Ohio Bureau of Workers' Compensation ACTION: Original …codes.ohio.gov/pdf/oh/admin/2020/4123-6-37.3_ph_of_a_app2_20200228_1118.pdfThe BWC 2020 Ambulatory Surgical Center Fee Schedule

Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee Schedule

By Report (BR) The procedure or service is not typically covered and will not routinely be reimbursed. Many of the –BR codes are unclassified/unspecified generic codes and are currently assigned a dollar amount of $0.00. Authorization and payment of codes identified as -BR require an individual analysis by the MCO prior to submission to BWC. The MCO analysis shall include researching the appropriateness of the code in relation to the service or procedure. If the pricing is listed at $0.00, the MCO shall perform a cost comparison to determine a reasonable price. The MCO shall utilize the price to negotiate a final reimbursement rate. The provider must submit a report to the MCO for reimbursement consideration.

Bundled (BN) BN indicates that reimbursement for the covered procedure, service or supply is bundled into the payment rate for the associated surgical procedure. No separate payment for these services.

BWC-certified ASC arthroplasty center (AC) These procedures may be reimbursed to ASCs which have been BWC-certified as ASC arthroplasty centers to perform the procedure according to rule OAC 4123-6-02.22. Not reimbursable to ASCs without this certification.

BWC Rate Reimbursement rate for the ASC facility for CPT® and HCPCS Level II codes.

Never Covered (NC) The procedure or service is never covered.

Not Routinely Covered (NRC) The procedure or service is not covered unless application of the Miller criteria requires an exception. See: OAC 4123-6-16.2(B)(1) through (B)(3). Where coverage is required, the pricing is listed on the fee schedule. If the pricing is listed at $0.00, the MCO shall perform a cost comparison to determine a reasonable price. The MCO shall utilize the price to negotiate a final reimbursement rate.

The five character codes included in the Ohio Bureau of Workers’ Compensation (BWC) 2020 Ambulatory Surgical Center Fee Schedule are obtained from Current Procedural Terminology (CPT®), copyright 2019 by the American Medical Association (AMA) and from the Health Care Procedure Coding System (HCPCS) National Level II Medicare codes.

CPT® is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.

HCPCS are released by the Center for Medicare and Medicaid Services (CMS) as a listing of five character codes and descriptive terminology used for reporting supplies, materials and services by health care providers.

The responsibility for the content of the BWC 2020 Ambulatory Surgical Center Fee Schedule is with the State of Ohio Bureau of Workers’ Compensation and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the BWC 2020 Ambulatory Surgical Center Fee Schedule. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT®. Any use of CPT® outside of the BWC 2020 Ambulatory Surgical Center Fee Schedule should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT® codes and descriptive terms. Applicable FARS/DFARS apply.

For the purposes of this fee schedule services and/or supplies must be medically necessary for the treatment of the work related injury. The following definitions apply:

CPT only © 2019 American MedicalAssociation. All Rights Reserved.

2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Definitions - Page 1 of 243

ENACTEDAppendix

4123-6-37.3

ACTION: Original DATE: 02/28/2020 11:18 AM

APPENDIX p(187405) pa(329891) d: (753202) ra(568558) print date: 02/28/2020 11:20 AM

Ohio Bureau of Workers' Compensation2020 Ambulatory Surgical Center Fee ScheduleThe BWC 2020 Ambulatory Surgical Center Fee Schedule rates for all covered services other than orthopedic procedures (CPT® range 20100-29999), pain management (CPT® ranges 62280-62282, 62320-62327, 64400-64681) and device-intensive procedures (identified in Addendum AA of the Department of Health and Human Services, Centers for Medicare and Medicaid Services rule specified below with a payment indicator of J8) shall be calculated using the Medicare 2020 Ambulatory Surgical Center Prospective Payment System rates published in Addenda AA and BB of the Department of Health and Human Services, Centers for Medicare and Medicaid Services' “42 CFR Parts 405, 410, 412, 414, 416, 419, and 486 Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Revisions of Organ Procurement Organizations Conditions of Coverage; Prior Authorization Process and Requirements for Certain Covered Outpatient Department Services; Potential Changes to the Laboratory Date of Service Policy; Changes to Grandfathered Children’s Hospitals-Within-Hospitals; Notice of Closure of Two Teaching Hospitals and Opportunity to Apply for Available Slots" final rule, Federal Register, Volume 84, Number 218, Pages 61142-61492, November 12, 2019. and correction 85 Fed. Reg. 224 - 230 (2020).

The BWC 2020 Ambulatory Surgical Center Fee Schedule rates for covered orthopedic procedures (CPT® range 20100-29999) shall be calculated using the Medicare 2020 Ambulatory Surgical Center Prospective Payment System rates published in Addenda AA and BB of the Department of Health and Human Services, Centers for Medicare and Medicaid Services rule specified above, multiplied by a payment adjustment factor of 1.12.

The BWC 2020 Ambulatory Surgical Center Fee Schedule rates for covered pain management services (CPT® ranges 62280-62282, 62320-62327, 64400-64681) shall be calculated using the Medicare 2020 Ambulatory Surgical Center Prospective Payment System rates published in Addenda AA and BB of the Department of Health and Human Services, Centers for Medicare and Medicaid Services rule specified above, multiplied by a payment adjustment factor of 1.10. The BWC 2020 Ambulatory Surgical Center Fee Schedule rates for covered, device-intensive services (payment indicator J8, identified in Addendum AA of the Medicare 2020 Ambulatory Surgical Center Prospective Payment System rates) shall be calculated using the Medicare 2020 Ambulatory Surgical Center Prospective Payment System rates published in Addenda AA and BB of the Department of Health and Human Services, Centers for Medicare and Medicaid Services rule specified above, multiplied by a payment adjustment factor of 1.14.

Modifiers BWC accepts all industry-standard modifiers as published with CPT codes by the AMA and published by CMS with HCPCS level II codes in effect on the billed date of service. Unless otherwise specified in this document, modifiers will not affect the fee schedule amount calculated for a procedure.

Modifier 50 Bilateral procedure. Reimbursement is 150% of fee schedule amount.

Modifier 52 Reduced services. Reimbursement is 50% of fee schedule amount.

Modifier 73 Discontinued procedure prior to administration of anesthesia. Reimbursement is 50% of fee schedule amount.

Modifier 74 Discontinued procedure after administration of anesthesia. Reimbursement is 100% of fee schedule amount.

Modifier FB Item provided without cost to provider, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples). When this modifier is billed, BWC will subtract the no cost device offset amount from the final fee. Reimbursement when FB modifier is appended to the surgical procedure is listed in Column E of the fee tab.

Modifier FC Partial credit received for replaced device. When this modifier is billed, BWC will subtract the partial cost device offset amount from the final fee. Reimbursement when FC modifier is appended to the surgical procedure is listed in Column F of the fee tab.

ASC Reimbursement Levels 2020




Multiple Procedure Discounting Services eligible for multiple procedure discounting are labeled as “Y” in the column titled “Subject to Multiple Procedure Discounting” of this appendix. When multiple surgical procedures in the same operative session are subject to the multiple procedure discount, reimbursement shall be at 100% of the fee schedule amount for the highest paying surgical procedure on the bill, plus 50% of the applicable fee schedule amount(s) for the other ASC-covered surgical procedures subject to multiple procedure discounting.

Medically Unlikely Edits (MUE) An MUE for a HCPCS/CPT code reflects the number of units of service a provider will use in most circumstances when treating an injured worker. Medical documentation supporting the necessity of additional units of service must be provided to an MCO when additional units of services beyond the listed MUE are necessary.




HCPCS Code

Subject to Multiple

Procedure Discounting

Coverage Status

BWC 2020 final rate

BWC Rate after applying Modifier FB for full device credit

BWC Rate after applying Modifier

FC for partial device credit

10004 N BN10005 Y $75.0710006 N BN10007 Y $232.4210008 N BN10009 Y $308.2310010 N BN10011 Y $308.2310012 N BN10021 Y $59.1910030 Y $308.2310035 Y BN10036 N BN10040 N BN10060 Y $75.4310061 Y $115.4910080 Y NRC $165.2910081 Y NRC $208.6010120 Y $106.8310121 Y $576.3910140 Y $110.0710160 Y $83.3710180 Y $994.3411000 Y $34.2911001 N BN11010 Y $308.2311011 Y $308.2311012 Y $994.3411042 Y $161.4511043 Y $251.1411044 Y $576.3911045 N BN11046 N BN11047 N BN11055 N BN11056 N BN11057 Y $58.1011102 Y $75.7911103 N BN11104 Y $88.2911105 N BN11106 Y $116.2111107 N BN


2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 Fees - Page 4 of 243


HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




11200 N BN11201 N BN11300 N BN11301 N BN11302 N BN11303 N BN11305 N BN11306 N BN11307 Y $88.2911308 N BN11310 Y $86.6211311 Y $88.2911312 Y $111.1611313 Y $123.0711400 Y NRC $92.3911401 Y NRC $105.3811402 Y NRC $115.1311403 Y NRC $124.8711404 Y NRC $576.3911406 Y NRC $576.3911420 Y NRC $88.7811421 Y NRC $104.3011422 Y NRC $115.4911423 Y NRC $125.2311424 Y NRC $576.3911426 Y NRC $994.3411440 Y NRC $101.4111441 Y NRC $114.0411442 Y NRC $123.4311443 Y NRC $136.7811444 Y NRC $576.3911446 Y NRC $994.3411450 Y NRC $994.3411451 Y NRC $994.3411462 Y NRC $994.3411463 Y NRC $994.3411470 Y NRC $994.3411471 Y NRC $994.3411600 Y $136.0611601 Y $151.5811602 Y $161.4511603 Y $175.4011604 Y $308.23




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




11606 Y $576.3911620 Y $136.4211621 Y $151.9411622 Y $164.9311623 Y $181.1711624 Y $576.3911626 Y $994.3411640 Y $140.3911641 Y $156.6311642 Y $171.4311643 Y $187.6711644 Y $576.3911646 Y $994.3411719 N BN11720 N BN11721 N BN11730 N BN11732 N BN11740 N BN11750 Y $99.2511755 Y $76.8711760 Y $251.1411762 Y $186.9411765 N BN11770 Y NRC $994.3411771 Y NRC $994.3411772 Y NRC $994.3411900 N BN11901 N BN11920 Y NRC $124.1511921 Y NRC $137.5011922 N BN11950 Y NRC $46.5611951 Y NRC $59.9111952 Y NRC $77.2311954 Y NRC $85.5311960 Y $1,504.3811970 Y $2,803.3611971 N $994.3411976 N NRC $75.4311980 N BN11981 N BN11982 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




11983 N BN12001 N BN12002 N BN12004 N BN12005 N $161.4512006 N $161.4512007 Y $88.2912011 N BN12013 N BN12014 N BN12015 N $88.2912016 N $161.4512017 N $161.4512018 N $88.2912020 Y $251.1412021 Y $161.4512031 Y $161.4512032 Y $161.4512034 Y $161.4512035 Y $161.4512036 Y $251.1412037 Y $819.9512041 N $161.4512042 Y $161.4512044 Y $251.1412045 Y $251.1412046 Y $161.4512047 Y $819.9512051 Y $161.4512052 Y $161.4512053 Y $161.4512054 N $161.4512055 Y $161.4512056 N $161.4512057 Y $161.4513100 Y $251.1413101 Y $251.1413102 N BN13120 Y $251.1413121 Y $251.1413122 N BN13131 Y $161.4513132 Y $251.14




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




13133 N BN13151 Y $251.1413152 Y $251.1413153 N BN13160 Y $819.9514000 Y $819.9514001 Y $819.9514020 Y $819.9514021 Y $819.9514040 Y $819.9514041 Y $819.9514060 Y $819.9514061 Y $819.9514301 Y $1,504.3814302 N BN14350 Y $819.9515002 Y $819.9515003 N BN15004 Y $251.1415005 N BN15040 Y $819.9515050 Y $251.1415100 Y $819.9515101 N BN15110 Y $819.9515111 N BN15115 Y $819.9515116 N BN15120 Y $1,504.3815121 N BN15130 Y $819.9515131 N BN15135 Y $1,504.3815136 N BN15150 Y $819.9515151 N BN15152 N BN15155 Y $1,504.3815156 N BN15157 N BN15200 Y $819.9515201 N BN15220 Y $819.95




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




15221 N BN15240 Y $819.9515241 N BN15260 Y $819.9515261 N BN15271 Y $819.9515272 N BN15273 Y $1,504.3815274 N BN15275 Y $819.9515276 N BN15277 Y $819.9515278 N BN15570 Y $819.9515572 Y $1,504.3815574 Y $819.9515576 Y $819.9515600 Y $1,504.3815610 Y $819.9515620 Y $819.9515630 Y $819.9515650 Y $819.9515730 Y $1,504.3815731 Y $1,504.3815733 Y $1,504.3815734 Y $1,504.3815736 Y $819.9515738 Y $1,504.3815740 Y $819.9515750 Y $1,504.3815760 Y $819.9515769 Y NRC $1,504.3815770 Y $1,504.3815771 Y NRC $1,504.3815773 Y NRC $819.9515775 Y NRC $161.4515776 Y NRC $161.4515777 N BN15780 Y NRC $565.8815781 Y NRC $308.2315782 Y NRC $378.5815783 Y NRC $161.4515786 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




15787 N BN15788 N BN15789 Y NRC $251.1415792 N BN15793 N BN15819 Y NRC $819.9515820 Y NRC $819.9515821 Y NRC $819.9515822 Y NRC $819.9515823 Y NRC $819.9515838 Y NRC $994.3415839 Y NRC $994.3415840 Y $1,504.3815841 Y $1,504.3815842 Y $819.9515845 Y $1,504.3815847 N BN15850 Y NRC $251.1415851 Y NRC $71.4615852 N BN15860 N BN15933 Y $994.3415934 Y $1,504.3815935 Y $1,504.3815936 Y $819.9515937 Y $819.9515940 Y $994.3415941 Y $994.3415944 Y $1,504.3815945 Y $819.9515946 Y $819.9515950 Y $576.3915951 Y $994.3415952 Y $819.9515953 Y $1,504.3815956 Y $819.9515958 Y $1,504.3816000 N BN16020 N BN16025 Y $88.2916030 Y $161.4516035 Y $161.4517000 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




17003 N BN17004 Y $107.9117106 Y $161.4517107 Y $251.1417108 Y $353.3217110 N BN17111 N BN17250 N BN17260 N BN17261 N BN17262 N BN17263 N BN17264 Y $132.0917266 Y $145.4417270 Y $88.2917271 Y $88.2917272 N BN17273 Y $130.2817274 Y $146.8817276 Y $161.4517280 N BN17281 Y $112.9617282 Y $127.0417283 Y $143.6417284 Y $158.4317286 Y $188.7517311 Y $251.1417312 N BN17313 Y $251.1417314 N BN17315 N BN17340 N BN17360 N BN19020 Y $576.3919030 N BN19081 Y $576.3919082 N BN19083 Y $576.3919084 N BN19085 Y $576.3919086 N BN19100 Y $576.3919101 Y $1,118.44




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




19105 Y $1,118.4419110 Y $1,118.4419112 Y $1,118.4419120 Y $1,118.4419125 Y $1,118.4419126 N BN19281 N BN19282 N BN19283 N BN19284 N BN19285 N BN19286 N BN19287 N BN19288 N BN19294 N BN19296 Y $4,760.47 $1,735.72 $3,248.0919297 N BN19298 Y $2,193.2719300 Y NRC $1,118.4419301 Y $1,118.4419302 Y $2,193.2719303 Y $2,193.2719316 Y NRC $2,193.2719318 Y NRC $2,193.2719324 Y NRC $2,679.4719325 Y NRC $2,679.4719328 N NRC $1,118.4419330 N NRC $1,118.4419340 Y NRC $2,193.2719342 Y NRC $2,679.4719350 Y NRC $1,118.4419355 Y NRC $1,118.4419357 Y NRC $5,339.42 $2,937.05 $4,138.2319366 Y NRC $2,193.2719370 Y NRC $1,118.4419371 Y NRC $1,118.4419380 Y NRC $2,193.2719396 Y NRC $1,118.4420103 Y $345.2220150 Y $1,440.6120200 Y $645.5620205 Y $1,113.6620206 Y $645.56




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




20220 Y $645.5620225 Y $645.5620240 Y $1,113.6620245 Y $1,113.6620250 Y $1,440.6120251 Y $3,139.7620500 Y $74.3720501 N BN20520 Y $155.6120525 Y $1,113.6620526 Y $46.4820527 Y $50.5220550 Y $29.1020551 Y $30.7220552 Y $33.9620553 Y $39.6120555 Y $1,440.6120600 Y $27.8920604 Y $48.1020605 Y $29.1020606 Y $52.1520610 Y $34.7620611 Y $58.6120612 Y $39.2120615 Y $181.4820650 Y $1,440.6120662 Y $798.5620663 Y $1,440.6120665 N $205.7720670 N $645.5620680 N $1,113.6620690 Y $4,282.19 $2,355.91 $3,319.0520692 Y $9,277.61 $4,403.82 $6,840.7120693 Y $3,139.7620694 N $798.5620696 Y $13,532.96 $4,966.25 $9,249.6020697 Y $798.5620822 Y $798.5620900 Y $3,139.7620902 Y $3,139.7620910 Y $281.2820912 Y $1,684.9120920 Y $918.34




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




20922 Y $918.3420924 Y $3,139.7620930 N BN20931 N BN20932 N BN20933 N BN20934 N BN20936 N BN20937 N BN20938 N BN20939 N BN20950 Y $345.2220972 Y $3,139.7620973 Y $3,139.7620975 N BN20979 N BN20982 Y $3,139.7620983 Y $4,327.57 $2,320.84 $3,324.2020985 N BN21010 Y $1,181.6721011 Y $276.8821012 Y $645.5621013 Y $358.1221014 Y $1,113.6621015 Y $1,113.6621016 Y $1,113.6621025 Y $2,516.1421026 Y $2,516.1421029 Y NRC $1,181.6721030 Y NRC $351.6621031 Y NRC $303.9621032 Y NRC $302.3421034 Y $2,516.1421040 Y NRC $1,181.6721044 Y $2,516.1421046 Y NRC $2,516.1421047 Y NRC $2,516.1421048 Y NRC $2,516.1421050 Y $2,516.1421060 Y $2,516.1421070 Y NRC $2,516.1421073 Y NRC $288.2021076 Y $457.15




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




21077 Y $1,109.5421079 Y $782.9521080 Y $913.9121081 Y $847.2121082 Y $799.9221083 Y $788.6021084 Y $884.4021085 Y $115.2421086 Y $834.2821087 Y $834.2821088 Y $1,181.6721100 Y $2,516.1421110 N NRC $600.9921116 N BN21120 Y NRC $2,516.1421121 Y NRC $1,181.6721122 Y NRC $2,516.1421123 Y NRC $1,181.6721125 Y NRC $2,516.1421127 Y NRC $2,516.1421137 Y NRC $1,181.6721138 Y NRC $2,516.1421139 Y NRC $2,516.1421150 Y NRC $2,516.1421181 Y NRC $2,516.1421198 Y NRC $2,516.1421199 Y NRC $2,516.1421206 Y NRC $2,516.1421208 Y $3,359.20 $1,944.01 $2,651.6021209 Y NRC $2,516.1421210 Y $2,516.1421215 Y $2,516.1421230 Y $2,516.1421235 Y $2,516.1421240 Y $2,516.1421242 Y $2,516.1421243 Y $13,803.88 $4,756.79 $9,280.3321244 Y $2,516.1421245 Y $2,516.1421246 Y $2,516.1421248 Y $2,516.1421249 Y $2,516.1421260 Y $2,516.14




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




21267 Y $2,516.1421270 Y $2,516.1421275 Y $2,516.1421280 Y NRC $1,181.6721282 Y NRC $1,181.6721295 Y NRC $600.9921296 Y NRC $1,181.6721310 Y $122.0421315 Y $600.9921320 Y $1,181.6721325 Y $1,181.6721330 Y $2,516.1421335 Y $1,181.6721336 Y $1,440.6121337 Y $1,181.6721338 Y $3,739.09 $1,650.32 $2,694.7021339 Y $2,516.1421340 Y $1,181.6721345 Y $600.9921355 Y $1,181.6721356 Y $2,516.1421360 Y $2,516.1421390 Y $2,516.1421400 Y $249.9721401 Y $600.9921406 Y $2,516.1421407 Y $2,516.1421421 Y $1,181.6721440 Y $571.5521445 Y $2,516.1421450 Y $249.9721451 Y $600.9921452 Y $2,516.1421453 Y $2,516.1421454 Y $2,516.1421461 Y $3,595.15 $1,761.58 $2,678.3621462 Y $3,520.94 $1,818.98 $2,669.9621465 Y $2,516.1421480 Y $122.0421485 Y $600.9921490 Y $1,181.6721497 Y $600.9921501 Y $1,113.66




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




21502 Y $1,440.6121550 Y $645.5621552 Y $1,113.6621554 Y $1,113.6621555 Y $645.5621556 Y $1,113.6621557 Y $1,113.6621558 Y $1,113.6621600 Y NRC $3,139.7621610 Y NRC $1,440.6121685 Y NRC $2,516.1421700 Y NRC $3,139.7621720 Y NRC $1,440.6121725 Y NRC $345.2221820 Y $122.0421920 Y $199.2721925 Y $645.5621930 Y $645.5621931 Y $645.5621932 Y $1,113.6621933 Y $1,113.6621935 Y $1,113.6621936 Y $1,113.6622102 Y $3,139.7622103 N BN22310 Y $122.0422315 Y $1,440.6122505 Y $798.5622510 Y $1,440.6122511 Y $1,440.6122512 N BN22513 Y $3,139.7622514 Y $3,139.7622515 N BN22551 Y $9,598.49 $4,155.72 $6,877.1022552 N BN22554 Y $9,606.80 $4,149.29 $6,878.0422585 N BN22612 Y $9,812.64 $3,990.16 $6,901.4022614 N BN22840 N BN22842 N BN22845 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




22853 N BN22854 N BN22856 Y $13,459.70 $5,022.90 $9,241.3022858 N BN22859 N BN22867 Y $13,959.79 $4,636.26 $9,298.0222868 N BN22869 Y $11,257.29 $2,873.24 $7,065.2622870 N BN22900 Y $1,113.6622901 Y $1,113.6622902 Y $645.5622903 Y $1,113.6622904 Y $1,113.6622905 Y $1,113.6623000 Y $1,113.6623020 Y $1,440.6123030 Y $1,113.6623031 Y $1,113.6623035 Y $798.5623040 Y $1,440.6123044 Y $1,440.6123065 Y $152.3923066 Y $1,113.6623071 Y $645.5623073 Y $1,113.6623075 Y $645.5623076 Y $1,113.6623077 Y $1,113.6623078 Y $1,113.6623100 Y $1,440.6123101 Y $1,440.6123105 Y $3,139.7623106 Y $1,440.6123107 Y $3,139.7623120 Y $1,440.6123125 Y $1,440.6123130 Y $1,440.6123140 Y $1,440.6123145 Y $1,440.6123146 Y $3,139.7623150 Y $1,440.6123155 Y $3,139.76




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




23156 Y $4,950.23 $1,839.44 $3,394.8323170 Y $1,440.6123172 Y $1,440.6123174 Y $3,139.7623180 Y $3,139.7623182 Y $3,139.7623184 Y $3,139.7623190 Y $1,440.6123195 Y $3,139.7623330 Y $345.2223333 Y $1,113.6623334 Y $1,113.6623350 N BN23395 Y $3,139.7623397 Y $3,139.7623400 Y $3,139.7623405 Y $3,139.7623406 Y $4,581.33 $2,124.65 $3,352.9923410 Y $3,139.7623412 Y $3,139.7623415 Y $3,139.7623420 Y $3,139.7623430 Y $3,139.7623440 Y $3,139.7623450 Y $3,139.7623455 Y $3,139.7623460 Y $3,139.7623462 Y $3,139.7623465 Y $3,139.7623466 Y $3,139.7623470 Y AC $9,449.54 $4,269.72 $6,859.6323472 Y AC $9,449.54 $4,269.72 $6,859.6323473 Y AC $9,449.54 $4,269.72 $6,859.6323480 Y $3,139.7623485 Y $8,957.99 $4,650.92 $6,804.4523490 Y $3,139.7623491 Y $9,125.47 $4,521.44 $6,823.4523500 Y $122.0423505 Y $798.5623515 Y $4,385.45 $2,276.08 $3,330.7623520 Y $798.5623525 Y $122.0423530 Y $3,139.76




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




23532 Y $3,139.7623540 Y $122.0423545 Y $122.0423550 Y $3,139.7623552 Y $4,357.30 $2,297.86 $3,327.5823570 Y $122.0423575 Y $798.5623585 Y $3,139.7623600 Y $122.0423605 Y $798.5623615 Y $9,450.20 $4,270.38 $6,860.2923616 Y $13,304.64 $5,142.77 $9,223.7023620 Y $122.0423625 Y $798.5623630 Y $4,225.56 $2,399.70 $3,312.6323650 Y $122.0423655 Y $798.5623660 Y $3,139.7623665 Y $798.5623670 Y $3,139.7623675 Y $798.5623680 Y $9,544.16 $4,197.73 $6,870.9423700 Y $798.5623800 Y $3,139.7623802 Y $6,414.3923921 Y $918.3423930 Y $1,113.6623931 Y $645.5623935 Y $1,440.6124000 Y $1,440.6124006 Y $1,440.6124065 Y $202.1024066 Y $1,113.6624071 Y $1,113.6624073 Y $1,113.6624075 Y $645.5624076 Y $1,113.6624077 Y $1,113.6624079 Y $1,113.6624100 Y $1,440.6124101 Y $1,440.6124102 Y $1,440.6124105 Y $1,440.61




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




24110 Y $1,440.6124115 Y $3,139.7624116 Y $3,139.7624120 Y $1,440.6124125 Y $1,440.6124126 Y $4,869.82 $1,901.61 $3,385.7124130 Y $1,440.6124134 Y $3,139.7624136 Y $1,440.6124138 Y $3,139.7624140 Y $1,440.6124145 Y $3,139.7624147 Y $1,440.6124149 Y $3,139.7624152 Y $3,139.7624155 Y $1,440.6124160 N $1,440.6124164 N $1,440.6124200 Y $164.9224201 Y $1,113.6624220 N BN24300 Y $798.5624301 Y $3,139.7624305 Y $1,440.6124310 Y $1,440.6124320 Y $3,139.7624330 Y $3,139.7624331 Y $3,139.7624332 Y $1,440.6124340 Y $3,139.7624341 Y $3,139.7624342 Y $3,139.7624343 Y $1,440.6124344 Y $3,139.7624345 Y $3,139.7624346 Y $6,414.3924357 Y $1,440.6124358 Y $1,440.6124359 Y $1,440.6124360 Y $3,139.7624361 Y $13,924.02 $4,663.93 $9,293.9724362 Y $6,414.3924363 Y $13,913.79 $4,671.83 $9,292.81




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




24365 Y $9,788.99 $4,008.45 $6,898.7224366 Y $10,407.12 $3,530.55 $6,968.8324370 Y $9,613.84 $4,143.86 $6,878.8524371 Y $12,469.73 $5,788.27 $9,129.0024400 Y $3,139.7624410 Y $6,414.3924420 Y $3,139.7624430 Y $9,147.84 $4,504.14 $6,825.9924435 Y $9,213.67 $4,453.23 $6,833.4524470 Y $1,440.6124495 Y $3,139.7624498 Y $9,020.64 $4,602.49 $6,811.5624500 Y $122.0424505 Y $798.5624515 Y $8,910.05 $4,687.99 $6,799.0224516 Y $9,037.25 $4,589.64 $6,813.4424530 Y $122.0424535 Y $798.5624538 Y $3,139.7624545 Y $9,354.32 $4,344.52 $6,849.4224546 Y $12,504.67 $5,761.27 $9,132.9724560 Y $122.0424565 Y $798.5624566 Y $798.5624575 Y $8,450.44 $5,043.32 $6,746.8824576 Y $122.0424577 Y $798.5624579 Y $8,594.90 $4,931.63 $6,763.2624582 Y $3,139.7624586 Y $6,414.3924587 Y $9,416.96 $4,296.08 $6,856.5224600 Y $122.0424605 Y $798.5624615 Y $3,139.7624620 Y $798.5624635 Y $4,460.24 $2,218.27 $3,339.2524640 Y NRC $62.6524650 Y $122.0424655 Y $798.5624665 Y $3,139.7624666 Y $10,354.06 $3,571.56 $6,962.8124670 Y $122.0424675 Y $798.56




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




24685 Y $4,198.96 $2,420.26 $3,309.6124800 Y $3,139.7624802 Y $6,414.3924925 Y $1,440.6125000 Y $798.5625001 Y $1,440.6125020 Y $798.5625023 Y $1,440.6125024 Y $1,440.6125025 Y $798.5625028 Y $1,440.6125031 Y $798.5625035 Y $3,139.7625040 Y $1,440.6125065 Y $204.5225066 Y $1,113.6625071 Y $645.5625073 Y $1,113.6625075 Y $645.5625076 Y $645.5625077 Y $1,113.6625078 Y $1,113.6625085 Y $1,440.6125100 Y $1,440.6125101 Y $1,440.6125105 Y $1,440.6125107 Y $1,440.6125109 Y $1,440.6125110 Y $798.5625111 Y $798.5625112 Y $798.5625115 Y $798.5625116 Y $1,440.6125118 Y $798.5625119 Y $1,440.6125120 Y $1,440.6125125 Y $798.5625126 Y $1,440.6125130 Y $1,440.6125135 Y $3,139.7625136 Y $4,234.01 $2,393.17 $3,313.5925145 Y $1,440.6125150 Y $1,440.61




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




25151 Y $1,440.6125210 Y $1,440.6125215 Y $1,440.6125230 Y $1,440.6125240 Y $1,440.6125246 N BN25248 Y $798.5625250 N $798.5625251 N $1,440.6125259 Y $798.5625260 Y $1,440.6125263 Y $3,139.7625265 Y $1,440.6125270 Y $1,440.6125272 Y $1,440.6125274 Y $1,440.6125275 Y $1,440.6125280 Y $1,440.6125290 Y $1,440.6125295 Y $1,440.6125300 Y $1,440.6125301 Y $1,440.6125310 Y $1,440.6125312 Y $1,440.6125315 Y $3,139.7625316 Y $3,139.7625320 Y $3,139.7625332 Y $1,440.6125335 Y $1,440.6125337 Y $3,139.7625350 Y $4,950.85 $1,838.95 $3,394.9025355 Y $1,440.6125360 Y $3,139.7625365 Y $6,414.3925370 Y $1,440.6125375 Y $1,440.6125390 Y $4,499.66 $2,187.79 $3,343.7225391 Y $9,166.38 $4,489.81 $6,828.0925392 Y $3,139.7625393 Y $3,139.7625394 Y $1,440.6125400 Y $4,508.11 $2,181.26 $3,344.6825405 Y $4,457.73 $2,220.20 $3,338.96




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




25415 Y $4,612.30 $2,100.70 $3,356.5025420 Y $3,139.7625425 Y $3,139.7625426 Y $1,440.6125430 Y $1,440.6125431 Y $3,139.7625440 Y $3,139.7625441 Y $10,645.55 $3,346.20 $6,995.8725442 Y $14,567.23 $4,166.63 $9,366.9325443 Y $4,455.85 $2,221.65 $3,338.7525444 Y $10,733.12 $3,278.49 $7,005.8025445 Y $4,502.78 $2,185.36 $3,344.0725446 Y $14,652.43 $4,100.76 $9,376.5925447 Y $1,440.6125449 Y $3,139.7625450 Y NRC $1,440.6125455 Y NRC $1,440.6125490 Y NRC $3,139.7625491 Y NRC $6,414.3925492 Y NRC $1,440.6125500 Y $122.0425505 Y $798.5625515 Y $4,289.71 $2,350.11 $3,319.9125520 Y $798.5625525 Y $3,139.7625526 Y $4,248.10 $2,382.29 $3,315.1925530 Y $122.0425535 Y $122.0425545 Y $4,207.73 $2,413.49 $3,310.6125560 Y $122.0425565 Y $798.5625574 Y $4,525.63 $2,167.71 $3,346.6725575 Y $4,400.16 $2,264.72 $3,332.4425600 Y $122.0425605 Y $798.5625606 Y $1,440.6125607 Y $4,602.29 $2,108.44 $3,355.3625608 Y $4,582.58 $2,123.68 $3,353.1325609 Y $4,601.35 $2,109.17 $3,355.2625622 Y $122.0425624 Y $798.5625628 Y $3,139.7625630 Y $122.04




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




25635 Y $798.5625645 Y $1,440.6125650 Y $122.0425651 Y $1,440.6125652 Y $3,139.7625660 Y $122.0425670 Y $3,139.7625671 Y $1,440.6125675 Y $122.0425676 Y $3,139.7625680 Y $122.0425685 Y $3,139.7625690 Y $798.5625695 Y $3,139.7625800 Y $4,647.35 $2,073.61 $3,360.4825805 Y $4,621.07 $2,093.93 $3,357.5025810 Y $9,066.66 $4,566.91 $6,816.7825820 Y $4,344.15 $2,308.02 $3,326.0825825 Y $4,319.12 $2,327.37 $3,323.2425830 Y $4,235.26 $2,392.20 $3,313.7325907 Y $1,440.6125922 Y $798.5625929 Y $918.3425931 Y $1,440.6126010 Y $98.8826011 Y $645.5626020 Y $1,440.6126025 Y $1,440.6126030 Y $1,440.6126034 Y $798.5626035 Y $1,440.6126037 Y $1,440.6126040 Y $798.5626045 Y $1,440.6126055 Y $798.5626060 Y $798.5626070 Y $798.5626075 Y $1,440.6126080 Y $798.5626100 Y $1,440.6126105 Y $1,440.6126110 Y $798.5626111 Y $645.56




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




26113 Y $645.5626115 Y $645.5626116 Y $645.5626117 Y $1,113.6626118 Y $1,113.6626121 Y $1,440.6126123 Y $1,440.6126125 N BN26130 Y $1,440.6126135 Y $1,440.6126140 Y $798.5626145 Y $798.5626160 Y $798.5626170 Y $798.5626180 Y $798.5626185 Y $798.5626200 Y $798.5626205 Y $3,139.7626210 Y $798.5626215 Y $1,440.6126230 Y $1,440.6126235 Y $798.5626236 Y $798.5626250 Y $1,440.6126260 Y $1,440.6126262 Y $798.5626320 N $645.5626340 Y $798.5626341 Y $80.0426350 Y $1,440.6126352 Y $3,139.7626356 Y $1,440.6126357 Y $1,440.6126358 Y $3,139.7626370 Y $1,440.6126372 Y $3,139.7626373 Y $1,440.6126390 Y $4,240.58 $2,388.09 $3,314.3326392 Y $3,139.7626410 Y $798.5626412 Y $1,440.6126415 Y $1,440.6126416 Y $1,440.61




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




26418 Y $798.5626420 Y $1,440.6126426 Y $1,440.6126428 Y $1,440.6126432 Y $798.5626433 Y $1,440.6126434 Y $1,440.6126437 Y $1,440.6126440 Y $798.5626442 Y $1,440.6126445 Y $1,440.6126449 Y $1,440.6126450 Y $1,440.6126455 Y $798.5626460 Y $798.5626471 Y $1,440.6126474 Y $798.5626476 Y $1,440.6126477 Y $1,440.6126478 Y $1,440.6126479 Y $1,440.6126480 Y $1,440.6126483 Y $1,440.6126485 Y $1,440.6126489 Y $1,440.6126490 Y $1,440.6126492 Y $1,440.6126494 Y $1,440.6126496 Y $1,440.6126497 Y $1,440.6126498 Y $1,440.6126499 Y $1,440.6126500 Y $3,139.7626502 Y $1,440.6126508 Y $1,440.6126510 Y $1,440.6126516 Y $1,440.6126517 Y $1,440.6126518 Y $3,139.7626520 Y $1,440.6126525 Y $798.5626530 Y $3,139.7626531 Y $4,584.15 $2,122.48 $3,353.31




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




26535 Y $1,440.6126536 Y $4,241.84 $2,387.13 $3,314.4826540 Y $1,440.6126541 Y $1,440.6126542 Y $1,440.6126545 Y $1,440.6126546 Y $3,139.7626548 Y $1,440.6126550 Y $1,440.6126555 Y $3,139.7626560 Y $798.5626561 Y $1,440.6126562 Y $1,440.6126565 Y $1,440.6126567 Y $1,440.6126568 Y $3,139.7626580 Y NRC $1,440.6126587 Y NRC $1,440.6126590 Y NRC $798.5626591 Y $1,440.6126593 Y $1,440.6126596 Y $1,440.6126600 Y $122.0426605 Y $122.0426607 Y $1,440.6126608 Y $1,440.6126615 Y $1,440.6126641 Y $122.0426645 Y $798.5626650 Y $1,440.6126665 Y $1,440.6126670 Y $122.0426675 Y $798.5626676 Y $1,440.6126685 Y $1,440.6126686 Y $1,440.6126700 Y $122.0426705 Y $798.5626706 Y $1,440.6126715 Y $1,440.6126720 Y $122.0426725 Y $122.0426727 Y $1,440.61




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




26735 Y $1,440.6126740 Y $122.0426742 Y $798.5626746 Y $1,440.6126750 Y $122.0426755 Y $122.0426756 Y $1,440.6126765 Y $1,440.6126770 Y $122.0426775 Y $130.0526776 Y $1,440.6126785 Y $1,440.6126820 Y $4,382.64 $2,278.26 $3,330.4526841 Y $3,139.7626842 Y $3,139.7626843 Y $3,139.7626844 Y $3,139.7626850 Y $3,139.7626852 Y $3,139.7626860 Y $1,440.6126861 N BN26862 Y $1,440.6126863 N BN26910 Y $1,440.6126951 Y $1,440.6126952 Y $1,440.6126990 Y $1,440.6126991 Y $798.5627000 Y $798.5627001 Y $1,440.6127003 Y $3,139.7627033 Y $3,139.7627035 Y $1,440.6127040 Y $645.5627041 Y $645.5627043 Y $1,113.6627045 Y $1,113.6627047 Y $1,113.6627048 Y $1,113.6627049 Y $1,113.6627050 Y $798.5627052 Y $798.5627059 Y $1,113.66




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




27060 Y $3,139.7627062 Y $1,440.6127065 Y $3,139.7627066 Y $1,440.6127067 Y $3,139.7627080 Y $1,440.6127086 Y $645.5627087 Y $1,440.6127093 N BN27095 N BN27097 Y $1,440.6127098 Y $1,440.6127100 Y $3,139.7627105 Y $1,440.6127110 Y $3,139.7627111 Y $1,440.6127125 Y AC $8,818.43 $3,273.89 $6,046.1627130 Y AC $8,818.43 $3,273.89 $6,046.1627132 Y AC $8,818.43 $3,273.89 $6,046.1627197 Y $122.0427198 Y $122.0427200 Y $122.0427202 Y $1,440.6127220 Y $122.0427230 Y $122.0427238 Y $798.5627246 Y $122.0427250 Y $122.0427252 Y $798.5627256 Y $122.0427257 Y $798.5627265 Y $122.0427266 Y $798.5627267 Y $1,440.6127275 Y $798.5627279 Y $14,799.81 $3,986.81 $9,393.3127301 Y $1,113.6627305 Y $1,440.6127306 Y $1,440.6127307 Y $1,440.6127310 Y $1,440.6127323 Y $645.5627324 Y $1,113.66




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




27325 Y $892.4027326 Y $892.4027327 Y $645.5627328 Y $1,113.6627329 Y $1,113.6627330 Y $1,440.6127331 Y $1,440.6127332 Y $1,440.6127333 Y $1,440.6127334 Y $1,440.6127335 Y $3,139.7627337 Y $1,113.6627339 Y $1,113.6627340 Y $1,440.6127345 Y $1,440.6127347 Y $1,440.6127350 Y $3,139.7627355 Y $1,440.6127356 Y $6,414.3927357 Y $3,139.7627358 N BN27360 Y $1,440.6127364 Y $1,113.6627369 N BN27372 Y $1,113.6627380 Y $3,139.7627381 Y $3,139.7627385 Y $3,139.7627386 Y $3,139.7627390 Y $1,440.6127391 Y $1,440.6127392 Y $1,440.6127393 Y $3,139.7627394 Y $3,139.7627395 Y $1,440.6127396 Y $3,139.7627397 Y $3,139.7627400 Y $3,139.7627403 Y $4,222.13 $2,402.37 $3,312.2527405 Y $3,139.7627407 Y $3,139.7627409 Y $3,139.7627415 Y $10,728.02 $3,282.46 $7,005.24




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




27416 Y $3,139.7627418 Y $3,139.7627420 Y $3,139.7627422 Y $3,139.7627424 Y $3,139.7627425 Y $1,440.6127427 Y $4,139.20 $2,466.46 $3,302.8327428 Y $8,797.54 $4,774.96 $6,786.2527429 Y $11,529.61 $2,662.72 $7,096.1627430 Y $3,139.7627435 Y $1,440.6127437 Y $3,139.7627438 Y $8,967.58 $4,643.51 $6,805.5427440 Y $9,643.24 $4,121.13 $6,882.1827441 Y $6,414.3927442 Y $9,661.77 $4,106.79 $6,884.2827443 Y $9,423.99 $4,290.64 $6,857.3127445 Y AC $9,814.45 $3,987.44 $6,900.9427446 Y $9,588.27 $4,163.63 $6,875.9527447 Y $9,815.19 $3,988.18 $6,901.6827475 Y NRC $3,139.7627479 Y NRC $3,139.7627496 Y $1,440.6127497 Y $1,440.6127498 Y $798.5627499 Y $3,139.7627500 Y $122.0427501 Y $122.0427502 Y $798.5627503 Y $798.5627508 Y $122.0427509 Y $3,139.7627510 Y $798.5627516 Y $122.0427517 Y $798.5627520 Y $122.0427524 Y $3,139.7627530 Y $122.0427532 Y $1,440.6127538 Y $122.0427550 Y $122.0427552 Y $798.5627560 Y $122.04




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




27562 Y $122.0427566 Y $3,139.7627570 Y $798.5627594 Y $1,440.6127600 Y $1,440.6127601 Y $1,440.6127602 Y $1,440.6127603 Y $1,113.6627604 Y $1,440.6127605 Y $798.5627606 Y $1,440.6127607 Y $1,440.6127610 Y $1,440.6127612 Y $1,440.6127613 Y $190.7827614 Y $1,113.6627615 Y $1,113.6627616 Y $1,113.6627618 Y $645.5627619 Y $1,113.6627620 Y $1,440.6127625 Y $1,440.6127626 Y $1,440.6127630 Y $1,440.6127632 Y $1,113.6627634 Y $1,113.6627635 Y $1,440.6127637 Y $3,139.7627638 Y $3,139.7627640 Y $1,440.6127641 Y $1,440.6127647 Y $1,440.6127648 N BN27650 Y $3,139.7627652 Y $3,139.7627654 Y $3,139.7627656 Y $1,440.6127658 Y $1,440.6127659 Y $3,139.7627664 Y $3,139.7627665 Y $3,139.7627675 Y $1,440.6127676 Y $3,139.76




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




27680 Y $1,440.6127681 Y $1,440.6127685 Y $1,440.6127686 Y $1,440.6127687 Y $1,440.6127690 Y $3,139.7627691 Y $3,139.7627692 N BN27695 Y $3,139.7627696 Y $3,139.7627698 Y $3,139.7627700 Y $3,139.7627702 Y AC $9,630.40 $4,129.82 $6,880.1127703 Y AC $9,630.40 $4,129.82 $6,880.1127704 N $1,440.6127705 Y $4,602.92 $2,107.96 $3,355.4427707 Y $1,440.6127709 Y $6,414.3927720 Y $4,386.39 $2,275.36 $3,330.8727726 Y $4,468.37 $2,211.98 $3,340.1727730 Y $1,440.6127732 Y $1,440.6127734 Y $1,440.6127740 Y $1,440.6127742 Y $1,440.6127745 Y $4,452.10 $2,224.56 $3,338.3327750 Y $122.0427752 Y $798.5627756 Y $4,669.25 $2,056.67 $3,362.9627758 Y $9,225.83 $4,443.85 $6,834.8427759 Y $9,108.85 $4,534.29 $6,821.5727760 Y $122.0427762 Y $798.5627766 Y $3,139.7627767 Y $122.0427768 Y $798.5627769 Y $3,139.7627780 Y $122.0427781 Y $798.5627784 Y $3,139.7627786 Y $122.0427788 Y $122.0427792 Y $4,223.69 $2,401.16 $3,312.42




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




27808 Y $122.0427810 Y $798.5627814 Y $4,290.64 $2,349.38 $3,320.0127816 Y $122.0427818 Y $798.5627822 Y $4,272.49 $2,363.41 $3,317.9527823 Y $4,258.42 $2,374.30 $3,316.3627824 Y $122.0427825 Y $798.5627826 Y $4,463.99 $2,215.37 $3,339.6827827 Y $9,139.53 $4,510.57 $6,825.0527828 Y $9,299.33 $4,387.01 $6,843.1727829 Y $3,139.7627830 Y $122.0427831 Y $1,440.6127832 Y $3,139.7627840 Y $122.0427842 Y $798.5627846 Y $3,139.7627848 Y $4,708.05 $2,026.68 $3,367.3627860 Y $1,440.6127870 Y $9,631.10 $4,130.52 $6,880.8127871 Y $9,282.07 $4,400.35 $6,841.2127884 Y $1,440.6127889 Y $3,139.7627892 Y $1,440.6127893 Y $3,139.7627894 Y $1,440.6128001 Y $202.5128002 Y $798.5628003 Y $1,440.6128005 Y $1,440.6128008 Y $1,440.6128010 Y $139.4528011 Y $798.5628020 Y $1,440.6128022 Y $1,440.6128024 Y $798.5628035 Y $892.4028039 Y $1,113.6628041 Y $1,113.6628043 Y $645.5628045 Y $1,113.66




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




28046 Y $1,113.6628047 Y $1,113.6628050 Y $1,440.6128052 Y $1,440.6128054 Y $1,440.6128055 Y $892.4028060 Y $1,440.6128062 Y $1,440.6128070 Y $3,139.7628072 Y $1,440.6128080 Y $798.5628086 Y $1,440.6128088 Y $1,440.6128090 Y $798.5628092 Y $798.5628100 Y $1,440.6128102 Y $3,139.7628103 Y $3,139.7628104 Y $1,440.6128106 Y $3,139.7628107 Y $3,139.7628108 Y $798.5628110 Y $1,440.6128111 Y $1,440.6128112 Y $1,440.6128113 Y $1,440.6128114 Y $1,440.6128116 Y $1,440.6128118 Y $1,440.6128119 Y $1,440.6128120 Y $1,440.6128122 Y $1,440.6128124 Y $337.9228126 Y $1,440.6128130 Y $4,769.37 $1,979.26 $3,374.3128140 Y $1,440.6128150 Y $1,440.6128153 Y $1,440.6128160 Y $1,440.6128171 Y $1,440.6128173 Y $1,440.6128175 Y $798.5628190 Y $204.12




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




28192 Y $645.5628193 Y $645.5628200 Y $1,440.6128202 Y $3,139.7628208 Y $1,440.6128210 Y $3,139.7628220 Y $319.3228222 Y $1,440.6128225 Y $1,440.6128226 Y $1,440.6128230 Y $314.8828232 Y $293.8528234 Y $798.5628238 Y $3,139.7628240 Y $1,440.6128250 Y $1,440.6128260 Y $1,440.6128261 Y $798.5628262 Y $5,054.74 $1,758.64 $3,406.6928264 Y $798.5628270 Y $1,440.6128272 Y $283.7528280 Y NRC $1,440.6128285 Y $1,440.6128286 Y $1,440.6128288 Y $1,440.6128289 Y $1,440.6128291 Y $4,902.67 $1,876.21 $3,389.4428292 Y NRC $1,440.6128295 Y $1,440.6128296 Y NRC $1,440.6128297 Y NRC $4,583.83 $2,122.72 $3,353.2728298 Y NRC $3,139.7628299 Y NRC $3,139.7628300 Y $4,274.37 $2,361.96 $3,318.1628302 Y $3,139.7628304 Y $3,139.7628305 Y $4,602.29 $2,108.44 $3,355.3628306 Y $3,139.7628307 Y $3,139.7628308 Y $1,440.6128309 Y $3,139.7628310 Y $3,139.76




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




28312 Y $1,440.6128313 Y NRC $1,440.6128315 Y $1,440.6128320 Y $10,120.74 $3,751.95 $6,936.3428322 Y $4,359.17 $2,296.41 $3,327.7928340 Y NRC $1,440.6128341 Y NRC $1,440.6128344 Y NRC $1,440.6128345 Y NRC $798.5628400 Y $122.0428405 Y $122.0428406 Y $3,139.7628415 Y $4,417.37 $2,251.41 $3,334.3928420 Y $9,405.46 $4,304.98 $6,855.2228430 Y $122.0428435 Y $798.5628436 Y $3,139.7628445 Y $4,147.02 $2,460.41 $3,303.7128446 Y $3,139.7628450 Y $122.0428455 Y $187.9628456 Y $3,139.7628465 Y $4,367.61 $2,289.87 $3,328.7428470 Y $122.0428475 Y $122.0428476 Y $1,440.6128485 Y $4,254.35 $2,377.44 $3,315.8928490 Y $110.7628495 Y $122.0428496 Y $1,440.6128505 Y $1,440.6128510 Y $87.7128515 Y $118.4328525 Y $1,440.6128530 Y $84.0828531 Y $3,139.7628540 Y $122.0428545 Y $1,440.6128546 Y $798.5628555 Y $3,139.7628570 Y $122.0428575 Y $1,440.6128576 Y $3,139.76




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




28585 Y $4,713.36 $2,022.56 $3,367.9628600 Y $122.0428605 Y $122.0428606 Y $1,440.6128615 Y $4,167.36 $2,444.69 $3,306.0228630 Y $99.8428635 Y $798.5628636 Y $1,440.6128645 Y $1,440.6128660 Y $77.2028665 Y $130.0528666 Y $1,440.6128675 Y $1,440.6128705 Y $13,199.85 $5,223.79 $9,211.8228715 Y $10,075.99 $3,786.54 $6,931.2628725 Y $9,255.23 $4,421.11 $6,838.1728730 Y $9,957.74 $3,877.97 $6,917.8528735 Y $10,057.46 $3,800.88 $6,929.1728737 Y $9,560.78 $4,184.88 $6,872.8328740 Y $4,724.95 $2,013.62 $3,369.2828750 Y $4,638.27 $2,080.62 $3,359.4428755 Y $3,139.7628760 Y $3,139.7628810 Y $1,440.6128820 Y $1,440.6128825 Y $1,440.6128890 Y $219.4929000 Y $130.0529010 Y $130.0529015 Y $130.0529035 Y $130.0529040 Y $130.0529044 Y $75.6929046 Y $130.0529049 Y $69.5229055 Y $130.0529058 Y $78.0129065 Y $67.5029075 Y $61.8529085 Y $67.1029086 Y $61.0429105 Y $55.7829125 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




29126 N BN29130 N BN29131 N BN29200 Y $21.0229240 N BN29260 N BN29280 N BN29305 Y $130.0529325 Y $130.0529345 Y $88.1229355 Y $89.7329358 Y $113.1829365 Y $83.2629405 Y $54.1629425 Y $50.9329435 Y $75.1929440 Y $24.6529445 Y $69.5229450 Y $73.1629505 Y $65.0729515 Y $47.2929520 N BN29530 N BN29540 Y $15.7629550 N BN29580 Y $47.2929581 Y $75.6929584 Y $75.6929700 Y $45.2729705 Y $38.4029710 Y $75.5929720 Y $63.4629730 Y $36.3829740 Y $59.4229750 Y NRC $62.2529800 Y $1,440.6129804 Y $1,440.6129805 Y $1,440.6129806 Y $3,139.7629807 Y $3,139.7629819 Y $1,440.6129820 Y $3,139.7629821 Y $1,440.61




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




29822 Y $1,440.6129823 Y $1,440.6129824 Y $1,440.6129825 Y $1,440.6129826 N BN29827 Y $3,139.7629828 Y $3,139.7629830 Y $1,440.6129834 Y $1,440.6129835 Y $1,440.6129836 Y $3,139.7629837 Y $1,440.6129838 Y $1,440.6129840 Y $1,440.6129843 Y $1,440.6129844 Y $1,440.6129845 Y $1,440.6129846 Y $1,440.6129847 Y $3,139.7629848 Y $798.5629850 Y $798.5629851 Y $798.5629855 Y $4,905.17 $1,874.27 $3,389.7229856 Y $8,941.37 $4,663.77 $6,802.5729860 Y $3,139.7629861 Y $3,139.7629862 Y $3,139.7629863 Y $1,440.6129866 Y $3,139.7629867 Y $9,673.29 $4,097.90 $6,885.5929870 Y $1,440.6129871 Y $1,440.6129873 Y $1,440.6129874 Y $1,440.6129875 Y $1,440.6129876 Y $1,440.6129877 Y $1,440.6129879 Y $1,440.6129880 Y $1,440.6129881 Y $1,440.6129882 Y $1,440.6129883 Y $1,440.6129884 Y $1,440.61




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




29885 Y $3,139.7629886 Y $1,440.6129887 Y $3,139.7629888 Y $4,415.49 $2,252.86 $3,334.1729889 Y $8,734.26 $4,823.90 $6,779.0829891 Y $1,440.6129892 Y $3,139.7629893 Y $1,440.6129894 Y $1,440.6129895 Y $1,440.6129897 Y $1,440.6129898 Y $1,440.6129899 Y $4,143.58 $2,463.08 $3,303.3329900 Y $1,440.6129901 Y $1,440.6129902 Y $798.5629904 Y $1,440.6129905 Y $3,139.7629906 Y $1,440.6129907 Y $8,962.46 $4,647.46 $6,804.9629914 Y $3,139.7629915 Y $3,139.7629916 Y $3,139.7630000 Y $102.8930020 Y $200.3030100 Y $107.1930110 Y $176.8430115 Y $1,055.0630117 Y $1,055.0630118 Y $1,055.0630120 Y $1,055.0630124 Y $536.6030125 Y $2,246.5530130 Y $1,055.0630140 Y $1,055.0630150 Y $2,246.5530160 Y $2,246.5530200 Y $82.6530210 Y $106.8330220 Y $536.6030300 N BN30310 Y $1,055.0630320 Y $536.60




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




30400 Y NRC $2,246.5530410 Y NRC $2,246.5530420 Y $2,246.5530430 Y $2,246.5530435 Y $2,246.5530450 Y $2,246.5530460 Y NRC $2,246.5530462 Y NRC $2,246.5530465 Y $2,246.5530520 Y $1,055.0630540 Y $2,246.5530545 Y NRC $2,246.5530560 Y $223.1930580 Y $2,246.5530600 Y $2,246.5530620 Y $2,246.5530630 Y $1,055.0630801 Y $536.6030802 Y $536.6030901 N BN30903 Y $55.0930905 Y $55.0930906 Y $102.8930915 Y $1,341.2330920 Y $1,341.2330930 Y $1,055.0631000 Y $102.8931002 Y $536.6031020 Y $1,055.0631030 Y $2,246.5531032 Y $2,246.5531040 Y $2,246.5531050 Y $2,246.5531051 Y $2,246.5531070 Y $2,246.5531075 Y $2,246.5531080 Y $2,246.5531081 Y $2,246.5531084 Y $2,246.5531085 Y $2,246.5531086 Y $2,246.5531087 Y $2,246.5531090 Y $2,246.55




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




31200 Y $2,246.5531201 Y $536.6031205 Y $1,055.0631231 Y NRC $79.1031233 Y NRC $190.9531235 Y NRC $611.6931237 Y NRC $611.6931238 Y $611.6931239 Y NRC $1,237.7131240 Y NRC $611.6931253 Y $1,895.8931254 Y $1,895.8931255 Y $1,895.8931256 Y $1,237.7131257 Y $1,895.8931259 Y $1,895.8931267 Y $1,895.8931276 Y $1,895.8931287 Y $1,895.8931288 Y $1,895.8931295 Y $1,821.4431296 Y $1,831.1931297 Y $1,816.7531298 Y $1,895.8931300 Y $1,055.0631400 Y $2,246.5531420 Y $2,246.5531500 Y $102.8931502 Y $102.8931505 Y $64.2431510 Y $1,237.7131511 Y $79.1031512 Y $1,237.7131513 Y $190.9531515 Y $190.9531520 Y NRC $190.9531525 Y $611.6931526 Y $611.6931527 Y $1,237.7131528 Y $1,237.7131529 Y $1,237.7131530 Y $611.6931531 Y $1,237.71




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




31535 Y $1,237.7131536 Y $1,237.7131540 Y $1,237.7131541 Y $1,237.7131545 Y $1,237.7131546 Y $1,895.8931551 Y NRC $2,246.5531552 Y $2,246.5531553 Y NRC $2,246.5531554 Y $2,246.5531560 Y $1,895.8931561 Y $1,895.8931570 Y $1,237.7131571 Y $1,237.7131572 Y $1,237.7131573 Y $182.9731574 Y $611.6931575 Y $79.1031576 Y $611.6931577 Y $190.9531578 Y $1,237.7131579 Y $119.8231580 Y $2,246.5531590 Y $2,246.5531591 Y $2,246.5531592 Y $2,246.5531603 Y $536.6031605 Y $102.8931611 Y $1,055.0631612 Y $1,055.0631613 Y $1,055.0631614 Y $2,246.5531615 Y $223.1931622 Y $611.6931623 Y $611.6931624 Y $611.6931625 Y $611.6931626 Y $1,895.8931627 N BN31628 Y $1,237.7131629 Y $1,237.7131630 Y $1,237.7131631 Y $1,895.89




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




31632 N BN31633 N BN31634 Y $1,895.8931635 Y $611.6931636 Y $3,162.63 $1,387.14 $2,274.8831637 N BN31638 Y $1,895.8931640 Y $1,237.7131641 Y $1,237.7131643 Y $611.6931645 Y $611.6931646 Y $190.9531647 Y $2,817.29 $1,654.14 $2,235.7131648 Y $1,237.7131649 N $611.6931651 N BN31652 Y $1,237.7131653 Y $1,237.7131654 N BN31717 Y $190.9531720 N BN31730 Y $611.6931750 Y $2,246.5531755 Y $2,246.5531820 Y $1,055.0631825 Y $1,055.0631830 Y $1,055.0632400 Y $576.3932405 Y $576.3932550 Y $1,377.2132552 N $318.5932553 N $629.2632554 Y $318.5932555 Y $318.5932556 Y $663.0632557 Y $579.9132960 Y $318.5932994 Y $2,194.0732998 Y $2,194.0733016 Y $579.9133206 Y NRC $8,419.83 $3,066.35 $5,743.0933207 Y NRC $8,702.71 $2,847.64 $5,775.1733208 Y NRC $8,911.57 $2,686.16 $5,798.86




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




33210 Y NRC $3,802.4733211 Y NRC $6,688.16 $2,515.35 $4,601.7533212 Y NRC $7,069.71 $2,220.37 $4,645.0433213 Y NRC $8,790.49 $2,779.78 $5,785.1333214 Y NRC $8,625.51 $2,907.32 $5,766.4133215 Y NRC $1,341.2333216 Y NRC $6,235.32 $2,865.46 $4,550.3933217 Y NRC $7,607.86 $1,804.30 $4,706.0833218 Y NRC $1,507.7833220 Y NRC $2,424.68 $1,173.19 $1,798.9333221 Y $13,370.02 $3,920.92 $8,645.4733222 Y NRC $819.9533223 Y NRC $819.9533224 Y NRC $8,935.37 $2,667.77 $5,801.5733225 N BN33226 Y NRC $1,341.2333227 Y $6,910.55 $2,343.41 $4,626.9833228 Y $8,703.77 $2,846.82 $5,775.2933229 Y $13,461.35 $3,850.32 $8,655.8333230 Y $22,744.22 $5,432.61 $14,088.4133231 Y $30,372.31 $7,158.74 $18,765.5233233 N NRC $6,102.48 $2,968.17 $4,535.3233234 N NRC $1,507.7833235 N NRC $2,224.76 $1,327.77 $1,776.2633240 Y NRC $22,506.55 $5,616.35 $14,061.4533241 N NRC $1,507.7833249 Y NRC $30,439.98 $7,106.42 $18,773.2033262 Y $22,234.57 $5,826.63 $14,030.6033263 Y $22,548.49 $5,583.92 $14,066.2033264 Y $30,483.98 $7,072.42 $18,778.2033270 Y $30,167.59 $7,317.02 $18,742.3033271 Y $7,136.34 $2,168.85 $4,652.5933273 Y $1,507.7833274 Y NRC $12,686.74 $3,933.35 $8,310.0433275 Y NRC $1,341.2333285 Y NRC $7,587.92 $1,819.73 $4,703.8233286 N NRC $308.2333419 N BN33508 N BN33866 N BN34490 Y NRC $1,341.2334713 N BN34714 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




34715 N BN34716 N BN35188 Y NRC $2,321.8135207 Y $1,341.2335572 N BN35875 Y NRC $2,321.8135876 Y NRC $2,321.8136000 N BN36002 Y $318.5936005 N BN36010 N BN36011 N BN36012 N BN36013 N BN36014 N BN36015 N BN36100 N BN36140 N BN36160 N BN36200 N BN36215 N BN36216 N BN36217 N BN36218 N BN36221 N BN36222 N BN36223 N BN36224 N BN36225 N BN36226 N BN36227 N BN36228 N BN36245 N BN36246 N BN36247 N BN36248 N BN36251 N BN36252 N BN36253 N BN36254 N BN36260 Y $2,321.8136261 Y $2,996.19 $731.33 $1,863.7636262 N $1,507.78




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




36400 N BN36405 N BN36406 N BN36410 N BN36416 N BN36420 N BN36425 N BN36430 N $35.0136440 N NRC $196.0736450 N NRC $196.0736455 N $196.0736465 Y NRC $819.9536466 Y NRC $819.9536468 N BN36470 Y NRC $80.1236471 Y NRC $137.5036473 Y $1,308.2536474 N BN36475 Y NRC $1,341.2336476 N BN36478 Y NRC $1,341.2336479 N BN36481 N BN36482 Y NRC $1,799.4336483 N BN36500 N BN36510 N BN36511 N $668.8136512 N $668.8136513 N $196.0736514 N $668.8136516 N $1,929.3736522 N $1,929.3736555 Y NRC $579.9136556 Y $579.9136557 Y NRC $2,321.8136558 Y $1,341.2336560 Y NRC $1,341.2336561 Y $1,341.2336563 Y $2,321.8136565 Y $1,341.2336566 Y $2,321.8136568 Y NRC $318.59




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




36569 Y $579.9136570 Y NRC $1,341.2336571 Y $1,341.2336573 Y $579.9136575 Y $318.5936576 Y $579.9136578 Y $1,341.2336580 Y $579.9136581 Y $1,341.2336582 Y $1,341.2336583 Y $4,773.16 $1,002.95 $2,888.0536584 Y $579.9136585 Y $1,341.2336589 N $318.5936590 N $318.5936591 N BN36592 N BN36593 Y $31.4036595 Y $1,341.2336596 Y $579.9136597 Y $579.9136598 Y $92.8436600 N BN36620 N BN36625 N BN36640 Y $1,341.2336680 N BN36800 Y NRC $2,321.8136810 Y NRC $1,341.2336815 Y NRC $2,321.8136818 Y NRC $2,321.8136819 Y NRC $2,321.8136820 Y NRC $2,321.8136821 Y NRC $1,341.2336825 Y NRC $2,321.8136830 Y NRC $2,321.8136831 Y NRC $2,321.8136832 Y NRC $2,321.8136833 Y NRC $2,321.8136835 Y NRC $2,279.60 $948.69 $1,614.1436860 Y NRC $318.5936861 Y NRC $2,321.8136901 Y NRC $573.46




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




36902 Y NRC $2,141.7436903 Y NRC $7,203.77 $2,885.79 $5,044.7836904 Y NRC $3,277.77 $1,795.09 $2,536.4336905 Y NRC $4,182.9436906 Y NRC $11,607.75 $4,767.56 $8,187.6536907 N BN36908 N BN36909 N BN37184 Y $7,329.84 $2,788.34 $5,059.0937185 N BN37186 N BN37187 Y $3,537.39 $1,594.39 $2,565.8937188 Y $1,341.2337197 Y $1,341.2337200 Y $2,321.8137211 Y $2,321.8137212 Y $1,341.2337220 Y NRC $2,141.7437221 Y NRC $7,045.04 $3,008.52 $5,026.7837222 N BN37223 N BN37224 Y NRC $3,556.74 $1,579.41 $2,568.0737225 Y NRC $7,609.96 $2,571.76 $5,090.8637226 Y NRC $7,347.11 $2,774.98 $5,061.0437227 Y NRC $12,473.53 $4,098.20 $8,285.8637228 Y NRC $6,464.24 $3,457.55 $4,960.8937229 Y NRC $11,726.88 $4,675.46 $8,201.1737230 Y NRC $11,515.94 $4,838.55 $8,177.2437231 Y NRC $12,140.42 $4,355.74 $8,248.0837232 N BN37233 N BN37234 N BN37235 N BN37236 Y $6,777.52 $3,215.35 $4,996.4337237 N BN37238 Y $7,061.38 $2,995.89 $5,028.6337239 N BN37241 Y $4,182.9437242 Y $6,950.26 $3,081.79 $5,016.0237243 Y $4,182.9437246 Y NRC $2,141.7437247 N BN37248 Y NRC $2,141.74




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




37249 N BN37252 N BN37253 N BN37500 Y NRC $2,321.8137607 Y NRC $1,341.2337609 Y $576.3937650 Y NRC $1,341.2337700 Y NRC $1,341.2337718 Y NRC $1,341.2337722 Y NRC $1,341.2337735 Y NRC $1,341.2337760 Y NRC $1,341.2337761 Y NRC $579.9137765 Y NRC $247.9437766 Y NRC $273.2037780 Y NRC $579.9137785 Y NRC $1,341.2337790 Y NRC $1,376.9738200 N BN38204 N BN38206 N NRC $668.8138220 Y $122.3438221 Y $111.8838222 Y $994.3438230 N NRC $668.8138232 N $1,929.3738241 N NRC $668.8138242 N NRC $668.8138243 N $668.8138300 Y $994.3438305 Y $994.3438308 Y NRC $1,118.4438500 Y $1,118.4438505 Y $576.3938510 Y $1,118.4438520 Y $1,118.4438525 Y $1,118.4438530 Y $1,118.4438542 Y $2,194.0738550 Y $1,118.4438555 Y $2,193.2738570 Y $2,194.0738571 Y $3,588.58




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




38572 Y $3,588.5838573 Y $3,588.5838700 Y $2,193.2738740 Y $2,194.0738745 Y $2,194.0738760 Y $2,193.2738790 N BN38792 N BN38794 N BN38900 N BN40490 Y $80.1240500 Y NRC $1,055.0640510 Y NRC $1,055.0640520 Y NRC $1,055.0640525 Y NRC $1,055.0640527 Y NRC $2,246.5540530 Y NRC $1,055.0640650 Y $223.1940652 Y $223.1940654 Y $536.6040700 Y NRC $2,246.5540701 Y NRC $2,246.5540702 Y NRC $2,246.5540720 Y NRC $1,055.0640761 Y NRC $2,246.5540800 Y $166.3740801 Y $223.1940804 N BN40805 Y $196.6940806 Y NRC $89.5040808 Y $121.9840810 Y $162.0440812 Y $200.6640814 Y $1,055.0640816 Y $1,055.0640818 Y $223.1940819 Y $536.6040820 Y $214.7340830 Y $102.8940831 Y $223.1940840 Y $2,246.5540842 Y $2,246.5540843 Y $2,246.55




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




40844 Y $2,246.5540845 Y $2,246.5541000 Y $109.7141005 Y $102.8941006 Y $536.6041007 Y $536.6041008 Y $1,055.0641009 Y $223.1941010 Y NRC $536.6041015 Y $223.1941016 Y $2,246.5541017 Y $1,055.0641018 Y $536.6041019 Y $2,246.5541100 Y $122.7041105 Y $122.7041108 Y $115.4941110 Y $163.1241112 Y $1,055.0641113 Y $1,055.0641114 Y $1,055.0641115 Y $188.0341116 Y $1,055.0641120 Y NRC $2,246.5541250 N BN41251 Y $102.8941252 Y $102.8941510 Y NRC $1,055.0641512 Y NRC $2,246.5541520 Y NRC $1,055.0641530 Y NRC $835.1141800 N BN41805 Y $252.2741806 Y $302.7941820 Y NRC $1,055.0641821 Y NRC $536.6041822 Y $254.0741823 Y $365.5941825 Y $167.8241826 Y $227.3641827 Y $2,246.5541828 Y $226.2841830 Y $325.53




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




41850 Y NRC $536.6041870 Y NRC $536.6041872 Y NRC $334.9141874 Y NRC $277.5342000 Y NRC $102.8942100 Y $97.4442104 Y $154.8242106 Y $189.1142107 Y $2,246.5542120 Y $2,246.5542140 Y $1,055.0642145 Y $2,246.5542160 Y $166.7342180 Y $223.1942182 Y $2,246.5542200 Y NRC $2,246.5542205 Y NRC $1,055.0642210 Y NRC $2,246.5542215 Y NRC $2,246.5542220 Y NRC $2,246.5542225 Y NRC $2,246.5542226 Y NRC $2,246.5542227 Y NRC $2,246.5542235 Y NRC $2,246.5542260 Y NRC $2,246.5542280 Y NRC $121.2642281 Y NRC $2,246.5542300 Y NRC $536.6042305 Y NRC $1,055.0642310 Y NRC $223.1942320 Y NRC $223.1942330 Y NRC $146.8842335 Y NRC $277.1742340 Y NRC $1,055.0642400 Y $75.0742405 Y $536.6042408 Y NRC $1,055.0642409 Y NRC $1,055.0642410 Y $2,246.5542415 Y $2,246.5542420 Y $2,246.5542425 Y $2,246.5542440 Y NRC $2,246.55




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




42450 Y NRC $2,246.5542500 Y $2,246.5542505 Y $2,246.5542507 Y NRC $2,246.5542509 Y NRC $2,246.5542510 Y NRC $1,055.0642550 N BN42600 Y NRC $1,055.0642650 Y NRC $49.4442660 Y NRC $75.4342665 Y NRC $1,055.0642700 Y NRC $102.8942720 Y NRC $1,055.0642725 Y NRC $2,246.5542800 Y $103.2242804 Y $1,055.0642806 Y $1,055.0642808 Y $1,055.0642809 N BN42810 Y NRC $1,055.0642815 Y NRC $2,246.5542820 Y NRC $2,246.5542821 Y NRC $1,055.0642825 Y NRC $2,246.5542826 Y NRC $1,055.0642830 Y NRC $1,055.0642831 Y NRC $1,055.0642835 Y NRC $1,055.0642836 Y NRC $1,055.0642860 Y NRC $1,055.0642870 Y NRC $2,246.5542890 Y NRC $2,246.5542892 Y NRC $2,246.5542900 Y $536.6042950 Y NRC $2,246.5542955 Y NRC $536.6042960 Y $223.1942962 Y $1,055.0642970 Y $102.8942972 Y $1,055.0643030 Y NRC $2,246.5543130 Y NRC $2,246.5543180 Y $2,246.55




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




43191 Y $663.0643192 Y $663.0643193 Y $663.0643194 Y $663.0643195 Y $1,306.1443196 Y $1,306.1443197 Y $135.3443198 Y $144.3643200 Y NRC $397.1243201 Y NRC $663.0643202 Y $663.0643204 Y NRC $663.0643205 Y NRC $663.0643206 Y NRC $663.0643210 Y $3,588.5843211 Y $663.0643212 Y $3,562.02 $1,209.12 $2,385.5743213 Y $663.0643214 Y $663.0643215 Y $663.0643216 Y $663.0643217 Y $663.0643220 Y NRC $663.0643226 Y NRC $663.0643227 Y $663.0643229 Y $1,306.1443231 Y NRC $663.0643232 Y $663.0643233 Y $663.0643235 Y $397.1243236 Y NRC $397.1243237 Y NRC $663.0643238 Y $663.0643239 Y $397.1243240 Y NRC $2,243.00 $906.06 $1,574.5343241 Y NRC $663.0643242 Y $663.0643243 Y NRC $663.0643244 Y NRC $663.0643245 Y $663.0643246 Y $663.0643247 Y $397.1243248 Y NRC $397.12




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




43249 Y NRC $663.0643250 Y $663.0643251 Y $663.0643252 Y NRC $1,306.1443253 Y $663.0643254 Y $663.0643255 Y $663.0643257 Y NRC $1,306.1443259 Y NRC $663.0643260 Y $1,306.1443261 Y $1,306.1443262 Y NRC $1,306.1443263 Y NRC $1,306.1443264 Y NRC $1,306.1443265 Y NRC $1,960.5743266 Y $3,608.42 $1,173.26 $2,390.8443270 Y $663.0643273 N BN43274 Y $1,960.5743275 Y $1,306.1443276 Y $1,960.5743277 Y $1,306.1443278 Y $1,306.1443284 Y NRC $5,838.92 $2,739.59 $4,289.2543285 N NRC $2,194.0743450 Y NRC $397.1243453 Y NRC $663.0643653 Y NRC $2,194.0743752 N $183.7243753 N BN43754 N BN43755 N NRC $69.9143756 N NRC $397.1243757 Y NRC $397.1243761 Y $118.6943762 Y NRC $118.6943763 Y NRC $118.6943870 Y NRC $1,306.1443886 Y NRC $1,504.3843887 N NRC $819.9543888 Y NRC $1,504.3844100 Y $397.1244312 Y NRC $1,504.38




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




44340 Y NRC $1,504.3844360 Y $663.0644361 Y $663.0644363 Y $663.0644364 Y $663.0644365 Y $663.0644366 Y NRC $663.0644369 Y $663.0644370 Y NRC $3,612.14 $1,170.38 $2,391.2644372 Y $663.0644373 Y $663.0644376 Y $663.0644377 Y $663.0644378 Y NRC $663.0644379 Y NRC $1,960.5744380 Y $397.1244381 Y NRC $663.0644382 Y $397.1244384 Y NRC $1,306.1444385 Y $385.9844386 Y $385.9844388 Y $385.9844389 Y $507.4244390 Y $385.9844391 Y NRC $507.4244392 Y $507.4244394 Y $507.4244401 Y $507.4244402 Y NRC $3,355.67 $1,368.66 $2,362.1644403 Y NRC $507.4244404 Y NRC $507.4244405 Y NRC $507.4244406 Y NRC $507.4244407 Y $507.4244408 Y NRC $385.9844500 Y NRC $397.1244701 N BN45000 Y NRC $507.4245005 Y NRC $507.4245020 Y NRC $1,100.2045100 Y $1,100.2045108 Y $1,100.2045150 Y NRC $507.42




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




45160 Y $1,100.2045171 Y $1,100.2045172 Y $1,100.2045190 Y $1,100.2045300 Y $94.1945303 Y NRC $507.4245305 Y $507.4245307 Y $1,100.2045308 Y $1,100.2045309 Y $507.4245315 Y $507.4245317 Y NRC $507.4245320 Y $1,100.2045321 Y NRC $1,100.2045327 Y NRC $2,892.64 $1,726.66 $2,309.6545330 Y $145.4445331 Y $385.9845332 Y $507.4245333 Y $385.9845334 Y NRC $507.4245335 Y NRC $385.9845337 Y NRC $385.9845338 Y $507.4245340 Y NRC $507.4245341 Y NRC $385.9845342 Y $507.4245346 Y $507.4245347 Y NRC $3,701.85 $1,101.01 $2,401.4345349 Y NRC $1,100.2045350 Y NRC $507.4245378 Y $385.9845379 Y $507.4245380 Y $507.4245381 Y NRC $507.4245382 Y NRC $507.4245384 Y $507.4245385 Y $507.4245386 Y NRC $507.4245388 Y $507.4245389 Y NRC $3,571.22 $1,202.02 $2,386.6245390 Y NRC $1,100.2045391 Y NRC $507.4245392 Y $507.42




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




45393 Y NRC $507.4245398 Y NRC $507.4245500 Y NRC $1,100.2045505 Y NRC $1,100.2045520 N BN45541 Y NRC $1,100.2045560 Y NRC $1,100.2045900 Y NRC $385.9845905 Y NRC $507.4245910 Y NRC $507.4245915 Y $507.4245990 Y NRC $1,100.2046020 Y NRC $1,100.2046030 Y NRC $507.4246040 Y $507.4246045 Y $1,100.2046050 Y $385.9846060 Y NRC $1,100.2046070 Y NRC $1,100.2046080 Y NRC $1,100.2046083 Y NRC $118.6946200 Y NRC $1,100.2046220 Y NRC $507.4246221 Y NRC $186.2246230 Y NRC $1,100.2046250 Y NRC $1,100.2046255 Y NRC $1,100.2046257 Y NRC $1,100.2046258 Y NRC $1,100.2046260 Y NRC $1,100.2046261 Y NRC $1,100.2046262 Y NRC $1,100.2046270 Y NRC $1,100.2046275 Y NRC $1,100.2046280 Y NRC $1,100.2046285 Y NRC $1,100.2046288 Y NRC $1,100.2046320 Y NRC $134.6146500 Y NRC $235.6746505 Y NRC $507.4246600 N BN46601 N BN46604 Y NRC $507.42




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




46606 Y $213.6546607 Y $507.4246608 Y $385.9846610 Y $1,100.2046611 Y NRC $385.9846612 Y $1,100.2046614 Y NRC $110.4346615 Y $1,100.2046700 Y NRC $1,100.2046706 Y NRC $1,100.2046707 Y NRC $1,100.2046750 Y NRC $1,100.2046753 Y NRC $1,100.2046754 Y NRC $1,100.2046760 Y NRC $1,100.2046761 Y NRC $1,100.2046900 Y $161.4546910 Y $186.9446916 Y $88.2946917 Y $1,100.2046922 Y $1,100.2046924 Y $1,100.2046930 Y NRC $154.8246940 Y NRC $158.0746942 Y NRC $157.7146945 Y NRC $1,100.2046946 Y NRC $1,100.2046947 Y NRC $1,100.2046948 Y NRC $1,100.2047000 Y $576.3947001 N BN47382 Y $2,194.0747383 Y $3,536.88 $1,700.55 $2,618.7147531 N BN47532 N BN47533 Y $1,377.2147534 Y $1,377.2147535 Y $1,377.2147536 Y $1,377.2147537 N $397.1247538 Y $3,795.49 $1,500.62 $2,648.0547539 Y $2,194.0747540 Y $3,555.99 $1,685.79 $2,620.89




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




47541 Y $1,377.2147542 N BN47543 N BN47544 N BN47552 Y NRC $1,377.2147553 Y NRC $1,377.2147554 Y NRC $2,194.0747555 Y NRC $1,377.2147556 Y NRC $3,707.33 $1,568.78 $2,638.0547562 Y NRC $2,194.0747563 Y NRC $2,194.0747564 Y NRC $2,194.0748102 Y $576.3949082 Y $397.1249083 Y $397.1249084 Y $397.1249180 Y $576.3949250 Y NRC $1,377.2149320 Y $2,194.0749321 Y $2,194.0749322 Y NRC $2,194.0749324 Y NRC $2,194.0749325 Y NRC $2,194.0749326 N BN49327 N BN49400 N BN49402 Y $1,377.2149406 Y $576.3949407 Y $576.3949411 N $362.7049418 Y $1,377.2149419 Y NRC $2,321.8149421 Y NRC $1,377.2149422 N NRC $1,341.2349423 Y NRC $663.0649424 N BN49426 Y $1,377.2149427 N BN49429 N $1,341.2349435 N BN49436 Y NRC $663.0649440 Y $663.0649441 Y $663.06




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




49442 Y $507.4249446 Y $663.0649450 Y $397.1249451 Y $397.1249452 Y $397.1249460 Y $397.1249465 N $117.7549495 Y NRC $1,377.2149496 Y NRC $1,377.2149500 Y NRC $1,377.2149501 Y NRC $1,377.2149505 Y $1,377.2149507 Y $1,377.2149520 Y $1,377.2149521 Y $1,377.2149525 Y $1,377.2149540 Y $2,194.0749550 Y $1,377.2149553 Y $1,377.2149555 Y $1,377.2149557 Y $1,377.2149560 Y $1,377.2149561 Y $1,377.2149565 Y $2,194.0749566 Y $2,194.0749568 N BN49570 Y $1,377.2149572 Y $1,377.2149580 Y NRC $1,377.2149582 Y NRC $1,377.2149585 Y $1,377.2149587 Y $1,377.2149590 Y $1,377.2149600 Y $1,377.2149650 Y $2,194.0749651 Y $2,194.0749652 Y $2,194.0749653 Y $2,194.0749654 Y $3,588.5849655 Y $3,588.5849656 Y $3,588.5849657 Y $3,588.5850080 Y NRC $3,995.65




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




50081 Y NRC $3,995.6550200 Y $576.3950382 Y NRC $789.7150384 N NRC $789.7150385 Y NRC $789.7150386 N NRC $639.5150387 Y NRC $789.7150389 N NRC $281.2150390 Y $308.2350391 Y NRC $49.0850396 Y NRC $281.2150430 N BN50431 N BN50432 Y $789.7150433 Y $1,376.9750434 Y $1,206.13 $663.80 $934.9650435 Y $789.7150436 Y NRC $789.7150437 Y NRC $1,376.9750551 Y NRC $1,976.2750553 Y NRC $1,976.2750555 Y $3,995.6550557 Y $3,995.6550561 Y NRC $1,976.2750562 Y $3,995.6550570 Y NRC $1,376.9750572 Y NRC $281.2150574 Y $789.7150575 Y NRC $1,976.2750576 Y $1,976.2750580 Y NRC $1,976.2750590 Y NRC $1,376.9750592 Y $2,194.0750593 Y $5,605.00 $2,920.43 $4,262.7150606 N BN50684 N BN50686 N NRC $69.9150688 Y NRC $789.7150690 N BN50693 Y $1,376.9750694 Y $1,376.9750695 Y $1,376.9750705 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




50706 N BN50727 Y NRC $1,376.9750947 Y NRC $2,194.0750948 Y NRC $3,588.5850951 Y NRC $1,376.9750953 Y NRC $1,376.9750955 Y $1,976.2750957 Y $1,976.2750961 Y NRC $1,976.2750970 Y NRC $1,376.9750972 Y NRC $1,376.9750974 Y $1,976.2750976 Y $1,976.2750980 Y NRC $1,976.2751020 Y NRC $1,376.9751030 Y NRC $1,376.9751040 Y NRC $789.7151045 Y NRC $789.7151050 Y NRC $1,976.2751065 Y NRC $1,376.9751080 Y NRC $994.3451100 Y NRC $38.9851101 N NRC $105.3851102 Y NRC $789.7151500 Y NRC $2,194.0751520 Y $1,376.9751535 Y $1,376.9751600 N BN51605 N BN51610 N BN51700 Y NRC $52.3351701 N BN51702 N BN51703 N $69.9151705 Y $61.3551710 Y $281.2151715 Y NRC $2,081.83 $1,173.82 $1,627.8251720 Y $51.2551725 Y $118.6951726 Y $118.6951727 Y $244.6951728 Y $251.1851729 Y $252.27




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




51736 N BN51741 N BN51784 N NRC $29.2351785 Y NRC $118.6951792 N BN51797 N BN51798 N BN51880 Y NRC $1,376.9751992 Y NRC $3,333.38 $1,857.89 $2,595.6352000 Y $281.2152001 Y NRC $1,376.9752005 Y $789.7152007 Y $1,376.9752010 Y NRC $281.2152204 Y $789.7152214 Y NRC $789.7152224 Y $789.7152234 Y $1,376.9752235 Y $1,376.9752240 Y $1,976.2752250 Y $1,376.9752260 Y NRC $789.7152265 Y NRC $271.7552270 Y NRC $789.7152275 Y NRC $789.7152276 Y NRC $789.7152277 Y NRC $1,376.9752281 Y $789.7152282 Y NRC $1,376.9752283 Y NRC $789.7152285 Y NRC $281.2152287 Y $789.7152290 Y NRC $789.7152300 Y NRC $1,376.9752301 Y NRC $1,376.9752305 Y NRC $1,976.2752310 Y $789.7152315 Y $789.7152317 Y NRC $1,376.9752318 Y NRC $1,376.9752320 Y NRC $1,376.9752325 Y NRC $1,976.2752327 Y NRC $3,064.24 $1,625.71 $2,344.97




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




52330 Y NRC $1,376.9752332 Y NRC $1,376.9752334 Y NRC $1,376.9752341 Y NRC $1,376.9752342 Y NRC $1,376.9752343 Y NRC $789.7152344 Y NRC $1,376.9752345 Y NRC $1,376.9752346 Y NRC $1,976.2752351 Y NRC $1,376.9752352 Y NRC $1,376.9752353 Y NRC $1,976.2752354 Y $1,976.2752355 Y $1,976.2752356 Y $1,976.2752400 Y NRC $1,376.9752402 Y NRC $1,376.9752450 Y NRC $1,376.9752500 Y NRC $1,376.9752601 Y NRC $1,976.2752630 Y NRC $1,976.2752640 Y NRC $1,376.9752647 Y NRC $1,976.2752648 Y NRC $1,976.2752649 Y NRC $1,976.2752700 Y NRC $1,376.9753000 Y NRC $789.7153010 Y NRC $1,976.2753020 Y NRC $789.7153025 Y NRC $789.7153040 Y NRC $789.7153060 Y NRC $81.9253080 Y NRC $281.2153085 Y NRC $789.7153200 Y $789.7153210 Y NRC $1,376.9753215 Y NRC $1,976.2753220 Y $1,376.9753230 Y $1,976.2753235 Y $1,976.2753240 Y NRC $1,376.9753250 Y NRC $1,376.9753260 Y $789.71




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




53265 Y $789.7153270 Y NRC $789.7153275 Y NRC $789.7153400 Y NRC $1,976.2753405 Y NRC $1,976.2753410 Y NRC $1,976.2753420 Y NRC $1,976.2753425 Y NRC $1,976.2753430 Y NRC $1,976.2753431 Y NRC $1,976.2753440 Y NRC $7,463.23 $2,306.63 $4,884.9353442 Y NRC $1,976.2753444 Y NRC $15,619.29 $5,672.66 $10,645.9753445 Y NRC $17,028.56 $4,583.11 $10,805.8353446 N NRC $1,976.2753447 Y NRC $16,511.11 $4,983.17 $10,747.1453449 Y NRC $1,976.2753450 Y NRC $1,376.9753460 Y NRC $1,376.9753502 Y $1,376.9753505 Y $1,976.2753510 Y $1,976.2753515 Y $1,976.2753520 Y NRC $1,976.2753600 Y NRC $39.3453601 N BN53605 Y NRC $789.7153620 Y NRC $87.3453621 Y NRC $89.5053660 N NRC $44.0353661 N BN53665 Y NRC $789.7153850 Y $1,376.9753852 Y $1,314.0253854 Y $789.7153855 Y NRC $695.0953860 Y NRC $789.7154000 Y NRC $1,376.9754001 Y NRC $789.7154015 Y $576.3954050 N BN54055 Y $79.7654056 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




54057 Y $819.9554060 Y $819.9554065 Y $819.9554100 Y $576.3954105 Y $994.3454110 Y $1,376.9754111 Y $1,976.2754112 Y $3,995.6554115 Y $994.3454120 Y $1,376.9754150 Y NRC $789.7154160 Y NRC $281.2154161 Y NRC $789.7154162 Y $789.7154163 Y NRC $789.7154164 Y NRC $789.7154200 Y $70.0154205 Y $1,976.2754220 Y $118.6954230 N BN54231 Y NRC $64.6054235 Y NRC $43.6754240 N NRC $37.8954250 Y NRC $12.2754300 Y NRC $1,376.9754304 Y NRC $1,376.9754308 Y NRC $1,976.2754312 Y NRC $1,376.9754316 Y NRC $1,976.2754318 Y NRC $1,376.9754322 Y NRC $1,376.9754324 Y NRC $1,376.9754326 Y NRC $789.7154328 Y NRC $1,376.9754340 Y NRC $1,376.9754344 Y NRC $1,976.2754348 Y NRC $1,976.2754352 Y NRC $1,976.2754360 Y NRC $1,376.9754380 Y NRC $789.7154385 Y NRC $789.7154400 N NRC $16,480.73 $5,006.66 $10,743.6954401 N NRC $16,945.26 $4,647.51 $10,796.38




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




54405 N NRC $17,031.50 $4,580.84 $10,806.1754406 N NRC $1,376.9754408 Y NRC $1,976.2754410 N NRC $16,791.40 $4,766.47 $10,778.9354415 N NRC $1,376.9754416 N NRC $16,684.57 $4,849.05 $10,766.8154420 Y NRC $789.7154435 Y NRC $1,376.9754437 Y $1,376.9754440 Y $1,376.9754450 Y NRC $118.6954500 Y $994.3454505 Y $1,376.9754512 Y $1,376.9754520 Y NRC $1,376.9754522 Y NRC $1,376.9754530 Y $1,377.2154550 Y NRC $1,377.2154560 Y NRC $789.7154600 Y NRC $1,376.9754620 Y NRC $1,376.9754640 Y NRC $1,377.2154660 Y NRC $3,126.01 $1,577.96 $2,351.9854670 Y NRC $789.7154680 Y NRC $1,376.9754690 Y NRC $2,194.0754692 Y NRC $2,194.0754700 Y NRC $789.7154800 Y $576.3954830 Y $789.7154840 Y $789.7154860 Y NRC $789.7154861 Y NRC $1,376.9754865 Y NRC $1,376.9754900 Y NRC $789.7154901 Y NRC $1,376.9755000 Y NRC $64.2455040 Y NRC $1,377.2155041 Y NRC $1,377.2155060 Y NRC $1,376.9755100 Y NRC $576.3955110 Y NRC $1,376.9755120 Y $789.71




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




55150 Y NRC $1,376.9755175 Y NRC $1,376.9755180 Y NRC $1,976.2755200 Y NRC $1,376.9755250 Y NRC $789.7155300 N BN55400 Y NRC $1,376.9755500 Y NRC $1,376.9755520 Y $1,376.9755530 Y NRC $1,376.9755535 Y NRC $1,377.2155540 Y NRC $1,377.2155550 Y NRC $2,194.0755600 Y NRC $789.7155680 Y $1,376.9755700 Y $789.7155705 Y $789.7155706 Y $1,376.9755720 Y NRC $789.7155725 Y NRC $1,376.9755860 Y $1,976.2755870 Y NRC $77.5955873 Y NRC $7,061.86 $2,616.95 $4,839.4055874 Y NRC $1,976.2755875 N NRC $1,976.2755876 N $81.2055920 Y $1,816.3656405 Y NRC $70.0156420 Y NRC $83.9056440 Y $1,235.3156441 Y $1,235.3156442 Y NRC $1,235.3156501 Y $103.5856515 Y $819.9556605 Y $47.6456606 N BN56620 Y NRC $1,235.3156625 Y NRC $1,235.3156700 Y NRC $1,235.3156740 Y $1,235.3156800 Y NRC $1,235.3156805 Y NRC $1,235.3156810 Y NRC $1,235.31




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




56820 Y NRC $60.9956821 Y $79.4057000 Y NRC $1,235.3157010 Y NRC $1,235.3157020 Y NRC $1,816.3657022 Y NRC $994.3457023 Y $994.3457061 Y $91.6757065 Y $1,235.3157100 Y $49.8057105 Y $1,235.3157120 Y NRC $1,816.3657130 Y $1,235.3157135 Y $1,235.3157150 N BN57155 Y $1,816.3657156 Y $136.7957160 Y NRC $33.9257170 Y NRC $35.3757180 Y $83.9057200 Y $1,235.3157210 Y NRC $1,235.3157220 Y NRC $1,816.3657230 Y $1,235.3157240 Y NRC $1,816.3657250 Y NRC $1,816.3657260 Y NRC $1,816.3657265 Y NRC $1,816.3657267 N BN57268 Y NRC $1,816.3657287 N NRC $1,235.3157288 Y NRC $2,795.02 $1,510.63 $2,152.8257289 Y NRC $2,730.3357291 Y NRC $1,816.3657295 Y NRC $1,235.3157300 Y NRC $1,235.3157310 Y $2,730.3357320 Y $1,816.3657400 Y NRC $1,235.3157410 Y NRC $1,235.3157415 Y NRC $1,235.3157420 Y $63.1657421 Y $83.37




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




57426 Y NRC $2,730.3357452 Y $61.7157454 Y $72.5457455 Y $77.2357456 Y $73.6257460 Y $198.8557461 Y $212.2157500 Y $98.1657505 Y NRC $83.7357510 Y NRC $76.8757511 Y NRC $98.8957513 Y NRC $1,235.3157520 Y NRC $1,235.3157522 Y NRC $1,235.3157530 Y NRC $1,816.3657550 Y NRC $1,816.3657556 Y NRC $1,816.3657558 Y NRC $1,235.3157700 Y NRC $1,235.3157720 Y NRC $1,235.3157800 Y NRC $40.4258100 Y $50.5358110 N BN58120 Y NRC $1,235.3158145 Y $1,235.3158260 Y NRC $1,816.3658262 Y NRC $1,816.3658301 N NRC $52.3358321 Y NRC $43.6758322 Y NRC $46.1958323 Y NRC $6.1458340 N BN58345 Y NRC $1,235.3158346 Y $1,816.3658350 Y NRC $1,816.3658353 Y NRC $1,816.3658356 Y NRC $1,610.3258541 Y NRC $2,194.0758542 Y NRC $3,588.5858543 Y NRC $3,588.5858544 Y NRC $3,588.5858545 Y NRC $2,194.0758546 Y NRC $3,588.58




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




58550 Y NRC $2,194.0758552 Y NRC $3,588.5858553 Y NRC $3,588.5858554 Y NRC $3,588.5858555 Y NRC $1,235.3158558 Y $1,235.3158559 Y NRC $1,816.3658560 Y NRC $1,816.3658561 Y NRC $1,816.3658562 Y NRC $1,235.3158563 Y NRC $1,816.3658565 Y NRC $1,816.3658570 Y NRC $3,588.5858571 Y NRC $3,588.5858572 Y NRC $3,588.5858573 Y NRC $3,588.5858600 Y NRC $1,235.3158615 Y NRC $1,235.3158660 Y NRC $2,194.0758661 Y NRC $2,194.0758662 Y $2,194.0758670 Y NRC $2,194.0758671 Y NRC $2,194.0758672 Y NRC $2,194.0758673 Y NRC $2,194.0758674 Y NRC $3,588.5858800 Y NRC $1,235.3158805 Y NRC $1,235.3158820 Y NRC $1,235.3158900 Y $1,235.3158970 Y NRC $322.6158976 Y NRC $136.7959000 Y NRC $65.6859001 Y NRC $136.7959012 Y NRC $136.7959015 Y $61.7159020 Y NRC $33.2059025 Y NRC $18.7759070 Y NRC $136.7959072 Y NRC $217.99 $107.97 $162.9859074 Y NRC $136.7959076 Y NRC $136.7959100 Y $1,816.36




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




59150 Y NRC $2,194.0759151 Y NRC $2,194.0759160 Y NRC $1,235.3159200 Y NRC $56.3059300 Y NRC $111.8859320 Y NRC $1,235.3159412 Y NRC $1,235.3159414 Y NRC $1,235.3159812 Y NRC $1,235.3159820 Y NRC $1,235.3159821 Y NRC $1,235.3159840 Y NRC $1,235.3159841 Y NRC $1,235.3159866 Y NRC $136.7959870 Y NRC $1,235.3159871 N NRC $1,235.3160000 Y NRC $536.6060100 Y $53.7760200 Y $2,194.0760210 Y NRC $2,194.0760212 Y NRC $2,194.0760220 Y NRC $2,194.0760225 Y NRC $2,194.0760240 Y NRC $2,194.0760280 Y $2,194.0760281 Y $2,194.0760300 Y NRC $78.6860500 Y NRC $2,246.5561000 Y NRC $315.8361001 Y NRC $315.8361020 Y $410.3261026 Y $315.8361050 Y $132.2761055 Y $132.2761070 Y $315.8361215 Y $2,170.2461330 Y $1,055.0661770 Y $2,170.2461781 N BN61782 N BN61783 N BN61790 Y NRC $796.7961791 Y NRC $796.79




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




61880 N $1,845.9561885 N $19,730.76 $3,722.40 $11,726.5861886 N $26,860.75 $5,060.68 $15,960.7161888 N $5,105.74 $2,118.45 $3,612.0962160 N BN62194 Y NRC $796.7962225 Y NRC $2,170.2462230 Y NRC $2,170.2462252 N NRC $35.0162263 Y $410.3262264 Y $410.3262267 Y $308.2362268 Y $410.3262269 Y $576.3962270 Y $315.8362272 Y $315.8362273 Y $315.8362280 Y $451.3562281 Y $451.3562282 Y $451.3562284 N BN62287 Y $796.7962290 N BN62291 N BN62292 Y $796.7962294 Y $410.3262302 N BN62303 N BN62304 N BN62305 N BN62320 Y $347.4162321 Y $347.4162322 Y $347.4162323 Y $347.4162324 Y $451.3562325 Y $451.3562326 Y $451.3562327 Y $451.3562328 Y $315.8362329 Y $315.8362350 Y $3,303.71 $1,832.65 $2,568.1862355 N $796.7962360 Y $15,760.45 $3,498.07 $9,629.26




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




62361 Y $16,235.87 $3,130.51 $9,683.1962362 Y $15,581.20 $3,636.67 $9,608.9362365 N $2,170.2462367 N $13.7162368 N $19.1362369 N $71.1062370 N $66.4062380 Y $2,803.3663001 Y $2,803.3663003 Y $2,803.3663005 Y $2,803.3663020 Y $2,803.3663030 Y $2,803.3663042 Y $2,803.3663044 N BN63045 Y $2,803.3663046 Y $2,803.3663047 Y $2,803.3663055 Y $2,803.3663056 Y $2,803.3663600 Y $796.7963610 Y $1,342.43 $572.74 $957.5863650 N $5,146.94 $2,086.60 $3,616.7763655 N $18,175.74 $4,924.63 $11,550.1863661 N $796.7963662 N $1,845.9563663 N $5,031.38 $2,175.94 $3,603.6663664 N $16,556.81 $6,176.28 $11,366.5463685 N $26,753.79 $5,143.37 $15,948.5863688 N $1,845.9563744 Y NRC $2,170.2463746 N NRC $796.7964400 Y $84.1664405 Y $36.5264408 Y $44.8664415 Y $451.3564416 Y $451.3564417 Y $451.3564418 Y $47.6464420 Y $347.4164421 Y $451.3564425 Y $82.5864430 Y NRC $451.35




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




64435 Y NRC $48.8364445 Y $98.4564446 Y $451.3564447 Y $53.2064448 Y $451.3564449 Y $451.3564450 Y $53.2064451 Y $347.4164454 Y $173.8864455 Y $22.6364461 Y $347.4164462 N BN64463 Y $347.4164479 Y $451.3564480 N BN64483 Y $451.3564484 N BN64486 N BN64487 N BN64488 N BN64489 N BN64490 Y $451.3564491 N BN64492 N BN64493 Y $451.3564494 N BN64495 N BN64505 Y NRC $78.6164510 Y $451.3564517 Y NRC $451.3564520 Y $451.3564530 Y NRC $451.3564553 N NRC $5,885.82 $1,515.35 $3,700.5864555 N $5,342.21 $1,935.63 $3,638.9264561 N NRC $5,339.52 $1,937.70 $3,638.6164566 Y $115.1364568 N NRC $27,299.99 $4,721.08 $16,010.5364569 N NRC $6,230.46 $1,248.88 $3,739.6764570 N NRC $2,387.2664575 N NRC $17,866.63 $5,163.62 $11,515.1264580 N NRC $19,424.78 $3,958.95 $11,691.8664581 N NRC $5,522.40 $1,796.31 $3,659.3564585 N $2,030.55




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




64590 N NRC $19,713.99 $3,735.36 $11,724.6764595 N $2,030.5564600 Y $451.3564605 Y $876.4764610 Y $876.4764611 Y NRC $82.9764612 Y $84.9564615 Y $75.0364616 Y $71.8564617 Y $97.6664620 Y $451.3564624 Y $350.5464625 Y $876.4764630 Y NRC $451.3564632 Y $46.8564633 Y $876.4764634 N BN64635 Y $876.4764636 N BN64640 Y $194.1364642 Y $86.9464643 N BN64644 Y $107.1864645 N BN64646 Y $87.3464647 Y $96.0764650 Y NRC $59.1564653 Y NRC $68.2864680 Y NRC $451.3564681 Y NRC $451.3564702 Y $796.7964704 Y $796.7964708 Y $796.7964712 Y $796.7964713 Y $796.7964714 Y $796.7964716 Y $796.7964718 Y $796.7964719 Y $796.7964721 Y $796.7964722 Y $796.7964726 Y $796.7964727 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




64732 Y $796.7964734 Y $796.7964736 Y $796.7964738 Y $796.7964740 Y $796.7964742 Y $796.7964744 Y $796.7964746 Y $796.7964763 Y $796.7964766 Y $796.7964771 Y $796.7964772 Y $796.7964774 Y $796.7964776 Y $796.7964778 N BN64782 Y $796.7964783 N BN64784 Y $796.7964786 Y $2,170.2464787 N BN64788 Y $796.7964790 Y $796.7964792 Y $2,170.2464795 Y $796.7964802 Y $796.7964820 Y $796.7964821 Y $1,286.2664822 Y $1,286.2664823 Y $1,286.2664831 Y $796.7964832 N BN64834 Y $2,170.2464835 Y $2,170.2464836 Y $2,170.2464837 N BN64840 Y $2,170.2464856 Y $2,170.2464857 Y $2,170.2464858 Y $796.7964859 N BN64861 Y $796.7964862 Y $2,170.2464864 Y $2,170.24




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




64865 Y $2,170.2464872 N BN64874 N BN64876 N BN64885 Y $2,170.2464886 Y $2,170.2464890 Y $2,170.2464891 Y $3,224.98 $1,893.51 $2,559.2464892 Y $2,170.2464893 Y $2,170.2464895 Y $2,170.2464896 Y $2,170.2464897 Y $2,170.2464898 Y $2,170.2464901 N BN64902 N BN64905 Y $2,170.2464907 Y $2,170.2464910 Y $3,571.37 $1,625.71 $2,598.5464912 Y $3,901.05 $1,370.83 $2,635.9464913 N BN65091 Y $1,355.6365093 Y $1,355.6365101 Y $1,355.6365103 Y $1,355.6365105 Y $1,355.6365110 Y $1,355.6365112 Y $1,355.6365114 Y $1,355.6365125 Y $836.9465130 Y $1,355.6365135 Y $1,355.6365140 Y $1,355.6365150 Y $1,355.6365155 Y $1,355.6365175 Y $1,355.6365205 N BN65210 N BN65220 N BN65222 N BN65235 Y $1,012.7265260 Y $1,012.7265265 Y $1,012.72




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




65270 Y $836.9465272 Y $836.9465275 Y $1,355.6365280 Y $1,835.8465285 Y $1,835.8465286 Y $462.6765290 Y $1,355.6365400 Y $407.7565410 Y $836.9465420 Y $836.9465426 Y $836.9465430 N BN65435 Y $48.0065436 Y $208.9665450 Y $136.6865600 Y $260.2165710 Y $1,835.8465730 Y $1,835.8465750 Y $1,835.8465755 Y $1,835.8465756 Y $1,835.8465757 N BN65770 Y $10,129.20 $3,516.42 $6,822.8165772 Y $407.7565775 Y $836.9465778 N BN65779 N BN65780 Y NRC $1,355.6365781 Y NRC $1,835.8465782 Y NRC $1,355.6365785 Y $1,835.8465800 Y NRC $1,012.7265810 Y NRC $1,012.7265815 Y $1,012.7265820 Y NRC $1,835.8465850 Y NRC $1,012.7265855 Y NRC $135.7065860 Y $177.2065865 Y $1,012.7265870 Y $1,012.7265875 Y $1,012.7265880 Y $1,835.8465900 Y $1,012.72




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




65920 Y $1,012.7265930 Y $1,012.7266020 Y $1,012.7266030 Y $1,012.7266130 Y $836.9466150 Y NRC $1,835.8466155 Y NRC $1,835.8466160 Y NRC $1,012.7266170 Y NRC $1,012.7266172 Y NRC $1,012.7266174 Y NRC $1,835.8466175 Y NRC $1,835.8466179 Y $1,835.8466180 Y NRC $2,806.95 $1,540.76 $2,173.8566183 Y $2,954.89 $1,426.38 $2,190.6366184 Y $1,012.7266185 Y NRC $1,012.7266225 Y $1,835.8466250 Y $836.9466500 Y $1,012.7266505 Y $1,012.7266600 Y $1,835.8466605 Y NRC $1,012.7266625 Y NRC $1,012.7266630 Y NRC $1,012.7266635 Y $1,012.7266680 Y $1,012.7266682 Y $1,012.7266700 Y $1,012.7266710 Y $836.9466711 Y $1,012.7266720 Y $836.9466740 Y $836.9466761 Y NRC $189.8366762 Y NRC $256.1466770 Y $256.1466820 Y NRC $1,012.7266821 Y NRC $256.1466825 Y $1,012.7266830 Y $1,012.7266840 Y $1,012.7266850 Y $1,012.7266852 Y NRC $1,835.84




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




66920 Y NRC $1,012.7266930 Y NRC $1,835.8466940 Y NRC $1,012.7266982 Y NRC $1,012.7266983 Y NRC $1,012.7266984 Y NRC $1,012.7266985 Y NRC $1,012.7266986 Y NRC $1,012.7266987 Y NRC $2,728.07 $1,601.76 $2,164.9166988 Y NRC $2,728.07 $1,601.76 $2,164.9166990 N BN67005 Y $1,012.7267010 Y $1,012.7267015 Y $1,012.7267025 Y $1,012.7267027 Y $1,629.2667028 N $47.2867030 Y NRC $1,012.7267031 Y NRC $256.1467036 Y $1,835.8467039 Y $1,835.8467040 Y $1,835.8467041 Y NRC $1,835.8467042 Y NRC $1,835.8467043 Y NRC $1,835.8467101 Y $202.8267105 Y $171.4367107 Y $1,835.8467108 Y $1,835.8467110 Y $508.5067113 Y $1,835.8467115 Y $1,835.8467120 Y NRC $1,012.7267121 Y NRC $1,012.7267141 Y NRC $136.6867145 Y NRC $256.1467208 Y $136.6867210 Y $256.1467218 Y $1,355.6367220 Y $256.1467221 Y NRC $153.0267225 N BN67227 Y $164.57




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




67228 Y $179.0067229 Y NRC $256.1467250 Y $836.9467255 Y $1,012.7267311 Y NRC $836.9467312 Y NRC $1,355.6367314 Y NRC $836.9467316 Y NRC $836.9467318 Y NRC $836.9467320 N BN67331 N BN67332 N BN67334 N BN67335 N BN67340 N BN67343 Y NRC $836.9467345 Y $126.3167346 Y $1,355.6367400 Y $1,355.6367405 Y $836.9467412 Y $836.9467413 Y $836.9467414 Y $1,355.6367415 Y NRC $836.9467420 Y $1,355.6367430 Y $1,355.6367440 Y $1,355.6367445 Y $1,355.6367450 Y $1,355.6367500 Y $136.6867505 Y $38.9867515 Y $36.0967550 Y $1,355.6367560 Y $1,355.6367570 Y $1,355.6367700 Y NRC $136.6867710 Y NRC $199.2167715 Y NRC $836.9467800 Y $76.5167801 Y $92.7567805 Y $118.7367808 Y $836.9467810 Y $136.68




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




67820 N BN67825 Y NRC $80.4867830 Y NRC $407.7567835 Y NRC $836.9467840 Y $204.2767850 Y $153.3867875 Y NRC $407.7567880 Y NRC $836.9467882 Y NRC $836.9467900 Y NRC $836.9467901 Y NRC $836.9467902 Y NRC $1,355.6367903 Y NRC $836.9467904 Y NRC $836.9467906 Y NRC $1,355.6367908 Y NRC $836.9467909 Y NRC $836.9467911 Y NRC $836.9467912 Y NRC $836.9467914 Y NRC $836.9467915 Y NRC $233.8667916 Y NRC $836.9467917 Y NRC $836.9467921 Y NRC $836.9467922 Y NRC $225.9267923 Y NRC $836.9467924 Y NRC $836.9467930 Y $235.3067935 Y $836.9467938 Y $136.6867950 Y $836.9467961 Y $836.9467966 Y $836.9467971 Y $836.9467973 Y $836.9467974 Y $1,355.6367975 Y $836.9468020 Y NRC $68.5768040 Y $31.7668100 Y $129.9268110 Y $168.9068115 Y $836.9468130 Y $836.94




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




68135 Y $88.0668200 N BN68320 Y NRC $836.9468325 Y NRC $1,355.6368326 Y NRC $1,355.6368328 Y NRC $836.9468330 Y NRC $1,012.7268335 Y NRC $1,355.6368340 Y NRC $836.9468360 Y NRC $1,355.6368362 Y NRC $836.9468371 Y NRC $836.9468400 Y NRC $232.0668420 Y NRC $245.7768440 Y NRC $66.4068500 Y $1,355.6368505 Y $1,355.6368510 Y $836.9468520 Y NRC $1,355.6368525 Y $836.9468530 Y $136.6868540 Y $836.9468550 Y $1,355.6368700 Y NRC $836.9468705 Y NRC $136.6868720 Y NRC $1,355.6368745 Y NRC $1,355.6368750 Y NRC $1,355.6368760 Y NRC $136.6868761 Y NRC $97.4468770 Y NRC $836.9468801 N BN68810 Y NRC $136.6868811 Y NRC $836.9468815 Y NRC $836.9468816 Y NRC $836.9468840 Y NRC $83.3768850 N BN69000 Y $130.2869005 Y $133.8969020 Y $173.2369100 Y $68.2169105 Y $109.71




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




69110 Y $994.3469120 Y $2,246.5569140 Y $2,246.5569145 Y $994.3469150 Y $2,246.5569200 N BN69205 Y $576.3969209 N BN69210 N BN69220 N BN69222 Y NRC $157.3569300 Y NRC $1,055.0669310 Y $2,246.5569320 Y NRC $2,246.5569420 Y NRC $102.8969421 Y NRC $1,055.0669424 N NRC $96.0069433 Y NRC $138.2269436 Y NRC $536.6069440 Y NRC $1,055.0669450 Y NRC $1,055.0669501 Y NRC $2,246.5569502 Y NRC $2,246.5569505 Y NRC $2,246.5569511 Y NRC $2,246.5569530 Y NRC $2,246.5569540 Y $158.7969550 Y $2,246.5569552 Y $2,246.5569601 Y NRC $2,246.5569602 Y NRC $2,246.5569603 Y NRC $2,246.5569604 Y NRC $2,246.5569605 Y NRC $2,246.5569610 Y $204.2769620 Y NRC $1,055.0669631 Y NRC $2,246.5569632 Y NRC $2,246.5569633 Y NRC $2,246.5569635 Y NRC $2,246.5569636 Y NRC $2,246.5569637 Y NRC $2,246.5569641 Y NRC $2,246.55




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




69642 Y NRC $2,246.5569643 Y NRC $2,246.5569644 Y NRC $2,246.5569645 Y NRC $2,246.5569646 Y NRC $2,246.5569650 Y NRC $1,055.0669660 Y NRC $2,246.5569661 Y NRC $2,246.5569662 Y NRC $2,246.5569666 Y NRC $1,055.0669667 Y NRC $1,055.0669670 Y NRC $2,246.5569676 Y NRC $1,055.0669700 Y NRC $536.6069711 N NRC $1,055.0669714 Y NRC $10,781.71 $3,240.94 $7,011.3269715 Y NRC $12,278.89 $5,935.81 $9,107.3569717 Y NRC $4,987.77 $1,810.40 $3,399.0869718 Y NRC $5,727.1369720 Y $2,246.5569740 Y $2,246.5569745 Y $2,246.5569801 Y NRC $133.8969805 Y NRC $2,246.5569806 Y NRC $2,246.5569905 Y NRC $2,246.5569910 Y NRC $2,246.5569915 Y $1,055.0669930 Y NRC $34,995.63 $7,314.14 $21,154.8869990 N BN70010 N BN70015 N BN70030 N BN70100 N BN70110 N BN70120 N BN70130 N BN70134 N BN70140 N BN70150 N BN70160 N BN70170 N BN70190 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




70200 N BN70210 N BN70220 N BN70240 N BN70250 N BN70260 N BN70300 N BN70310 N BN70320 N BN70328 N BN70330 N BN70332 N BN70336 N $117.7570350 N BN70355 N BN70360 N BN70370 N BN70371 N BN70380 N BN70390 N BN70450 N $56.6370460 N $92.0870470 N $92.0870480 N $56.6370481 N $92.0870482 N $92.0870486 N $56.6370487 N $92.0870488 N $92.0870490 N $56.6370491 N $92.0870492 N $92.0870496 N $92.0870498 N $92.0870540 N $117.7570542 N $192.9570543 N $192.9570544 N $117.7570545 N $192.9570546 N $192.9570547 N $117.7570548 N $192.9570549 N $192.95




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




70551 N $117.7570552 N $192.9570553 N $192.9570554 N $117.7570555 N $117.7570557 N $243.3470558 N $92.0870559 N $92.0871045 N $16.2471046 N $21.6571047 N BN71048 N BN71100 N BN71101 N BN71110 N BN71111 N BN71120 N BN71130 N BN71250 N $56.6371260 N $92.0871270 N $92.0871275 N $92.0871550 N $117.7571551 N $344.0171552 N $192.9572020 N BN72040 N BN72050 N BN72052 N BN72070 N BN72072 N BN72074 N BN72080 N BN72081 N BN72082 N BN72083 N $56.6372084 N $56.6372100 N BN72110 N BN72114 N BN72120 N BN72125 N $56.6372126 N $135.70




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




72127 N $92.0872128 N $56.6372129 N $92.0872130 N $92.0872131 N $56.6372132 N $136.0672133 N $92.0872141 N $117.7572142 N $192.9572146 N $117.7572147 N $192.9572148 N $117.7572149 N $192.9572156 N $192.9572157 N $192.9572158 N $192.9572170 N BN72190 N BN72191 N $92.0872192 N $56.6372193 N $92.0872194 N $92.0872195 N $117.7572196 N $192.9572197 N $192.9572200 N BN72202 N BN72220 N BN72240 N BN72255 N BN72265 N BN72270 N BN72275 N BN72285 N BN72295 N BN73000 N BN73010 N BN73020 N BN73030 N BN73040 N BN73050 N BN73060 N BN73070 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




73080 N BN73085 N BN73090 N BN73092 N BN73100 N BN73110 N BN73115 N BN73120 N BN73130 N BN73140 N BN73200 N $56.6373201 N $166.3773202 N $92.0873206 N $92.0873218 N $117.7573219 N $192.9573220 N $192.9573221 N $117.7573222 N $286.9173223 N $192.9573501 N BN73502 N BN73503 N BN73521 N BN73522 N BN73523 N BN73525 N BN73551 N BN73552 N BN73560 N BN73562 N BN73564 N BN73565 N BN73580 N BN73590 N BN73592 N BN73600 N BN73610 N BN73615 N BN73620 N BN73630 N BN73650 N BN73660 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




73700 N $56.6373701 N $92.0873702 N $92.0873706 N $92.0873718 N $117.7573719 N $192.9573720 N $192.9573721 N $117.7573722 N $287.6373723 N $192.9574018 N BN74019 N BN74021 N BN74022 N BN74150 N $56.6374160 N $92.0874170 N $92.0874174 N $192.9574175 N $92.0874176 N $113.6874177 N $192.9574178 N $192.9574181 N $117.7574182 N $192.9574183 N $192.9574190 N BN74210 N BN74220 N BN74230 N $92.0874235 N BN74240 N $80.4874246 N NRC $92.0874250 N NRC $80.8474251 N NRC $92.0874261 N NRC $56.6374262 N NRC $92.0874270 N BN74280 N BN74283 N NRC $92.0874290 N BN74300 N BN74301 N BN74328 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




74329 N BN74330 N BN74340 N BN74355 N BN74360 N BN74363 N BN74400 N NRC $92.0874410 N NRC $92.0874415 N NRC $92.0874420 N NRC $192.9574425 N BN74430 N BN74440 N BN74445 N BN74450 N BN74455 N BN74470 N BN74485 N BN74710 N BN74712 N NRC $117.7574713 N BN74740 N BN74742 N BN74775 N NRC $117.7575557 N NRC $117.7575559 N NRC $243.3475561 N NRC $192.9575563 N NRC $344.0175565 N BN75571 N BN75572 N $92.0875573 N NRC $92.0875574 N $92.0875600 N BN75605 N BN75625 N BN75630 N BN75635 N BN75705 N BN75710 N BN75716 N BN75726 N BN75731 N NRC $106.83




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




75733 N BN75736 N BN75741 N BN75743 N BN75746 N NRC $89.5075756 N BN75774 N BN75801 N BN75803 N NRC $579.9175805 N NRC $579.9175807 N BN75809 N BN75810 N NRC $579.9175820 N BN75822 N NRC $75.0775825 N BN75827 N BN75831 N BN75833 N BN75840 N BN75842 N BN75860 N BN75870 N NRC $120.9075872 N BN75880 N BN75885 N BN75887 N NRC $82.2875889 N BN75891 N BN75893 N BN75894 N BN75898 N NRC $579.9175901 N BN75902 N BN75970 N BN75984 N BN75989 N BN76000 N $26.3576010 N BN76080 N BN76098 N BN76100 N BN76101 N NRC $56.63




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




76102 N NRC $56.6376120 N BN76125 N BN76376 N BN76377 N BN76380 N BN76391 N $117.7576496 N BN76497 N BN76498 N $40.3376499 N BN76506 N BN76510 N BN76511 N BN76512 N BN76513 N BN76514 N BN76516 N BN76519 N BN76529 N BN76536 N BN76604 N BN76641 N BN76642 N BN76700 N $56.6376705 N $56.6376770 N $56.6376775 N BN76776 N $56.6376800 N BN76801 N NRC $56.6376802 N BN76805 N NRC $56.6376810 N BN76811 N NRC $83.3776812 N BN76813 N BN76814 N BN76815 N BN76816 N BN76817 N BN76818 N NRC $56.6376819 N NRC $48.72




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




76820 N BN76821 N BN76825 N NRC $193.4476826 N NRC $117.7576827 N BN76828 N BN76830 N NRC $56.6376831 N NRC $84.0976856 N NRC $56.6376857 N NRC $23.8276870 N BN76872 N NRC $56.6376873 N NRC $56.6376881 N NRC $46.5676882 N BN76885 N BN76886 N BN76932 N BN76936 N NRC $127.8976937 N BN76940 N BN76941 N BN76942 N BN76945 N BN76946 N BN76948 N BN76965 N BN76970 N BN76975 N BN76977 N NRC $3.9776978 N $92.0876979 N BN76981 N $56.6376982 N $56.6376983 N BN76998 N BN76999 N BN77001 N BN77002 N BN77003 N BN77011 N BN77012 N BN77013 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




77014 N BN77021 N BN77022 N BN77046 N $117.7577047 N $117.7577053 N BN77054 N BN77071 N BN77072 N BN77073 N BN77074 N BN77075 N BN77076 N BN77077 N BN77078 N NRC $40.3377080 N NRC $29.5977081 N NRC $22.0177084 N $117.7577085 N BN77086 N BN77280 N $63.9777285 N $169.3577290 N $169.3577293 N BN77295 N $263.4577299 N $63.9777300 N $33.9277301 N $629.2677306 N $75.7977307 N $136.7877316 N $144.7277317 N $169.3577318 N $169.3577321 N $44.0377331 N $18.7777332 N $23.4677333 N $63.9777334 N $67.1377336 N $63.9777338 N $169.3577370 N $63.9777385 N $272.2777386 N $272.27




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




77387 N BN77399 N $63.9777401 N $24.5477402 N $62.0077407 N $119.4377412 N $119.4377417 N BN77423 N $26.7177424 N $1,922.6177425 N $1,922.6177435 N BN77470 N $25.6277520 N $272.2777522 N $629.9777523 N $629.9777525 N $629.9777600 N NRC $119.4377605 N NRC $374.1877610 N NRC $272.2777615 N NRC $272.2777620 N NRC $272.2777750 N $119.4377761 N $202.1077762 N $231.3377763 N $298.4677767 N $119.4377768 N $119.4377770 N $235.3077771 N $374.1877772 N $374.1877778 N $374.1877789 N $62.0077790 N BN77799 N $62.0078012 N $186.0178013 N $186.0178014 N $186.0178015 N $186.0178016 N $186.0178018 N $238.4978020 N BN78070 N NRC $186.0178071 N $186.01




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




78072 N NRC $238.4978075 N NRC $642.8278099 N $186.0178102 N $186.0178103 N $186.0178104 N $186.0178110 N NRC $642.8278111 N NRC $642.8278120 N NRC $186.0178121 N NRC $238.4978122 N $238.4978130 N $186.0178135 N $186.0178140 N $186.0178185 N $186.0178191 N $186.0178195 N $238.4978199 N $186.0178201 N $642.8278202 N $642.8278215 N $186.0178216 N $186.0178226 N $186.0178227 N $238.4978230 N NRC $186.0178231 N NRC $186.0178232 N NRC $186.0178258 N NRC $186.0178261 N NRC $186.0178262 N NRC $186.0178264 N NRC $186.0178265 N NRC $186.0178266 N NRC $238.4978278 N $186.0178282 N NRC $186.0178290 N NRC $186.0178291 N NRC $186.0178299 N $186.0178300 N $186.0178305 N $186.0178306 N $186.0178315 N $186.0178399 N $186.01




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




78414 N NRC $238.4978428 N NRC $186.0178429 N NRC $729.2178430 N NRC $729.2178431 N NRC $1,137.1578432 N NRC $1,389.7978433 N NRC $1,389.7978434 N BN78445 N $186.0178451 N $642.8278452 N $642.8278453 N $642.8278454 N $642.8278456 N $642.8278457 N $642.8278458 N $186.0178459 N NRC $642.8278466 N NRC $186.0178468 N NRC $238.4978469 N NRC $642.8278472 N NRC $186.0178473 N NRC $186.0178481 N NRC $238.4978483 N NRC $238.4978491 N NRC $729.2178492 N NRC $729.2178494 N NRC $186.0178496 N BN78499 N NRC $186.0178579 N $186.0178580 N $186.0178582 N $238.4978597 N $186.0178598 N $238.4978599 N $186.0178600 N $186.0178601 N $186.0178605 N $238.4978606 N $238.4978608 N NRC $729.2178610 N $238.4978630 N $238.4978635 N $238.49




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




78645 N $238.4978650 N $642.8278660 N $186.0178699 N $186.0178700 N $186.0178701 N $186.0178707 N NRC $238.4978708 N NRC $238.4978709 N NRC $238.4978725 N $186.0178730 N BN78740 N NRC $186.0178761 N NRC $186.0178799 N $186.0178800 N $186.0178801 N $186.0178802 N $642.8278803 N $642.8278804 N $642.8278808 N BN78811 N NRC $642.8278812 N NRC $729.2178813 N NRC $729.2178814 N NRC $729.2178815 N NRC $729.2178816 N NRC $729.2178830 N $642.8278831 N $642.8278832 N $729.2178999 N $186.0179005 N $50.5379101 N $51.2579200 N $53.4179300 N $119.9579403 N NRC $81.9279440 N NRC $39.7079445 N NRC $119.9579999 N $119.9590371 N $110.6790375 N $280.6490376 N $271.3790378 N NRC $1,205.0590396 N NRC $1,716.18




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




90476 N BN90630 N BN90632 N BN90633 N BN90634 N BN90636 N BN90647 N BN90648 N BN90653 N BN90654 N BN90655 N BN90656 N BN90657 N BN90660 N BN90661 N BN90662 N BN90670 N BN90672 N BN90673 N BN90674 N BN90675 N $297.5990676 N $130.0190680 N BN90682 N BN90685 N BN90686 N BN90687 N BN90688 N BN90689 N BN90690 N BN90691 N BN90696 N BN90698 N BN90717 N BN90732 N BN90740 N BR $0.0090743 N BR $0.0090744 N BR $0.0090746 N BR $0.0090747 N BR $0.0090749 N BN90756 N BN91035 N $245.37




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




92920 Y $3,444.64 $1,666.10 $2,555.3792921 N BN92928 Y $6,905.90 $3,116.08 $5,010.9992929 N BN93451 Y $1,374.3693452 Y $1,374.3693453 Y $1,374.3693454 Y $1,374.3693455 Y $1,374.3693456 Y $1,374.3693457 Y $1,374.3693458 Y $1,374.3693459 Y $1,374.3693460 Y $1,374.3693461 Y $1,374.3693462 N BN93566 N BN93567 N BN93568 N BN93571 N BN93572 N BN93985 N $117.7593986 N $56.630100T Y NRC $168,500.99 $25,486.02 $96,993.500101T Y NRC $1,286.260102T Y NRC $1,286.260191T Y NRC $3,098.12 $1,315.65 $2,206.880200T Y NRC $4,406.11 $2,260.12 $3,333.110201T Y NRC $2,803.360213T Y NRC $410.320214T N BN0215T N BN0216T Y NRC $410.320217T N BN0218T N BN0228T Y NRC $410.320229T N BN0230T Y NRC $410.320231T N BN0232T N BN0238T Y NRC $11,708.67 $4,689.54 $8,199.100253T Y NRC $2,934.19 $1,442.38 $2,188.280263T N NRC $1,929.37




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




0264T N NRC $1,929.370265T N NRC $1,929.370269T N NRC $2,170.240270T N NRC $1,845.950271T N NRC $1,845.950274T Y NRC $2,803.360275T Y NRC $2,803.360278T N BN0290T N BN0308T Y NRC $23,570.21 $4,655.61 $14,112.910313T Y NRC $3,938.92 $686.05 $2,312.480314T N NRC $1,845.950315T N NRC $1,845.950316T N NRC $28,000.21 $4,179.70 $16,089.950330T N BN0331T N NRC $642.820332T N NRC $642.820335T Y NRC $4,850.10 $1,916.85 $3,383.470338T N NRC $2,141.740339T N NRC $2,141.740342T N NRC $1,929.370347T N BN0348T N BN0349T N BN0350T N BN0351T N BN0353T N BN0356T N BN0376T N BN0379T N BN0394T N NRC $119.430395T N NRC $374.180396T N BN0397T N BN0400T N BN0401T N BN0402T Y NRC $836.940408T Y NRC $21,122.51 $6,686.40 $13,904.450409T Y NRC $16,920.83 $9,934.89 $13,427.860410T Y NRC $5,650.48 $3,317.62 $4,484.050411T Y NRC $5,650.48 $3,317.62 $4,484.050412T N NRC $1,507.780413T N NRC $1,507.78




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




0414T Y NRC $16,920.83 $9,934.89 $13,427.860415T Y NRC $318.590416T Y NRC $819.950419T Y NRC $251.140420T Y NRC $251.140421T Y NRC $3,995.650422T N NRC $40.330424T Y NRC $25,197.89 $6,346.30 $15,772.090425T Y NRC $3,000.870426T Y NRC $9,388.140427T Y NRC $12,777.290428T N NRC $1,845.950429T N NRC $1,845.950430T N NRC $1,845.950431T Y NRC $27,144.54 $4,841.26 $15,992.900432T Y NRC $1,845.950433T Y NRC $1,845.950434T N NRC $57.310437T N BN0439T N BN0440T Y NRC $796.790441T Y NRC $796.790442T Y NRC $3,661.24 $1,556.23 $2,608.730443T N BN0444T N BN0445T N BN0446T Y NRC $251.140447T N NRC $88.290448T Y NRC $251.140449T Y NRC $3,217.38 $1,223.45 $2,220.410450T N BN0465T Y NRC $156.440466T N BN0467T N NRC $1,845.950468T N NRC $1,845.950471T N BN0479T Y NRC $161.450480T N BN0487T N BN0491T Y NRC $161.450492T N BN0493T N BN0502T N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




0503T N BN0508T N NRC $56.630510T N NRC $1,286.260511T Y NRC $4,165.80 $2,445.90 $3,305.850512T N NRC $161.450513T N BN0514T N BN0523T N BN0524T Y NRC $1,341.230525T Y NRC $7,039.77 $4,133.33 $5,586.550526T Y NRC $5,650.48 $3,317.62 $4,484.050527T Y NRC $5,650.48 $3,317.62 $4,484.050530T N NRC $1,507.780531T N NRC $1,507.780532T N NRC $1,507.780548T Y NRC $5,937.55 $3,486.17 $4,711.860549T Y NRC $2,936.75 $1,724.28 $2,330.510550T Y NRC $1,376.970551T Y NRC $118.690558T N NRC $40.330566T Y NRC $132.270587T Y NRC $469.33 $275.56 $372.440588T Y NRC $132.27A9500 N BNA9501 N BNA9502 N BNA9503 N BNA9504 N BNA9505 N BNA9507 N BNA9508 N BNA9509 N BNA9510 N BNA9512 N BNA9515 N BNA9516 N BNA9520 N BNA9521 N BNA9524 N BNA9526 N BNA9527 N NRC $31.26A9528 N BNA9529 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




A9531 N BNA9532 N BNA9536 N BNA9537 N BNA9538 N BNA9539 N BNA9540 N BNA9541 N BNA9542 N BNA9546 N BNA9547 N BNA9548 N BNA9550 N BNA9551 N BNA9552 N BNA9553 N BNA9554 N BNA9555 N BNA9556 N BNA9557 N BNA9558 N BNA9559 N BNA9560 N BNA9561 N BNA9562 N BNA9566 N BNA9567 N BNA9568 N BNA9569 N BNA9570 N BNA9571 N BNA9572 N BNA9575 N BNA9576 N BNA9577 N BNA9578 N BNA9579 N BNA9580 N BNA9581 N BNA9582 N BNA9583 N BNA9584 N BNA9585 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




A9586 N $3,028.84A9587 N BNA9588 N BNA9590 N BNA9597 N BNA9598 N BNA9698 N BNA9700 N BNC1713 N BNC1714 N BNC1715 N BNC1716 N NRC $116.44C1717 N NRC $321.98C1719 N NRC $62.96C1721 N BNC1722 N BNC1724 N BNC1725 N BNC1726 N BNC1727 N BNC1728 N BNC1729 N BNC1730 N BNC1731 N BNC1732 N BNC1733 N BNC1734 N BR $0.00C1749 N BNC1750 N BNC1751 N BNC1752 N BNC1753 N BNC1754 N BNC1755 N BNC1756 N BNC1757 N BNC1758 N BNC1759 N BNC1760 N BNC1762 N BNC1763 N BNC1764 N BNC1765 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




C1766 N BNC1767 N BNC1768 N BNC1769 N BNC1770 N BNC1771 N BNC1772 N BNC1773 N BNC1776 N BNC1777 N BNC1778 N BNC1779 N BNC1780 N BNC1781 N BNC1782 N BNC1783 N BNC1784 N BNC1785 N BNC1786 N BNC1787 N BNC1788 N BNC1789 N BNC1813 N BNC1814 N BNC1815 N BNC1816 N BNC1817 N BNC1818 N BNC1819 N BNC1820 N BNC1821 N BNC1822 N BNC1823 N BR $0.00C1824 N BR $0.00C1830 N BNC1839 N BR $0.00C1840 N BNC1841 N BNC1842 N BNC1874 N BNC1875 N BNC1876 N BNC1877 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




C1878 N BNC1880 N BNC1881 N BNC1882 N BNC1883 N BNC1884 N BNC1885 N BNC1886 N BNC1887 N BNC1888 N BNC1889 N BNC1890 N BR $0.00C1891 N BNC1892 N BNC1893 N BNC1894 N BNC1895 N BNC1896 N BNC1897 N BNC1898 N BNC1899 N BNC1900 N BNC1982 N BR $0.00C2596 N BR $0.00C2613 N BNC2614 N BNC2615 N BNC2616 N NRC $17,089.66C2617 N BNC2618 N BNC2619 N BNC2620 N BNC2621 N BNC2622 N BNC2623 N BNC2624 N BNC2625 N BNC2626 N BNC2627 N BNC2628 N BNC2629 N BNC2630 N BNC2631 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




C2634 N NRC $181.89C2635 N NRC $56.37C2636 N NRC $36.03C2638 N NRC $34.54C2639 N NRC $35.63C2640 N NRC $83.59C2641 N NRC $69.39C2642 N NRC $76.70C2643 N NRC $95.70C2645 N NRC $4.69C2698 N NRC $34.54C2699 N NRC $35.63C5271 Y $251.14C5272 N BNC5273 Y $819.95C5274 N BNC5275 Y $251.14C5276 N BNC5277 Y $251.14C5278 N BNC8900 N NRC $192.95C8901 N NRC $117.75C8902 N NRC $192.95C8903 N NRC $92.08C8905 N NRC $192.95C8906 N NRC $192.95C8908 N NRC $192.95C8909 N NRC $192.95C8910 N NRC $117.75C8911 N NRC $192.95C8912 N NRC $192.95C8913 N NRC $117.75C8914 N NRC $192.95C8918 N NRC $192.95C8919 N NRC $117.75C8920 N NRC $192.95C8931 N NRC $192.95C8932 N NRC $117.75C8933 N NRC $192.95C8934 N NRC $192.95C8935 N NRC $117.75C8936 N NRC $192.95C9046 N NRC $0.86




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




C9047 N NRC $683.55C9054 N $0.70C9055 N $76.74C9113 N BNC9132 N NRC $2.00C9248 N BNC9250 N $164.85C9254 N BNC9257 N NRC $2.03C9285 N BNC9290 N $1.25C9293 N BNC9352 N BNC9353 N BNC9354 N BNC9355 N BNC9356 N BNC9358 N BNC9359 N BNC9360 N BNC9361 N BNC9362 N BNC9363 N BNC9364 N BNC9399 N NRC $0.00C9460 N $15.38C9462 N $0.47C9482 N NRC $9.99C9488 N NRC $31.56C9600 Y $7,055.78 $3,000.22 $5,028.00C9601 N BNC9725 Y NRC $385.98C9726 N BNC9727 Y NRC $536.60C9728 N NRC $629.26C9738 N BNC9739 Y $3,741.20 $1,102.33 $2,421.76C9740 Y $7,876.19 $1,987.34 $4,931.76C9745 Y NRC $3,828.85 $1,580.91 $2,704.88C9747 Y $1,976.27C9749 Y NRC $3,896.55 $1,528.56 $2,712.55C9752 Y NRC $8,510.53 $4,996.87 $6,753.70C9753 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




C9754 Y NRC $10,102.32 $5,931.47 $8,016.89C9755 Y NRC $10,102.32 $5,931.47 $8,016.89C9757 Y $8,510.53 $4,996.87 $6,753.70G0104 Y $145.44G0105 Y $385.98G0121 Y $385.98G0130 N NRC $23.82G0186 Y $256.14G0260 Y $315.83G0276 Y NRC $2,803.36G0429 Y NRC $52.69G0516 N BNG0517 N BNG0518 N BNJ0120 N BNJ0121 N $3.49J0122 N $0.96J0129 N NRC $54.32J0130 N BNJ0131 N BNJ0132 N BNJ0133 N BNJ0135 N NRC $1,371.14J0153 N BNJ0171 N BNJ0178 N $952.47J0179 N NRC $317.58J0180 N NRC $183.43J0185 N $2.17J0202 N NRC $1,917.04J0207 N $1,003.59J0210 N BNJ0220 N NRC $141.14J0221 N $171.05J0222 N NRC $98.32J0256 N NRC $4.55J0257 N $4.82J0278 N BNJ0280 N BNJ0282 N BNJ0285 N BNJ0287 N $6.18J0289 N $26.09




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J0290 N BNJ0291 N NRC $3.22J0295 N BNJ0300 N NRC $56.62J0330 N BNJ0348 N BNJ0360 N BNJ0390 N BNJ0400 N BNJ0401 N NRC $5.70J0456 N BNJ0461 N BNJ0470 N BNJ0475 N $169.51J0476 N BNJ0480 N NRC $3,799.93J0485 N $3.78J0490 N $44.82J0500 N BNJ0515 N BNJ0517 N $168.50J0558 N $10.89J0561 N $13.82J0565 N NRC $39.83J0567 N NRC $93.51J0570 N NRC $1,303.53J0583 N BNJ0584 N NRC $353.21J0585 N $6.12J0586 N $8.43J0587 N $11.99J0588 N $5.05J0592 N BNJ0593 N NRC $76.34J0594 N NRC $4.58J0595 N BNJ0596 N NRC $28.22J0597 N NRC $51.31J0598 N NRC $57.03J0599 N NRC $9.67J0600 N NRC $5,594.42J0606 N NRC $2.60J0610 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J0620 N BNJ0630 N NRC $2,661.05J0636 N BNJ0637 N BNJ0638 N NRC $111.01J0640 N BNJ0641 N $0.58J0642 N $2.04J0670 N BNJ0690 N BNJ0692 N BNJ0694 N BNJ0695 N $5.60J0696 N BNJ0697 N BNJ0698 N BNJ0702 N BNJ0706 N BNJ0712 N $3.19J0713 N BNJ0714 N $92.05J0715 N BNJ0716 N $4,822.43J0717 N NRC $8.02J0720 N BNJ0725 N BNJ0735 N BNJ0740 N $623.27J0743 N BNJ0744 N BNJ0745 N BNJ0770 N BNJ0775 N NRC $48.76J0780 N BNJ0795 N NRC $9.04J0800 N NRC $3,946.50J0834 N BNJ0840 N $3,285.19J0841 N NRC $1,264.42J0850 N $1,129.15J0875 N $14.95J0878 N $0.33J0881 N $3.85




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J0882 N $3.85J0883 N $1.19J0884 N $1.19J0885 N $11.03J0887 N BNJ0888 N BNJ0894 N $7.49J0895 N BNJ0897 N $19.28J0945 N BNJ1000 N BNJ1020 N BNJ1030 N BNJ1040 N BNJ1050 N BNJ1071 N BNJ1094 N BNJ1095 N $1.19J1096 N NRC $151.41J1097 N NRC $112.35J1100 N BNJ1110 N BNJ1120 N BNJ1130 N BNJ1160 N BNJ1162 N NRC $3,780.19J1165 N BNJ1170 N BNJ1190 N $194.34J1200 N BNJ1205 N BNJ1212 N NRC $586.51J1230 N BNJ1240 N BNJ1245 N BNJ1250 N BNJ1260 N BNJ1265 N BNJ1267 N $0.89J1270 N BNJ1290 N NRC $493.74J1300 N NRC $230.48J1301 N $19.49




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J1303 N NRC $226.28J1320 N BNJ1322 N NRC $241.45J1325 N BNJ1327 N NRC $4.29J1335 N BNJ1364 N BNJ1380 N BNJ1410 N NRC $308.93J1428 N NRC $167.36J1430 N NRC $444.10J1438 N NRC $685.56J1439 N $1.10J1442 N $0.96J1447 N $0.57J1450 N BNJ1451 N NRC $8.54J1453 N $1.97J1454 N $416.87J1455 N NRC $82.27J1458 N NRC $397.92J1459 N NRC $40.12J1460 N $39.91J1555 N NRC $13.79J1556 N BNJ1557 N $45.82J1559 N NRC $10.44J1560 N $399.09J1561 N $39.14J1566 N NRC $61.20J1568 N $35.68J1569 N $37.47J1570 N BNJ1571 N $60.06J1572 N $35.59J1573 N $60.06J1575 N NRC $14.56J1580 N BNJ1595 N NRC $163.40J1599 N BNJ1602 N NRC $21.58J1610 N NRC $199.27J1626 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J1627 N $2.74J1628 N NRC $100.21J1630 N BNJ1631 N BNJ1640 N NRC $23.72J1642 N BNJ1644 N BNJ1645 N BNJ1650 N BNJ1652 N BNJ1655 N BNJ1670 N $432.66J1700 N BNJ1710 N BNJ1720 N BNJ1726 N NRC $22.40J1729 N NRC $10.81J1740 N NRC $43.48J1741 N BNJ1742 N NRC $278.77J1743 N NRC $542.89J1744 N $377.08J1745 N NRC $63.29J1746 N NRC $60.16J1750 N $14.41J1756 N BNJ1786 N NRC $42.94J1790 N BNJ1800 N BNJ1815 N BNJ1817 N BNJ1826 N $2,785.97J1830 N NRC $386.24J1833 N $0.78J1840 N BNJ1850 N BNJ1885 N BNJ1890 N BNJ1930 N $62.32J1931 N NRC $32.14J1940 N BNJ1943 N NRC $2.86J1944 N NRC $2.78




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J1950 N $1,269.23J1953 N BNJ1956 N BNJ1960 N BNJ1980 N BNJ1990 N BNJ2001 N BNJ2010 N BNJ2020 N BNJ2060 N BNJ2062 N BNJ2150 N BNJ2170 N BNJ2175 N BNJ2180 N BNJ2182 N NRC $29.72J2185 N BNJ2186 N NRC $1.79J2210 N BNJ2212 N BNJ2248 N BNJ2250 N BNJ2260 N BNJ2265 N $1.81J2270 N BNJ2274 N BNJ2278 N $7.91J2280 N BNJ2300 N BNJ2310 N BNJ2315 N NRC $3.25J2320 N BNJ2323 N NRC $20.24J2325 N NRC $74.80J2326 N NRC $1,101.83J2350 N NRC $57.42J2353 N $206.57J2354 N BNJ2355 N NRC $163.98J2357 N $36.78J2358 N BNJ2360 N BNJ2370 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J2400 N BNJ2405 N BNJ2407 N $23.78J2410 N BNJ2425 N $21.28J2426 N NRC $11.63J2430 N BNJ2440 N BNJ2469 N BNJ2501 N BNJ2502 N $303.03J2503 N BNJ2504 N NRC $367.96J2505 N $4,432.56J2507 N $2,512.55J2510 N BNJ2515 N $37.02J2540 N BNJ2543 N BNJ2547 N NRC $1.64J2550 N BNJ2560 N BNJ2562 N NRC $347.71J2590 N BNJ2597 N NRC $12.14J2650 N BNJ2675 N BNJ2680 N BNJ2690 N BNJ2700 N BNJ2704 N BNJ2710 N BNJ2720 N BNJ2724 N NRC $15.10J2730 N BNJ2760 N NRC $377.57J2765 N BNJ2770 N $417.49J2778 N NRC $352.17J2780 N BNJ2783 N $289.82J2785 N BNJ2786 N NRC $9.62




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J2788 N BNJ2790 N BNJ2791 N BNJ2792 N NRC $29.78J2794 N $10.04J2795 N BNJ2796 N NRC $74.28J2797 N $0.94J2798 N NRC $9.87J2800 N BNJ2805 N BNJ2810 N BNJ2820 N $43.44J2840 N NRC $541.13J2850 N NRC $34.78J2860 N NRC $103.06J2916 N BNJ2920 N BNJ2930 N BNJ2941 N NRC $1.67J2950 N BNJ2993 N BNJ2997 N $87.64J3000 N BNJ3010 N BNJ3030 N BNJ3031 N NRC $2.51J3060 N NRC $40.08J3070 N BNJ3090 N $1.49J3095 N NRC $5.74J3101 N $121.83J3105 N BNJ3111 N NRC $8.95J3121 N BNJ3145 N NRC $1.47J3230 N BNJ3240 N $1,695.12J3243 N $1.57J3245 N NRC $136.49J3246 N $6.92J3250 N BNJ3260 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J3262 N NRC $4.96J3265 N BNJ3285 N NRC $63.85J3300 N BNJ3301 N BNJ3302 N BNJ3303 N BNJ3304 N NRC $18.88J3310 N BNJ3315 N $258.74J3316 N $2,897.33J3350 N BNJ3357 N NRC $191.39J3358 N NRC $12.04J3360 N BNJ3364 N BNJ3370 N BNJ3380 N NRC $19.86J3385 N NRC $345.52J3396 N NRC $11.08J3397 N NRC $218.33J3398 N NRC $2,923.67J3410 N BNJ3411 N BNJ3415 N BNJ3420 N BNJ3430 N BNJ3465 N BNJ3470 N BNJ3471 N BNJ3472 N BNJ3473 N BNJ3475 N BNJ3480 N BNJ3485 N BNJ3486 N BNJ3489 N BNJ3490 N BNJ3530 N BNJ3590 N BNJ7030 N BNJ7040 N BNJ7042 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J7050 N BNJ7060 N BNJ7070 N BNJ7100 N BNJ7110 N BNJ7120 N BNJ7121 N BNJ7131 N BNJ7170 N NRC $47.35J7175 N $7.51J7177 N NRC $1.14J7178 N $1.20J7179 N NRC $1.83J7180 N $8.47J7181 N NRC $15.52J7182 N $1.31J7183 N $0.97J7185 N $1.27J7186 N $1.06J7187 N $1.16J7188 N $3.18J7189 N $2.15J7190 N $1.07J7192 N $1.25J7193 N $1.15J7194 N $1.47J7195 N $1.50J7196 N $103.35J7197 N $3.32J7198 N $1.90J7200 N $1.32J7201 N $3.11J7202 N $4.29J7203 N NRC $3.99J7205 N $2.08J7207 N NRC $1.74J7208 N $2.02J7209 N NRC $1.24J7210 N NRC $1.36J7211 N BNJ7308 N NRC $390.98J7311 N NRC $341.62J7312 N $200.03




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J7313 N NRC $490.87J7314 N NRC $491.13J7315 N BNJ7316 N NRC $1,046.93J7318 N $17.23J7320 N $16.92J7321 N BNJ7322 N $31.67J7323 N $145.08J7324 N $143.40J7325 N $11.41J7326 N NRC $1,166.00J7327 N $769.51J7328 N $2.18J7329 N $7.20J7336 N $3.15J7340 N $219.45J7342 N NRC $29.97J7345 N NRC $1.45J7500 N BNJ7501 N NRC $238.19J7502 N BNJ7503 N BNJ7504 N NRC $2,066.02J7505 N BNJ7507 N BNJ7508 N BNJ7509 N BNJ7510 N BNJ7511 N NRC $768.56J7512 N BNJ7515 N BNJ7516 N BNJ7517 N BNJ7518 N BNJ7520 N BNJ7525 N NRC $211.84J7527 N BNJ7599 N BNJ7665 N BNJ7674 N BNJ7799 N BNJ7999 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J8501 N BNJ8510 N $24.18J8520 N BNJ8521 N BNJ8530 N BNJ8540 N BNJ8560 N $75.36J8597 N BNJ8600 N BNJ8610 N BNJ8655 N $245.74J8670 N $2.12J8700 N BNJ8705 N BNJ9000 N BNJ9015 N $4,964.62J9017 N $44.31J9019 N $414.83J9022 N $77.01J9023 N $82.97J9025 N $1.16J9027 N $61.69J9030 N $2.82J9032 N $40.07J9033 N $27.84J9034 N $22.85J9035 N $81.18J9036 N $24.36J9039 N $113.40J9040 N BNJ9041 N $44.69J9042 N $162.44J9043 N $173.67J9044 N $25.04J9045 N BNJ9047 N $37.60J9050 N $3,039.01J9055 N $62.05J9057 N $79.42J9060 N BNJ9065 N $19.00J9070 N $34.14J9098 N $81.42




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J9100 N BNJ9119 N $27.45J9120 N $1,098.20J9130 N BNJ9145 N $53.95J9150 N $46.74J9153 N $192.31J9155 N $3.97J9171 N $0.87J9173 N $74.64J9175 N BNJ9176 N $6.50J9178 N BNJ9179 N $114.27J9181 N BNJ9185 N BNJ9190 N BNJ9200 N BNJ9201 N BNJ9202 N $497.72J9203 N $199.23J9204 N $200.87J9205 N $49.91J9206 N BNJ9207 N $91.07J9208 N BNJ9209 N BNJ9210 N NRC $780.05J9211 N BNJ9213 N $169.33J9214 N $34.24J9217 N $224.70J9218 N BNJ9225 N $4,085.61J9226 N NRC $36,647.60J9228 N $153.13J9229 N $2,270.31J9230 N $328.29J9245 N $610.88J9250 N BNJ9260 N BNJ9261 N $152.48J9262 N $3.11




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J9263 N BNJ9264 N $12.51J9266 N $17,566.89J9267 N BNJ9268 N $1,968.61J9269 N $258.96J9270 N BNJ9271 N $49.39J9280 N $87.75J9285 N $52.13J9293 N $27.39J9295 N $5.74J9299 N $27.81J9301 N $62.86J9302 N $60.09J9303 N $119.07J9305 N $69.47J9306 N $12.29J9307 N $291.26J9308 N $58.42J9309 N $110.36J9311 N $43.53J9312 N $94.67J9313 N $22.08J9315 N $297.59J9320 N $349.70J9325 N $51.47J9328 N $10.39J9330 N $53.14J9340 N $404.28J9351 N BNJ9352 N $312.91J9354 N $31.36J9355 N $106.62J9356 N $80.26J9357 N $1,438.59J9360 N BNJ9370 N BNJ9371 N $3,080.04J9390 N BNJ9395 N $94.87J9400 N $8.37J9600 N $21,397.87




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




J9999 N BNL8600 N BNL8603 N BNL8604 N BNL8605 N BNL8606 N BNL8607 N BNL8609 N BNL8610 N BNL8612 N BNL8613 N BNL8614 N BNL8630 N BNL8631 N BNL8641 N BNL8642 N BNL8658 N BNL8659 N BNL8670 N BNL8679 N BNL8682 N BNL8690 N BNL8699 N BNL9900 N BNP9041 N NRC $10.49P9045 N NRC $52.45P9046 N NRC $20.98P9047 N NRC $52.45Q0138 N $1.00Q0139 N NRC $1.00Q0161 N BNQ0162 N BNQ0163 N BNQ0164 N BNQ0166 N BNQ0167 N BNQ0169 N BNQ0173 N BNQ0175 N BNQ0177 N BNQ0180 N BNQ0181 N BNQ2004 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




Q2009 N $1.73Q2017 N $2,645.71Q2026 N $473.90Q2028 N $3.28Q2034 N BNQ2035 N BNQ2036 N BNQ2037 N BNQ2038 N BNQ2039 N BNQ2043 N NRC $46,374.20Q2049 N $470.40Q2050 N $355.07Q3027 N $53.58Q3031 N BNQ4100 N BNQ4101 N BNQ4102 N BNQ4103 N BNQ4104 N BNQ4105 N BNQ4106 N BNQ4107 N BNQ4108 N BNQ4110 N BNQ4111 N BNQ4112 N BNQ4113 N BNQ4114 N BNQ4115 N BNQ4116 N BNQ4117 N BNQ4118 N BNQ4121 N BNQ4122 N BNQ4123 N BNQ4124 N BNQ4125 N BNQ4126 N BNQ4127 N BNQ4128 N BNQ4130 N BNQ4132 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




Q4133 N BNQ4134 N BNQ4135 N BNQ4136 N BNQ4137 N BNQ4138 N BNQ4139 N BNQ4140 N BNQ4141 N BNQ4142 N BNQ4143 N BNQ4145 N BNQ4146 N BNQ4147 N BNQ4148 N BNQ4149 N BNQ4150 N BNQ4151 N BNQ4152 N BNQ4153 N BNQ4154 N BNQ4155 N BNQ4156 N BNQ4157 N BNQ4158 N BNQ4159 N BNQ4160 N BNQ4161 N BNQ4162 N BNQ4163 N BNQ4164 N BNQ4165 N BNQ4166 N BNQ4167 N BNQ4168 N BNQ4169 N BNQ4170 N BNQ4171 N BNQ4173 N BNQ4174 N BNQ4175 N BNQ4176 N BNQ4177 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




Q4178 N BNQ4179 N BNQ4180 N BNQ4181 N BNQ4182 N BNQ4183 N BNQ4184 N BNQ4185 N BNQ4186 N BNQ4187 N BNQ4188 N BNQ4189 N BNQ4190 N BNQ4191 N BNQ4192 N BNQ4193 N BNQ4194 N BNQ4195 N $89.70Q4196 N $104.83Q4197 N BNQ4198 N BNQ4200 N BNQ4201 N BNQ4202 N BNQ4203 N BNQ4204 N BNQ5101 N $0.57Q5103 N NRC $49.25Q5104 N NRC $53.40Q5105 N NRC $0.96Q5106 N $9.63Q5107 N $69.77Q5108 N $327.41Q5110 N $0.64Q5111 N $347.06Q5117 N $90.67Q9950 N $19.54Q9951 N BNQ9953 N BNQ9954 N BNQ9955 N BNQ9956 N BNQ9957 N BN




HCPCS Code

Subject to Multiple


Coverage Status

BWC 2020 final rate




Q9958 N BNQ9959 N BNQ9960 N BNQ9961 N BNQ9962 N BNQ9963 N BNQ9964 N BNQ9965 N BNQ9966 N BNQ9967 N BNQ9968 N NRC $6.40Q9982 N BNQ9983 N BNQ9991 N $1,673.36Q9992 N $1,673.36V2630 N BNV2631 N BNV2632 N BNV2785 N BR $0.00V2790 N BN




HCPCS Code 2020 ASC MUE10004 010005 110006 010007 110008 010009 110010 010011 110012 010021 110030 210035 010036 010040 010060 110061 110080 110081 110120 310121 210140 210160 310180 211000 111001 011010 211011 211012 211042 111043 111044 111045 011046 011047 011055 011056 011057 111102 111103 011104 111105 011106 111107 011200 011201 011300 011301 011302 011303 011305 011306 011307 311308 011310 411311 411312 3


2020 Ambulatory Surgical Center Fee ScheduleEffective 05-01-2020 MUE - Page 137 of 243


























































































































































































































































































































HCPCS Code 2020 ASC MUE90746 190747 190749 090756 091035 192920 392921 092928 392929 093451 193452 193453 193454 193455 193456 193457 193458 193459 193460 193461 193462 093566 093567 093568 093571 093572 093985 193986 10100T 10101T 10102T 20191T 20200T 10201T 10213T 10214T 00215T 00216T 10217T 00218T 00228T 10229T 00230T 10231T 00232T 00238T 20253T 10263T 10264T 10265T 10269T 10270T 10271T 10274T 10275T 10278T 0




HCPCS Code 2020 ASC MUE0290T 00308T 10313T 10314T 10315T 10316T 10330T 00331T 10332T 10335T 20338T 10339T 10342T 10347T 00348T 00349T 00350T 00351T 00353T 00356T 00376T 00379T 00394T 20395T 20396T 00397T 00400T 00401T 00402T 20408T 10409T 10410T 10411T 10412T 10413T 10414T 10415T 10416T 10419T 10420T 10421T 10422T 10424T 10425T 10426T 10427T 10428T 10429T 10430T 10431T 10432T 10433T 10434T 10437T 00439T 00440T 3




HCPCS Code 2020 ASC MUE0441T 30442T 30443T 00444T 00445T 00446T 10447T 10448T 10449T 10450T 00465T 10466T 00467T 10468T 10471T 00479T 10480T 00487T 00491T 10492T 00493T 00502T 00503T 00508T 10510T 10511T 10512T 10513T 00514T 00523T 00524T 30525T 10526T 10527T 10530T 10531T 10532T 10548T 10549T 10550T 10551T 10558T 10566T 10587T 10588T 1A9500 0A9501 0A9502 0A9503 0A9504 0A9505 0A9507 0A9508 0A9509 0A9510 0A9512 0




HCPCS Code 2020 ASC MUEA9515 0A9516 0A9520 0A9521 0A9524 0A9526 0A9527 195A9528 0A9529 0A9531 0A9532 0A9536 0A9537 0A9538 0A9539 0A9540 0A9541 0A9542 0A9546 0A9547 0A9548 0A9550 0A9551 0A9552 0A9553 0A9554 0A9555 0A9556 0A9557 0A9558 0A9559 0A9560 0A9561 0A9562 0A9566 0A9567 0A9568 0A9569 0A9570 0A9571 0A9572 0A9575 0A9576 0A9577 0A9578 0A9579 0A9580 0A9581 0A9582 0A9583 0A9584 0A9585 0A9586 1A9587 0A9588 0A9590 1




HCPCS Code 2020 ASC MUEA9597 0A9598 0A9698 0A9700 0C1713 0C1714 0C1715 0C1716 4C1717 10C1719 99C1721 0C1722 0C1724 0C1725 0C1726 0C1727 0C1728 0C1729 0C1730 0C1731 0C1732 0C1733 0C1734 1C1749 0C1750 0C1751 0C1752 0C1753 0C1754 0C1755 0C1756 0C1757 0C1758 0C1759 0C1760 0C1762 0C1763 0C1764 0C1765 0C1766 0C1767 0C1768 0C1769 0C1770 0C1771 0C1772 0C1773 0C1776 0C1777 0C1778 0C1779 0C1780 0C1781 0C1782 0C1783 0C1784 0




HCPCS Code 2020 ASC MUEC1785 0C1786 0C1787 0C1788 0C1789 0C1813 0C1814 0C1815 0C1816 0C1817 0C1818 0C1819 0C1820 0C1821 0C1822 0C1823 1C1824 1C1830 0C1839 1C1840 0C1841 0C1842 0C1874 0C1875 0C1876 0C1877 0C1878 0C1880 0C1881 0C1882 0C1883 0C1884 0C1885 0C1886 0C1887 0C1888 0C1889 0C1890 1C1891 0C1892 0C1893 0C1894 0C1895 0C1896 0C1897 0C1898 0C1899 0C1900 0C1982 1C2596 1C2613 0C2614 0C2615 0C2616 1C2617 0C2618 0




HCPCS Code 2020 ASC MUEC2619 0C2620 0C2621 0C2622 0C2623 0C2624 0C2625 0C2626 0C2627 0C2628 0C2629 0C2630 0C2631 0C2634 24C2635 124C2636 690C2638 150C2639 150C2640 150C2641 150C2642 120C2643 120C2645 4608C2698 1C2699 1C5271 1C5272 0C5273 1C5274 0C5275 1C5276 0C5277 1C5278 0C8900 1C8901 1C8902 1C8903 1C8905 1C8906 1C8908 1C8909 1C8910 1C8911 1C8912 1C8913 1C8914 1C8918 1C8919 1C8920 1C8931 1C8932 1C8933 1C8934 2C8935 2C8936 2C9046 160




HCPCS Code 2020 ASC MUEC9047 1C9054 1C9055 1C9113 0C9132 5500C9248 0C9250 1C9254 0C9257 5C9285 0C9290 266C9293 0C9352 0C9353 0C9354 0C9355 0C9356 0C9358 0C9359 0C9360 0C9361 0C9362 0C9363 0C9364 0C9399 1C9460 1C9462 600C9482 150C9488 20C9600 3C9601 0C9725 1C9726 0C9727 1C9728 1C9738 0C9739 1C9740 1C9745 2C9747 1C9749 1C9752 1C9753 0C9754 1C9755 1C9757 1G0104 1G0105 1G0121 1G0130 1G0186 1G0260 2G0276 1G0429 1G0516 0G0517 0




HCPCS Code 2020 ASC MUE

G0518 0J0120 0J0121 1J0122 1J0129 100J0130 0J0131 0J0132 0J0133 0J0135 8J0153 0J0171 0J0178 4J0179 1J0180 125J0185 130J0202 12J0207 4J0210 0J0220 1J0221 250J0222 1J0256 1600J0257 1400J0278 0J0280 0J0282 0J0285 0J0287 50J0289 50J0290 0J0291 1J0295 0J0300 8J0330 0J0348 0J0360 0J0390 0J0400 0J0401 400J0456 0J0461 0J0470 0J0475 8J0476 0J0480 1J0485 1500J0490 160J0500 0J0515 0J0517 30J0558 24J0561 24J0565 200J0567 300J0570 4




HCPCS Code 2020 ASC MUEJ0583 0J0584 90J0585 600J0586 300J0587 300J0588 600J0592 0J0593 1J0594 320J0595 0J0596 840J0597 250J0598 100J0599 900J0600 3J0606 150J0610 0J0620 0J0630 1J0636 0J0637 0J0638 150J0640 0J0641 1200J0642 1J0670 0J0690 0J0692 0J0694 0J0695 60J0696 0J0697 0J0698 0J0702 0J0706 0J0712 120J0713 0J0714 4J0715 0J0716 4J0717 400J0720 0J0725 0J0735 0J0740 2J0743 0J0744 0J0745 0J0770 0J0775 180J0780 0J0795 100J0800 3J0834 0J0840 6J0841 20








































HCPCS Code 2020 ASC MUEJ9328 400J9330 50J9340 4J9351 0J9352 40J9354 600J9355 105J9356 60J9357 4J9360 0J9370 0J9371 5J9390 0J9395 20J9400 500J9600 4J9999 0L8600 0L8603 0L8604 0L8605 0L8606 0L8607 0L8609 0L8610 0L8612 0L8613 0L8614 0L8630 0L8631 0L8641 0L8642 0L8658 0L8659 0L8670 0L8679 0L8682 0L8690 0L8699 0L9900 0P9041 5P9045 20P9046 25P9047 20Q0138 510Q0139 510Q0161 0Q0162 0Q0163 0Q0164 0Q0166 0Q0167 0Q0169 0Q0173 0Q0175 0Q0177 0





Q0180 0Q0181 0Q2004 0Q2009 100Q2017 12Q2026 45Q2028 1470Q2034 0Q2035 0Q2036 0Q2037 0Q2038 0Q2039 0Q2043 1Q2049 14Q2050 14Q3027 30Q3031 0Q4100 0Q4101 0Q4102 0Q4103 0Q4104 0Q4105 0Q4106 0Q4107 0Q4108 0Q4110 0Q4111 0Q4112 0Q4113 0Q4114 0Q4115 0Q4116 0Q4117 0Q4118 0Q4121 0Q4122 0Q4123 0Q4124 0Q4125 0Q4126 0Q4127 0Q4128 0Q4130 0Q4132 0Q4133 0Q4134 0Q4135 0Q4136 0Q4137 0Q4138 0Q4139 0Q4140 0Q4141 0Q4142 0





Q4143 0Q4145 0Q4146 0Q4147 0Q4148 0Q4149 0Q4150 0Q4151 0Q4152 0Q4153 0Q4154 0Q4155 0Q4156 0Q4157 0Q4158 0Q4159 0Q4160 0Q4161 0Q4162 0Q4163 0Q4164 0Q4165 0Q4166 0Q4167 0Q4168 0Q4169 0Q4170 0Q4171 0Q4173 0Q4174 0Q4175 0Q4176 0Q4177 0Q4178 0Q4179 0Q4180 0Q4181 0Q4182 0Q4183 0Q4184 0Q4185 0Q4186 0Q4187 0Q4188 0Q4189 0Q4190 0Q4191 0Q4192 0Q4193 0Q4194 0Q4195 1Q4196 1Q4197 0Q4198 0Q4200 0Q4201 0





Q4202 0Q4203 0Q4204 0Q5101 1500Q5103 150Q5104 150Q5105 100Q5106 60Q5107 170Q5108 12Q5110 1500Q5111 12Q5117 1Q9950 5Q9951 0Q9953 0Q9954 0Q9955 0Q9956 0Q9957 0Q9958 0Q9959 0Q9960 0Q9961 0Q9962 0Q9963 0Q9964 0Q9965 0Q9966 0Q9967 0Q9968 1Q9982 0Q9983 0Q9991 1Q9992 1V2630 0V2631 0V2632 0V2785 2V2790 0



Ohio Bureau of Workers' Compensation 2020 Ambulatory Surgical Center Services

STATE NPI 2020 ASCs Determined to Not Meet Quality Requirements Under CMS ASCQR

AK 1205892197ALASKA SURGERY CENTER LIMITED PARTNERSHIP DBA ALASKA SURGERY CENTER HEALTHSOUTH

AK 1912202896 ALASKA EYE SURGERY AND LASER CENTER INCAR 1457379364 JONESBORO SURGERY CENTER LLCAR 1578643607 PAIN CENTER LLCAR 1730132853 OUTPATIENT SURGERY CENTER INCAR 1831182641 MERCY AMBULATORY SURGERY CENTER LLCAZ 1013195569 DESERT MIRAGE SURGERY CENTERAZ 1104957869 AZ PAIN CENTERSAZ 1528284767 MESA SURGICAL CENTER LLCAZ 1598968927 ORTHOPEDIC CLINIC ASSOCIATION AMB SURG CENTER THEAZ 1639431653 DESERT CLIFFS SURGERY CENTER LLCAZ 1811940398 DESERT SUN SURGERY CENTER LLCAZ 1851531248 LASER SURGERY HOLDING COMPANY LTDAZ 1871513705 SQUAW PEAK SURGICAL FACILITY INCCA 1023365913 PACIFIC SURGERY CTRCA 1033368378 MISSION ENDOSCOPY CENTER INCCA 1033448782 ENDOSCOPY SURGERY CENTER OF SILICON VALLEY LLCCA 1073794855 SURGICARE OF LA VETA LTD DBA BARRANCA SURGERY CENTERCA 1093847311 SURGICAL EYE CARE CENTER INCCA 1124439419 RANCHO CORDOVA SURGERY CENTER LLCCA 1154554160 CABRILLO SURGERY CENTERCA 1194913103 LASERVUE EYE CENTER MEDICAL CORPORATIONCA 1215019625 FOUR SEASONS SURGERY CENTERS OF ONTARIO LPCA 1215238076 KNOWLES SURGERY CENTER LLCCA 1225123227 COMPREHENSIVE PAIN MANAGEMENT CENTER INCCA 1225245723 FRESNO ENDOSCOPY CENTERCA 1245393602 PACIFIC COAST SPINE INSTITUTE AND PAIN CENTERCA 1285028803 PALOS VERDES SKIN SURGERY CTR INCCA 1295897585 FOLSOM SIERRA ENDOSCOPY CENTER LPCA 1295918977 WEST COAST CENTER FOR SURGERIESCA 1366485385 WEBSTER SURGERY CENTER LPCA 1366635609 APPLE SURGERY CENTER INCCA 1396005823 LDAC SURGERY CENTER INCCA 1407932619 PACIFIC EYE INSTITUTE A MEDICAL GROUP INCCA 1447352737 SAMARITAN ENDOSCOPY CENTERCA 1497130660 NIVANO AMBULATORY SURGERY CENTER LPCA 1497705883 MISSION AMBULATORY SURGICENTER LTDCA 1528473030 UNICARE SURGERY CENTER A MEDICAL CORPORATIONCA 1558514158 BAKERSFIELD SURGERY CENTER LLCCA 1578505079 TRUXTUN SURGERY CENTER INCCA 1669660817 SPH IRVINE LLCCA 1679913552 SPINE SPORTS SURGERY CENTER LLCCA 1730514027 KY ADVANCED SURGICAL CENTER INCCA 1740318153 PLAZA SURGERY CENTER LP DBA PLAZA SURGERY CENTERCA 1750553376 SAN MATEO SURGERY CENTER LLCCA 1760423180 CENTRAL COAST ENDOSCOPY CENTER INC

Ohio BWC2020 Ambulatory Surgical Center Services

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CA 1861760670 PAIN CARE PROVIDERS A PROFESSIONAL MEDICAL CORPORATIONCA 1912362955 ST CHARLES SURGICAL CENTERCA 1922027176 SAN DIEGO EYE COR INCCA 1942335468 INNOVATIVE PAIN TREATMENT SURGERY CENTER OF TEMECULA INCCA 1982931465 GARDEN GROVE SURGICAL CENTER INCCO 1215981113 ENGLEWOOD SURGERY CENTER LLCCO 1356610174 CHERRY CREEK SURGERY CENTER LLCCO 1437549359 CENTER OF SURGICAL EXCELLENCE LLCCO 1871602227 THE MOHS CENTERCO 1922005610 EYE SURGERY CENTER OF COLORADO PCCT 1023113701 SURGICAL CENTER OF CONNECTICUT LLCCT 1386794980 NEW VISION CATARACT CENTER LLC DBA NEW VISION CATARACT CENTERCT 1811318785 CONNECTICUT ORTHOPAEDIC SPECIALISTS OUTPATIENT SURGICAL CENTER LLCFL 1164719209 BLUE WATER SURGERY CENTERFL 1265407142 NAPLES DAY SURGERY LLC DBA NAPLES DAY SURGERY SOUTHFL 1265494553 CORAL VIEW SURGERY CENTER LLCFL 1295793974 SANTA LUCIA SURGICAL CENTER LLCFL 1336100189 ST MICHAELS SURGERY CENTER INCFL 1386654630 BERAJA HEALTHCARE CORPORATIONFL 1467405837 PARKCREEK SURGERY CENTER LLLPFL 1467783688 PREMIER SURGICAL CENTER LLCFL 1477526143 UNIVERSITY EYE SURGERY CENTERFL 1578917035 HABANA AMBULATORY SURGERY CENTER LLCFL 1669803391 SURGERY CENTER OF VIERA LLCFL 1750313144 AMBULATORY SURGICAL CARE LLCFL 1770528838 BREVARD SURGERY CENTERFL 1790761393 ST. LUCIE SURGICAL CENTER PAFL 1891184826 SURGICAL CENTER OF NORTH FLORIDA LLCGA 1215204128 MINIMALLY INVASIVE NEUROSPINE AND PAIN INSTITUTE PCGA 1285083477 GEORGIA INTERVENTIONAL PAIN B LLCGA 1326494147 CENTER FOR SPINE AND PAIN MEDICINE PC DBA CSPM GAINESVILLE ASCGA 1356732804 ATHENS DIGESTIVE ENDOSCOPY CENTERGA 1417217183 PAULSEN STREET SUGERY CENTER LLCGA 1437250248 GEORGIA SURGICAL CENTER ON PEACHTREE LLCGA 1508210378 APEX MEDICAL SURGERY CENTER LLCGA 1679894505 AP SURGERY CENTER LLCGA 1700943958 LOWNDES COUNTY AMBULATORY SURGICAL CENTERGA 1801110275 GA PAIN MANAGEMENT CENTER LLCGA 1861491987 THE PLASTIC SURGERY CENTER LAND LLCHI 1952366874 HONOLULU SURGERY CENTER LP DBA SURGICARE OF HAWAIIIA 1386624815 QUALITY CARE CLINIC AND SURGICENTERIL 1205964103 FULLERTON KIMBALL MEDICAL & SURGICAL CENTERIL 1275599086 BELLEVILLE SURGICAL CENTER LTDIL 1275933756 BELLEVILLE SURGICAL CENTER LTDIL 1356412894 ROCKFORD ORTHOPEDIC SURGERY CENTER LLCIL 1487612024 QUAD CITY AMBULATORY SURGERY CENTER LLCIL 1548390081 ADVANCED AMBULATORY SURGICAL CENTER INC


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IL 1568426260 PEORIA DAY SURGERY CENTER SCIN 1033190566 RIVERPOINTE SURGERY CENTERIN 1063556421 MEMORIAL SPINE AND NEUROSCIENCE CENTERIN 1700854072 SULLIVAN SURGICENTER LLCIN 1831508357 CLEARVIEW EYE SURGERY CENTER LLCIN 1902134372 METRO SPECIALTY SURGERY CENTER LLCIN 1942637301 MICHIANA SURGERY CENTER LLCKS 1316043631 VIA CHRISTI CLINIC PALA 1851686596 ADVANCED PAIN INSTITUTE TREATMENT CENTER LLCMA 1851491013 NEW ENGLAND AMBULATORY SURGICENTER LLCMD 1033524855 KENT ISLAND SURGERY CENTER LLCMD 1083624225 UNIVERSITY OF MARYLAND UROLOGICAL SURGERY CENTERMD 1124492996 MOHS AND SKIN SURGERY CENTER LLCMD 1336288224 EYE SURGERY CENTER OF WHITE MARSH LLCMD 1346215316 CHESAPEAKE EYE SURGERY CENTER LLCMD 1508813197 ENDOSCOPY CENTER AT TOWSON INCMD 1598756306 YORK GREEN SURGERY CENTER LLCMD 1629016076 UNIVERSITY CENTER FOR AMBULATORY SURGERY LLCMD 1649501073 SHORE HEALTH SYSTEM INCMD 1710959556 SURGERY CENTER OF ROCKVILLE LLCMD 1790871184 MID- ATLANTIC NEUROSURGICAL ASSOCIATES PAIN CENTERMD 1831489335 HAGERSTOWN SURGERY CENTER LLCMD 1851369615 OPHTHALMOLOGY ASSOCIATES LLCMD 1871751859 WESTMINSTER SURGERY CENTERMD 1902220627 FREDERICK FOOT AND ANKLE ASC LLCMD 1902991979 WESTERN MARYLAND EYE SURGICAL CENTERME 1558456459 PORTLAND ENDOSCOPY CENTERMI 1013385046 INTERVENTIONAL PAIN CENTER PLLCMI 1023358116 OAKLAND PHYSICAN SURGERY CENTERMI 1255342366 MILLMANDERR CENTER FOR EYE CARE PCMI 1861947558 MINIMALLY INVASIVE ASC DBA FLINT REGION ASCMO 1003171745 MIDWEST SURGERY CENTER LLCMO 1023428281 HEARTLAND REGIONAL MEDICAL CENTERMO 1811028293 PHYSICIANS SURGERY CENTERMS 1487094058 COMPREHENSIVE PAIN CENTER FOR SURGERYMS 1508922865 INSTITUTE FOR SPINAL PAIN TREATMENTMS 1720161771 EYE CARE SURGERY CENTER OF OLIVE BRANCHLLCMS 1780767673 EYE CARE SURGERY CENTER OF SOUTHAVEN LLCNJ 1255376653 ENDOSCOPY CENTER OF SOUTH JERSEY P CNJ 1356643944 UNION SURGERY CENTER LLCNJ 1437512514 NEW CENTURY SPINE AND OUTPATIENT SURGICAL INSTITUTENJ 1518286681 LIBERTY AMBULATORY SURGERY CENTER LLCNJ 1538199799 MIDDLESEX SURGERY CENTER LLCNJ 1821242488 SPECIALTY SURGICAL CENTER OF NORTH BRUNSWICK LLCNJ 1912909433 CENTENNIAL SURGERY CENTERNJ 1972556900 GLEN RIDGE SURGI CENTERNV 1386004018 COPPEL SURGICAL SOLUTIONS DBA NEVADA SURGICAL SUITES EAST


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NV 1942318498 DIGESTIVE DISEASE CENTERNY 1033517263 ISLAND AMBULATORY SURGERY CENTERNY 1104125939 GASTROENTEROLOGY CARE INCNY 1164516084 ENDOSCOPIC AMBULATORY SPECIALTY CENTER OF BAY RIDGE INCNY 1164793725 HUDSON VALLEY CENTER FOR DIGESTIVE HEALTH LLCNY 1477645711 PROGRESSIVE SURGERY CENTER LLCNY 1598039125 ROOSEVELT SURGERY CENTER LLC DBA MANHATTAN SURGERY CENTERNY 1841213923 NORTH SHORE SURGI CENTER INCNY 1841222353 PRO HEALTH DAY OP OF MINEOLANY 1851717383 NYEEQ ASC LLC DBA NORTH QUEENS SURGICAL CENTERNY 1972980415 CENTRAL NEW YORK ASC DBA OMNI OUTPATIENT SURGERY CENTEROH 1104835776 MID OHIO SURGERY CENTEROH 1154412757 SURGICENTER LTDOH 1396812491 VALLEY ENDOSCOPY CENTER INCOH 1407247208 COLONOSCOPY AND ENDOSCOPY CENTER LLCOH 1619257409 ASHTABULA SURGERY CENTER LLCOH 1700815552 SURGCENTER HUDSON LLCOH 1760470942 SAMARITAN NORTH SURGERY CENTER LTDOH 1831287580 CLINTON COUNTY OUTPATIENT SURGERY INCOH 1891793915 NORTHEAST OHIO SURGERY CENTER LLCOR 1437320017 OREGON EYE SURGERY CENTER INCOR 1851520514 CAPITOL SURGERY CENTER LLC DBA WAVERLY LAKE SURGERY CENTEROR 1912045154 CROISAN RIDGE SURGERY CENTER LLCPA 1043281660 UPMC MONROEVILLE SURGERY CTRPA 1053356436 SURGERY CENTER AT EDGEWORTH COMMONSPA 1134241946 BERKS AMBULATORY SURGERY CENTER LLCPA 1366647968 NORTH POINTE SURGERY CENTER LPPA 1467535773 AMBULATORY ENDOSCOPIC SURGICAL CENTER OF BUCKS COUNTY LLCPA 1487699385 BRANDYWINE VALLEY ENDOSCOPY CENTERPA 1629409578 PAIN CENTER OF WYOMING VALLEY LLCRI 1811168164 UROLOGIC SPECIALISTS OF NEW ENGLAND LLCSC 1932132065 THE SURGERY CENTER OF AIKEN LLCTN 1396828323 EYE CARE SURGERY CENTER OF MEMPHIS LLCTN 1538139811 SAINT THOMAS OUTPATIENT NEUROSURGICAL CENTERTN 1619071214 PREMIER RADIOLOGY PAIN MANAGEMENT CENTERTX 1063586105 DKJJ INC DBA REAGAN EYE CENTERTX 1083000715 CLEBURNE ENDOSCOPY CENTER LLCTX 1083038186 FRISCO AMBULATORY SURGERY CENTER LLCTX 1205267341 SURGCENTER OF WESTOVER HILLS LLCTX 1306199757 SONTERRA PROCEDURE CENTER LLCTX 1376540096 DEHAVEN CATARACT SURGICAL CENTER INCTX 1437505948 WATER LEAF SURGERY CENTER LTDTX 1497767149 PEARLAND PREMIER SURGERY CENTER LTDTX 1548374267 DALLAS SURGI CENTER INCTX 1558782268 HOUSTON SURGERY CENTER

TX 1609206614HURST AMBULATORY SURGERY CENTER LLC DBA PRECINCT AMBULATORY SURGERY CENTER LLC


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TX 1841397171 SUMMIT ASC LLPTX 1861869869 BLUE STAR SURGERY CENTER LLCVA 1598786477 OSTEOPATHIC SURGICAL CENTERS LLCWA 1083785398 OLYMPIA ORTHOPAEDIC ASSOCIATES PLLCWA 1164976478 THE DOCTORS CLINIC ASC THE FRANCISCAN MEDICAL GROUPWA 1225230634 VALLEY EYE AND LASER CENTER INCPSWA 1528000155 SOUND UROLOGICAL ASSOCIATES PSWA 1588743009 VALLEY GASTROENTEROLOGY PSWA 1720111792 BELLEVUE SPINE SPECIALISTWA 1891722609 EYE MDS OF PUGET SOUND PLLCWV 1447286562 ANWAR EYE CENTER INCWV 1992896310 JERRY N BLACK SURGICAL SUITE


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Documents

Ohio Bureau of Workers' Compensation ACTION: Original …codes.ohio.gov/pdf/oh/admin/2020/4123-6-37.3_ph_of_a_app2_20200228_1118.pdfThe BWC 2020 Ambulatory Surgical Center Fee Schedule