

91040 26 $82.88

91040 TC $366.33

91065 $144.67

91065 26 $18.53

91065 TC $126.14

91110 $1,432.21

91110 26 $340.50

163

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

91110 TC $1,091.71

91111 $1,158.73

91111 26 $93.33

91111 TC $1,065.39

91112 $1,708.37

91112 TC $1,511.82

91117 $266.50

91120 $618.65

91120 26 $88.19

91120 TC $530.45

91122 $353.90

91122 26 $156.95

91122 TC $196.95

91132 $247.17

91132 26 $48.79

91132 TC $198.39

91133 $286.07

91133 26 $62.33

91133 TC $223.75

92002 $132.56

92004 $246.08

92012 $139.56

92014 $203.27

92015 $34.58

92018 $247.55

92019 $122.25

92020 $45.40

92025 $60.50

92025 26 $34.37

92025 TC $26.13

92060 $106.45

92060 26 $66.92

92060 TC $39.53

92065 $84.81

92065 26 $31.88

92065 TC $52.93

92071 $80.00*

92072 $80.00*

92081 $54.38

92081 26 $28.72

92081 TC $25.66

92082 $77.67

92082 26 $38.62

92082 TC $39.05

92083 $102.76

92083 26 $48.88

92083 TC $53.89

92100 $126.61

92132 $57.27

92132 26 $34.00

92132 TC $23.26

92133 $72.62

92133 26 $48.88

92133 TC $23.74

164

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

92134 $74.05

92134 26 $49.83

92134 TC $24.22

92136 $141.22

92136 26 $53.84

92136 TC $87.38

92140 $100.55

92225 $45.59

92226 $41.15

92227 $19.44

92228 $57.54

92228 TC $20.39

92230 $95.13

92235 $174.33

92235 26 $81.21

92235 TC $93.12

92240 $394.80

92240 26 $110.29

92240 TC $284.51

92250 $122.54

92250 26 $41.38

92250 TC $81.16

92260 $30.97

92265 $129.72

92265 26 $75.36

92265 TC $54.36

92270 $147.06

92270 26 $72.60

92270 TC $74.46

92275 $251.24

92275 26 $101.18

92275 TC $150.06

92283 $83.80

92283 26 $16.04

92283 TC $67.76

92284 $94.25

92284 26 $21.70

92284 TC $72.55

92285 $30.75

92285 26 $5.10

92285 TC $25.66

92286 $61.95

92286 26 $38.21

92286 TC $23.74

92310 $80.00#

92311 $80.00#

92312 $80.00#

92313 $80.00#

92314 $80.00#

92315 $80.00#

92316 $80.00#

92317 $80.00#

92340 $57.36

92341 $66.00

165

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

92342 $71.29

92352 $64.53

92353 $76.15

92358 $16.56

92502 $164.89

92504 $47.81

92506 $321.54

92507 $123.97

92511 $213.70

92512 $98.65

92516 $109.72

92520 $119.58

92526 $133.36

92532 $75.00

92540 $169.85

92540 26 $137.97

92540 TC $31.88

92541 $49.99

92541 26 $36.29

92541 TC $13.69

92542 $43.84

92542 26 $30.15

92542 TC $13.69

92543 $24.54

92543 26 $9.42

92543 TC $15.13

92544 $37.70

92544 26 $24.01

92544 TC $13.69

92545 $33.77

92545 26 $21.03

92545 TC $12.74

92546 $155.51

92546 26 $26.02

92546 TC $129.49

92547 $8.91

92548 $159.59

92548 26 $44.93

92548 TC $114.65

92550 $35.80

92551 $17.52

92552 $45.27

92553 $54.84

92555 $34.27

92556 $53.89

92557 $63.74

92560 $76.00

92561 $55.32

92562 $68.72

92563 $46.23

92564 $41.92

92565 $24.70

92567 $23.80

92568 $26.98

166

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

92570 $55.11

92571 $40.01

92572 $77.33

92575 $111.30

92576 $50.06

92577 $27.09

92579 $71.42

92582 $105.56

92583 $75.90

92584 $102.69

92585 $193.56

92585 26 $45.89

92585 TC $147.67

92586 $125.66

92587 $36.69

92587 26 $32.57

92587 TC $4.12

92588 $56.55

92588 26 $50.99

92588 TC $5.56

92590 $94.11

92591 $176.47

92592 $47.06

92593 $76.47

92594 $52.94

92595 $76.47

92596 $63.46

92597 $120.80

92601 $229.26

92602 $150.29

92603 $248.39

92604 $147.77

92611 $147.53

92612 $276.50

92613 $66.65

92614 $241.09

92615 $58.58

92616 $333.26

92617 $72.99

92620 $158.00

92621 $37.72

92625 $118.07

92626 $151.75

92627 $36.37

92630 $145.35

92633 $144.50

92640 $200.65

92920 $921.33

92924 $1,094.88

92928 $1,022.84

92933 $1,143.87

92937 $1,021.69

92941 $1,145.99

92943 $1,145.99

167

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

92950 $504.87

92953 $19.12

92960 $330.14

92961 $417.49

92970 $309.72

92971 $161.08

92973 $299.09

92974 $273.22

92975 $660.63

92977 $79.36

92986 $2,234.88#

92987 $2,312.66

92990 $1,809.42

92992 $3,248.79

92997 $1,100.91

92998 $545.58

93000 $28.77

93005 $14.17

93010 $14.60

93015 $125.98

93016 $38.70

93017 $61.54

93018 $25.74

93024 $180.18

93024 26 $100.46

93024 TC $79.72

93025 $254.51

93025 26 $65.21

93025 TC $189.30

93040 $21.21

93041 $8.43

93042 $12.78

93224 $141.61

93225 $39.53

93226 $55.80

93227 $46.28

93228 $44.96

93229 $1,034.77

93268 $320.56

93270 $13.22

93271 $263.46

93272 $43.89

93278 $48.03

93278 26 $21.90

93278 TC $26.13

93279 $81.75

93279 26 $56.57

93279 TC $25.18

93280 $94.61

93280 26 $66.56

93280 TC $28.05

93281 $110.53

93281 26 $77.70

93281 TC $32.83

168

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

93282 $102.86

93282 26 $73.85

93282 TC $29.01

93283 $133.38

93283 26 $99.59

93283 TC $33.79

93284 $146.81

93284 26 $108.23

93284 TC $38.57

93285 $67.15

93285 26 $44.84

93285 TC $22.31

93286 $42.78

93286 26 $26.22

93286 TC $16.56

93287 $57.18

93287 26 $38.70

93287 TC $18.48

93288 $59.66

93288 26 $36.88

93288 TC $22.78

93289 $107.57

93289 26 $79.52

93289 TC $28.05

93290 $50.57

93290 26 $36.88

93290 TC $13.69

93291 $57.75

93291 26 $36.88

93291 TC $20.87

93292 $52.96

93292 26 $36.88

93292 TC $16.09

93293 $80.49

93293 26 $27.08

93293 TC $53.41

93294 $57.83

93295 $114.02

93296 $36.66

93297 $45.44

93298 $45.44

93299 By Report

93303 $302.33

93303 26 $112.08

93303 TC $190.25

93304 $198.53

93304 26 $64.74

93304 TC $133.79

93306 $290.85

93306 26 $111.60

93306 TC $179.25

93307 $177.90

93307 26 $79.52

93307 TC $98.38

169

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

93308 $151.08

93308 26 $45.04

93308 TC $106.04

93312 $471.05

93312 26 $184.99

93312 TC $286.06

93313 $75.07

93314 $423.96

93314 26 $105.84

93314 TC $318.12

93315 $443.22

93315 26 $240.71

93315 TC $224.60

93316 $76.02

93317 $367.53

93317 26 $160.06

93317 TC $224.60

93318 By Report

93318 26 $191.14

93320 $70.17

93320 26 $32.56

93320 TC $37.62

93321 $36.04

93321 26 $12.78

93321 TC $23.26

93325 $29.23

93325 26 $6.44

93325 TC $22.78

93350 $309.08

93350 26 $125.53

93350 TC $183.55

93351 $362.20

93351 26 $150.30

93351 TC $211.90

93352 $52.31

93451 $1,192.75

93451 26 $248.30

93451 TC $944.45

93452 $1,347.06

93452 26 $434.19

93452 TC $912.87

93453 $1,757.73

93453 26 $570.39

93453 TC $1,187.34

93454 $1,378.46

93454 26 $437.35

93454 TC $941.10

93455 $1,601.60

93455 26 $505.17

93455 TC $1,096.43

93456 $1,730.40

93456 26 $560.76

93456 TC $1,169.63

93457 $1,952.20

170

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

93457 26 $628.50

93457 TC $1,323.70

93458 $1,652.57

93458 26 $534.13

93458 TC $1,118.44

93459 $1,827.27

93459 26 $601.65

93459 TC $1,225.62

93460 $1,962.37

93460 26 $670.24

93460 TC $1,292.13

93461 $2,242.85

93461 26 $739.42

93461 TC $1,503.43

93462 $344.95

93463 $180.54

93464 $437.98

93464 TC $274.94

93503 $232.45

93505 $1,171.14

93505 26 $394.63

93505 TC $776.51

93563 $96.77

93564 $98.89

93565 $75.05

93566 $264.05

93567 $221.21

93568 $238.12

93580 $1,660.37

93581 $2,241.84

93613 $647.78

93616 $129.15

93616 26 $117.36

93616 TC $19.84

93620 $1,458.40

93620 26 $1,070.19

93620 TC $524.54

93631 $1,008.37

93631 26 $682.86

93631 TC $394.51

93642 $640.71

93642 26 $424.98

93642 TC $215.73

93650 $985.82

93653 $1,388.69

93654 $1,853.02

93655 $694.44

93656 $1,853.89

93657 $694.73

93660 $254.86

93660 26 $164.14

93660 TC $90.73

93662 $239.18

93662 26 $246.90

171

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

93662 TC $240.52

93668 $28.05

93701 $35.23

93701 TC $34.32

93724 $463.08

93724 26 $422.59

93724 TC $40.49

93740 $14.52

93740 26 $13.81

93740 TC $2.30

93750 $92.55

93770 $14.52

93770 TC $0.80

93784 $85.30

93786 $44.32

93788 $7.95

93790 $33.03

93797 $26.76

93798 $40.18

93880 $354.29

93880 26 $51.59

93880 TC $302.70

93882 $254.05

93882 26 $34.61

93882 TC $219.44

93886 $552.76

93886 26 $84.03

93886 TC $468.73

93888 $322.14

93888 26 $54.85

93888 TC $267.29

93890 $439.57

93890 26 $88.07

93890 TC $351.50

93892 $496.85

93892 26 $101.80

93892 TC $395.04

93893 $528.90

93893 26 $102.76

93893 TC $426.14

93922 $137.03

93922 26 $21.42

93922 TC $115.61

93923 $213.57

93923 26 $38.63

93923 TC $174.94

93924 $266.70

93924 26 $42.95

93924 TC $223.75

93925 $375.15

93925 26 $68.99

93925 TC $306.16

93926 $216.09

93926 26 $43.07

172

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

93926 TC $173.03

93930 $353.01

93930 26 $39.78

93930 TC $313.22

93931 $236.40

93931 26 $26.53

93931 TC $209.87

93965 $183.11

93965 26 $30.17

93965 TC $152.93

93970 $284.39

93970 26 $60.64

93970 TC $223.75

93971 $172.42

93971 26 $38.63

93971 TC $133.79

93975 $551.49

93975 26 $155.37

93975 TC $396.11

93976 $323.30

93976 26 $104.34

93976 TC $218.96

93978 $344.67

93978 26 $56.32

93978 TC $288.34

93979 $238.26

93979 26 $37.48

93979 TC $200.78

93980 $253.92

93980 26 $107.69

93980 TC $146.23

93981 $166.19

93981 26 $37.66

93981 TC $128.53

93982 $67.12

93990 $299.17

93990 26 $21.35

93990 TC $277.81

94002 $164.44

94003 $118.08

94004 $86.57

94010 $55.57

94010 26 $14.60

94010 TC $40.97

94011 $175.52

94012 $275.63

94013 $61.37

94014 $79.59

94014 26 $40.82

94014 TC $26.70

94016 $43.89

94060 $95.31

94060 26 $23.24

94060 TC $72.07

173

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

94070 $97.05

94070 26 $51.30

94070 TC $45.75

94150 $37.84

94150 26 $6.44

94150 TC $31.40

94200 $38.61

94200 26 $9.61

94200 TC $29.01

94250 $39.09

94250 26 $9.61

94250 TC $29.48

94375 $62.59

94375 26 $26.41

94375 TC $36.18

94400 $91.62

94400 26 $33.90

94400 TC $57.71

94450 $106.45

94450 26 $34.86

94450 TC $71.59

94452 $92.26#

94452 26 $26.41#

94452 TC $65.85#

94453 $128.94#

94453 26 $33.90#

94453 TC $95.04#

94610 $105.46

94620 $92.08

94620 26 $54.47

94620 TC $37.62

94621 $261.89

94621 26 $121.88

94621 TC $140.01

94640 $27.09

94644 $65.85

94645 $20.87

94660 $103.80

94662 $64.09

94664 $26.13

94667 $36.66

94668 $38.10

94680 $90.81

94680 26 $22.57

94680 TC $68.24

94681 $81.03

94681 26 $17.58

94681 TC $63.46

94690 $73.72

94690 26 $6.44

94690 TC $67.28

94726 $90.15

94726 26 $23.05

94726 TC $67.10

174

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

94727 $71.67

94727 TC $48.62

94728 $69.28

94728 TC $46.23

94729 $91.37

94729 26 $16.90

94729 TC $74.46

94750 $126.59

94750 26 $19.60

94750 TC $107.00

94760 $4.60

94761 $7.00

94762 $35.23

94770 $13.85

94770 TC $37.32

95004 $9.58

95012 $29.01

95017 $13.62

95018 $33.16

95024 $11.50

95027 $7.19

95028 $20.39

95044 $7.95

95052 $9.87

95056 $66.33

95060 $49.58

95065 $38.57

95070 $44.32

95071 $50.54

95076 $192.81

95079 $141.68

95115 $13.22

95117 $15.13

95120 $18.50

95125 $23.50

95130 $20.00

95144 $19.17

95145 $33.04

95146 $57.92

95147 $52.66

95148 $78.02

95149 $104.81

95165 $19.64

95170 $14.86

95180 $224.84

95250 $233.79

95251 $75.59

95782 $1,515.10

95782 TC $1,287.00

95783 $1,617.88

95783 TC $1,368.94

95800 $275.94

95800 TC $184.51

95801 $152.48

175

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

95801 TC $66.81

95803 $230.92

95803 26 $78.47

95803 TC $152.45

95805 $625.69

95805 26 $103.44

95805 TC $522.25

95806 $280.72

95806 26 $109.01

95806 TC $171.71

95807 $725.01

95807 26 $109.59

95807 TC $615.42

95808 $951.29

95808 26 $152.13

95808 TC $799.16

95810 $952.88

95810 26 $215.15

95810 TC $737.73

95811 $998.95

95811 26 $223.61

95811 TC $775.35

95812 $657.03

95812 26 $98.71

95812 TC $558.32

95813 $764.14

95813 26 $158.16

95813 TC $605.98

95816 $604.22

95816 26 $99.49

95816 TC $504.73

95819 $691.48

95819 26 $99.19

95819 TC $592.29

95822 $620.19

95822 26 $99.19

95822 TC $521.00

95827 $1,161.21

95827 26 $99.01

95827 TC $1,062.20

95829 $2,890.79

95829 26 $565.81

95829 TC $2,324.98

95830 $408.46

95831 $45.56

95832 $43.84

95833 $61.58

95834 $84.31

95851 $28.76

95852 $25.88

95857 $85.16

95860 $196.86

95860 26 $89.39

95860 TC $107.48

176

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

95861 $274.27

95861 26 $142.87

95861 TC $131.40

95863 $334.86

95863 26 $172.36

95863 TC $162.50

95864 $381.21

95864 26 $183.78

95864 TC $197.43

95865 $221.45

95865 26 $143.16

95865 TC $78.29

95866 $219.36

95866 26 $116.19

95866 TC $103.17

95867 $176.82

95867 26 $72.69

95867 TC $104.13

95868 $225.36

95868 26 $108.31

95868 TC $117.05

95869 $129.31

95869 26 $33.80

95869 TC $95.51

95870 $135.53

95870 26 $34.28

95870 TC $101.26

95872 $339.39

95872 26 $265.41

95872 TC $73.98

95873 $116.87

95873 26 $35.23

95873 TC $81.64

95874 $112.56

95874 26 $34.28

95874 TC $78.29

95875 $200.65

95875 26 $101.31

95875 TC $99.34

95885 $92.56

95885 26 $32.45

95885 TC $60.11

95886 $132.19

95886 26 $64.90

95886 TC $67.28

95887 $109.24

95887 26 $43.39

95887 TC $65.85

95905 $100.61

95905 26 $4.62

95905 TC $95.99

95907 $151.34

95907 26 $91.60

95907 TC $59.74

177

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

95908 $187.12

95908 26 $114.93

95908 TC $72.18

95909 $224.14

95909 26 $137.49

95909 TC $86.65

95910 $295.51

95910 26 $183.68

95910 TC $111.83

95911 $359.22

95911 26 $229.57

95911 TC $129.65

95912 $421.97

95912 26 $275.28

95912 TC $146.69

95913 $490.67

95913 26 $326.64

95913 TC $164.03

95921 $143.84

95921 26 $79.91

95921 TC $63.93

95922 $170.84

95922 26 $85.86

95922 TC $84.99

95923 $386.43

95923 26 $82.30

95923 TC $304.13

95924 $239.61

95924 TC $85.47

95925 $287.16

95925 26 $49.06

95925 TC $238.10

95926 $277.71

95926 26 $49.65

95926 TC $228.05

95927 $253.19

95927 26 $48.58

95927 TC $204.61

95928 $444.06

95928 26 $137.90

95928 TC $306.16

95929 $446.45

95929 26 $137.90

95929 TC $308.55

95930 $237.54

95930 26 $31.97

95930 TC $205.56

95933 $140.40

95933 26 $54.45

95933 TC $85.94

95937 $123.20

95937 26 $59.26

95937 TC $63.93

95938 $484.81

178

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

95938 26 $79.13

95938 TC $405.68

95939 $758.20

95939 26 $207.24

95939 TC $550.96

95940 $56.08#

95950 $519.38#

95950 26 $138.57#

95950 TC $380.80#

95953 $679.99#

95953 26 $282.44#

95953 TC $397.55#

95954 $718.54

95954 26 $216.39

95954 TC $502.15

95955 $355.07

95955 26 $93.05

95955 TC $262.03

95956 $2,512.65#

95956 26 $330.35#

95956 TC $2,182.31#

95957 $691.48

95957 26 $181.60

95957 TC $509.88

95958 $902.97

95958 26 $385.99

95958 TC $516.99

95961 $459.25

95961 26 $272.35

95961 TC $186.90

95962 $409.85

95962 26 $293.76

95962 TC $116.09

95965 26 $744.94

95966 26 $346.96

95967 26 $304.12

95970 $108.97

95971 $98.56

95972 $181.13

95973 $105.40

95974 $343.00

95975 $185.37

95978 $412.72

95979 $180.02

95980 $77.69

95981 $52.65

95982 $86.35

95990 $135.34

95991 $194.43

95992 $74.42

96000 $170.27#

96001 $174.97#

96002 $37.56#

96003 $30.08#

179

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

96004 $196.42#

96020 26 $292.06

96105 $165.79

96110 $12.74

96111 $226.04

96116 $159.66

96125 $183.41

96360 $85.05

96361 $23.10

96365 $109.75

96366 $33.94

96367 $48.48

96368 $29.44

96369 $302.10

96370 $27.72

96371 $142.41

96372 $39.48

96373 $31.35

96374 $83.81

96375 $33.34

96401 $110.05

96402 $49.44

96405 $127.74

96406 $181.32

96409 $161.17

96411 $91.38

96413 $205.97

96415 $46.57

96416 $203.29

96417 $103.53

96420 $153.04

96422 $244.43

96423 $114.54

96425 $262.25

96440 $1,309.42

96446 $287.26

96450 $281.78

96521 $201.26

96522 $163.94

96523 $36.00

96542 $185.13

96567 $202.22

96570 $97.99*

96571 $46.79*

96900 $30.92

96902 $37.56

96904 $102.21

96910 $107.00

96912 $137.14

96913 $193.12

96920 $244.57

96921 $269.97

96922 $379.52

97001 $127.66

180

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

97002 $70.44

97003 $141.53

97004 $86.23

97010 $9.60

97012 $27.16

97014 $25.80

97016 $31.06

97018 $16.77

97022 $36.61

97024 $10.07

97026 $9.60

97028 $11.90

97032 $31.47

97033 $51.28

97034 $29.26

97035 $21.60

97036 $52.15

97039 $17.03#

97110 $53.53

97112 $55.45

97113 $69.61

97116 $47.30

97124 $43.46

97139 $23.41#

97140 $50.27

97150 $29.85

97530 $57.64

97532 $45.20

97597 $119.04

97598 $40.00

97605 $69.03

97606 $73.47

97750 $55.08

98925 $52.41

98926 $75.92

98927 $100.21

98928 $123.84

98929 $147.77

99002 $6.00

99050 $29.30

99090 $97.41

99091 $97.60

99100 $36.08

99116 $36.00

99135 $35.00

99140 $37.64

99143 $201.47

99144 $222.39

99145 $64.62

99170 $208.83

99173 $4.12

99174 $42.88

99175 $23.74

99183 $347.41

181

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

99190 $660.00

99191 $495.00

99192 $330.00

99195 $143.59#

99201 $70.32

99202 $121.57

99203 $177.18

99204 $274.58

99205 $343.25

99211 $32.02

99212 $70.32

99213 $119.96

99214 $177.55

99215 $239.38

99217 $122.92

99218 $170.98

99219 $232.56

99220 $318.83

99221 $173.72

99222 $236.15

99223 $348.15

99224 $68.21

99225 $124.28

99226 $179.42

99231 $67.44

99232 $124.10

99233 $178.76

99234 $230.40

99235 $290.01

99236 $374.84

99238 $123.10

99239 $182.26

99241 $76.70

99242 $146.92

99243 $201.65

99244 $303.44

99245 $372.24

99251 $84.65

99252 $129.34

99253 $197.33

99254 $285.49

99255 $353.69

99281 $36.90

99282 $72.27

99283 $108.41

99284 $206.95

99285 $304.21

99288 $125.00#

99291 $463.97

99292 $210.27

99304 $158.01

99305 $224.77

99306 $286.34

99307 $75.27

182

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

99308 $116.47

99309 $153.52

99310 $229.21

99315 $123.88

99316 $179.09

99324 $94.89

99325 $138.22

99326 $239.55

99327 $318.69

99328 $371.70

99334 $102.76

99335 $161.72

99336 $229.91

99337 $329.93

99341 $94.42

99342 $137.08

99343 $225.76

99344 $311.87

99345 $376.13

99347 $94.70

99348 $144.26

99349 $218.30

99350 $303.71

99354 $169.21#

99355 $166.34#

99356 $157.04#

99357 $156.56#

99360 $106.54#

99381 $181.85

99382 $190.20

99383 $198.66

99384 $225.95

99385 $218.65

99391 $163.72

99392 $175.63

99393 $175.16

99394 $192.44

99395 $196.76

99401 $59.49

99402 $103.88

99403 $146.63

99404 $189.27

99406 $24.10

99407 $46.96

99408 $60.22

99409 $117.57

99456 $230.37** #

99460 $160.71

99461 $163.20

99462 $72.34

99463 $197.73

99464 $132.64

99465 $254.33

99468 $1,644.67

183

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 CPT Fee Schedule for Physicians1

Alaska Medical AssistanceA

99469 $688.66

99471 $1,468.16

99472 $704.31

99475 $977.45

99476 $601.51

99477 $610.35

99478 $243.43

99479 $221.23

99480 $207.81

99485 $132.46#

99486 $115.18#

99489 $67.06

184

Service Authorization Required

Coverage and rates are subject to change

1 CPT codes and descriptions only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Service is covered for recipients requiring disability examination only (Eligibility Code 15 or 25)

*

**

# Medical Justification Required

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 HCPC Fee Schedule for Physician Services

Alaska Medical AssistanceA

A4217 $1.53

A4261 $45.00

A4266 $28.00

A4267 $0.42

A4268 $2.55

A4465 $10.00

A4565 $16.00

A4570 $39.00

A4614 $23.78

A4635 $10.08

A5512 $24.22

A5513 $36.14

A9500 $78.00

A9505 $102.00

A9555 * $875.00

A9579 $5.81

A9585 Price By NDC

A9586 Price By NDC

D0145 $56.70

D1206 $28.00

E0100 $20.18

E0114 $47.66

E0783 * $7,033.47

E0785 * $405.93

E0860 $43.88

E0942 $25.76

E1810 $153.00

G0101 $61.78

G0117 $86.18

G0130 $52.71

G0130 26 $19.40

G0130 TC $33.31

G0166 $203.21

G0168 $157.48

G0202 $207.90

G0202 26 $61.67

G0202 TC $146.23

G0204 $253.61

G0204 26 $76.75

G0204 TC $176.86

G0206 $200.25

G0206 26 $61.67

G0206 TC $138.58

G0252 26* $133.05

G0275 $21.42

G0278 $21.42

G0288 $54.84

G0289 $145.95

G0364 $20.15

G0365 26 $21.53

J0120 Price By NDC

J0129 Price By NDC

J0131 Price By NDC

J0132 Price By NDC

J0133 * Price By NDC

J0135 Price By NDC

J0150 Price By NDC

J0152 $166.06

J0178 # Price By NDC

J0200 Price By NDC

J0205 Price By NDC

J0207 Price By NDC

Service Authorization Required*Coverage and rates are subject to change

185

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Medical Justification Required #

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 HCPC Fee Schedule for Physician Services

Alaska Medical AssistanceA

J0210 Price By NDC

J0215 Price By NDC

J0220 Price By NDC

J0221 Price By NDC

J0256 Price By NDC

J0257 * Price By NDC

J0278 Price By NDC

J0282 Price By NDC

J0285 Price By NDC

J0287 Price By NDC

J0288 Price By NDC

J0289 Price By NDC

J0290 Price By NDC

J0295 Price By NDC

J0300 Price By NDC

J0330 Price By NDC

J0348 Price By NDC

J0350 Price By NDC

J0360 Price By NDC

J0364 Price By NDC

J0380 Price By NDC

J0390 Price By NDC

J0395 Price By NDC

J0400 Price By NDC

J0456 Price By NDC

J0470 Price By NDC

J0475 Price By NDC

J0476 Price By NDC

J0485 Price By NDC

J0490 Price By NDC

J0520 Price By NDC

J0583 Price By NDC

J0585 * Price By NDC

J0587 * Price By NDC

J0592 Price By NDC

J0594 Price By NDC

J0595 Price By NDC

J0600 Price By NDC

J0630 Price By NDC

J0636 Price By NDC

J0637 Price By NDC

J0640 Price By NDC

J0670 Price By NDC

J0690 Price By NDC

J0692 Price By NDC

J0694 # Price By NDC

J0696 Price By NDC

J0697 Price By NDC

J0698 Price By NDC

J0702 Price By NDC

J0706 Price By NDC

J0710 Price By NDC

J0712 Price By NDC

J0713 Price By NDC

J0715 Price By NDC

J0716 Price By NDC

J0725 * Price By NDC

J0735 Price By NDC

J0740 Price By NDC

J0743 Price By NDC

J0744 Price By NDC

J0745 Price By NDC

Service Authorization Required*Coverage and rates are subject to change

186

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Medical Justification Required #

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 HCPC Fee Schedule for Physician Services

Alaska Medical AssistanceA

J0760 Price By NDC

J0770 Price By NDC

J0780 Price By NDC

J0800 Price By NDC

J0850 Price By NDC

J0878 Price By NDC

J0881 * Price By NDC

J0882 Price By NDC

J0885 * Price By NDC

J0886 Price By NDC

J0890 Price By NDC

J0894 Price By NDC

J0895 # Price By NDC

J0897 Price By NDC

J0945 Price By NDC

J1000 Price By NDC

J1020 Price By NDC

J1030 Price By NDC

J1040 Price By NDC

J1050 Price By NDC

J1070 Price By NDC

J1080 Price By NDC

J1094 Price By NDC

J1100 Price By NDC

J1120 Price By NDC

J1160 Price By NDC

J1162 Price By NDC

J1165 Price By NDC

J1170 Price By NDC

J1190 Price By NDC

J1200 Price By NDC

J1205 Price By NDC

J1212 $60.00

J1230 Price By NDC

J1245 Price By NDC

J1260 Price By NDC

J1265 Price By NDC

J1270 Price By NDC

J1300 Price By NDC

J1320 Price By NDC

J1330 Price By NDC

J1335 Price By NDC

J1364 Price By NDC

J1430 Price By NDC

J1435 Price By NDC

J1436 Price By NDC

J1440 Price By NDC

J1441 Price By NDC

J1450 Price By NDC

J1451 Price By NDC

J1452 Price By NDC

J1455 Price By NDC

J1457 Price By NDC

J1458 Price By NDC

J1460 Price By NDC

J1557 Price By NDC

J1561 Price By NDC

J1566 Price By NDC

J1570 Price By NDC

J1580 Price By NDC

J1590 $0.86

J1595 Price By NDC

Service Authorization Required*Coverage and rates are subject to change

187

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Medical Justification Required #

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 HCPC Fee Schedule for Physician Services

Alaska Medical AssistanceA

J1610 Price By NDC

J1620 Price By NDC

J1626 Price By NDC

J1630 Price By NDC

J1631 Price By NDC

J1640 Price By NDC

J1642 Price By NDC

J1644 Price By NDC

J1645 Price By NDC

J1650 Price By NDC

J1652 Price By NDC

J1655 Price By NDC

J1670 Price By NDC

J1700 Price By NDC

J1710 Price By NDC

J1720 Price By NDC

J1730 Price By NDC

J1741 Price By NDC

J1742 Price By NDC

J1744 Price By NDC

J1745 Price By NDC

J1756 Price By NDC

J1790 Price By NDC

J1800 Price By NDC

J1810 Price By NDC

J1815 Price By NDC

J1835 Price By NDC

J1840 Price By NDC

J1885 Price By NDC

J1890 Price By NDC

J1931 Price By NDC

J1940 Price By NDC

J1950 * Price By NDC

J1955 Price By NDC

J1956 Price By NDC

J1960 Price By NDC

J1980 Price By NDC

J1990 Price By NDC

J2001 Price By NDC

J2010 Price By NDC

J2020 Price By NDC

J2060 Price By NDC

J2150 Price By NDC

J2175 Price By NDC

J2180 Price By NDC

J2185 Price By NDC

J2210 Price By NDC

J2212 Price By NDC

J2248 Price By NDC

J2250 Price By NDC

J2260 Price By NDC

J2265 Price By NDC

J2270 Price By NDC

J2271 Price By NDC

J2275 Price By NDC

J2278 Price By NDC

J2280 Price By NDC

J2300 Price By NDC

J2310 Price By NDC

J2315 Price By NDC

J2320 Price By NDC

J2325 Price By NDC

Service Authorization Required*Coverage and rates are subject to change

188

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Medical Justification Required #

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 HCPC Fee Schedule for Physician Services

Alaska Medical AssistanceA

J2353 Price By NDC

J2354 Price By NDC

J2355 Price By NDC

J2357 Price By NDC

J2358 Price By NDC

J2360 Price By NDC

J2370 Price By NDC

J2400 Price By NDC

J2405 Price By NDC

J2410 Price By NDC

J2425 Price By NDC

J2426 Price By NDC

J2430 Price By NDC

J2469 Price By NDC

J2501 Price By NDC

J2503 Price By NDC

J2504 Price By NDC

J2505 Price By NDC

J2507 Price By NDC

J2510 Price By NDC

J2515 Price By NDC

J2540 Price By NDC

J2543 Price By NDC

J2545 # Price By NDC

J2550 Price By NDC

J2560 Price By NDC

J2590 Price By NDC

J2597 Price By NDC

J2675 * Price By NDC

J2690 Price By NDC

J2700 Price By NDC

J2720 Price By NDC

J2725 Price By NDC

J2730 Price By NDC

J2760 Price By NDC

J2765 Price By NDC

J2770 Price By NDC

J2778 * Price By NDC

J2780 Price By NDC

J2783 Price By NDC

J2788 Price By NDC

J2790 Price By NDC

J2792 Price By NDC

J2794 Price By NDC

J2795 Price By NDC

J2800 Price By NDC

J2820 Price By NDC

J2910 Price By NDC

J2916 Price By NDC

J2920 Price By NDC

J2930 Price By NDC

J2993 # Price By NDC

J2995 Price By NDC

J2997 # Price By NDC

J3000 Price By NDC

J3010 Price By NDC

J3030 Price By NDC

J3070 Price By NDC

J3105 Price By NDC

J3110 Price By NDC

J3120 Price By NDC

J3130 Price By NDC

Service Authorization Required*Coverage and rates are subject to change

189

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Medical Justification Required #

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 HCPC Fee Schedule for Physician Services

Alaska Medical AssistanceA

J3150 Price By NDC

J3230 Price By NDC

J3240 Price By NDC

J3243 Price By NDC

J3246 Price By NDC

J3250 Price By NDC

J3260 Price By NDC

J3265 Price By NDC

J3301 Price By NDC

J3302 Price By NDC

J3303 Price By NDC

J3305 Price By NDC

J3310 Price By NDC

J3315 Price By NDC

J3320 Price By NDC

J3350 Price By NDC

J3360 Price By NDC

J3364 Price By NDC

J3365 # Price By NDC

J3370 Price By NDC

J3396 Price By NDC

J3400 Price By NDC

J3410 Price By NDC

J3411 Price By NDC

J3415 Price By NDC

J3420 Price By NDC

J3430 Price By NDC

J3465 Price By NDC

J3470 Price By NDC

J3471 Price By NDC

J3472 Price By NDC

J3473 Price By NDC

J3475 Price By NDC

J3480 Price By NDC

J3485 Price By NDC

J3486 Price By NDC

J3487 Price By NDC

J3520 Price By NDC

J7030 Price By NDC

J7040 Price By NDC

J7042 Price By NDC

J7050 Price By NDC

J7060 Price By NDC

J7070 Price By NDC

J7120 Price By NDC

J7131 Price By NDC

J7178 Price By NDC

J7180 Price By NDC

J7183 Price By NDC

J7192 Price By NDC

J7196 Price By NDC

J7197 # Price By NDC

J7300 $681.72

J7302 Price By NDC

J7303 Price By NDC

J7308 Price By NDC

J7310 # Price By NDC

J7311 Price By NDC

J7315 Price By NDC

J7321 $137.75

J7323 $145.45

J7324 $248.92

Service Authorization Required*Coverage and rates are subject to change

190

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Medical Justification Required #

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 HCPC Fee Schedule for Physician Services

Alaska Medical AssistanceA

J7501 Price By NDC

J7504 Price By NDC

J7505 Price By NDC

J7511 Price By NDC

J7513 Price By NDC

J7525 Price By NDC

J7527 Price By NDC

J7644 Price By NDC

J7648 Price By NDC

J7674 Price By NDC

J7682 Price By NDC

J9000 Price By NDC

J9002 Price By NDC

J9015 Price By NDC

J9017 Price By NDC

J9019 Price By NDC

J9020 Price By NDC

J9025 Price By NDC

J9027 Price By NDC

J9031 Price By NDC

J9035 Price By NDC

J9040 Price By NDC

J9041 Price By NDC

J9042 Price By NDC

J9043 Price By NDC

J9045 Price By NDC

J9050 Price By NDC

J9055 Price By NDC

J9060 Price By NDC

J9065 Price By NDC

J9070 Price By NDC

J9098 Price By NDC

J9100 Price By NDC

J9120 Price By NDC

J9130 Price By NDC

J9150 Price By NDC

J9151 Price By NDC

J9160 Price By NDC

J9165 Price By NDC

J9178 Price By NDC

J9179 Price By NDC

J9181 Price By NDC

J9185 Price By NDC

J9190 Price By NDC

J9200 Price By NDC

J9201 Price By NDC

J9202 Price By NDC

J9206 Price By NDC

J9208 Price By NDC

J9209 Price By NDC

J9211 Price By NDC

J9212 Price By NDC

J9213 Price By NDC

J9214 Price By NDC

J9215 Price By NDC

J9216 Price By NDC

J9217 * Price By NDC

J9218 Price By NDC

J9226 * Price By NDC

J9228 Price By NDC

J9230 Price By NDC

J9250 Price By NDC

Service Authorization Required*Coverage and rates are subject to change

191

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Medical Justification Required #

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 HCPC Fee Schedule for Physician Services

Alaska Medical AssistanceA

J9260 Price By NDC

J9261 Price By NDC

J9263 Price By NDC

J9264 Price By NDC

J9265 Price By NDC

J9266 Price By NDC

J9268 Price By NDC

J9270 Price By NDC

J9280 Price By NDC

J9293 Price By NDC

J9300 Price By NDC

J9305 Price By NDC

J9310 Price By NDC

J9340 Price By NDC

J9355 Price By NDC

J9357 Price By NDC

J9360 Price By NDC

J9370 Price By NDC

J9390 Price By NDC

J9395 Price By NDC

J9600 Price By NDC

L0120 $36.92

L0130 $133.31

L0140 $42.06

L0150 $105.84

L0976 $119.62

L1000 $2,488.75

L1005 $2,514.93

L1020 $113.09

L1620 $125.93

L1640 $300.64

L1650 $196.57

L1810 $102.12

L1820 $118.97

L1830 $136.38

L1844 $1,415.61

L1845 $628.99

L1846 $1,159.68

L1902 $71.17

L1906 $195.10

L1930 $281.71

L1990 $572.68

L2035 $137.48

L2106 $899.37

L2108 $1,016.90

L2112 $433.97

L2114 $689.64

L2116 $859.20

L2132 $650.82

L2134 $1,021.02

L2180 $135.13

L3002 $126.90

L3003 $136.92

L3010 $136.92

L3030 $59.97

L3040 $36.97

L3060 $57.97

L3100 $33.97

L3170 $39.99

L3208 $14.00

L3260 $25.00

L3265 $14.00

Service Authorization Required*Coverage and rates are subject to change

192

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Medical Justification Required #

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 HCPC Fee Schedule for Physician Services

Alaska Medical AssistanceA

L3300 $40.97

L3332 $57.97

L3334 $29.98

L3350 $18.00

L3400 $31.99

L3430 $125.92

L3480 $48.96

L3485 $8.00

L3580 $50.96

L3590 $41.97

L3650 $64.72

L3660 $89.19

L3670 $132.03

L3740 # $1,515.43

L3900 $1,189.22

L3904 $3,910.50

L3906 $398.45

L3908 $77.07

L3917 $75.54

L3923 $27.82

L3960 $784.39

L3980 $362.15

L3982 $559.18

L3984 $358.99

L4210 $57.00

L4350 $127.03

L4360 $245.59

L4370 $133.49

L4386 $124.58

L6050 $2,091.59

P2038 $6.91

P7001 $17.93

P9019 $65.00

P9045 $85.50

P9046 $38.00

P9047 $85.50

P9048 $83.13

Q0091 $71.23

Q0111 $5.87

Q0112 $5.87

Q0113 $7.44

Q0114 $9.83

Q0115 $13.60

Q2004 Price By NDC

Q2009 Price By NDC

Q2017 Price By NDC

Q2035 $10.26

Q2036 $7.65

Q2037 $12.26

Q2038 $11.93

Q2039 $28.62

Q4005 $25.50

Q4006 $55.25

Q4007 $25.50

Q4008 $38.25

Q4009 $21.25

Q4010 $29.75

Q4011 $21.25

Q4012 $25.50

Q4013 $25.50

Q4014 $29.75

Q4015 $21.25

Service Authorization Required*Coverage and rates are subject to change

193

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Medical Justification Required #

Procedure Modifier Alaska Fee Procedure Modifier Alaska Fee

State Fiscal Year 2014 HCPC Fee Schedule for Physician Services

Alaska Medical AssistanceA

Q4016 $25.50

Q4017 $17.00

Q4018 $50.15

Q4019 $17.00

Q4020 $50.15

Q4021 $17.00

Q4022 $50.15

Q4023 $17.00

Q4024 $50.15

Q4029 $32.30

Q4030 $130.05

Q4031 $32.30

Q4032 $130.05

Q4033 $29.75

Q4034 $72.68

Q4035 $29.75

Q4036 $72.68

Q4037 $25.50

Q4038 $67.58

Q4039 $25.50

Q4040 $67.58

Q4041 $25.50

Q4042 $71.40

Q4043 $25.50

Q4044 $71.40

Q4045 $25.50

Q4046 $43.35

Q4047 $25.50

Q4048 $43.35

Q4049 $17.50

Q4051 $16.92

Q9957 $74.21

S0017 Price By NDC

S0020 Price By NDC

S0023 Price By NDC

S0028 Price By NDC

S0030 Price By NDC

S0032 Price By NDC

S0034 Price By NDC

S0039 Price By NDC

S0040 Price By NDC

S0073 Price By NDC

S0074 Price By NDC

S0077 Price By NDC

S0078 Price By NDC

S0080 Price By NDC

S0081 Price By NDC

S0157 Price By NDC

S0164 Price By NDC

S3620 $79.97

S3652 $48.60

S8450 $37.00

V2510 * $0.10

Service Authorization Required*Coverage and rates are subject to change

194

Effective 7/1/2013 thru 6/30/2014 Dates of Service7/26/2013

Medical Justification Required #