Wyo. Code R. 053-0021-9
Workers' Compensation Division
Chapter 9: Fee Schedules
Effective Date: 04/02/2004 to 09/30/2005
Rule Type: Superceded Rules & Regulations
Reference Number: 053.0021.9.04022004
Section 1. Medical, Surgery Center, and Hospital Fee Schedule. The Administrator adopts the Relative Values for Physicians (RVP), as published by Ingenix Inc., as authored by Relative Value Studies, Inc., insofar as it addresses medical matters compensable under the Act unless otherwise defined in this chapter. Such adoption shall be the current edition as of the first day of each calendar year unless the Administrator gives written notice to the contrary. Notice shall be given to all currently participating providers. Adoption is contingent upon the date of receipt of the RVP and testing / validation of the electronic data file. Fees in all cases must conform to the applicable edition of the Relative Values for Physicians. This RVP establishes fees determined to be fair compensation with a usual time of follow-up for care to injured workers.
Section 2. Dental Treatment and Fee Schedule. The Administrator adopts the Relative Values for Dentists (RVD), as published and authored by Relative Value Studies, Inc., Denver, Colorado. Such adoption shall be the current edition as of the first day of each calendar year unless the Administrator gives written notice to the contrary. Notice shall be given to all active providers. Adoption is contingent upon the date of receipt of the RVD and testing/validation of the electronic data file.
Section 3. Conversion Factors. The Administrator adopts the following conversion factors.
| SPECIALTY GROUP | CONVERSION FACTOR |
|---|---|
| Anesthesia | $ 39.41 |
| Surgery | $ 99.48 |
| Radiology/Nuclear Medicine | $ 20.50 |
| Pathology/Laboratory | $ 15.23 |
| Medicine | $ 6.15 |
| Physical Medicine and Chiropractic | $ 5.32 |
| Dental | $ 25.00 |
Section 4. Fees for Ambulance Service - Air. Air transports are furnished when the injured worker's medical condition requires rapid transport to a treatment facility and transport by ground ambulance is not appropriate because of the injured worker's condition. The base rate includes all personnel, infection control, EKG, oximetry and standard disposable supplies.
Section 5. Fees for Ambulance Service - Ground. Ambulance services shall be assigned to one of the three following categories. The base rate includes all personnel, infection control, EKG, oximetry and standard disposable supplies.
(a) The Basic Life Support (BLS) base rate of $230.00 shall apply if the injured worker:
(i) requires the establishment of an IV line; or (ii) is unable to get up from bed without assistance; or (iii) is unable to ambulate or sit in a chair or wheelchair.
(b) The Basic Life Support - Emergency (BLS-E) rate of $282.00 shall apply if the injured worker presents with a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the injured worker's health in serious jeopardy.
(c) The Advanced Life Support, level 2 (ALS-2) base rate of $463.00 shall apply if the injured worker requires the administration of three or more different medications and the provision of at least one of the following ALS procedures:
(i) manual defibrillation/cardioversion or (ii) endotracheal intubation; or (iii) cardiac pacing; or (iv) chest decompression; or (v) surgical airway.
(d) The mileage rate for all categories of ground ambulance services is $5.00 per loaded statute mile.
(e) The Division shall pay the following in addition to the base rate.
(i) intravenous procedure and all supplies/solutions: $30.00
(ii) spinal immobilization (head locks, c-collar, and backboard) includes all supplies: $92.00
(iii) oxygen and all supplies used in the delivery of oxygen including, but not limited to, tubing, mask or cannula: $50.00
(iv) services or supplies not defined here and not having a Medicare HCPCS rate, shall be paid at 80% of the billed amount. Charges deemed excessive may require additional documentation.
(a) Physicians billing for compounding drugs must provide the pharmacy invoice. The provider shall receive invoice cost and may be allowed a handling fee.
(b) Compounding pharmacies who bill directly, shall be compensated for the drugs prescribed and related materials. The Division may allow a professional fee for compounding services.
(c) The Division may utilize its Medical Advisor(s) to determine reasonable and appropriate payment for the charges.
(a) The Division shall pay 130% of the supplier's/manufacturer's invoice price when the provider submits the invoice to the Division.
(b) The Division adopts the HCPCS code, V5160, for hearing aid dispensing services. The Division shall pay $300.00 when coded and documented appropriately.
(c) The Division adopts the Wyoming Medicare rate for payment of frames and lenses as prescribed for compensable vision loss, or for replacement due to a work-related accident.
(d) The Division shall reimburse an injured worker for the repair or comparable replacement of a hearing aid device or prescription lens damaged or destroyed in a work-related accident.
(a) The Division adopts the following fee schedule guidelines for home health nursing. This fee schedule is for long term daily care at home. This is a straight fee, no overtime, holiday rate, or shift differential shall be paid.
| Type of Nursing | Hourly Rate |
|---|---|
| RN | $35.00 |
| LPN | $35.00 |
| CNA | $16.00 |
| Attendant* | *Federal minimum wage |
*Attendant care includes personal care for activities of daily living. A physician prescription and time limit is required. Attendant care shall be provided by individuals approved by the primary treating health care provider.
Section 9. Fees for Independent Medical Evaluations (IME), Permanent Partial Impairment Ratings (PPI), Medical Testimony and Deposition(s). See Chapter 10, Sections 13 and 14 of these Rules. Bills must indicate time spent.
(a) The Division shall pay Independent Medical Evaluations or Impairment Ratings according to the following fee schedule:
| CODE | TIME | PAYMENT |
|---|---|---|
| 99455-99456 | 1st hour | $500.00 |
| Each additional 15 minutes | 62.50 |
(b) The Division shall pay medical testimony and deposition charges according to the following fee schedule:
| CODE | TIME | PAYMENT |
|---|---|---|
| (c) | ||
| 99075 | 1st hour | $500.00 |
| Each additional 15 minutes | $ 62.50 |
Section 10. Fees for Pharmaceuticals. Payment for prescribed drugs shall be determined by using the following formula: 'The Redbook' average wholesale price, plus $5.00 dispensing fee per prescription item. Pharmaceuticals must be billed with a National Drug Code (NDC).
Over the counter items that do not have a valid NDC number shall be considered supplies and will not be paid with an added dispensing fee. See Section 11 of this chapter.
(b) When a generic equivalent exists for a prescribed brand name drug, the Division shall only pay for the medication with the lowest Redbook price.
(c) See Chapter 10, Section 23 of these Rules for general guidelines.
(a) The Division adopts the Wyoming Medicare rate of the Healthcare Common Procedure Coding System (HCPCS) for the payment of supplies, DME, orthotics and prosthetic devices prescribed by a health care provider. Such adoption shall be effective on the first day of each calendar year unless the Administrator gives written notice to the contrary. Notice shall be given to all currently participating providers. Adoption is contingent upon the date of receipt of Medicare data and testing/validation of the data file. See Chapter 9 Section 1 of these Rules for additional guidelines.
(b) Any related charges for supplies, DME, orthotics and prosthetics not listed in the Medicare HCPCS fee schedule shall be paid at eighty percent (80%) of billed charges. Charges deemed excessive may require additional documentation for justification. The preceding fees are not intended to address newly developed items or technologies. The Division may utilize its medical advisors in establishing specific fee schedules for such items.
(c) The Division shall not pay for any supplies, DME, orthotics, or prosthetics unless prescribed by the primary health care provider..
(d) Fees for Prosthetic and Orthotic Evaluation and Management.
| Code | Description | Fee |
|---|---|---|
| L8499 | Unlisted procedure for miscellaneous prosthetic services. | $20.00/15 minutes |
| L2999 | Lower extremity orthoses, not otherwise specified. | $20.00/15 minutes |
| L3999 | Upper limb orthosis, not otherwise specified. | $20.00/15 minutes |
| L7520 | Repair of prosthetic device, labor component. | $20.00/15 minutes |
| L4205 | Repair of orthotic device, labor component. | $20.00/15 minutes |
Surgical Assistants.
MD assistants shall be paid 20% of the surgical allowance.
(ii) non-MD assistants shall be paid 15% of the surgical allowance.
Spinal Procedures:
Bilateral posterior spinal procedures shall be paid at the code value for the first side and as an additional interspace for the opposite side unless billed on a bilateral code;
Microscopes used per a surgeon's preference for routine laminectomies and discectomies are not compensable.;
(A) The Division shall consider payment of the microscope, if the surgeon determines it is necessary to improve the surgical outcome. Use of the microscope must be recorded and justified in the operative report.
Removal of posterior segmental fixation with exploration shall be paid as a single procedure under code 22853 at 18 units.
The Division shall not pay for the repair of the dura if cut during a routine laminectomy.
Spinal fusions with instrumentation shall be paid using the following codes. Multiple procedure guidelines apply.
(A) Decompression Laminectomy - Bilateral.
| Code | Description |
|---|---|
| 63045 | Cervical |
| 63046 | Thoracic |
| 63047 | Lumbar |
| 63048 Additional Interspace |
(B) Segmental Fixation (Posterior).
| Code | Description |
|---|---|
| 22842 | Posterior, less than 7 segments |
(C) Arthrodesis (Posterior).
| Code | Description |
|---|---|
| 22600 | Cervical |
| 22610 | Thoracic |
| 22612 | Lumbar |
| 22614 | Additional Interspace |
| 22630 | Lumbar |
| 22632 | Additional Interspace |
| 22851 | Will not be paid when 22612, 22630, 22842, 63047 are billed. |
(D) Arthrodesis (Anterior). Paid at 80% if part of an anterior/posterior procedure
| Code | Description |
|---|---|
| 22554 | Cervical |
| 22556 | Thoracic |
| 22258 | Lumbar |
| 22585 | Additional Interspace |
Knee Procedures.
| Code | Description | Unit |
|---|---|---|
| 27425 | Lateral Release, any method | 12 |
| With additional procedure | 6 | |
| 29877.01 | Extensive Chondroplasty | 18 |
Guyon's Canal Release. Guyon's canal release shall be included in code 64721 as an incidental procedure if NOT diagnosed before surgery
| Code | Description |
|---|---|
| 64719 | Ulnar nerve at wrist |
| 64721 | Median nerve at carpal tunnel |
(e) Capsular Shrinkage Procedure. (Multiple procedure guidelines apply.)
| Code | Description | Unit |
|---|---|---|
| 29820.05 | Shoulder | 16.4 |
| 29838.05 | Elbow | 13.8 |
| 29845.05 | Wrist | 10.7 |
| 29860.05 | Hip | 15.6 |
| 29877.05 | Knee | 17.6 |
| 29895.05 | Ankle | 12.0 |
(f) Diskograms. Codes 62290 and 62291 shall be paid per code unit value for the primary level and at 80% of the code unit value for each additional level. Codes 72285 and 72295 shall be paid as a single service.
(g) IDET Procedure (includes fluoroscopy).
| Code | Description | Fee |
|---|---|---|
| 69999 | 1st disc interspace | $1,426.00 |
| 69999.01 | Each additional disc and/or bilateral interspace performed at the same time | $1,140.80 |
(h) Neurotomy, Rhizotomy. The injection of anesthetic, antispasmodic, contrast or steroids are included in the procedure.
| Code | Description |
|---|---|
| Unit | |
| 64999 | 1st level |
| 4 | |
| 64999.01 | Each additional level and/or bilateral side |
| 3.2 |
(a) Injections / Professional Fees.
(i) Anesthesia services where time units are not allowed, as defined in the anesthesia specialty section of the RVP guidelines, shall be paid at the anesthesia conversion rate when an individual health care provider performs the total procedure.
(ii) Unit values of these procedures shall revert to those found in the surgery section of the RVP when two health care providers perform the total service.
(a) Injections and IV Sedation. Fees include pre and post injection services.
(i) Injections.
| Procedure | Without Fluroscopy | With Fluroscopy |
|---|---|---|
| Nursing Time | $ 45.00 | $ 70.00 |
| Supplies and Medication | $ 24.00 | $ 82.50 |
| C-arm | $ 0.00 | $ 77.90 |
| General, Admin., Deprec. | $222.00 | $222.00 |
| TOTAL | $291.00* | $452.40* |
* The Division shall pay 25% of the base value for each additional level.
(ii) IV Sedation. Documented IV sedation shall be paid as follows:
| Procedure | Fee |
|---|---|
| Nursing Increments | $ 25.00 |
| Supplies and Medication | $100.00 |
Room Rate
50% of Wyoming average room rate.
Surgery Centers. Single procedures shall be paid per the listed reimbursement rates. Multiple procedures in the same anatomical surgical site shall be paid 100% of the reimbursement rates for the primary procedure and 30% of the reimbursement rates for each additional procedure. Bilateral procedures shall be paid at 100% of the reimbursement rates for the first surgical area and 50% of the reimbursement rate for the bilateral side. Multiple procedure guidelines apply. Documentation must be sent with each bill supporting the medical necessity for overnight stays. For overnight stay facility fee, use code 19999. Payments shall be made based upon the Wyoming's hospital average room rate.
Payment to surgery centers/surgicenters shall be made according to the following reimbursement rates:
| Procedure Codes | Surgery Center Allowable |
|---|---|
| 19999 | 470.00 |
| 10120 | 1,011.30 |
| 10121 | 750.00 |
| 10180 | 1,267.40 |
| 11010 | 1,125.75 |
| 11012, 26952 | 1,003.03 |
| 11042 | 968.00 |
| 11043 | 847.20 |
| 11044 | 1,083.60 |
| 11421 | 391.10 |
| 11423 | 935.90 |
| 11750 | 617.00 |
| 11752 | 1,371.10 |
| 11760 | 851.96 |
| 12001 | 395.40 |
| 12001, 15050 | 1,690.27 |
| 12002 | 1,324.01 |
| 12005 | 1,403.81 |
| 12020 | 1,021.90 |
| 13120 | 1,144.62 |
| 13131 | 1,105.26 |
| 13132 | 1,347.70 |
| 13160 | 955.70 |
| 13300 | 909.30 |
| 14000 | 1,367.02 |
| 14040 | 780.40 |
| 14060 | 1,649.96 |
| 15100 | 1,747.80 |
| 15100 15000 | 1,542.60 |
| 15120 15000 | 1,211.00 |
| 15240 11042 | 1,438.30 |
| 15620 | 1,426.00 |
|---|---|
| 15852 | 996.40 |
| 16010 | 759.20 |
| 20103 | 696.30 |
| 20525 | 967.10 |
| 20550 | 173.02 |
| 20605, 76005 | 825.00 |
| 20610 | 1,666.70 |
| 20670 | 827.20 |
| Procedure Codes | Surgery Center Allowable |
| 20680 | 972.30 |
| 20694 | 654.60 |
| 21315 | 776.60 |
| 21320 | 1,042.50 |
| 21337 | 1,051.00 |
| 21360 | 1,005.10 |
| 22100 | 1,491.85 |
| 22554 | 2,911.40 |
| 23020 | 1,623.00 |
| 23075 | 2,221.30 |
| 23076 | 1,918.60 |
| 23107 | 2,195.20 |
| 23120 | 1,460.50 |
| 23130 | 1,979.00 |
| 23130, 23120, 20551, 19999 | 3,794.48 |
| 23330 | 1,076.40 |
| 23410 | 2,865.50 |
| 23412 | 2,134.30 |
| 23412, 29805 | 2,899.25 |
| 23412, 23430, 29823, 23120 | 4,821.260 |
| 23415 | 1,835.10 |
| 23420 | 2,558.20 |
| 23430 | 2,307.60 |
| 23450 | 1,989.40 |
|---|---|
| 23455 | 2,921.50 |
| 23455, 29805 | 3,822.66 |
| 23460 | 2,688.10 |
| 23462 | 1,560.53 |
| 23465, 19999 | 3,483.43 |
| 23470 | 2,981.70 |
| 23485 | 2,509.40 |
| 23485, 29805, 19999 | 4,588.53 |
| 23490 | 2,028.20 |
| 23515 | 2,506.30 |
| 23550 | 1,842.80 |
| 23532, 19999 | 3,574.30 |
| 23585 | 2,413.00 |
| 23700 | 596.80 |
| 23929 | 4,249.66 |
| 24000 | 1,360.23 |
| Procedure Codes | Surgery Center Allowable |
| 24076 | 1,088.30 |
| 24101 | 1,355.00 |
| 24101, 24330, 19999 | 5,528.57 |
| 24102, 64718 | 1,841.95 |
| 24105 | 1,270.30 |
| 24110, 64718 | 2,155.53 |
| 24130 | 1,722.40 |
| 24147 | 2,282.90 |
| 24200 | 647.66 |
| 24201 | 1,490.50 |
| 24340 | 2,060.80 |
| 24341 | 1,892.50 |
| 24342 | 2,983.90 |
| 24350 | 1,211.70 |
| 24351 | 1,115.00 |
| 24356 | 1,266.00 |
|---|---|
| 24360 | 860.80 |
| 24430 | 4,432.44 |
| 24546 | 3,841.20 |
| 24575 | 864.50 |
| 24665 | 1,538.90 |
| 24685 | 1,822.10 |
| 25000 | 888.70 |
| 25028 | 754.60 |
| 25066 | 1,285.41 |
| 25101 | 817.20 |
| 25105 | 1,497.08 |
| 25107 | 1,327.80 |
| 25111 | 712.80 |
| 25112 | 783.60 |
| 25116 | 937.56 |
| 25120 | 996.00 |
| 25215, 19999 | 2,870.17 |
| 25215x2, 25230 | 2,727.04 |
| 25215, 29840 | 2,465.18 |
| 25230 | 1,346.62 |
| 25259 | 585.21 |
| 25263 | 2,122.30 |
| 25270 | 1,581.30 |
| 25275 | 1,259.11 |
| 25295 | 1,703.70 |
| Procedure Codes | Surgery Center Allowable |
| 25295, 25085 | 1,631.06 |
| 25301 | 966.20 |
| 25320 | 1,964.60 |
| 25320, 25670 | 3,593.27 |
| 25320, 64721, 29840, 19999 | 5,396.25 |
| 25360 | 2,352.50 |
| 25390 | 1,958.70 |
|---|---|
| 25400 | 1,921.20 |
| 25405 | 1,483.50 |
| 25447 | 1,204.60 |
| 25515 | 1,273.30 |
| 25337, 25150 | 1,731.18 |
| 25400, 29840, 19999 | 5,392.67 |
| 25440 | 2,460.14 |
| 25545 | 1,709.90 |
| 25574 | 2,386.70 |
| 25605 | 1,254.50 |
| 25605, 20690, 19999 | 3,728.10 |
| 25611 | 723.00 |
| 25611, 25660 | 1,700.01 |
| 25620 | 2,425.30 |
| 25628 | 1,468.00 |
| 25628, 19999 | 4,319.05 |
| 25645 | 1,716.30 |
| 25810 | 3,019.60 |
| 25810 x 2, 20902 | 4,736.29 |
| 25825 | 2,394.26 |
| 26011 | 1,261.20 |
| 26020 | 1,922.10 |
| 26055 | 664.20 |
| 26055, 25075 | 1,653.82 |
| 26075 | 789.70 |
| 26115 | 961.30 |
| 26116 | 925.80 |
| 26121 | 484.90 |
| 26123 | 1,747.79 |
| 26140, 11042 | 1,718.28 |
| 26145 | 1,264.60 |
| 26160 | 628.20 |
| 26230 | 563.01 |
|---|---|
| 26235 | 1,259.49 |
| Procedure Codes | Surgery Center Allowable |
| 26320 | 1,068.10 |
| 26350 | 1,330.30 |
| 26356 | 1,707.10 |
| 26370 | 1,338.90 |
| 26410 | 809.80 |
| 26418 | 1,154.50 |
| 26426 | 1,372.00 |
| 26432, 26445 | 1,576.18 |
| 26433 | 1,142.40 |
| 26434 | 2,929.84 |
| 26440 | 1,674.49 |
| 26445 | 1,270.90 |
| 26449 | 1,230.00 |
| 26460 | 482.60 |
| 26464 | 2,929.84 |
| 26480 | 1,201.40 |
| 26520 | 1,297.50 |
| 26530 | 1,681.50 |
| 26535 | 1,324.20 |
| 26540 | 1,234.50 |
| 26541 | 1,855.20 |
| 26546 | 1,954.10 |
| 26546, 20902 | 1,787.47 |
| 26548 | 2,080.30 |
| 26605 | 878.30 |
| 26607 | 1,272.10 |
| 26608 | 1,413.80 |
| 26615 | 1,525.30 |
| 26615, 20902, 26746, 19999 | 4,970.00 |
| 26665 | 1,657.40 |
| 26676 | 1,553.00 |
|---|---|
| 26727 | 1,260.80 |
| 26735 | 1,470.30 |
| 26746 | 1,451.30 |
| 26756 | 1,149.33 |
| 26765 | 1,523.90 |
| 26775 | 902.18 |
| 26775,26740, 12041, 11040 | 1,729.92 |
| 26785 | 1,348.70 |
| 26841 | 1,721.90 |
| Procedure Codes | Surgery Center Allowable |
| 26842 | 1,794.40 |
| 26843 | 1,898.60 |
| 26844 | 1,590.50 |
| 26852 | 1,703.80 |
| 26860 | 1,506.00 |
| 26910 | 2,118.60 |
| 26951 | 928.40 |
| 26952 | 1,425.20 |
| 27066 | 1,450.80 |
| 27080 | 2,235.80 |
| 27170 | 2,524.50 |
| 27252 | 1,418.20 |
| 27301 | 1,962.50 |
| 27305 | 2,297.40 |
| 27340 | 1,653.00 |
| 27347 | 1,538.70 |
| 27350 | 1,908.50 |
| 27380 | 2,151.70 |
| 27385 | 3,097.10 |
| 27405 | 2,413.70 |
| 27418 | 2,720.30 |
| 27422 | 2,756.80 |
| 27424 | 2,310.20 |
|---|---|
| 27425 | 2,052.20 |
| 27427 | 1,637.31 |
| 27428 | 2,423.20 |
| 27429 | 2,895.70 |
| 27440 | 1,505.40 |
| 27442 | 3,770.00 |
| 27443 | 1,557.60 |
| 27446, 19999 | 9,170.00 |
| 27524 | 2,001.60 |
| 27535,19999 | 2,419.99 |
| 27570 | 605.30 |
| 27606 | 1,200.90 |
| 27610 | 1,476.00 |
| 27618 | 1,486.15 |
| 27619 | 929.00 |
| 27620 | 1,158.60 |
| 27630 | 969.80 |
| 27640 | 1,377.75 |
| Procedure Codes | Surgery Center Allowable |
| 27650 | 1,756.40 |
| 27676 | 1,594.40 |
| 27658, 64722, 19999 | 2,533.63 |
| 27680 | 1,338.87 |
| 27685 | 2,002.22 |
| 27695 | 1,663.50 |
| 27696 | 1,435.00 |
| 27698 | 1,924.40 |
| 27700 | 1,456.30 |
| 27720 | 4,173.50 |
| 27724 | 2,513.50 |
| 27724, 27380, 27599, 19999 | 5,188.36 |
| 27758 | 2,356.50 |
| 27759 | 2,198.00 |
|---|---|
| 27766 | 1,567.40 |
| 27784 | 1,360.50 |
| 27792 | 2,178.40 |
| 27814 | 2,496.10 |
| 27822 | 1,986.40 |
| 27825 | 666.80 |
| 27829 | 1200.57 |
| 27829, 27695 | 2,299.03 |
| 28035 | 1,440.81 |
| 28060 | 1,269.00 |
| 28062 | 1,363.30 |
| 28080 | 1,082.20 |
| 28112 bilateral | 2650.60 |
| 28118 | 1,496.80 |
| 28122 | 867.80 |
| 28124 | 1,500.00 |
| 28238 | 2,247.60 |
| 28285 | 1,262.50 |
| 28322 | 2,640.30 |
| 28415 | 2,649.90 |
| 28465 | 1,374.70 |
| 28485 | 1,594.58 |
| 28505 | 676.20 |
| 28606 | 1,132.60 |
| 28615 | 2,235.03 |
| 28725 | 2,805.40 |
| 28725, 20900, 20680 | 3,753.82 |
| Procedure Codes | Surgery Center Allowable |
| 28725, 27691 | 5,798.73 |
| 28740 | 2,006.40 |
| 28740, 20900, 28285, 28270 | 4,499.25 |
| 28825 | 342.84 |
| 29805, 23120 | 1,517.88 |
|---|---|
| 29806 | 4056.88 |
| 29807 | 2,902.97 |
| 29807, 23120 | 2,943.54 |
| 29815 | 1,900.00 |
| 29819 | 2,180.10 |
| 29820 | 2,527.20 |
| 29820.05 (capsular shrinkage) | 2,097.94 |
| 29822 | 2,361.60 |
| 29823 | 2,870.20 |
| 29823, 23182 | 2,368.33 |
| 29823, 24356 | 2,889.43 |
| 29825 | 1,722.50 |
| 29826 | 2,338.80 |
| 29834 | 1,759.60 |
| 29835 | 2,428.00 |
| 29836 | 2,174.50 |
| 29837 | 2,063.10 |
| 29838, 24147 | 2,400.63 |
| 29844, 25107 | 1,895.30 |
| 29845 | 1,234.50 |
| 29846 | 1,578.10 |
| 29848 | 1,186.64 |
| 29848, 64722 | 2,274.79 |
| 29870 | 1,427.80 |
| 29874 | 1,258.50 |
| 29875 | 1,777.80 |
| 29875, 29873 | 2773.60 |
| 29876 | 1,951.20 |
| 29877 | 1,767.80 |
| 29879 | 1,929.70 |
| 29879, 29877, 29873 | 2,438.57 |
| 29880 | 2,310.90 |
| 29880, 27345 | 2,870.84 |
|---|---|
| 29881 | 1,757.10 |
| 29881, 19999, 20924 | 4,970.00 |
| Procedure Codes | Surgery Center Allowable |
| 29880, 27345 | 2,870.84 |
| 29881, 29877, 29873 | 2,631.97 |
| 29882 | 2,208.50 |
| 29883 | 1,697.20 |
| 29884 | 2,139.40 |
| 29885 | 2,949.10 |
| 29887 | 1,652.40 |
| 29888 | 2,966.20 |
| 29891 | 1,781.30 |
| 29894 | 1,852.60 |
| 29895 | 1,519.40 |
| 29895, 27695, 28300, 19999 | 6,770.00 |
| 29897 | 1,818.30 |
| 29898 | 1,690.20 |
| 31570 | 364.50 |
| 38760, 64774, 64774 | 1,647.95 |
| 43239 | 511.00 |
| 44312 | 2,264.50 |
| 45330 | 96.00 |
| 49500 | 1,694.00 |
| 49505 | 2,062.30 |
| 49505, 55520 | 1,785.53 |
| 49507 | 1,950.00 |
| 49520 | 1,216.10 |
| 49525 | 1,318.40 |
| 49560 | 980.40 |
| 49561 | 822.00 |
| 49566 | 1,737.70 |
| 49570 | 1,160.90 |
| 49585 | 1,151.20 |
|---|---|
| 49587 | 961.30 |
| 49650 | 2,185.50 |
| 49651 | 1,903.60 |
| 49659 | 2,278.09 |
| 52276 | 2,057.30 |
| 52281 | 944.40 |
| 52332 | 823.50 |
| 52336 | 520.10 |
| 54520 | 1,639.60 |
| 56316 | 2,687.70 |
| 56317 | 2,376.90 |
| Procedure Codes | Surgery Center Allowable |
| 57288 | 2,622.80 |
| 62287, 76003, IV Sedation sedation | 4,084.89 |
| 62290 | (see 72295) one level |
| 62290-50 | (see 72295-50) |
| 62291 | (see 72285) one level |
| 62291-50 | (see 72285-50) |
| 62350 | 2,225.60 |
| 62362 | 2,610.10 |
| 62365 | 797.70 |
| 63020 | 3,020.00 |
| 63030 | 2,343.30 |
| 63042 | 2,872.00 |
| 63047 | 2,737.40 |
| 63056 | 2,144.08 |
| 63075 | 5,106.30 |
| 63075, 22554, 22845, 20931 | 8,223.41 |
| As above x 2 levels | 9,037.62 |
| 63081, 22554, 22845, 22851 2 levels | 8,358.62 |
| 63185 | 1,462.60 |
| 63190 | 1,720.90 |
| 63650, 95972, elect x 1, 76005 | 2,626.14 |
|---|---|
| 63650, 95972, elect x 2, 76005 | 4,731.80 |
| 64626, 64627, 76005 | 1,312.58 |
| 64613, 64614 | 1,151.29 |
| 64622, 64623, 27096, 76005 | 1,091.45 |
| 64640, 76005 | 698.01 |
| 64702 | 1,210.00 |
| 64704 | 1,477.70 |
| 64708 | 1,944.40 |
| 64718 | 1,502.60 |
| 64718, 64721, 29840 | 2,120.04 |
| 64719 | 1,654.20 |
| 64721 | 1,031.60 |
| 64722 | 1,352.40 |
| 64776 | 1,103.55 |
| Procedure Codes | Surgery Center Allowable |
| 64782 | 1,250.00 |
| 64784 | 1,123.40 |
| 64784, 64787 | 1,665.97 |
| 64831 | 1,508.20 |
| 64836 | 1,688.00 |
| 64837 | 984.12 |
| 64856 | 1,819.16 |
| 64890, 26350 64890,11012, | 2,090.09 |
| 26862, 64831 | 2,899.49 |
| 64898 | 2,293.40 |
| 65285 | 1,048.00 |
| 67312 | 2,536.60 |
| 67036 | 1,427.90 |
| 64999.01, one level rhizotomy/ neurotomy (includes fluoro, IV sedation and supplies) | 563.90 |
| 64999.01, two level rhizotomy/ neurotomy (includes fluoro, IV sedation and supplies) | 678.00 |
| 64999.01, three level rhizotomy/ neurotomy | 819.10 |
| (includes fluoro, IV sedation and supplies) | |
|---|---|
| 64999.01, four level rhizotomy/ neurotomy (includes fluoro, IV sedation and supplies) | 960.20 |
| 67108 | 3,005.20 |
| 67950, 27880, 20926 | 2,146.52 |
| 69631 | 1,493.50 |
| 69999, one level IDET (includes fluoro, IV sedation and supplies) | 2,312.82 |
| 69999, two level IDET (includes fluoro, IV sedation and supplies) | 5,066.54 |
| 69999, three level IDET (includes fluoro, IV sedation and supplies) | 7,174.18 |
| 69999, four level IDET (includes fluoro, IV sedation and supplies) | 8,680.05 |
| 72285 (one level) | 502.25 |
| Procedure Codes | Surgery Center Allowable |
| 72285-50 (each add. Level) | 125.65 |
| 72295 (one level) | 471.50 |
| 72295-50 | 117.88 |
(c) Fees for Inpatient Hospital Services. Services or items shall be paid per usual and customary services pursuant to section 1 of this chapter. Bills shall be audited for unidentified and unrelated services and/or items. The Division shall provide a copy of the audit upon request.
(i) Hospital Room Rates. The Division shall pay inpatient hospital room rates based upon an annual survey conducted by the Division, the results of which shall be furnished to each hospital in the state before the start of each calendar year. The hospital room rates reported for a semi-private and intensive care unit bed shall be at the usual and customary rates charged to the general public. Such rates shall be effective automatically on the first day of each calendar year unless the Administrator gives written notice to the contrary before the first day of the calendar year. The remainder of charges for services will be audited and paid per fee schedule. The Division will periodically review payment methods and agreements for lower reimbursement rates with hospitals to promote cost containment without compromising the quality of patient care.